Cognitive, Visual, Auditory, and Emotional Factors That
Affect Participation in Older Adults
KEY WORDS
 cognition disorders
 depression
 hearing disorders
 home care services
 human activities
 mass screening
 vision disorders
Monica S. Perlmutter, MA, OTR/L, is Instructor of
Occupational Therapy and Ophthalmology, Program in
Occupational Therapy, Washington University School of
Medicine, 660 South Euclid, Box 8505, St. Louis, MO
63110; perlmutterm@wusm.wustl.edu
Anjali Bhorade, MD, is Assistant Professor of
Ophthalmology, Department of Ophthalmology and Visual
Sciences, Washington University School of Medicine,
St. Louis, MO.
Mae Gordon, PhD, is Professor of Ophthalmology and
Biostatistics, Department of Ophthalmology and Visual
Sciences, Washington University School of Medicine,
St. Louis, MO.
Holly H. Hollingsworth, PhD, is Research Associate
Professor of Occupational Therapy, Washington University
School of Medicine, Program in Occupational Therapy,
St. Louis, MO.
M. Carolyn Baum, PhD, OTR/L, is Professor of
Occupational Therapy, Program in Occupational Therapy,
and Professor of Neurology, Department of Neurology,
Washington University School of Medicine, St. Louis, MO.
570
Monica S. Perlmutter, Anjali Bhorade, Mae Gordon,
Holly H. Hollingsworth, M. Carolyn Baum
OBJECTIVE. To determine whether changes in hearing, cognition, depression, and vision affect daily life
participation and whether screening tests that identify problems could be used in the home.
METHOD. Interviewers assessed presence of medical conditions, social class, distance acuity, cognition,
hearing, depression, and participation using valid screening tools. Participation scores were subgrouped
according to negative or positive results. Multiple regression analysis determined association of screening
tests with participation.
RESULTS. Eighty-eight older adults, ages 62–90, participated. Positive screening tests were found in
43% of participants for distance acuity, 9% for cognitive problems, 8% for depression, and 15% for
hearing loss. Relationships were found among age, cognition, depression, and vision and participation.
CONCLUSION. Mild levels of decreased vision, depression, and decreased cognition are associated with
lower participation. These conditions can be screened by occupational therapists and managed to help older
adults remain active and maintain their health.
Perlmutter, M. S., Bhorade, A., Gordon, M., Hollingsworth, H. H., & Baum, M. C. (2010). Cognitive, visual, auditory, and
emotional factors that affect participation in older adults. American Journal of Occupational Therapy, 64, 570–579.
doi: 10.5014/ajot.2010.09089
A common fear people have as they age is losing the ability to participate in
necessary and desired activities. Many older adults remain active in their
family and community lives. At the same time, a growing population of older
adults will need to use social services and medical systems to manage their chronic
diseases and resulting disabilities (Beck & Stuck, 1996; Fried & Guralnik,
1997). Older adults are the fastest growing segment of the U.S. population
today. It has been reported that as many as 40% of people ³ age 65 experience
difficulty performing their usual activities (Rubin, Roche, Prasada-Rao, &
Fried, 1994). Manton, Corder, and Stallard (1997) estimated that by 2050, the
number of older people with one or more disabilities will triple; this poses
a major challenge for older adults, their families, and society.
Everyday instrumental, leisure, and social activities help people sustain their
health as they engage in activities that allow them to remain involved with their
families, communities, and society (Glass, Seeman, Herzog, Kahn, & Berkman,
1995; Marsiske, Klumb, & Baltes, 1997; Wilson et al., 2002). As the number
of older adults increases, it is vital that society anticipate the resources needed to
support older adults’ performance. Understanding the difference between
successful and unsuccessful aging and how the normal conditions of aging can
be managed to retain older adults in a successful state will be important (Rowe
& Kahn, 1997). We must also increase our efforts to understand the psycho-
logical, physiological, social, and environmental factors associated with the
decline in engagement in activity and occupational performance. We chose to
address participation, which is defined by the World Health Organization
July/August 2010, Volume 64, Number 4
(2001) as involvement in a life situation. With this un-
derstanding, it will be possible to design programs and
services to maximize older adults’ participation in family
and community life.
Depression and the loss of vision, hearing, and cog-
nitive abilities are common in older adults. Reidy et al.
(1998) conducted a community-based study and found
that bilateral vision impairment occurs in 30% of adults
³ age 65. Several common eye conditions, such as macular
degeneration, glaucoma, and cataract, may result in vi-
sion loss significant enough to affect older people’s oc-
cupational performance. Of community-dwelling older
adults, 8% have macular degeneration (Reidy et al.,
1998), which causes central vision loss and affects activ-
ities such as reading, shopping, community mobility, and
participation in leisure activities (Lamoureux, Hassell, &
Keeffe, 2004). Open-angle glaucoma, which primarily
affects peripheral vision, occurs in 3% to 8% of older
adults living in the community (Campbell, Crews,
Moriarty, Azck, & Blackman, 1999; Reidy et al., 1998).
Approximately 20.5 million (17.2%) of Americans > age
40 have cataracts in one or both eyes, with the total
number expected to increase to 30.1 million by 2020
(Eye Diseases Prevalence Research Group, 2004). Cata-
racts can be managed with surgery, but if left untreated
they can cause blurred vision, difficulty with color rec-
ognition, problems with glare, and loss of contrast sen-
sitivity (Colby, 2008).
Hearing loss is another common chronic condition
and has been reported at a level of 33.2% to 87% of older
adults living in the community (Campbell et al., 1999;
Cruickshanks et al., 1998; Keller, Morton, Thomas, &
Potter, 1999; Strawbridge, Wallhagen, Seema, & Kaplan,
2000). Hearing loss has the potential to disrupt com-
munication with others (Hooyman & Kiyak, 2005) and
to affect participation in activities such as talking on the
telephone (Stuck et al., 1999). To compensate for a single
sensory impairment, elders will depend on their intact
senses. Unfortunately, older adults with dual sensory
impairments have more difficulty compensating. Dual
sensory losses have been found in 8.6% of older adults
(Campbell et al., 1999), and another study (Bergman &
Rosenhall, 2001) found that 23% of people > age 81 have
some degree of dual sensory impairment.
Even in the absence of neurological disease, older adults
may experience a variety of age-related central nervous
system changes that have the potential to cause cognitive
decline (Foster, Perlmutter, & Baum, 2008). Decreased
executive functioning is thought to occur as a result of loss
of frontal cortex (Grigsby, Kaye, & Robbins, 1995). Other
changes in the brain result in changes in neurotransmitter
The American Journal of Occupational Therapy
functioning and synapse structure that manifest as in-
creased reaction time and slowed processing of in-
formation (Hooyman & Kiyak, 2005). In addition,
chronic illness has been linked to cognitive decline among
older adults; this accelerated cognitive loss is one of the key
risk factors for decreased occupational performance among
community-residing elders (Stuck et al., 1999).
The aging process can involve many stressful events;
one’s ability to alleviate stress, learn from experience, and
obtain a sense of meaning and fulfillment greatly influ-
ences psychological well-being in older adulthood (Foster
et al., 2008). Psychological disorders are common among
community-dwelling older adults, ranging from 15% to
25% (Hooyman & Kiyak, 2005). Depression alone or in
combination with other chronic diseases can lead to
a shortened active life expectancy (Reynolds, Haley, &
Kozlenko, 2008). Lack of identification and treatment of
psychological conditions is a key related issue and is
problematic for many reasons. For example, some symp-
toms of depression, such as changes in sleeping and eating
patterns and loss of interest in activities, may be associ-
ated with normal aging (Hooyman & Kiyak, 2005).
Another factor is that mental health services may not be
covered by Medicare or Medicaid (Norris, Molinari, &
Rosowsky, 1998); therefore, older adults seek treatment
by primary care physicians, who may be more likely to
prescribe medication than to recommend psychosocial
approaches to therapy (Wetherall, 1998). Given the
prevalence of these impairments, it is imperative that
occupational therapists identify problems that threaten
older adults’ occupational performance.
The objective of this descriptive pilot study was to
answer the following research questions:
1. What are the influences on participation of common
conditions faced by older adults, such as depression
and changes in hearing, cognition, and vision?
2. Can screening tests that identify problems, such as
depression and changes in hearing, cognition, and
vision, be used in the home?
Method
Participants and Recruitment
The institutional review board of Washington University
School of Medicine approved the protocol. Ninety-six
community-dwelling adults were recruited from three
sources. A systematic proportional sample of community-
dwelling elders was recruited from the 2000, 2001, and
2002 membership lists of the Older Adults Services
and Information System (OASIS), an arts-, humanity-,
571
and health-oriented volunteer organization. Every fifth
name on the list of OASIS members residing in three
target zip code areas in metropolitan St. Louis was selected
from each yearly membership list. To be included, the
participants had to live in the community, be ³ age
55, and be willing to participate. Selected members were
mailed an invitation to participate in the study and were
contacted by telephone. We attempted to contact 636
people (96, Year 1; 386, Year 2; and 154, Year 3). We were
unable to contact a high proportion of the target sample
because of out-of-date contact information and people not
being at home. A total of 81 people were contacted by
telephone, 74 of whom signed a consent form and com-
pleted the assessment. We selected a sample of 20 people
recently discharged to home from the stroke service at
Barnes–Jewish Hospital, St. Louis, Missouri; 14 were in-
cluded. To enrich the sample with people managing a visual
condition, we enrolled 8 patients diagnosed with age-related
macular degeneration. These participants were living in-
dependently in the community and were recruited consec-
utively by ophthalmologists at the Barnes Retina Institute.
Measures
Participants completed a comprehensive assessment battery
that included screening tools to capture cognition, de-
pression, audition, and a standardized measure of distance
acuity as well as a measure of participation to determine the
older adults’ current level of engagement in instrumental,
leisure, and social activities. The Person–Environment–
Occupational Performance (PEOP) Measurement Model
(Baum & Christiansen, 2005) provided the rationale for
the selection of the measurements of the sensory, affective,
and cognitive problems faced by older adults in the context
of their everyday lives. Data from environment and occu-
pation measures were also collected and will be the focus of
future articles. Specific variables include cognition, hearing,
vision, depression, and activity participation. Measures
used to describe the sample and to collect data for each
variable are described briefly; psychometric properties and
scoring information are included in Table 1.
We used a modified version of the Physical Health
portion of the Older Adult Resources and Services (OARS;
Fillenbaum, 1988) Multidimensional Functional Assess-
ment Questionnaire and Services Supplement to gather
information regarding the study participants’ medical
conditions. The Hollingshead Index of Social Position
was used to measure social class and further describe the
sample (Hollingshead & Redlich, 1957).
To screen for memory and concentration deficits,
we used the Short Blessed Test (or Short Orientation–
Memory–Concentration Test; Blessed, Tomlinson, &
572
Roth, 1968; Katzman et al., 1983). The Hearing Screening
Test assesses the capacity for hearing a combination of
high- and low-pitched sounds used in everyday conversa-
tion without the benefit of lip reading (Scheuerle, 2000).
We tested binocular distance visual acuity with the
Early Treatment of Diabetic Retinopathy Study (ETDRS)
chart developed by Ferris, Kassoff, Bresnick, and Bailey
(1982) to standardize the measurement of distance visual
acuity. Rather than testing each eye individually, we
tested binocular vision to better reflect functional vision
(Azen et al., 2002). Visual acuity was tested initially with
the participants’ usual distance correction under ambient
household lighting and again under standardized lighting
similar to an ophthalmic clinical setting. Standard light-
ing levels were achieved with the use of a gooseneck-style
floor lamp. Household lighting was measured with the
Luna-Pro digital light meter (Model No. 4022; Gossen
GmbH, Erlangen, Germany).
We used the Geriatric Depression Scale–Short Form
(Alden, Austin, & Sturgeon, 1989; Sheikh & Yesavage,
1986), a 15-item version of a 30-item scale, to assess
presence of depression. The Activity Card Sort (ACS;
Baum, 1995; Baum & Edwards, 2008) assesses an in-
dividual’s participation in instrumental, leisure, and so-
cial activities and provides a profile of the extent to which
activities relevant to the individual have been retained,
given up, or performed less often.
Procedure
Occupational therapy graduate students participated in
a 1-wk training course to learn to conduct interviews and
functional testing. The occupational therapy students also
had 2 additional days of training on the vision measures by
Anne Coleman, Department of Ophthalmology, Uni-
versity of California, Los Angeles, who provided in-
struction and supervision as the students tested normal
volunteers from Washington University and community
volunteers. In-house training at the university was fol-
lowed by a day of training in the St. Louis community,
which consisted of performing the battery of assessments
with older adults in their own homes. Interrater reliability
was established for the vision measure on the sample of
Washington University community volunteers (intraclass
correlation coefficient 5 .92). Older adults who gave
verbal consent by telephone for study participation were
scheduled for a home visit. After verbal consent, potential
participants received letters that confirmed the date and
time of appointment and included contact information
for research staff and photographs of the evaluators.
During the home visit, study participation was de-
scribed, and written consent was obtained by the
July/August 2010, Volume 64, Number 4
Table 1. Measures Used to Assess Participation, Vision, Depression, Hearing, Social Class, Health Conditions, and Cognition
Instrument Purpose and Psychometrics Scoring
ACS (Baum, 1995; Assesses an individual’s participation in instrumental, Yields a profile of activities that have been retained or
Baum & Edwards, 2008) leisure, and social activities. The content, construct, given up or are now being done with less frequency
and predictive validity have been established (Katz, since age 60. A total score of 80 is possible with a
Karpin, Lak, Furman, & Hartman-Maeir, 2003; range of 0–80.
Sachs & Josman, 2003). The ACS has high internal
consistency for instrumental activities of daily living
and social activities and moderate internal
consistency for low and high physical leisure
activities (Katz et al., 2003).
ETDRS chart (Ferris et al., 1982; Measure of distance visual acuity. Test–retest reliability Positive screening value of 20/40 or worse is indicative
Lovie-Kitchin, 1988) is .98; concurrent validities with the Flom, Snellen, of declining visual function (Salive et al., 1994).
and Illiterate E charts are .91, .94, and .96,
respectively.
Geriatric Depression Study participants answer 15 yes–no questions about Range of possible scores is 0–15. A score of ³5
Scale–Short Form (Alden et al., feelings, interests, activities, and hopes. Reliability, indicates possible depression.
1989; Brink et al., 1985; validity, and sensitivity–specificity studies have been
Sheikh & Yesavage, 1986) conducted on the original 30-item version (Sheikh &
Yesavage, 1986), and the short form distinguishes
depressed from nondepressed study participants
(r 5 .84, p < .001)
Hearing Screening Test Assesses capacity for hearing a combination of high- Score of £4 on a scale ranging from 0 (worst)
(Scheuerle, 2000) and low-pitched sounds used in everyday to 5 (best) is indicative of possible hearing loss.
conversation without the benefit of lip reading.
Hollingshead Index of Social Uses self-reported information regarding the head of Social class scale ranges from 1–5, with 5 being the
Position (Hollingshead & household’s occupation and the participant’s level of highest.
Redlich, 1957) education to determine position on social class scale.
OARS Multidimensional Functional Gathers information regarding medical conditions Participants indicate conditions they have and the
Assessment Questionnaire of the study participants. Concurrent validity, degree to which the conditions bother them.
and Services Supplement–Physical Spearman rank-order correlation coefficient 5 0.82;
Health (Fillenbaum, 1988; interrater reliability, complete agreement for 74% of
Fillenbaum & Smyer, 1981) items; intraclass correlation coefficient 5 .662.
Short Blessed Test (or Short Consists of six items assessing memory, orientation, Range of possible scores is 0–28; the higher the score is,
Orientation–Memory–Concentration and concentration and is a reliable and valid screening the greater is the cognitive impairment. A score of ³8
Test; Blessed et al., 1968; tool for detection of dementia in community and long- is considered indicative of possible cognitive impairment.
Katzman et al., 1983) term care populations. Concurrent validity was established
with the Mental Status Questionnaire (r 5 .945).
Note. ACS 5 Activity Card Sort; ETDRS 5 Early Treatment of Diabetic Retinopathy Study; OARS 5 Older Adult Resources and Services.

evaluator. Demographic information was collected, and
the assessments were administered. Trained occupational
therapy graduate students collected data for this pilot
study over a period of 3 years as part of their master’s
degree projects. To understand the impact of these mild
impairments, 8 study participants of the original 96 were
excluded from the analysis dataset because they had sig-
nificant vision loss; more than two positive screening
values on cognitive, depressive, or auditory tests; or both.
Data Analysis
We calculated descriptive statistics including means,
standard deviations, and range of scores for each de-
mographic and outcome variable. Correlation coefficients
were used to calculate relationships between variables.
Student’s paired t tests were conducted to compare ac-
tivity participation for negative and positive findings for
vision, cognition, depression, hearing, and age. To mea-
sure the magnitude of the standardized differences of
participation, we also computed an effect size for vision,
cognition, depression, hearing, and age differences. A
multiple regression analysis was performed to assess the
contribution of vision, cognition, depression, hearing,
gender, and age to the variability of participation.
Results
The participants ranged in age from 62 to 90 yr; the mean
age was 74.3 (Table 2). The participants were primarily
female (64%); self-identified White (96%); and married
(58%) and represented a uniform distribution of social
status.
Table 3 reports the means, standard deviations, and
ranges for the ETDRS distance acuity chart, Short
Blessed Test, Geriatric Depression Scale, Hearing Screen-
ing Test, and age. In addition, mean activity participation
scores, as measured by the ACS, are stratified by classifi-
cation on the screening tests as negative or positive. A
participant could screen positive on more than one test, so

The American Journal of Occupational Therapy 573

Table 2. Demographic Characteristics of Study Participants vision was limited on the basis of their eye exam. Binocular
(N 5 88) distance visual acuity was assessed with the participant’s
Characteristic n (%) M (SD), range usual correction (95% wore glasses). The mean distance
Age 74.3 (7.2), 62–90 visual acuity value was 52.0 or approximately 20/25 dis-
Gender tance equivalent. Among the 35 participants with a posi-
Female 56 (64)
tive screening value of £20/40 for binocular distance visual
Male 32 (36)
Ethnicity
acuity tested under ambient household light, the mean
White 84 (96) ACS score was 38.4 (standard deviation [SD] 5 10.8)
African-American 3 (3) compared with 48.8 (SD 5 10.7) among those with
Other 1 (1) a normal screening value for vision (p < .0001). We
Marital status computed a moderate effect size correlation of .43 for this
Married 51 (58)
difference.
Single (never married) 6 (7)
Single, divorced, widowed 31 (35)
Few participants had a positive auditory screening,
Socioeconomic status but 15% (n 5 13) could not repeat all of the sounds
1 Lower 14 (16) when tested. Among the 13 participants with a positive
2 25 (28) screening value for hearing, the mean ACS score was 44.5
3 Middle 25 (28) (SD 5 7.5) compared with 44.5 (SD 5 12.5) among
4 15 (17)
participants with a negative screening value (p 5 .80),
5 Upper 6 (7)
Missing 3 (3)
showing no difference. A small effect size correlation for
this difference was computed to be .03.
Note. M 5 mean; SD 5 standard deviation.
In the sample of older adults, only 9% (n 5 8) had
the total number of participants with positive screening cognitive limitations when tested, whereas 25% (n 5 22)
tests is >100%. Of 88 participants, 35 had a positive indicated on the modified Duke Medical Index that they
screening value for one impairment, and 9 had a positive had memory problems. Among the 8 participants with
screening value for two impairments. a positive screening value for cognition, the mean ACS score
Of the participants, 40% (n 5 35) had a positive was 38.7 (SD 5 13.4) compared with 45.3 (SD 5 11.6) for
vision screening score, yet only 15% (n 5 13) self-reported those with a normal screening value (p 5 .14). The small
on the Physical Health portion of the OARS that their effect size correlation for this difference was .16.

Table 3. Comparison of Mean Activity Participation Scores Stratified by Screening Status and Age
Activity Card Sort
Measure n (%) M (SD) Range
Early Treatment of Diabetic Retinopathy Study (binocular distance acuity) 52.0 (8.4) 28–66
Negative (better than 20/40) 53 (60) 48.8 (10.7)
Positive (220/40 or worse) 35 (40) 38.4 (10.8)
t(86) 5 24.44, p < .0001, r 5 .43
Short Blessed Test 2.7 (7.2) 0–16
Negative (<8) 80 (91) 45.3 (11.6)
Positive (³8) 8 (9) 38.7 (13.4)
t(86) 5 1.49, p 5 .14, r 5 .16
Geriatric Depression Scale 1.5 (0.6) 0–12
Negative (<5) 81 (92) 45.3 (11.9)
Positive (>5) 7 (8) 37.4 (9.1)
t(86) 5 1.70, p 5 .09, r 5 .18
Hearing Screening Test 4.8 (3.3) 0–5
Negative (5) 75 (85) 44.5 (12.5)
Positive (£4) 13 (15) 44.5 (7.5)
t(86) 5 2.26, p 5 .80, r 5 .03
Age 74.3 (7.2) 62–90
Younger (<75 years) 48 (55) 48.8 (11.4)
Older (³75 years) 40 (45) 39.7 (10.6)
t(86) 5 3.33, p 5 .001, r 5 .34
Note. N 5 88. M 5 mean; SD 5 standard deviation; r 5 effect size correlation.

574 July/August 2010, Volume 64, Number 4

Table 4. Pearson Correlation Coefficients of Key Variables (N 5 88)
Variable 1 2 3 4 5 6 7
1. Gender —
2. Age .02 —
3. Hearing screening test 2.05 2.16 —
4. Short Blessed Test 2.17 .18* .07 —
5. Geriatric Depression Scale–Short Form 2.05 .12 .02 .02 —
6. Early Treatment of Diabetic Retinopathy Study .02 2.45** .01 2.14 2.13 —
7. Activity Card Sort 2.09 2.45** 2.01 2.31** 2.39** .51** —
*p < .05. *p < .01.

Of the participants, 8% (n 5 7) had a positive
screening value of ³5 on the Geriatric Depression Scale,
and 5% (n 5 4) reported mental health problems.
Among the 7 participants with a positive screening value
for depression, the mean ACS score was 37.4 (SD 5 9.1)
compared with 45.3 (SD 5 11.9) for those with a nega-
tive screening value (p 5 .09). The small effect size
correlation was computed as .18. Older participants en-
gaged in fewer activities (mean 5 39.7, SD 5 10.6) than
younger participants (mean 5 48.8, SD 5 11.4, p <
.001). The moderate effect size correlation for this dif-
ference was .34 (Table 3).
Table 4 reports Pearson correlation coefficients be-
tween gender, age, Hearing Screening Test, Short Blessed
Test scores, Geriatric Depression Scale–Short Form rat-
ing, ETDRS binocular distance visual acuity scores ob-
tained under ambient light, and ACS participation scores.
The highest intercorrelations with the ACS were found
for binocular distance visual acuity (r 5 .51), age (r 5
2.45), Short Blessed Test scores (r 5 2.31), and Geriatric
Depression Scale scores (r 5 2.39).
Table 5 reports a multiple regression analysis of the
relationship of screening assessment scores (vision, de-
pression, hearing, and cognition) and demographic fac-
tors (age, gender) to activity participation. Factors that
significantly contributed to participation included age,
depression, cognition, and vision. Hearing and gender
were not associated with ACS participation scores.
Table 5. Summary of Multiple Regression Analysis for Variables
Predicting Active Participation (N 5 88)
Step and Variable B Standard Error
1. Gender 23.76 1.20
2. Age 20.35 0.15
3. Hearing 20.55 1.52
4. Cognition 20.89 0.30
5. Depression 21.87 0.47
6. Distant vision 0.47 0.13
Note. R 5 .48, F(6, 81) 5 12.54, p < .0001. B 5 unstandardized coefficients;
2
The measures used in the data analysis were selected
from a much larger 2.5-hr battery of assessments used in
a research project. The measures reported in this article
required approximately 25 min to complete. Participants
were receptive to the entire assessment process. All measures
are available free of cost in the public domain and can easily
be used in the home setting or included in a routine initial
assessment to determine factors that influence design of
rehabilitation programs.
Discussion
The PEOP Measurement Model (Baum & Christiansen,
2005) proved to be a valuable structure for guiding the
assessment of sensory, affective, and cognitive problems
older adults face in their everyday lives and guided us to
address the physical and social environments as well.
Pearson (2000) supported this notion, stating that a con-
ceptual framework “provides the frame of reference for
understanding the variables studied, for selecting the in-
struments used to collect information and for interpreting
results” (p. 22). By using the PEOP model, we were able
to create an approach to assessment that allowed us to
detect changes in daily activities in a community-residing
sample of older adults and determined that vision, cognition,
and depression had a significant impact on participation.
The findings of this pilot study suggest that partici-
pation changes as people age. As would be expected,
younger participants were more active (engaging in 48.8 of
80 activities) than older participants (engaging in 39.7 of
80 activities). However, the problems of decreased vision,
b decreased cognition, and depression are limiting factors
2.15 beyond age and must be considered to foster health and
2.21* participation in older adults. The importance of a com-
2.03 prehensive screening procedure to identify factors that
2.25* may limit participation is supported by the results. People
2.32*
at risk for restricted participation need to be identified
.34*
because many of these age-related conditions may be

b 5 standardized coefficients. improved with proper medical care; in addition, activity

*p < .05. plays an important role in maintaining health and

The American Journal of Occupational Therapy 575

avoiding excess disabilities. We discuss each of the con-
tributing factors in further detail.
A distance visual acuity level in the range of 20/40 to
20/70 was a positive screening test for mild visual im-
pairment. We found a statistically significant decrease in
participation at this seemingly adequate visual acuity level.
These findings are surprising considering that 20/40 visual
acuity is considered sufficient to possess an unrestricted
driver’s license in many states. The 1999–2002 National
Health and Nutritional Examination Survey (Vitale,
Cotch, Sperduto, & Ellwein, 2006) found that 83% of
the visual impairment, defined as distance visual acuity of
20/50 or worse, could be improved to 20/40 or better
with refractive correction. Small changes, such as getting
new glasses or increasing levels of luminance in the home,
may increase visual acuity. In addition, adding contrast
can increase the visibility and safety of the environment.
This finding suggests that low-cost public health in-
tervention could have an important impact on quality of
life and function.
Surprisingly, we found no significant difference in
participation levels between the study participants who
had a positive Hearing Screening Test (n 5 13, 15%) and
those with a normal screening value. The small number
of participants with a positive Hearing Screening Test
limited the statistical power to detect differences. In ad-
dition, it is possible that the Hearing Screening Test
(Scheuerle, 2000) is not sensitive enough to detect mild
hearing losses or that mild hearing loss may not have an
impact on instrumental activities of daily living or leisure
activities that are performed alone, thus participation
levels would not be affected. Further investigation is
warranted.
In our sample, age, depression, cognition, and vision
were related to participation. As people aged, they were
less active. In addition, depression and decreased cognition
negatively affected participation. People with minor vision
impairment (20/40) experienced reduced participation.
These results were surprising and of particular interest
in light of low vision’s being defined as 20/70 or worse.
These findings suggest the importance of occupational
therapists’ administering screening tools to identify these
issues that may affect what people need and want to do.
The negative relationship indicates that as depression
scores increase, activity participation decreases. Similar
findings have been noted by Williamson (1998), who
concluded that stressful life events experienced by older
adults affect psychological well-being “largely (and some-
times, only) to the extent to which they restrict the ability to
engage in routine activities” (p. 327). Benyamini and
Lomranz (2004) found that giving up activities because
576
of failing health was linked to depressive symptoms and
that replacing these activities with suitable alternatives
resulted in psychological well-being comparable to that
of healthier adults. Depression must be detected early, di-
agnosed accurately, and managed (Ormel et al., 1998). In
addition to referring clients to their primary physician to
address depressive symptoms, occupational therapists are
well positioned to adapt activities of interest or assist
clients in choosing meaningful replacement activities.
The tests selected to screen for distance acuity, cog-
nition, hearing, depression, and activity participation were
sensitive to mild problems that affected performance. The
ETDRS distance acuity chart (Ferris et al., 1982), Short
Blessed Test (Blessed et al., 1968; Katzman et al., 1983),
Hearing Screening Test (Scheuerle, 2000), Geriatric
Depression Screen–Short Form (Alden et al., 1989;
Sheikh & Yesavage, 1986), and ACS (Baum, 1995; Baum
& Edwards, 2008) proved to be easy to administer and
applicable for use in home and community settings.
Rather than rely on self-report of these problems, we
found actual screening for deficits to be important. Actual
measurement of vision, cognition, hearing, depression,
and participation is important because older adults may
under- or overreport problems or attribute changes to the
normal aging process. In addition, changes may be so
gradual that they are not noted by the individual or his or
her family members.
Administration of these tests as part of routine oc-
cupational therapy plays an important role in supporting
successful aging in two ways: identifying impairments that
can limit participation in older adults and addressing these
impairments through occupational therapy intervention
or referring older adults to their primary care physician
and other health care professionals.
The limitations of our study include possible selection
bias because people who agreed to participate may have
a higher level of participation than is truly present in the
community. The small sample size of positive screening
tests for hearing, cognition, and depression may not ac-
curately reflect the effects these sensory modalities have on
participation. Future studies including a larger, more rep-
resentative sample size may provide a better understanding
of whether such associations exist. The population used in
this study was predominantly White and resided in
a community-dwelling neighborhood. These participants
were relatively healthy and had fairly good visual acuity.
The results of this study may not generalize to other
ethnicities, older adults in nursing homes, or people
with increased comorbidities or substantially decreased
vision. The etiology of decreased vision in this report was
not documented. Further assessment of whether various
July/August 2010, Volume 64, Number 4
ocular disorders affect participation differently will be
important to determine as well. Last, the cross-sectional
nature of our study makes it difficult to attribute a cause-
and-effect relationship among vision, depression, and
participation.
The cause-and-effect relationship of these variables
and their impact on occupation and participation are not
known. We pose the following interesting questions that
could guide future research in the area of productive
aging.
1. Does decreased vision limit participation and ulti-
mately result in depression?
2. Do people who self-identify cognitive and sensory
changes limit their activities?
3. Does depression limit participation and cause further
decline in participation when vision is limited?
4. Is it possible that people with depression and limited
vision restrict participation and, therefore, decrease
engagement in experiences, resulting in cognitive
loss?
These questions can be addressed with large samples
of people with a broader range of sensory and cognitive
impairment, as well as more diverse ethnic and socio-
economic representation. An ideal situation would be to
have a longitudinal cohort study to test the hypothesis
using a structured equation model.
A broader issue is the evolution of our understanding
of the importance of participation and its relationship to
health and well-being. Inherent in understanding suc-
cessful aging is the need to determine how changes as-
sociated with aging affect social engagement, leisure
participation, and activities instrumental to community
independence. This study is a beginning step in describing
how person, environmental, and occupational factors
contribute to the participation of older adults. Eventually,
such work can inform policy, inform the practice of
medicine and rehabilitation, and provide evidence for
innovative programs for older adults.
Factors such as cognition, vision and other sensory
modalities, and depression dictate, in part, a person’s
capacity for doing and influence his or her desire and
need to engage in occupation (Foster et al., 2008) and
should be routinely assessed. Knowledge of the presence
of these impairments can be incorporated into client-
centered assessment and intervention plans. Occupational
therapists should be aware that even seemingly minimal
losses of vision and cognition and mild depression can
have negative ramifications on participation and poten-
tially on quality of life and that excess disabilities can
occur when a person has untreated vision or hearing loss
or has unrecognized cognitive impairment or depression
The American Journal of Occupational Therapy
(Baum, Perlmutter, & Edwards, 2000). Occupational
therapists are in a prime position to identify impairments
that will affect the occupational therapy assessment and
intervention process and to connect clients with services
and other health care professionals to enhance occupa-
tional performance and well-being. s
Acknowledgments
This project was possible because of the efforts of occu-
pational therapy graduate students at Washington Uni-
versity in St. Louis’s Program in Occupational Therapy.
We acknowledge the contributions and support of Michael
Kass, MD, and Anne Coleman, MD. Preliminary results
of this study were presented at the Association for Re-
search in Vision and Ophthalmology Annual Conference,
Ft. Lauderdale, Florida, May 2005.
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