الفهرس 
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Abstract
Dry eye disease (DED) is one of the most common ocular disorders in the geriatric patients. It is also known as dry eye syndrome (DES) and keratoconjunctivitis sicca (KCS), which is a major global health concern being one of the most prevalent causes of the primary eye care visits of the patients. DED can be defined as “A multifactorial disease of the tears and ocular surface that causes discomfort, and visual disruption, accompanied by rise in the tear film osmolality, ocular surface irritation and injury”. Additionally, DED is strongly linked in patients to a disruption of their ADLs due to poor sleep quality.
DED is considered a chronic, incurable ailment; thus palliative and pharmacological treatment may be required for the remainder of the life of the patients. According to studies by chan, 2021 and Morthen et al, 2021, the geriatric patients with DED who have poor eyesight, and less education have the most trouble adhering to DED treatment due to lack of their knowledge about the importance of compliance with the eye drops and inability to see it due to reduced visual function; leading to increased susceptibility of the patients to the complications of DED.
Geriatric patients with poor manual dexterity as a result of their neurodegenerative and autoimmune pathology (dementia, Parkinson’s disease, multiple sclerosis, RA), may also have reduced physical functions leading to increased dependence as a result of their inability to administer eye drops themselves. DED can affect visual functions predisposing to diminished depth perception, color discrimination, peripheral vision, visual processing speed, visual search, difficult light and dark adaptation and causing intermittent blurred, foggy, glare or fluctuating vision due to insufficient tear production and/or poor quality tears.
Gerontological nurse has a central and main role in caring for patients with DED, being one of the primary health care providers, spending more time and effort with the patients than other members of interdisciplinary team. Role of gerontological nurses role must include assessment and identification of the problems and needs of the patients, planning, implementation of the suitable nursing interventions as providing patients with needed DED related data, demonstration of tear duct occlusion technique, practicing ophthalmic exercises as clock work, palming, blinking, up and down as well as near and far sight, exercises, additionally advising geriatric patients about the importance of follow up in controlling manifestations of DED and preventing its complications and evaluation of its related interventions.
Aim of study:
This study aimed to determine effect of the implementation of nursing interventions program on the visual activities among geriatric patients with DED.
Research hypothesis:
Geriatric patients with dry eye disease who receive the proposed nursing interventions program achieve lower score on the visual activities grading scale than those who do not receive it.
Materials:
Setting:
The study was carried out in the Ophthalmology Hospital (Farouk hospital) at Alexandria governorate, Egypt. The hospital is affiliated to the Ministry of Health, Egypt.
Subjects:
The study included 70 geriatric patients, are aged sixty years and above, who are diagnosed with DED, have intact cognitive function or mild cognitive impairment according to the Saint Louis University Mental Status (SLUMS) Examination, additionally have a score of 21 and more for patients with high school education, score 20 and more for patients with less than high school education, and score of 19 and more for illiterate patients. Moreover, have no depression score less than 3 on the Patient Health Questionnaire- 2 (PHQ-2) and have no other eye problems than DED. The sample size was divided equally and randomly into two groups; study and control groups, 35 geriatric patients each. The control group received the routine care of the hospital, while the study group received routine care of the hospital the proposed nursing interventions program. The researcher additionally divided this group into two sub groups (sub group A and B).
Tools of the study
Five tools were used for data collection and to attain the study aim;
Tool (I): Saint Louis University Mental Status (SLUMS) Examination:
This tool was adopted in this study to assess the cognitive function of geriatric patients and identify those with cognitive impairment.
Tool (II): Patient Health Questionnaire- 2 (PHQ-2):
This tool was adopted to assess depressed mood and anhedonia over the past two weeks and to screen for depression in a “first-step” approach.
Tool (III): Older Adults Socio–Demographic and Clinical Data Structured Interview Schedule:
This tool was developed by the researcher based on review of relevant literature to collect necessary data related to socio-demographic characteristics and clinical data of the geriatric patients.
Tool (IV): Knowledge of Geriatric Patients with Dry Eye Disease Structured Interview Schedule:
This tool was developed by the researcher based on review of relevant literature to assess knowledge of geriatric patients about: Causes, prevalence, manifestations, complications, and also management of DED.
Tool (V): Visual Activities Questionnaire (VAQ):
This visual activities questionnaire was adapted to assess problems in daily visual activities of geriatric patients with DED.
Method:
Approval to carry out the study from the Research Ethics Committee, Faculty of Nursing, Alexandria University, was obtained.
An official letter was issued from the Faculty of Nursing, Alexandria University to the director of the Farouk Ophthalmology Hospital to obtain his permission to collect the necessary data.
Written approval was obtained from the director of the study setting, who was informed prior conducting the study about its purpose, the date and time of data collection.
The study tools were tested for content validity by 5 experts in the related field of the study.
Pilot study was done on 7 geriatric patients with DED selected from the Ophthalmology Hospital and excluded from the study sample.
The implementation of the proposed nursing interventions program was covered in 14 weeks (one session per week; every other day) from the beginning of June to the end of September 2022 as follows:
The first session: Information about DED session
In this session the researcher provided simple information about DED such as: definition, pathophysiology, risk factors in geriatric patients, signs and symptoms, diagnosis, follow up, complications and management.
The second session: healthy nutrition for eye
Necessary information was provided by the researcher related to: the importance of consumption and components of well-balanced diet, in addition to drinking the recommended daily amount of fluids unless contraindicated.
The third session: Smoking cessation
Information regarding smoking was clarified by the researcher such as, its different types, its associated eye problems, the importance of smoking cessation, and strategies for quitting smoking gradually.
The fourth session: Environmental modifications
In this session, the researcher advised the patients about the importance and methods of environmental modifications and how to prevent falls.
The fifth session: Tear duct occlusion technique
The resrearcher taught the patients how to instill eye drops or ointments and gave them the opportunity for re-demonstration
The sixth session: Clock work exercise
The clock work exercise was carried out by the researcher, starting with explaining its importance, then performed the technique more than one time in front of the study group, followed by re- demonstration and advising them to repeat the exercise every an hour daily for five consecutive weeks.
The seventh session: Palming exercise
The technique of palming exercise was performed by the researcher for the patients, where the researcher gave the opportunity for re- demonstration and instructed the patients to repeat the exercise three times daily for five (5) weeks.
The eighth session: Blinking exercise:
The blinking exercise was demonstrated and explained by the researcher emphasizing on its importance in stimulating the LG to increase tears production to lessen DED symptoms. Furthermore, the researcher advised the patients to re demonstrate the exercise and perform it five (5) times per day.
The ninth session: Up and down viewing exercise
The Up and Down exercise was performed and explained by the researcher and instructing the patients to re-demonstrate and repeat the exercises ten (10) times per day.
The tenth session: Near and distant view exercise
The researcher led the near and far view exercise, explained how it should be done clarifying its importance. Where, the researcher asked the patients to re-demonstrate the exercises and repeat it from ten to twelve (10-12) times per day.
Statistical analysis, the collected data were organized, tabulated and statically analyzed using the statistical package for social studies (SPSS) Version 25.0. The following statistical analysis measures were used:
- Descriptive statistical measures, which included: numbers, percentages, and averages (Arithmetic mean, Standard deviation (SD), and effect size).
- Moreover, further utilized tests included: Chi square test, Student T- test, Cohen’s test, and Anova test and the level of significance was set as ≤ 0.05.
The main results obtained were as follows:
The results showed that, 77.1% and 80% of patients in the study and control groups; respectively are females. Regarding age, geriatric patients who are aged 60 to less than 65 years constituted 62.9% for the both groups with a mean age of 64.03 ± 4.162, 63.91± 4.368 years for patients in the study and control groups; respectively.
Regarding the level of education, it is noticed that 71.4%, 14.3% and11.4% of patients in the two groups are illiterate, read and write, and have secondary education; respectively. In relation to the occupation, 80% of patients in two groups are not working. As for smoking, 51.4% and 54.3% of patients in the study and control groups; respectively are smokers; of those who are smokers 77.8%, 89.5% in the study and control groups; respectively are passive smokers.
Regarding regular follow up before the implementation of the nursing interventions program, it was reported by 80% of patients in two groups. Additionally 25.7% and 34.3% of patients in the study and control groups; respectively reported previous eye surgeries; 88.9% and 75% of them reported phacoemulsification; respectively.
The nursing interventions program has a large effect on the knowledge level of study patients (0.945) with a mean of 5.63±3.663, and 21.57±1.290 before and after the implementation; respectively. Additionally the intervention has a medium effect on their visual activities (0.711) with a mean of 77.86±19.33, 49.74±3.43 before and after the implementation of nursing interventions; respectively.
It is evident in the results that age, level of education and regular follow up P=0.016, P=0.017, P=0.004; respectively were significantly associated with total levels of knowledge. Additionally, the R2 value is 0.358 which means that 35.8% of the variability in the outcome is explained by the characteristics of patients with overall significance of (P=0.000).
It is evident that age, level of education, living style, presence of chronic diseases, duration of DED and regular follow up P=0.000, P=0.000, P=0.000, P=0.003, P=0.015, P=0.003; respectively were significantly associated with total levels of visual activities. the R2 value is 0.424 which means that 42.4% of the variability in the outcome is explained by the characteristics of patients with overall significance of (P=0.004).`