A Study to Assess the Effectiveness of Warm Compress on level of Dry Eye among Elderly Adults in a selected Old Age Home, Mangalore

Bibin Mathew

Kailkeri Rukmini Shetty Memorial College of Nursing Mangalore, (RGUHS),

Plakkoottathil (House), Kozhichal (PO), Cherupuzha (Via), Kannur (Dist), Pin 670511

*Corresponding Author Email:

ABSTRACT:

Dry eye syndrome is a common disorder of the tear film among elderly adults. Dry eye is caused by decreased tear production, excessive tear evaporation, and an abnormality in the production of mucus or lipids normally found in the tear layer, or a combination of these. Poor production of tears by the lacrimal gland may be a result of age, hormonal changes, or various autoimmune diseases, such as rheumatoid arthritis. Evaporative loss of the watery tear layer is usually a result of an insufficient overlying lipid layer. Dry eyes can usually be diagnosed by the symptoms alone. A slit lamp examination can be performed to diagnose dry eyes and to document any damage to the eye. A Schimer’s test can measure the amount of moisture bathing the eye. Health care professionals have the responsibilities to minimise the level of dry eye among elderly adults by various measures such as warm compression, hygienic care, and dietary modification. Moreover, it minimizes the risk of infection and integrated treatment for any associated dry eye syndrome.

Aim:

The aim of this study was to assess the effectiveness of warm compress on level of dry eye among elderly adults in missionaries of charity, Mangalore.

Objectives:

1. To assess the level of dry eye among elderly adults in both experimental and control group.

2. To evaluate the effectiveness of warm compress on level of dry eye among elderly adults.

3. To associate the level of dry eye among elderly adults with their selected demographic variable and clinical variable in both experimental and control group.

Methods:

In view of problem under study and to accomplish the objectives of the study the quasi experimental non randomized design was adopted to assess the effectiveness of warm compress on level of dry eye among elderly adults. The conceptual framework of the present study was developed by modification of Widenbach’s prescription theory. The sample consisted of 60 elderly adults, with 30 in each group from a selected old age home at Mangalore. Purposive sampling technique was used to select elderly adults. Data was collected from 25th September to 7th October 2013. Written permission was obtained from the concerned authorities to conduct the study and informed consent was obtained from elderly adults prior to the data collection process. On the first day, pre-test was conducted after which 5 minutes warm compress was given for 5 consecutive days. The data was analysed by using descriptive and inferential statistics. Paired‘t’ test was used to find out the effectiveness of warm compression on level of dry eye and chi-square was used to find the association of pre test level of dry eye and score with selected demographic variable.

Results:

Result of this study showed that in the pre-test level of dry eye among elderly adults in experimental group was equal in 5 (16.7%) which mild and severe level of dry eye, and 20 (66.7) had moderate level of dry eye and the mean, SD scores were 6.07, 2.377, whereas in the post test experimental group 3(10.0) had mild level of dry eye, 5(16.7%) had severe level of dry eye, and 22(73.3%) had moderate level of dry eye. This showed that there was significant improvement in the level of dry eye after the application of warm compress on level of dry eye. The difference in mean level of dry eye sore was statistically significant at 0.05 level (t59=14.917, p<0.05), whereas in the pre-test control group 1 (3.3%) had severe level of dry eye, 6 (20%) had mild level of dry eye, 23 (76.7%) had moderate level of dry eye and the mean, SD scores were 6.20, 2.091. The control group has not undergone any treatment, and therefore, the post-test scores were same as those in the pre-test. There was no significant association between pre-test level of dry eye level and selected demographic variables at 0.05 level of significance.

Interpretation and conclusion:

The finding of the study emphasizes the need for introducing warm compression on level of dry eye among elderly adults. The study proved that the level of dry eye among elderly adults had minimized to a remarkable extent after the Application of warm compress. Hence, warm compress was an effective strategy for providing information and minimize the risk dry eye.

KEYWORDS: Schimer’s test; dry eye; lacrimal gland; warm compress;

INTRODUCTION:

Dry eye syndrome also called as dry eye or keratoconjunctivitis sicca is a common disorder of the tear film that affects a significant percentage of the population, especially those older than 40 years of age. Dry eye is caused by decreased tear production, excessive tear evaporation, and an abnormality in the production of mucus or lipids normally found in the tear layer, or a combination of these. Poor production of tears by the lacrimal gland may be a result of age, hormonal changes, or various autoimmune diseases, such as primary Sjögren’s syndrome, rheumatoid arthritis, or lupus. Evaporative loss of the watery tear layer is usually a result of an insufficient overlying lipid layer¹. Non-inflamed obstructive meibomian gland dysfunction is another major cause of lipid tear deficiency or evaporative dry eye and has recently attracted attention as a cause of ocular discomfort. Meibomian gland dysfunction the supply of normal lipid, which leads to increased tear evaporation decreased tear stability, loss of lubrication, and damage to the ocular surface epithelium resulting in dry eye².

BACKGROUND OF THE STUDY:

The stages of life have been defined by cultures and religions in many ways, human life can be explained more concretely by looking at these life stages. Birth, infancy, childhood, adolescence, adulthood, and finally comes the old age. Most developed world countries have accepted the chronological age of 65 years as a definition of ‘elderly’ or older person.³ India’s older population is projected to quadruple by mid-century, while that of the world is expected to triple, the US Census Bureau has said. In its latest report of the same world’s 65-and-older population is projected to increase from 516 million in 2009 to 1.53 billion in 2050⁴.

To help alleviate the dry eye syndrome, certain self-care tips at home may help. Hot compresses and eyelid scrubs/massage with baby shampoo will help by providing a thicker, more stable lipid layer. This is especially helpful if a person has meibomian gland dysfunction, rosacea, or blepharitis. The heat warms up the oil in the oil glands, making it flow more easily; the massaging action helps get the oil out of the glands⁵. Hot compresses are very beneficial to the normal functioning of the eye. For chronic conditions like meibomian gland dysfunction or blepharitis hot compress help in two ways. First, the warm moisture helps loosen up eyelid debris that has collected on the eyelash follicles. Secondly, hot compresses help the eyelid glands function normally. In meibomian gland dysfunction this is critical and it will help to reduce dry eye symptoms. For more acute conditions like hordeolum, hot compresses help to increase the blood flow to the eyelid area and help the body’s nature process of healing⁶

NEED FOR THE STUDY:

Aging produces a change in the ability to participate in physical activity which is accelerated beginning at approximately age 50. All cells experience changes with aging. They begin to function abnormally. Waste products build up in tissue with aging. Connective tissue changes and becomes stiffer. This makes the glands which are present in the body especially in the eye where they become rigid hard and plug the opening, and keeps the oil from getting in to the tear film. Cell membranes change, many tissues lose mass. Because of this organs also change as you age⁷. The common eye problems often happen with the elderly adults are presbyopia, tearing, floaters, corneal disease, eyelid problem, conjunctivitis, cataract, and glaucoma. Apart from this one of the most striking problem among elderly adults are dry eye. Dry eye is a chronic disease in which an unstable tear film inadequately supports the health of the ocular surface epithelium. It affects 10% of the general population between the ages of 30 to 60 years. However, prevalence increases to 15% in people over 65 years⁸.

Dry eye is characterized by dry, irritated eyes due to a lack of lubricating tears from meibomian gland due to an imbalance between tear production and tear volume drainage via the nasolacrimal ducts (NLD). It can also be a result of excessively watery eyes due to tears lacking the proper balance of mucous, water and oil to coat the eyes properly⁹. Non-inflamed obstructive meibomian gland dysfunctions (MGD) is the major cause of lipid tear deficiency (LTD) or evaporative dry eye, and has recently attracted attention as a cause of ocular discomfort. MGD decreases the supply of normal lipid, which leads to increased tear evaporation, decreased tear stability, loss of lubrication, and damage to the ocular surface epithelium, resulting in symptoms¹⁰.

Patients with dry eye typically complain of sensations of burning, grittiness, foreign body sensation and actual dryness. These symptoms are usually increased by wind, air condition, prolonged staring reading or computer use and other conditions that lead to a decrease in the blink rate or an increase in evaporation rate. Tearing, which is a paradoxical symptom, sometimes appears in patients with dry eye syndrome owing to reflex tearing. In patients with more severe dry eye, intermittent or continuous blurring of vision may arise due to damage in the central corneal epithelium as well as changes in the quality of tears¹¹. In meibomian gland disease, initially the meibomian gland secretions become thicker and the glands change in appearance. The first observable change is an increase in the viscosity of the meibum, which makes expressing the glands somewhat more difficult. Different types of test are using to detect the dry eye such as comprehensive eye exam, an eye exam that includes a complete history of your overall health and your eye health can help your doctor diagnose the cause of your dry eyes. Other tests use special dyes in eye drops to determine the surface condition of your eyes¹².

STATEMENT OF PROBLEM:

“A study to assess the effectiveness of warm compress on level of dry eye among elderly adults in a selected old age home, Mangalore.”

OBJECTIVES:

1. To assess the level of dry eye among elderly adults in both experimental and control group.

2. To evaluate the effectiveness of warm compress on level of dry eye among elderly adults.

3. To associate the level of dry eye among elderly adults with their selected demographic variable and clinical variable in both experimental and control group.

Assumptions:

1.Elderly adults may have some level of dry eye.

2.Warm compression may have some effect on reducing the level of dry eye.

Delimitations:

The study is delimited to both male and female elderly adults 60 years old in a selected old age home, Mangalore.

Hypotheses:

The following hypothesis will be tested at a .05 level of significance:

H1: There will be significant difference between pre- and post-test level of dry eye among elderly adults in both experimental and control group.

H2: There will be significant difference in the level of dry eye among elderly adults between experimental and control group.

H3: There will be no significant association between level of dry eye and demographic, clinical variables among elderly adults in both experimental and control group.

RESEARCH METHODOLOGY:

Research approach:

An experimental approach is used in this study to assess the effectiveness of warm compression on the level of dry eye among elderly adults.

Research design:

The research design adopted for this study is a quasi–experimental design.

Setting of the study:

The present study is conducted in missionaries of charity old age home, Mangalore.

Population:

In this study population comprised of elderly adults in missionaries of charity old age home, Mangalore.

Sample:

Sample refers to the subject of the population selected to participate in research study. In the present study sample comprises of 60 elderly adults; 30 in experimental and 30 in control group in missionaries of charity at Mangalore.

Sampling technique:

In the present study, non-probability purposive sampling technique is used to select 60 dry eye adults in a selected old age home, Mangalore. Sample for the study will be selected by purposive sampling technique.

Data collection Method:

Sampling criteria:

Inclusion criteria for sampling:

1. Who have qualified tear film assessment in both eyes.

2. Who are willing to comply with study protocol.

Exclusion criteria for sampling:

This study excludes elderly adults who:

1. are using other treatments for meibomian gland dysfunction or dry eye

2. have undergone ocular surgery, trauma, herpes infection, punctual plug insertion or punctual occlusion since three months.

3. have single dry eye problem.

4. have active eye infection or eyelid inflammation with in past three months.

5. have participated in another ophthalmic clinical trial since 30 days.

Description of the tool:

Section 1:

It contained 7 items for obtaining information regarding the demographic variable such as age, sex, educational qualification and clinical variable.

Section 2:

Schirmer’s test used to assess the level of dry among elderly adults in selected old age home, which has the level of interpretation such as normal mild, moderate, and severe as per Schirmer’s test.

RESULT:

The data is analyzed and presented under the following headings:

Section A:

Frequency and percentage distribution of demographic characteristics among elderly adults in both experimental and control group.

Section B:

Pre-test level of dry eye among elderly adults in both experimental and control groups.

Section C:

Effectiveness of warm compress on level of dry eye among elderly adults in both experimental and control groups.

Section D:

Association of pre-test level of dry eye among elderly adults in both experimental and control groups with their selected demographic variables. This section describes the elderly adult’s characteristic in terms of frequency and percentage and is depicted in Table 1.

Section I: demographic characteristics

This section describes the elderly adult’s characteristic in terms of frequency and percentage and is depicted in Table 1.

Table 1: Frequency and percentage distribution of elderly adults according to demographic variables N=60

Variable	Experimental group		Control group
Variable	Frequency (F)	Percentage (%)	Frequency (F)	Percentage (%)
1. Age (years)
a. 60-65	9	30.0	13	43.3
b. 66-70	10	33.3	9	30.0
c. 71-75	6	20.0	2	6.7
d. 76-80	5	16.7	6	20.0
2. Gender
a. Male	18	60.0	18	60.0
b. Female	12	40.0	12	40.0
3. Previous annual income of the family
a. 20000-30000	1	3.3	0	0.0
b. 30000-40000	12	40.0	5	16.7
c. ³ 40000	17	56.7	25	83.3
4. Educational status
a. No formal education	25	83.3	27	90.0
	5	16.7	3	10.0

The data in Table 1 depicts the frequency and percentage distribution of the elderly adults according to demographic variables and is presented by figures.

Section II: Pre-test level of dry eye among elderly adults in both experimental and control group with their selected demographic variable:

This section deals with the analysis and interpretation of data to assess the pre-test level of dry eye among elderly adults.

Table 2: Frequency and percentage distribution of pre-test level of dry eye among elderly adults. N=60

Level of dry eye	Experimental group		Control group
Level of dry eye	Frequency (F)	Percentage (%)	Frequency (F)	Percentage (%)
1. Normal	-	-	-	-
2. Mild dry eye	5	16.7	6	20.0
3. Moderate dry eye	20	66.7	23	76.7
4. Severe dry eye	5	16.7	1	3.3

Table 4: Frequency and percentage distribution of pre- and post-test level of dry eye among elderly adults N=60

Level of dry eye	Experimental group				Control group
	Pre-test		Post-test		Pre-test		Post-test
	(F)	(%)	(F)	(%)	(F)	(%)	(F)	(%)
Normal	0	0.0	3	10.0	0	0.0	0	0.0
Mild dry eye	5	16.7	22	73.3	6	20.0	6	20.0
Moderate dry eye	20	66.7	5	16.7	23	76.7	23	76.7
Severe dry eye	5	16.7	0	0.0	1	3.3	1	3.3

Data in Table 4 and Figure 10 shows that in the experimental group, in the pre-test 20 (66.7%) elderly adults had moderate level of dry and 5 (16.7%) each had mild and severe level of dry eye .

Whereas, in the post-test 22 (of dry eye, 5 (16.7%) had moderate level of dry eye and 3 (10%) had normal level of dry eye. Regarding control group, in both pre-test and post-test had the same value, 23 (76.7%) had moderate level of dry eye, 6 (20%) had mild level of dry eye and 1 (3.3%) had severe level of dry eye.

H_01:There will be significant difference between pre- and post-test level of dry eye among elderly adults in both experimental and control group.

Table 5: Range, Mean, Median, standard deviation and t value of pre-test and post-test score of dry eye. N=60

Level of dry eye	Range	Mean	Median	SD	‘t’ value
Experimental group					14.917*
Pre-test	2-11	6.07	6.00	2.377
Post-test	5-15	9.47	9.00	2.763
Control group
Pre-test	3-11	6.20	6.00	2.091
Post-test	3-11	6.20	6.00	2.091

· Significant, p<0.001

Table 7: Chi-square value of pre-test score of dry eye of both experimental and control group with selected demographic variables N=30+30

Variables	Experimental group			Control group
	Dry eye score		c² value	Dry eye score		c² value
	<mean	>mean	c² value	<mean	> mean	c² value
1. Age
a. Below 70	8	11	0.032	10	12	0.000
b. Above 70	5	6	0.032	3	5	0.000
2. Gender
a. Male	7	11	0.362	7	11	0.362
b. Female	6	6	0.362	6	6	0.362
3. Education
a. No formal education	11	14	.000	13	14	0.167
b. Medical related	2	3	.000	0	3	0.167
4. Previous income
a. Below 40,000	6	7	.074	0	5	0.043
b. Above 40,000	7	10	.074	13	12	0.043
5. Religion
a. Hindu	4	1	1.738	3	4	0.000
b. Christian	9	16	1.738	10	13	0.000
6. Previous occupation
a. Medical and other	7	6	1.033	10	13	0.000
b. Factory related	6	11	1.033	3	4	0.000
7. Previous residence
a. Rural area	3	10	2.516	4	6	0.000
b. Urban area	10	7	2.516	9	11	0.000

DISCUSSION:

Section 1: Sample characteristics:

In the sample majority of elderly adults in experimental group (33.3%) were in the age group of 66-70, control group (43.3%) in the age group of 60-65. Most of the elderly adults were male in both experimental and control group 18 (60%) whereas female only 12 (40%) in both experimental and control group. Many of the elderly adults were Christians 25 (83.3%) in experimental group and control group 23 (76.7%). Hindus were only 5 (16.7%) in experimental group and 7 (23.3%) in the control group. Most of the elderly adults’ previous occupation was factory-related 18 (60%) in experimental group and 18 in the control group 23 (76.7%). Remain elderly adults occupation was medical related occupation 6(20%) in experimental group and 3(10%) in control group. The findings of the study is consistent with a study conducted in lady Harding Medical College and Smt Sucheta Kriplani Hospital, New Delhi, to estimate the prevalence of dry eye among Indian patients. Four hundred consecutive elderly adults aged >65 years attending the ophthalmology outpatient department. These estimates were then compared with the results of various clinical tests and examinations of the same patients, including Schirmer’s tests. Compared with the younger patients, those aged ³ 65 years were more likely to have OSDI that were indicative of dry eye (41.2%)⁴⁸.

Section II: level of dry eye among elderly adults:

Data collected in the experimental group pre-test reflected that majority 20 (66.7%) of the elderly adults had moderate level of dry eye, whereas in control group pre-test many 23 (76.7%) of the elderly adults had

moderate level of dry eye. A similar study was conducted in Japan, the pre-test results in the experimental group pre-test reveals that most 18 (60%) of the elderly adults had moderate level of dry eye, whereas in the control group pre-test reflected that majority 26 (86.6%) of elderly adults had moderate level of dry eye.⁴⁹

Section III: Effectiveness of warm compress on level of dry eye:

Mean, median, SD score of pre-test in experimental group are 6.07, 6.00, and 2.377. Whereas mean median SD score of post-test in experimental group are 9.47, 9.00, and 2.763 which is higher than the pre-test. Mean while mean ,median, and SD scores of pre-test in control group are 6.20, 2.091, and 6.00, whereas in post-test result also reveals that does not have changes from pre-test value because control group does not undergone for any intervention. The difference between the mean pre-test and mean post-test score was found to be statistically significant (t₅₉₌14.917) at 0.05 level of significance, which shows that the application of warm compression was effective on level of dry eye. The finding of the study is consistent with a study conducted in USA to determine the effectiveness of warm compression on level of dry eye. The data shows that mean, median, SD score of pre-test in experimental group are 4.07, 3.00, and 1.266, whereas mean median SD score of post-test in experimental group are 7.40, 6.00, and 1.963 which are higher than the pre-test. Meanwhile the mean, median, and SD scores of pre-test in control group are 3.25, 1.491, and 3.00 whereas in post-test result also revealed that there were no changes from pre-test value because control group did not undergone for any intervention⁵⁰. The difference between the mean pre-test and mean post-test score was found to be statistically significant (t₅₉₌12.921) at 0.05 level of significance, which shows that the application of warm compress was effective on the level of dry eye. An evaluative study was conducted among elderly adults in missionaries of charity at Mangalore. The study finding revealed that majority 20(66.7%) had moderate level of dry eye, whereas in the post-test level of dry eye changed to 5 (16.7%) which indicates the effectiveness of warm compression on level of dry eye. Meanwhile control group does not have any changes because which has gone normal routine. It was also found that there was significant correlation between level of dry eye and warm compression (P<0.001).

Section IV: Association of pre-test level of dry eye:

The findings of the study revealed that there was no significant association between pre-test level of dry eye and selected demographic variables at 0.05 level of significance. The conclusions which have drawn from the study are that there is no association between the pre-test level of dry eye and selected Demographic variables.

Implications for nursing practice:

The expanded role of the professional nurse emphasizes those activities which promotes health and preventive behavior among people. Nursing practice should be based on scientific knowledge. To thrive as a profession, nursing must keep pace with knowledge explosion, update the knowledge and set pace for future health care. Nurses can contribute to the profession by accumulating new knowledge regarding Warm compression on level of dry eye, assessing the level of dry eye. They can take professional Accountability to educate and motivate other nurses and elderly adults. Information about warm compression are usually available from many other sources but most of the times traditional practice and other hospital protocols can affect the ideal way in warm compression. Hence professionals working in the hospital as well as in the community should enhance their knowledge regarding warm compression on level of dry eye for better patient outcome.

Implication for nursing education:

Nursing education plays an important role in preparing the nursing professionals for the wellbeing of the elderly adults. To provide effective nursing care in old age home nurses require enhanced knowledge and understanding. Nurses should have an understanding regarding the dry eye and application of warm compression so he/she can explain and motivate other nursing professionals to incorporate the same into practice. This can be done by integrating knowledge regarding warm compression on level of dry eye into all levels of curricula in nursing education. The nursing students should be encouraged to take up innovative, interesting health education activities in health promotion. It should incorporate newer approaches and strategies in the curriculum. The curriculum should provide an opportunity for innovation and experience to conduct health education, thereby spreading the knowledge regarding dry eye and application of warm compression on level of dry eye and also the importance of that procedure. Nursing curriculum should also provide an opportunity to plan and conduct research studies in a variety of settings such as old age homes, family, community, industry, hospital and other health care agencies.

Implication for nursing administration:

Nursing administration plays a pivotal role in the supervision and management of nursing professionals. Nursing administrators are the back bone for providing facilities to improve knowledge regarding the level of dry eye and application of warm compression on level of dry eye. There should be provision for nurses to devote time for giving health education regarding importance of prevention of dry eye and associated management. Necessary administrative support should be adopted to provide necessary information for the nursing professionals.

The administration should enable the nursing personnel to develop newer skills through in-service education and continuing education. There should be individualized teaching and ongoing feedback on their performance. They should develop clear cut policy guidelines and give relevant information, education and training. They should plan and organize programmes that are cost effective. There should be some protocols to be made in the wards and old age homes regarding application of warm compression on level of dry eye. The nursing professionals should be encouraged to prepare teaching materials and audio visual aids regarding various health related topics.

Implications for nursing research:

Nursing personnel being one of the important healthcare personnel providing primary health care have the challenging task of health promotion. Nurses are more close to patients and should take initiative to conduct further research regarding knowledge and practice regarding level of dry eye and application of warm compression on level of dry eye. Implications for research include replicating the study in other health care settings, using a larger sample from a wide range of ages, years of experience, and educational and occupational background to see if the study results are consistent with what has been derived in this study. There is a need for extended and intensive research in the areas of knowledge, practice and attitude of nurses regarding level of dry eye and application of warm compression on level of dry eye, provision given by the institutions, economical and psychosocial support given by the nurse administrators and institution administrators.

LIMITATIONS:

· Sample size was small; hence generalization of the finding is limited.

· Study was conducted by using non probability purposive sampling thereby restricting the generalization of findings.

· Study is restricted to only elderly adults in a particular old age home

· No attempt was made to do the follow-up to measure the retention of knowledge of nursing professionals regarding dry eye and associated management.

SUGGESTIONS:

1. Health education could help the elderly adults to update their knowledge on dry eye.

2. An educational programme on level of dry eye and application of warm compression on level of dry eye could be beneficial and it could ensure effective for both elderly adults and health professionals.

3. Doctors and nursing professionals should meet together to update the knowledge and practice and to discuss the possibility of minimizing the level of dry eye.

4. Community health nurses should be trained so that during the home visit he/she can teach the elderly adults and family members regarding dry eye.

RECOMMENDATIONS:

Based on the findings of the study the following recommendations are put forward for further research:

· A similar study can be undertaken on a larger sample to generalize findings.

· A similar study can be undertaken using random sampling technique to generalize findings

BIBLIOGRAPHY:

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Received on 25.07.2015 Modified on 05.08.2015

Int. J. Nur. Edu. and Research 4(1): Jan.-Mar., 2016; Page 15-23

DOI: 10.5958/2454-2660.2016.00003.X

Group	Range	Mean	SD
Experimental group	2-11	6.07	2.377
Control group	3-11	6.20	2.091

Group	Mean	SD	Mean diff.	‘t’ value	P value
Experimental group	6.07	2.763	3.267	5.163^*	<0.001
Control group	6.20	2.091	3.267	5.163^*	<0.001