By learning about the basics of vision-related rehabilitation services, healthcare professionals can help elder persons retain their independence.

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any professionals working as in-home healthcare providers or in an array of residential facilities encounter older persons who are experiencing age-related vision loss. Frequently, 1 of their first thoughts is that these older individuals need everything done for them. With a little knowledge about vision-related rehabilitation services, however, healthcare professionals can learn to facilitate an increased level of independence for some older people who are experiencing vision loss. This article is designed to provide some basics that may go a long way toward enhancing an older person’s independence.
       Vision and aging. Vision loss is closely associated with the aging process. As people live longer, service providers across many professional disciplines experience more older people with vision problems but frequently do not know what to do for them. Over 5 million individuals aged 65 and older and 6.5 million aged 55 and older in the US experience vision loss.¹ Because this number of older persons with vision loss will continue to grow dramatically as the baby boomers begin to reach age 65, it is essential that we prepare for both the current and future groups of older persons.
       Legal blindness and eye conditions associated with aging. Many healthcare providers may see the words “legally blind” written on an older person’s chart. It is important to realize that legal blindness is not synonymous with total blindness, and many older people with some eye conditions may not become blind; macular degeneration alone does not cause total blindness.
       Age-related vision loss is caused by 4 leading eye conditions:
• Macular degeneration
• Glaucoma
• Diabetic retinopathy
• Complicated cataracts.
       Vision loss can also be caused by a stroke. The condition is called hemianopia.

Types of Visual Field Loss

       Knowledge of the 3 types of visual field loss is important for caregivers to understand an older person’s functioning.
       Central field loss. Some eye conditions result in central field loss and affect activities like reading and recognizing faces or activities like handcraft that require central viewing. This is the type of field loss older people with macular degeneration experience.
       Peripheral field loss. Peripheral (or side) field loss makes it difficult for the older person to move about the environment, because he or she can only see directly in front of him or herself. This type of field loss is frequently described as “tunnel vision” and is experienced by those with glaucoma. Individuals with hemianopia, most often resulting from stroke, can only see half of the visual field depending on the side of the brain affected. This makes mobility very difficult.
       Overall blurring. The third type of field loss is overall blurring, which makes many tasks difficult. This is what people experience when they have cataracts. Fortunately, cataracts can be treated successfully (eg, at least some improvement) in 95% of the cases. Those with diabetic retinopathy also experience overall blurring but with dark spots in the visual field as well.

Understanding Residents Who Are Experiencing Vision Loss

       An older person who has recently lost vision may be experiencing an array of other age-related losses concurrently. It is important for healthcare workers to understand how vision loss can affect older people and how they may be feeling (see Table 1 for a list of possible feelings).

Table 1

       Many residents may already be upset and depressed, because they have recently had to move from their homes. They may have lost a spouse or a good friend. Vision loss may increase depression, and it is especially hard for individuals who have always valued their independence. Many people also feel frightened because of their vision loss. In fact, visual impairment is 1 of the most feared disabilities in this country.
       While it is very important to keep these feelings and reactions in mind, it is also important to be aware that many older people with vision loss will want to be staunchly independent and try anything to do so. By learning adapted ways to carry out some routine activities from vision rehabilitation professionals, residents may be able to adjust to their different life circumstances more easily.
       Many strong negative feelings are natural to the adjustment process, and learning to do the simplest task or make the slightest adaptation may make all the difference and inspire the older person to see that perhaps there are alternative methods. For example, consider the environment: The older person may have stopped watching television because glare is shining on the screen from the window. Drawing the mini-blinds may be the simple solution for better resolution.
       A brighter nightstand light may make it easier for an older person to read large-print materials. An older person may have stopped going to the dining room because he or she cannot see to eat. Adding contrast to the place setting and showing him or her a few basic eating techniques could make the difference in this situation.

How to Help Residents with Visual Impairments

       Caregivers can help residents regain independence, self-confidence, and self-esteem by building their hope that they may be able to do some routine activities in new, adapted ways. Many older people still living at home and also those in residential facilities can do some things for themselves depending on their other physical and cognitive status.
       One of the most important things caregivers can do to help residents who are visually impaired is to assist them in solving problems that occur as a result of vision loss. Table 2 lists some key solutions that are easy to remember. By instructing the older person to perform a routine task in an adapted way, the caregiver will increase the older person’s ability to function independently.

Table 2

       It is also important to use sighted guide techniques for walking comfortably and safely with an older person with visual impairment. Have the older person take your arm just above the elbow and walk with you. In this position, you will always be at least a half step ahead of the visually impaired person. Falls are very closely associated with vision loss and may result in a broken hip. This is why it is important for the older person to learn to walk with a cane and to use sighted guide. Many of these suggestions are readily available, easy-to-use, and low-cost items that can help the older person. See “Resources” for more on this topic.

Getting Started

       Begin by making sure that the older person has had a dilated-eye examination by an eyecare professional (either an ophthalmologist or optometrist) and, when indicated, a low-vision evaluation by a low-vision specialist (who also may be an ophthalmologist or an optometrist with a specialization in low vision). A low-vision specialist helps the individual make the best use of remaining vision by prescribing optical devices, such as special lenses, hand-held or stand magnifiers for close-up tasks, telescopes for distance viewing, and high-intensity lighting for reading and other near-sight tasks. It is important to note that older visually impaired residents, especially those who reside in residential facilities, may be referred to the occupational therapist (OT) who teaches basic adaptive ways to perform routine activities to individuals with all disabilities. At the present time, OTs are very interested in gaining knowledge to help patients with low vision (not blindness), because they see patients with low vision in their practices, and training is becoming increasingly available for OTs.
       However, there is an entire vision rehabilitation field with professionals trained to work specifically with people who are blind or visually impaired. These professionals include the rehabilitation teacher who teaches adaptive methods for carrying out instrumental activities of daily living (IADL) and the orientation and mobility specialist who provides orientation and travel both in the home and in outdoor environments. A referral to a vision rehabilitation agency is worthwhile when the older person has stopped doing things he or she used to enjoy, such as reading or watching television. In every state, there is special federal funding, referred to as Title VII Chapter 2 of the Rehabilitation Act or “Older Blind Program,” to provide independent living skills training to older people according to their needs, interests, and capacities. Caregivers can discuss it with the older person and then make an appointment for someone to come to his or her home for a discussion and interview. By demonstrating some easily adapted methods for doing routine tasks, the older person may gain self-esteem and self-confidence.

Test Your Knowledge of Aging and Visual Impairment

Resources

       The website of the American Federation for the Blind (AFB), http://www.afb.org, contains more information about vision rehabilitation services and items covered in this article, including aids and appliances to maintain or regain independence and related books and videos like the following:
• Solutions for Success: A Training Manual for Working with Older People Who Are Visually Impaired, by Alberta L. Orr and Priscilla Rogers
• Solutions for Everyday Living for Older People with Visual Impairments, by Alberta L. Orr and Priscilla Rogers
• Making Life More Livable: Simple Adaptations for Living at Home After Vision Loss, edited by Maureen A. Duffy.