Understanding the particular needs of elder residents with vision loss can help caregivers to foster safe self-administration of medication.

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edication error, management of medications, and medication adherence are critical concerns for older persons who are blind or visually impaired for a variety of reasons, some of which may be related to the aging process and others to the person’s vision. This article will address vision-related issues, including:
• Not being able to read labels and instructions
• Lack of knowledge of possible side effects or contraindications due to difficulty reading
• Inability to differentiate among medications easily and/or take medications on a timely basis
• Having to rely on audible and tactile systems
• Having to rely on memory
• Having to rely on someone for assistance.
       As a healthcare provider, you can help to lessen the error rate and increase medication adherence by learning about some possible solutions.

The Effect of Vision Loss on the Ability to Read Medication Bottles

       First, we will briefly address vision loss and how it affects the ability to read prescription bottles and prescription information sheets. Visual acuity decreases as a normal part of aging. The normal acuity for an older person is 20/40, just slightly reduced from 20/20. An acuity of 20/40 means that the older person sees at a 20-foot distance what the younger person with 20/20 vision sees at 40 feet away. Additionally, people 80 years of age and above need up to 10 times more light than do younger persons. This means that without good lighting for reading, an older person who is experiencing normal vision changes due to aging may have a difficult time reading prescription labels.
       According to the American Foundation for the Blind (AFB)¹, the number of older persons with age-related eye conditions, such as macular degeneration, diabetic retinopathy, glaucoma, and cataracts, is continuing to increase. Presently 1 in 6 persons 65 years of age and above experiences vision loss from stroke or hemianopia (which can result from stroke, brain trauma, or tumor). This increases to 1 in 3 for persons 85 years of age and above. These numbers are expected to grow by epidemic proportions as Baby Boomers enter their senior years.
       Some of these conditions (eg, macular degeneration) affect the central vision, making it difficult to read normal print or sometimes even to read with large print or good magnification. Diabetic retinopathy and complicated cataracts can make the central vision so blurred that it is difficult or impossible to read. Persons with glaucoma lose peripheral vision and may only be able to read a few letters at a time
       Persons with these conditions normally have low vision and make up the bulk of the older population with vision loss. Persons who have very limited vision or are blind deal with different issues than do individuals with low vision. (For more information about how these and other eye conditions affect vision, visit the National Eye Institute website at www.nei.gov or the AFB website at www.afb.org.)

The Problem

       Medication bottles, both prescription and over-the-counter, are sometimes difficult to read, even for people who have normal vision. They are totally inaccessible for people who are blind. Likewise, the patient education guides called written prescription information leaflets (WPILs) are often written in small print (although some pharmacies have made them available in large print for their customers, depending on the flexibility of the software program that they use). Although WPILs are legally required to contain pertinent drug information, such as possible side effects and cautions, at present time the print size has not been addressed beyond a 10-point minimum requirement.²
       Recently, the Food and Drug Administration (FDA) changed the requirements for the formatting of package inserts and over-the-counter medications into an easier-to-follow, standardized format. The plan also includes a government database that will ultimately allow individuals to search for the information online at http://dailymed.nlm.nih.gov.³ Font size has been addressed but not to the extent that it will help most people with low vision.²
       Additionally, the FDA has not addressed issues related to print readability for prescription drugs. Governmental regulations for prescription drugs exist concerning content of a prescription label, but the print characteristics (eg, contrast, font, layout, type size, and color of the lettering) are not regulated by government agencies.⁴ (Some major retailers, such as Target and Walgreens, have taken the iniative to offer large-print labels.)
       So what does this mean for older persons who cannot read medication labels and package inserts? What can you do to help ensure that older persons with vision problems are taking their medications appropriately and safely?
       The first step is to learn about some of the systems and techniques available to help persons who have low vision or are blind to be safe and accurate about taking medications by applying the following suggestions.

Labeling Medications

       There are different ways to label medications. Talk with the older consumer about a system that would work best for him or her. Some people may prefer a system with both visual and tactile cues. Others may need audible help.
       Different sizes and even colors of rubber bands can be used to differentiate between medicine bottles. Another solution is to attach strips of tape in different directions (eg, vertical, horizontal, or zig-zag) or affix a series of bump dots (raised dots in a variety of colors) to identify individual medications.
       Large print labels should be printed in font sizes of at minimum of 18-point. You will need to check with each individual you are helping to determine appropriate print size. The labels should be made with contrasting background and font (eg, black lettering on white or light non-glossy paper). When attaching labels to medication bottles, be sure to place them on the side of the bottle that does not have the label so that someone else can still help by reading the print.
       Medication bottles can also be distinguished by size and shape. Most bottles are the same color, but there are some variations. Another method of organization is to keep medicines in alphabetical order to store them in different places (eg, a nightstand if it is to be taken at night or in the kitchen if it is to be taken 3 times a day). Braille labels can be made for the small percentage of older individuals who can read it. Check with a local rehabilitation agency for Braille resources.

Magnifying Prescription Labels

       Products that enlarge the prescription label are also available and fit all standard prescription vials. They may not help individuals who have an eye condition that affects the central vision. Most older persons with eye conditions need a prescriptive magnifier and should go to a low-vision specialist (either an ophthalmologist or optometrist with a specialization in low vision) to find out the type or types of magnifiers that will be most useful to them. Also, video magnification systems are available both in portable styles and through a closed-circuit television system that can enlarge print tremendously as well as alter contrast.

Talking Prescription Labels

       Several systems are available that can identify medications and give information about them by speaking aloud the information written on the labels. Some of these require the pharmacist to set them up; a friend or relative can set others up.

Using Pillboxes

       Weekly or daily pillboxes (ie, plastic boxes with a section for every day of the week) are often useful to individuals who are visually impaired. These come with large-print labels. However, for consumers with low vision, make sure the labels are in contrasting colors (eg, black on white). These also come with tactile labels. Older consumers may need help sorting the medications into the sections of the box. Also, be sure to note that:
• Some prescription bottles come with an alarm system to remind the individual when to take the medication.
• Liquid-level indicators that beep or talk are available for measuring liquid dosages.
• Products are available for people who have diabetes and vision loss. For example, there are a few glucometers on the market that have voice output, a critical feature. Some other products include specialized syringes and syringe holders, syringe magnifiers, count-a-dose devices, and compartmentalized syringe holders to hold daily medications.
• Other audible products are also on the market, such as talking thermometers, scales, and blood pressure monitors.
       (To find out more about these products, visit www.afb.org/aw/main.asp for the AFB’s free online publication, AccessWorld^®: Technology and People with Visual Impairments, detailing the latest technology news and objective product evaluations.)

Other Solution Strategies

       It is vital to educate your staff and consumers about age-related vision loss and what kinds of vision-related services are available to ameliorate the impact of vision loss and enable persons to be as independent as possible. Many professionals across a number of disciplines as well as consumers and family members are unaware of vision rehabilitation services and products that help persons who have vision loss to live

Table 1

independent lives. (To find out about services available in each state, visit AFB’s online nationwide directory.)
       Remember to separate vision issues from other issues, such as memory impairment and literacy. Because the issues that persons with vision loss face are often similar to those with literacy issues, some of the solutions (eg, the use of audible devices) may be similar. Prescription organizers with audible signals and alarm systems may be useful to individuals with vision loss as well as those with memory impairment.
       Lastly, learn how to help older persons with vision and hearing loss (see Table 1 and Table 2

Table 2

for a summary on what is helpful for you to know in dealing with an older person with vision loss and with the combination of hearing and vision loss).

Conclusion

       In many cases, you may be the first person to identify the older person’s need for assistance with medications and to help him or her to find appropriate solutions or assistance. As such, you have a very important role to play in helping older persons who have vision loss with taking medications safely. You can help them to make important connections, such as to vision-rehabilitation services.