Supervised by Dr. Lauren
Scharff
Stephen F. Austin State University
This entire paper contains several sections: Introduction, Changes in Vision and Their Effects, Impact of Low Vision, Available Services, Obstacles to Services, the Need for Additional Services and an Interdisciplinary Approach, and References.
Although many services are already available, the elderly population could benefit from changes in available services or a number of services that are not currently readily available. These fall into two major categories: training and the development of better and more convenient measures of vision. Finally, a brighter future would be possible if a more interdisciplinary apporach was taken to aid individuals with low-vision.
Training improvements could improve multiple aspects of the lives of individuals with low vision. For example, caregivers who work for home health agencies should receive at least basic training in perceptual changes in the elderly. Law does not require this training and many agencies do not realize the importance of understanding the vision or other common sensory changes of their clients.
Other professionals also need to be trained in this area. Architects and interior designers who work on facilities created for the elderly should understand the needs of the people who will use the buildings. They should be taught where to place windows for the best lighting but least glare and that sheer curtains or blinds are the best way to control the amount of natural light that enters a room (American, 2000a). Another design feature that would accommodate low-vision elderly is for fire extinguishers, water fountains, and other wall-mounted objects to be placed on a single wall in a hallway, so that the individual may use the opposite wall to guide them, and to utilize furniture with textured fabrics that can provide tactile cues (American, 2000a).
Social workers need to be informed of the changes that take place in vision with age so that they can appropriately refer clients to agencies and organizations that can provide them with the proper services. The same is true of general physicians. Physicians should be aware of what questions to ask their elderly patients so that their vision changes can be detected as early as possible. They should also be aware of a variety of ophthalmologists, agencies, and organizations to which they can refer their elderly patients for evaluation and assistance. Senior citizens' primary physicians should be the first to notice age-related changes because many senior citizens do not regularly see an optometrist or ophthalmologist (Fletcher, 1994).
Physical therapists and occupational therapists also need more training on perceptual changes in the elderly. Physical therapists work to build strength and mobility in patients recovering from injuries or losses due to strokes and disease. While vision is one of the largest factors affecting immobility, physical therapists receive little or no training on how it can affect the rehabilitation of their older clients. Occupational therapists are responsible for rehabilitating clients back to a functional state where they are able to maintain their independence. With the elderly, this includes dressing, writing, feeding, toileting, and other daily activities that can be impaired with injury or disease. Even when their clients are primarily senior citizens, occupational therapists also receive little or no training on the perceptual changes in the elderly. The attitude among both these ttypes of herapists is often that vision has little impact on their clients' progress unless the doctor has already noted it. Without the knowledge of clients' changing vision, therapists have little way of knowing whether trouble in daily activities is due to impairment of the clients' fine motor skills or low vision. For example, elderly clients who have difficulty writing may be experiencing poor motor control or they may have lowered acuity that makes it hard for them to see their own writing (K. Marino, personal communication, June 29, 2002).
More realistic measurements of visual functioning are also needed to assist low-vision elders. Senior citizens may retain good acuity well into old age, but good acuity does not signify good visual functioning in "real world" conditions (Haegerstrom-Portnoy, Schneck, & Brabyn, 1999). Clinically, this means that optometrists and ophthalmologists need to use more than simple acuity tests to evaluate patients. Senior citizens who score well on acuity measures are still likely to have difficulty functioning in everyday tasks. For example, common acuity measures test a patient's ability to read high-contrast letters in optimal lighting and at regulated distances. In realistic situations, the elderly need to be able to see low-contrast stimuli in poor lighting. High-contrast acuity measures will not predict senior citizens' ability to perform low-contrast acuity tasks in their everyday environments (Haegerstrom-Portnoy, Schneck, & Brabyn, 1999; Brabyn, Schneck, Haegerstrom-Portnoy, et al., 2001; Haegerstrom-Portnoy, Brabyn, Schneck, et al. 1997). The Smith-Kettlewell Institute Low Luminance (SKILL) card allows professionals to test low-contrast and low-luminance acuity simply and quickly (Haegerstrom-Portnoy, Brabyn, Schneck, et al., 1997). The card is also very inexpensive; it can be accurately made for approximately five dollars per card.
Another way for professionals to get a realistic measure of senior citizens' functional ability is to evaluate them in the home (E. Davidson, personal communication, July 1, 2002). Evaluations in a clinical setting are may measure a person's visual abilities, but it does not measure the person's ability to function in the normal environment. In-home evaluations would also help senior citizens by giving them specific instruction for modifying their environments to effectively accommodate their low-vision needs. In-home evaluations are currently available, but they are very expensive because they are not covered by medical or Medicare benefits. These in-home services need to be made available to the elderly at a cost they can afford (E. Davidson, personal communication, July 1, 2002).
Outside the home, the elderly still need more assistance to stay safe while driving. Senior citizens could drive more safely if roads were better lit, had wider strips, and if signs were designed to be easy for low-vision persons to read (Fost, 1991). Another way to help keep driving senior citizens safe is to institute better licensing tests. Vision tests for driver's licenses should include more than simple acuity measures because driving also requires other visual functions such as good contrast sensitivity, depth perception, field of vision, and short-term memory. Some states have revised their licensing procedures to more thoroughly consider senior citizens who may be hazardous drivers. Oregon, for example, has a program that utilizes individuals trained to evaluate driving skills, to evaluate a variety of visual and cognitive skills, and to approach senior citizens with dignity and sensitivity (Fost, 1991). This program sends these trained employees to interact with senior citizens who may be unsafe on road and to decide if the drivers should lose driving privileges or be retested. This type of program may be more effective than simple acuity measures because it addresses many of the visual issues involved in driving and it protects the self-esteem of the aging driver.
Currently, the study and treatment of age-related low vision has been modular and segmented, with different professionals working within their fields independent of other disciplines. These professionals would be more effective in their work if they used a multi-disciplinary approach to vision and aging. Disciplines that should be included in this type of approach include general physicians, ophthalmologists, optometrists, physical and occupational therapists, rehabilitation specialists, home health care providers, social service providers, and even insurance providers and Medicare. Without the cooperation of all these independent disciplines, research and rehabilitation efforts are not as effective as possible. For example, new research is useless if physicians, optometrists, and ophthalmologists are not made aware of new findings and their impact to the overall field of vision and aging. Professionals who provide services to the elderly often do not use current knowledge of age-related low vision effectively; these professionals often have little or no knowledge of clients' normal visual impairments. Rehabilitation specialists may be able to offer much needed assistance in learning to live independently, but senior citizens cannot afford the services. At some point, to benefit a growing population of elderly persons in the country, these disciplines must pull together and create an interdisciplinary field aiming to provide the best possible services to low-vision senior citizens.
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