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.
While understanding age-related vision loss is important for professionals who work to treat older low-vision patients, it is important that the elderly, their families, and their caregivers understand the impact age-related changes have in the elderly individual's everyday life. The number of activities that are impacted by low vision are innumerable and cannot all be adequately discussed.
This section will focus on the major impacts of low vision on general everyday activities, and then focus on driving, social activities, health care, and self-care. Many examples from interviews and published articles are included to help illustrate these issues.
As mentioned in Changes in Vision and Their Effects, the aging eye receives significantly less light than younger, healthier eyes. This means that senior citizens require environments with more lighting than younger people may require. What may seem like bright lighting to younger caregivers may seem like very dim lighting to the elderly. This need for additional lighting makes it very difficult for the elderly to function in environments with low illumination, which limits the places in which they can function. For example, theaters, parking lots at night, and dark restaurants are often difficult for senior citizens' to function in because of inadequate lighting (M. Nolan, personal communication, July 27, 2002).
Along with the need for increased illumination, the elderly struggle with the impacts of glare in the performance of everyday activities. Each of the three major types of glare, dazzling glare, veiling glare, and scotomatic glare, results from a different lighting situation and causes a different visual effect. One of the biggest problem sources of light is a large amount of natural light (Pastalan, 1982, p. 324). Large amounts of natural light can interfere with the elderly person's vision when spending time outdoors or when driving during the daylight. It can also impair vision indoors when large windows face the sun or when there are very bright artificial light sources. Examples include sun entering the front windows of large grocery markets (Pastalan, 1982, p. 324; Braus, 1995) and everyday situations, such extra light reflecting from the bathroom mirror, which would cause scotomatic glare. These large amounts of light have a partial blinding effect on the individual. To complicate the problem, the older eye has a more difficult time recovering from glare than younger eyes (Haegerstrom-Portnoy, Schneck, & Brabyn, 1999). This means the blinding effects are long lasting.
The decreased ability to distinguish between different colors and intensities of color impacts the elderly eye in a number of ways. Senior citizens may have trouble dressing themselves in clothes that society will find acceptable. This is because it is difficult to match clothing when many colors are indistinguishable and look alike. Other grooming activities may be difficult to do with impaired color discrimination also. For example, low-vision women may not realize the intensity of the cosmetics they apply. This means they may wear more make-up than expected. Both of these situations will influence the way people treat low-vision senior citizens. The section, Impact on Self-Care, addresses these issues in greater detail.
Poor color discrimination also affects senior citizens' perceptions of their environments. Because softer colors and colors of similar intensities are very difficult for the aging eye to discriminate, rooms and facilities decorated in pastels will appear very dull and sometimes gray to senior citizens. Often times, facilities and products designed specifically for the elderly utilize pastel shades of colors. Elderly persons who spend significant amounts of time in these environments may find themselves feeling depressed by the constant drabness of the colors they perceive.
The same is true for objects within the environments of elderly persons. Greeting cards, artwork, craft supplies, wrapping papers, flowers, and other objects of pastel colors are often given to senior citizens. High-detail objects can compound the problem, such as thin, scrolling scripts on greeting cards. While these gifts may be very attractive to younger eyes that can distinguish the colors, to the elderly they can appear dull and gray. This inability can leave senior citizens feeling frustrated. Family, friends, and caregivers can help by giving gifts, cards, and other objects that use high contrast, long wavelength colors, such as reds, yellows, and oranges.
Senior citizens are at a disadvantage when it comes to their medical care because of their inability to discriminate colors. Medications come in a wide variety of shapes and colors, but still there are many different pills that have similar shapes. These similarities, combined with an inability to discriminate colors, make it especially difficult for senior citizens to distinguish one medication from another. Obviously, the risk of misusing medications implies a wide range of dangers. The impact of low vision on health care is discussed in greater detail in the subsection Impact on Health Care.
Lowered acuity influences the elderly person's ability to perform a number of everyday activities. Difficulty reading is the most obvious impact when living with lowered acuity. Senior citizens begin to require larger size fonts when reading and find it hard to read writing with little contrast at any size font. Reading problems can impact several aspects of senior citizens' daily lives. Recreational reading is impaired, such as books, magazines, newspapers, menus, and personal letters. Phonebooks and advertisements are often printed in small fonts, making it difficult for senior citizens to find needed information. Labels on products, such as food and medicines, use very small fonts, making meal planning and medicine organization a challenge. Other impacts of poor acuity on daily life include difficulties reading clocks, watches, telephones, and television remote controls.
Reading is not the only task that is impaired by lowered acuity in the elderly. All tasks that involve resolving fine details become difficult. Writing also becomes harder as acuity decreases. Tasks such as mending clothes or sewing buttons also require the resolution of fine details.
Other age-related factors impact the daily lives of senior citizens. For the elderly, age-related changes introduce visual challenges, such as recognizing faces at long distances or at low contrasts. Visual-motor coordination, often referred to as eye-hand coordination, decreases with age and adds to the problems caused by low acuity, poor contrast sensitivity, and poor color discrimination to further impair tasks such as writing and sewing.
Driving involves a complex combination of skills including vision, attention, motor coordination, and cognition (Shipp, 1999; Fox, 1999; Owsley, 1997). Of all these skills, however, vision plays one of the most important roles. Much of the incoming information received during driving is visual information. The amount of visual information relied upon is so great, with 90% of sensory information being visual, that some experts actually believe that visual information, apart from all other sensory information, would be enough to drive safely (Fox, 1999). With this in mind, it is easy to see that vision impairments can have significant impacts on safe driving.
One of the most noticeable impacts of aging vision on driving is the need for increased lighting due to the changes in the variable lens and the pupil discussed in the section, Changes in Vision. This means that driving becomes even more dangerous for the elderly at night, when adequate lighting is usually unavailable. This change is so significant that many senior citizens choose to stop driving during the dark hours (Rubin, 1999). Senior citizens' ability to drive safely is also influenced by age-related problems with glare. As described earlier, the elderly experience more glare and take much longer to recover from glare than younger drivers (Brabyn, 1999). During this recovery time, senior citizens are effectually blind, making them unable to use the visual information necessary to make the quick and safe decisions necessary for driving. During the already problematic dark hours, the major source of glare is headlights from oncoming cars. During the day, glare results from the large amounts of natural light entering through the windows of the vehicle. Window tints and sunglasses may help to control glare, but will further limit the amount of light that enters the eye.
Research has shown that the age-related changes that best predict senior citizens' ability to drive safely are reduced stereoacuity (depth perception), reduced visual attention, and reduced size of visual field (Rubin, 1999). The impacts of these changes on driving should be obvious. A reduction in depth perception means that senior citizens will have a harder time judging distance than younger drivers. Reduced visual attention impacts driving because senior citizens are less able to attend to the many stimuli involved in driving tasks. Of these three, the most impairing change may be the reduction of the visual field. While it is vital that drivers be able to see the road ahead clearly, it is just as important to see the surrounding areas. People with a reduced field of vision may not be able to see possible dangers, such as cars pulling onto the road, people, animals, or objects which may enter the road suddenly, or emergency vehicles in their peripheral fields of vision.
Reduced acuity influences the ability to drive in more subtle ways. One acuity-related problem in driving is the inability to read dashboard instruments (Baker, 1989). While some components use large print, like most speedometers, other components use font that may be too small for the elderly driver to read. Senior citizens who cannot easily read gas and temperature gauges may unknowingly put themselves in dangerous situations. Other automobile parts may also use print that is too small, such as radio and air conditioner controls. Elderly drivers may be unable to drive safely when attention is divided between the road and inside controls. Reading signs while driving can also present a challenge to the elderly. Senior citizens may need to slow their vehicles to read a road sign, which can put them at risk for an accident with faster traffic. If they do not slow down, the risk may be smaller, but they cannot read the sign. Obviously, challenge of driving is not one that can be easily solved for the elderly.
Low vision affects the social activities of older persons in a number of ways. Psychologically, low vision limits senior citizens because they are often afraid to leave their homes. Studies have shown that low vision adults have a much harder time moving about in unfamiliar places than in their more familiar homes (Backman, 2000). Senior citizens who know they are more likely to fall in an unfamiliar area may be likely to leave the home. This can add to the social isolation that the elderly already face.
Low vision also plays a more direct role in limiting the social activities of low-vision senior citizens. Interacting with other people can be challenging for the elderly because many features within human faces tend to be low contrast (Sekuler & Owsley, 1982, p. 195). Examples of low contrast features include the nose and sometimes the lips. Inability to easily see the lips may impact individuals' ability to communicate, especially if they are also hard of hearing and rely on lip movements to help them understand spoken language. Senior citizens often have a difficult time recognizing even the most familiar people by visual cues alone (T. Steadman, personal communication, June 14, 2002).
Social activities are also limited by transportation issues. The previous section discusses the impact of low vision on driving for senior citizens. Many elderly will not leave their homes unless absolutely necessary because driving can be extremely hazardous. This inability to get from one place to another severely impacts the ability to socialize outside the home.
Finally, poor acuity contributes to the lack of social activities by limiting senior citizens' ability to read. Menus, bibles, sheet music, playing cards, dominoes and other common items used during social functions are often printed in small print, making them difficult to read. Rather than deal with the frustration of being unable to function normally in a social setting, the elderly often choose to avoid these situations altogether.
Low vision affects both the business aspect of health care and the medical aspect of health care for the elderly. While age-related cognitive declines will affect the ability of the elderly to understand the business issues concerning their health care, low vision can seriously impair the ability to understand as well (Butler, 1997). Medicare and insurance companies send out large amounts of information to the elderly, but most is in small font and is difficult for senior citizens to read without help. In many cases, large print material is available, but many elderly do no know this. Rather than seek assistance, it is common for the elderly to ignore the information sent to them, leaving them frustrated at not understanding their benefits.
Lowered acuity and difficulty reading also affect the business aspect of senior citizens' health care when the elderly are required to complete forms for Medicare, insurance companies, and doctor's offices. Difficulties in accurately reading forms may result in dangerously inaccurate information being given. This is especially true in the case of medical history forms, where doctors may base treatment plans on inaccurate information.
The medical aspect of health care is also impacted by age-related vision loss. Reduced acuity means that the elderly may have a difficult time or a total inability to read medicine labels or treatment directions from doctors. Without being able to read this information, the elderly may set their own dosage or ignore the drugs and treatment recommendations entirely. Senior citizens may also find it difficult to read the pharmacy information given to them with prescription drugs, meaning they may not understand side effects, warnings, or interactions with other substances.
Poor color discrimination makes pill organization a challenge. Many pills come in the same size, color, and shape (T. Steadman, personal communication, June 14, 2002). While all have markings that make them distinguishable from other pills, these markings are usually etched into the pill (meaning there is no color or luminance contrast) or printed in fine print. In either case, these markings do not serve to help the elderly in distinguishing one pill from another. Even when pills are slightly different colors, the poor color discrimination that comes with age prevents the elderly from being able to distinguish the pills. This can lead to extremely dangerous mismanagement of medications.
Poor color discrimination may also impair senior citizens' ability to notice changes in their bodies. Changes in skin color may be harder for the elderly to detect than for younger people. This can result in bruises, rashes, changed moles, or small lesions that go unnoticed and untreated.
Low-vision also impedes good health care by limiting the driving activities of the elderly. Many senior citizens prefer to ignore recommendations to see medical professionals rather than drive to their appointment or seek alternate transportation.
Self-care refers to daily living activities, such as, bathing, moving about within the home, eating, dressing, and grooming. Ideally, the elderly would be capable of performing these tasks independently, but these tasks are commonly impaired by normal, age-related vision loss. The self-care task with the highest physical risk involved may be bathing. This risk is compounded by physical impairments that prevent the elderly from functioning safely. Poor depth perception can prevent the elderly from accurately judging the depth of the bathtub. Poor contrast sensitivity can prevent the elderly from accurately judging the edges and the contours of the bathtub. Both of these impairments can cause serious injuries in senior citizens. Young and older people alike have experienced the injuries caused from misjudging the distance of a stair step. For the elderly, this is even more dangerous because the step into a bathtub is typically deeper than the average stair step and also because the bones of the elderly are more brittle and more susceptible to injury. Bathtub transfer benches, walk-in showers, and caregiver assistance can all reduce the risk of injury during bathing.
Mobility within the home is also a major part of self-care and also involves some physical risk. Studies have shown that the elderly are more confident and less likely to fall in the familiarity of the home than in unfamiliar environments, but too many senior citizens still experience falls at home (Abdulrazzak, 1997). While these falls often result from physical ailments and disabilities, age-related vision loss can certainly increase the risk. Poor contrast sensitivity and poor color discrimination combine to limit the ability of the elderly to determine edges. Examples of edges that are important to detect are the edges of stair steps or edges between two surface types, like carpet and tile. Detecting edges is important when the elderly are moving about because the an individual who can detect a change in the surface they are walking on, such as from carpet to slick tile, can be prepared for the change and continue moving safely.
Poor contrast sensitivity and poor color discrimination can also limit the ability to perceive obstacles in their path. Modifying the environment to meet low-vision senior citizens' needs can reduce these risks. There are specialists trained specifically to evaluate the home for safety; these services will be discussed in the section, The Need for Additional Services and an Interdisciplinary Approach.
Senior citizens may also find planning and preparing meals becomes more challenging with older age. Because of age-related health problems, doctors often prescribe special diets that limit substances such as sodium, sugar, and cholesterol. Many elderly may also have food allergies for which they must plan. While the ingredients of food products are required to be printed in a standard format on all product labels, this information can be inaccessible to the elderly with poor acuity. Poor contrast sensitivity affects the ability to read this small print when the labels are printed in low-contrast colors. Glare can also impair senior citizens' ability to read food labels on products with plastic or shiny labels. Unfortunately, the marketing industry produces product labels designed with younger, healthier eyes in mind (Baker, 1989; Braus, 1995).
After planning a healthy diet and shopping for the right products, the elderly must face the challenges of low vision while cooking. Acuity and poor contrast sensitivity may impact the ability of the elderly to do their own cooking. For example, stove and oven knobs are often printed in smaller print and sometimes in low contrast. The same is true for cooking instructions on product packaging. Poor color discrimination can make it difficult for the elderly to determine when their food is done. For example, the younger person's may be able to look through the oven glass to see that bread has turned a golden color; older individuals may not be able to discriminate the change between the color of unbaked bread.
Although senior citizens may be physically capable of dressing independently, choosing clothes that are both attractive to the individual wearing them and socially acceptable can be a challenge (T. Steadman, personal communication, June 14, 2002). This is the result of poor color discrimination caused by changes in the variable lens as discussed in Effects of Visual Changes. For clothing to appear attractive to the individual the colors should be bright enough and bold enough that the older person wearing them can distinguish the colors. To be socially acceptable, the different pieces of clothing should match. Elderly persons with poor color discrimination may need assistance when choosing clothing to wear outside the home.
Personal grooming, including hair and makeup, can be challenging to senior citizens also. The phrase "blue haired" is not as far fetched as some think. Senior citizens who color their hair may end up with strangely tinted hair, and do not notice it, especially if the hairdresser is also older or if they color their own hair at home. This is because of age-related impairments in color discrimination. The yellowing of the variable lens filters out much of the color information taken in, so the elderly eye sees the tint as gray.
Cosmetics also challenge elderly women when grooming. As the eye ages, it requires more stimulation for a given response. This means that the older eye needs greater intensities of color for perception to occur. This need for increased intensities may mean elderly women will wear too much make-up, because they cannot perceive less make-up or more appropriate colors. Poor color discrimination adds to the problem, because elderly women may choose colors that do not match each other, resulting in an unusual look. Greater amounts of light would normally help in these tasks, but this type of activity in this type of environment make greater amounts of light more harmful than good. For the elderly, large amounts of light should be aimed at the task at hand, not at the eyes, but when the task involves the face, aiming light at the eyes may be difficult to avoid (American, 2000a). Extra light aimed at the face will cause glare, which will only make the task harder. Mirrors and porcelain bathtubs and toilets make extra light problematic as well. Reflection of light from mirrors and shiny porcelain surfaces will add to temporarily blinding glare. While blue hair and unusual makeup will not put senior citizens in any physical danger, it can affect the way people interact with them. Poor interactions can only serve to further the social isolation that senior citizens already feel.
While cosmetics and blue hair involve mostly elderly women, elderly men face challenges in grooming as well. Elderly men may shave less frequently than expected because it may be difficult to see the stubble growing on the face, especially if facial hair is a light shade of gray or white on light skin or if facial hair is dark on dark skin. This is due to a number of age-related changes combined, including poor acuity, poor color discrimination, and poor contrast sensitivity, all of which are discussed in Visual Effects of Changes.
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