Normal Age-Related Vision Loss
and Related Services for the Elderly

by Donia E. Nolan

Supervised by Dr. LaurenScharff
Stephen F. Austin State University

This entire paper contains several sections: Introduction,Changes in Vision and TheirEffects, Impact of LowVision, Available Services,Obstacles to Services, theNeed for Additional Services and anInterdisciplinary Approach, and References.

The Need for Additional Services and an InterdisciplinaryApproach to Vision and Aging

Although many services are already available, the elderlypopulation could benefit from changes in available services or anumber of services that are not currently readily available. Thesefall into two major categories: training and thedevelopment of better and more convenient measures of vision.Finally, a brighter future would be possible if a moreinterdisciplinary apporach was taken to aid individuals withlow-vision.

Training Issues

Training improvements could improve multiple aspects of the livesof individuals with low vision. For example, caregivers who work forhome health agencies should receive at least basic training inperceptual changes in the elderly. Law does not require this trainingand many agencies do not realize the importance of understanding thevision 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 forthe elderly should understand the needs of the people who will usethe buildings. They should be taught where to place windows for thebest lighting but least glare and that sheer curtains or blinds arethe best way to control the amount of natural light that enters aroom (American, 2000a). Another design feature that would accommodatelow-vision elderly is for fire extinguishers, water fountains, andother wall-mounted objects to be placed on a single wall in ahallway, so that the individual may use the opposite wall to guidethem, and to utilize furniture with textured fabrics that can providetactile cues (American, 2000a).

Social workers need to be informed of the changes that take placein vision with age so that they can appropriately refer clients toagencies and organizations that can provide them with the properservices. The same is true of general physicians. Physicians shouldbe aware of what questions to ask their elderly patients so thattheir vision changes can be detected as early as possible. Theyshould also be aware of a variety of ophthalmologists, agencies, andorganizations to which they can refer their elderly patients forevaluation and assistance. Senior citizens' primary physicians shouldbe the first to notice age-related changes because many seniorcitizens do not regularly see an optometrist or ophthalmologist(Fletcher, 1994).

Physical therapists and occupational therapists also need moretraining on perceptual changes in the elderly. Physical therapistswork to build strength and mobility in patients recovering frominjuries or losses due to strokes and disease. While vision is one ofthe largest factors affecting immobility, physical therapists receivelittle or no training on how it can affect the rehabilitation oftheir older clients. Occupational therapists are responsible forrehabilitating clients back to a functional state where they are ableto maintain their independence. With the elderly, this includesdressing, writing, feeding, toileting, and other daily activitiesthat can be impaired with injury or disease. Even when their clientsare primarily senior citizens, occupational therapists also receivelittle or no training on the perceptual changes in the elderly. Theattitude among both these ttypes of herapists is often that visionhas little impact on their clients' progress unless the doctor hasalready noted it. Without the knowledge of clients' changing vision,therapists have little way of knowing whether trouble in dailyactivities is due to impairment of the clients' fine motor skills orlow vision. For example, elderly clients who have difficulty writingmay be experiencing poor motor control or they may have loweredacuity that makes it hard for them to see their own writing (K.Marino, personal communication, June 29, 2002).

The Development of Better and More Convenient Measures ofVision

More realistic measurements of visual functioning are also neededto assist low-vision elders. Senior citizens may retain good acuitywell into old age, but good acuity does not signify good visualfunctioning in "real world" conditions (Haegerstrom-Portnoy, Schneck,& Brabyn, 1999). Clinically, this means that optometrists andophthalmologists need to use more than simple acuity tests toevaluate patients. Senior citizens who score well on acuity measuresare still likely to have difficulty functioning in everyday tasks.For example, common acuity measures test a patient's ability to readhigh-contrast letters in optimal lighting and at regulated distances.In realistic situations, the elderly need to be able to seelow-contrast stimuli in poor lighting. High-contrast acuity measureswill not predict senior citizens' ability to perform low-contrastacuity tasks in their everyday environments (Haegerstrom-Portnoy,Schneck, & Brabyn, 1999; Brabyn, Schneck, Haegerstrom-Portnoy, etal., 2001; Haegerstrom-Portnoy, Brabyn, Schneck, et al. 1997). TheSmith-Kettlewell Institute Low Luminance (SKILL) card allowsprofessionals to test low-contrast and low-luminance acuity simplyand quickly (Haegerstrom-Portnoy, Brabyn, Schneck, et al., 1997). Thecard is also very inexpensive; it can be accurately made forapproximately five dollars per card.

Another way for professionals to get a realistic measure of seniorcitizens' functional ability is to evaluate them in the home (E.Davidson, personal communication, July 1, 2002). Evaluations in aclinical setting are may measure a person's visual abilities, but itdoes not measure the person's ability to function in the normalenvironment. In-home evaluations would also help senior citizens bygiving them specific instruction for modifying their environments toeffectively accommodate their low-vision needs. In-home evaluationsare currently available, but they are very expensive because they arenot covered by medical or Medicare benefits. These in-home servicesneed 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 staysafe while driving. Senior citizens could drive more safely if roadswere better lit, had wider strips, and if signs were designed to beeasy for low-vision persons to read (Fost, 1991). Another way to helpkeep driving senior citizens safe is to institute better licensingtests. Vision tests for driver's licenses should include more thansimple acuity measures because driving also requires other visualfunctions such as good contrast sensitivity, depth perception, fieldof vision, and short-term memory. Some states have revised theirlicensing procedures to more thoroughly consider senior citizens whomay be hazardous drivers. Oregon, for example, has a program thatutilizes individuals trained to evaluate driving skills, to evaluatea variety of visual and cognitive skills, and to approach seniorcitizens with dignity and sensitivity (Fost, 1991). This programsends these trained employees to interact with senior citizens whomay be unsafe on road and to decide if the drivers should losedriving privileges or be retested. This type of program may be moreeffective than simple acuity measures because it addresses many ofthe visual issues involved in driving and it protects the self-esteemof the aging driver.

The Need for an Interdisciplinary Approach

Currently, the study and treatment of age-related low vision hasbeen modular and segmented, with different professionals workingwithin their fields independent of other disciplines. Theseprofessionals would be more effective in their work if they used amulti-disciplinary approach to vision and aging. Disciplines thatshould be included in this type of approach include generalphysicians, ophthalmologists, optometrists, physical and occupationaltherapists, 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, andophthalmologists are not made aware of new findings and their impactto the overall field of vision and aging. Professionals who provideservices to the elderly often do not use current knowledge ofage-related low vision effectively; these professionals often havelittle or no knowledge of clients' normal visual impairments.Rehabilitation specialists may be able to offer much neededassistance in learning to live independently, but senior citizenscannot afford the services. At some point, to benefit a growingpopulation of elderly persons in the country, these disciplines mustpull together and create an interdisciplinary field aiming to providethe best possible services to low-vision senior citizens.

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