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.


Impact of Low Vision on Daily Life

While understanding age-related vision loss is important forprofessionals who work to treat older low-vision patients, it isimportant that the elderly, their families, and their caregiversunderstand the impact age-related changes have in the elderlyindividual's everyday life. The number of activities that areimpacted by low vision are innumerable and cannot all be adequatelydiscussed.

This section will focus on the major impacts of low vision ongeneral everyday activities, and then focus on driving,social activities, health care, and self-care.Many examples from interviews and published articles are included tohelp illustrate these issues.

Impact on General, Everyday Activities

As mentioned in Changes in Vision and Their Effects, the aging eyereceives significantly less light than younger, healthier eyes. Thismeans that senior citizens require environments with morelighting than younger people may require. What may seem likebright lighting to younger caregivers may seem like very dim lightingto the elderly. This need for additional lighting makes it verydifficult for the elderly to function in environments with lowillumination, which limits the places in which they can function. Forexample, theaters, parking lots at night, and dark restaurants areoften difficult for senior citizens' to function in because ofinadequate lighting (M. Nolan, personal communication, July 27,2002).

Along with the need for increased illumination, the elderlystruggle with the impacts of glare in the performance ofeveryday activities. Each of the three major types of glare, dazzlingglare, veiling glare, and scotomatic glare, results from a differentlighting situation and causes a different visual effect. One of thebiggest problem sources of light is a large amount of natural light(Pastalan, 1982, p. 324). Large amounts of natural light caninterfere with the elderly person's vision when spending timeoutdoors or when driving during the daylight. It can also impairvision indoors when large windows face the sun or when there are verybright artificial light sources. Examples include sun entering thefront windows of large grocery markets (Pastalan, 1982, p. 324;Braus, 1995) and everyday situations, such extra light reflectingfrom the bathroom mirror, which would cause scotomatic glare. Theselarge amounts of light have a partial blinding effect on theindividual. To complicate the problem, the older eye has a moredifficult time recovering from glare than younger eyes(Haegerstrom-Portnoy, Schneck, & Brabyn, 1999). This means theblinding effects are long lasting.

The decreased ability to distinguish between different colors andintensities of color impacts the elderly eye in a number ofways. Senior citizens may have trouble dressing themselves in clothesthat society will find acceptable. This is because it is difficult tomatch clothing when many colors are indistinguishable and look alike.Other grooming activities may be difficult to do with impaired colordiscrimination also. For example, low-vision women may not realizethe intensity of the cosmetics they apply. This means they may wearmore make-up than expected. Both of these situations will influencethe way people treat low-vision senior citizens. The section, Impacton Self-Care, addresses these issues in greater detail.

Poor color discrimination also affects senior citizens'perceptions of their environments. Because softer colors and colorsof similar intensities are very difficult for the aging eye todiscriminate, rooms and facilities decorated in pastels will appearvery dull and sometimes gray to senior citizens. Often times,facilities and products designed specifically for the elderly utilizepastel shades of colors. Elderly persons who spend significantamounts of time in these environments may find themselves feelingdepressed by the constant drabness of the colors they perceive.

The same is true for objects within the environments of elderlypersons. Greeting cards, artwork, craft supplies, wrapping papers,flowers, and other objects of pastel colors are often given to seniorcitizens. High-detail objects can compound the problem, such as thin,scrolling scripts on greeting cards. While these gifts may be veryattractive to younger eyes that can distinguish the colors, to theelderly they can appear dull and gray. This inability can leavesenior citizens feeling frustrated. Family, friends, and caregiverscan help by giving gifts, cards, and other objects that use highcontrast, long wavelength colors, such as reds, yellows, andoranges.

Senior citizens are at a disadvantage when it comes to theirmedical care because of their inability to discriminate colors.Medications come in a wide variety of shapes and colors, but stillthere are many different pills that have similar shapes. Thesesimilarities, combined with an inability to discriminate colors, makeit especially difficult for senior citizens to distinguish onemedication from another. Obviously, the risk of misusing medicationsimplies a wide range of dangers. The impact of low vision on healthcare is discussed in greater detail in the subsection Impact onHealth Care.

Lowered acuity influences the elderly person's ability toperform a number of everyday activities. Difficulty reading is themost obvious impact when living with lowered acuity. Senior citizensbegin to require larger size fonts when reading and find it hard toread writing with little contrast at any size font. Reading problemscan impact several aspects of senior citizens' daily lives.Recreational reading is impaired, such as books, magazines,newspapers, menus, and personal letters. Phonebooks andadvertisements are often printed in small fonts, making it difficultfor senior citizens to find needed information. Labels on products,such as food and medicines, use very small fonts, making mealplanning and medicine organization a challenge. Other impacts of pooracuity 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 inthe elderly. All tasks that involve resolving fine details becomedifficult. Writing also becomes harder as acuity decreases. Taskssuch as mending clothes or sewing buttons also require the resolutionof fine details.

Other age-related factors impact the daily lives of seniorcitizens. For the elderly, age-related changes introduce visualchallenges, such as recognizing faces at long distances or at lowcontrasts. Visual-motor coordination, often referred to aseye-hand coordination, decreases with age and adds to the problemscaused by low acuity, poor contrast sensitivity, and poor colordiscrimination to further impair tasks such as writing andsewing.

Impact on Driving

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 themost important roles. Much of the incoming information receivedduring driving is visual information. The amount of visualinformation relied upon is so great, with 90% of sensory informationbeing visual, that some experts actually believe that visualinformation, apart from all other sensory information, would beenough to drive safely (Fox, 1999). With this in mind, it is easy tosee that vision impairments can have significant impacts on safedriving.

One of the most noticeable impacts of aging vision on driving isthe need for increased lighting due to the changes in the variablelens and the pupil discussed in the section, Changes in Vision. Thismeans that driving becomes even more dangerous for the elderly atnight, when adequate lighting is usually unavailable. This change isso significant that many senior citizens choose to stop drivingduring the dark hours (Rubin, 1999). Senior citizens' ability todrive safely is also influenced by age-related problems with glare.As described earlier, the elderly experience more glare and take muchlonger 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 makethe quick and safe decisions necessary for driving. During thealready problematic dark hours, the major source of glare isheadlights from oncoming cars. During the day, glare results from thelarge amounts of natural light entering through the windows of thevehicle. Window tints and sunglasses may help to control glare, butwill further limit the amount of light that enters the eye.

Research has shown that the age-related changes that best predictsenior citizens' ability to drive safely are reduced stereoacuity(depth perception), reduced visual attention, and reduced size ofvisual field (Rubin, 1999). The impacts of these changes on drivingshould be obvious. A reduction in depth perception means that seniorcitizens will have a harder time judging distance than youngerdrivers. Reduced visual attention impacts driving because seniorcitizens are less able to attend to the many stimuli involved indriving tasks. Of these three, the most impairing change may be thereduction of the visual field. While it is vital that drivers be ableto see the road ahead clearly, it is just as important to see thesurrounding areas. People with a reduced field of vision may not beable to see possible dangers, such as cars pulling onto the road,people, animals, or objects which may enter the road suddenly, oremergency vehicles in their peripheral fields of vision.

Reduced acuity influences the ability to drive in more subtleways. One acuity-related problem in driving is the inability to readdashboard instruments (Baker, 1989). While some components use largeprint, like most speedometers, other components use font that may betoo small for the elderly driver to read. Senior citizens who cannoteasily read gas and temperature gauges may unknowingly put themselvesin dangerous situations. Other automobile parts may also use printthat is too small, such as radio and air conditioner controls.Elderly drivers may be unable to drive safely when attention isdivided between the road and inside controls. Reading signs whiledriving can also present a challenge to the elderly. Senior citizensmay need to slow their vehicles to read a road sign, which can putthem at risk for an accident with faster traffic. If they do not slowdown, the risk may be smaller, but they cannot read the sign.Obviously, challenge of driving is not one that can be easily solvedfor the elderly.

Impact on Social Activities

Low vision affects the social activities of older persons in anumber of ways. Psychologically, low vision limits senior citizensbecause they are often afraid to leave their homes. Studies haveshown that low vision adults have a much harder time moving about inunfamiliar places than in their more familiar homes (Backman, 2000).Senior citizens who know they are more likely to fall in anunfamiliar area may be likely to leave the home. This can add to thesocial isolation that the elderly already face.

Low vision also plays a more direct role in limiting the socialactivities of low-vision senior citizens. Interacting with otherpeople can be challenging for the elderly because many featureswithin human faces tend to be low contrast (Sekuler & Owsley,1982, p. 195). Examples of low contrast features include the nose andsometimes the lips. Inability to easily see the lips may impactindividuals' ability to communicate, especially if they are also hardof hearing and rely on lip movements to help them understand spokenlanguage. Senior citizens often have a difficult time recognizingeven the most familiar people by visual cues alone (T. Steadman,personal communication, June 14, 2002).

Social activities are also limited by transportation issues. Theprevious section discusses the impact of low vision on driving forsenior citizens. Many elderly will not leave their homes unlessabsolutely necessary because driving can be extremely hazardous. Thisinability to get from one place to another severely impacts theability to socialize outside the home.

Finally, poor acuity contributes to the lack of social activitiesby limiting senior citizens' ability to read. Menus, bibles, sheetmusic, playing cards, dominoes and other common items used duringsocial functions are often printed in small print, making themdifficult to read. Rather than deal with the frustration of beingunable to function normally in a social setting, the elderly oftenchoose to avoid these situations altogether.

Impact on Health Care

Low vision affects both the business aspect of health care and themedical aspect of health care for the elderly. While age-relatedcognitive declines will affect the ability of the elderly tounderstand the business issues concerning their health care, lowvision can seriously impair the ability to understand as well(Butler, 1997). Medicare and insurance companies send out largeamounts of information to the elderly, but most is in small font andis 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 ignorethe information sent to them, leaving them frustrated at notunderstanding their benefits.

Lowered acuity and difficulty reading also affect the businessaspect of senior citizens' health care when the elderly are requiredto complete forms for Medicare, insurance companies, and doctor'soffices. Difficulties in accurately reading forms may result indangerously inaccurate information being given. This is especiallytrue in the case of medical history forms, where doctors may basetreatment plans on inaccurate information.

The medical aspect of health care is also impacted by age-relatedvision loss. Reduced acuity means that the elderly may have adifficult time or a total inability to read medicine labels ortreatment directions from doctors. Without being able to read thisinformation, the elderly may set their own dosage or ignore the drugsand treatment recommendations entirely. Senior citizens may also findit difficult to read the pharmacy information given to them withprescription 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 thatmake them distinguishable from other pills, these markings areusually etched into the pill (meaning there is no color or luminancecontrast) or printed in fine print. In either case, these markings donot serve to help the elderly in distinguishing one pill fromanother. Even when pills are slightly different colors, the poorcolor discrimination that comes with age prevents the elderly frombeing able to distinguish the pills. This can lead to extremelydangerous mismanagement of medications.

Poor color discrimination may also impair senior citizens' abilityto notice changes in their bodies. Changes in skin color may beharder for the elderly to detect than for younger people. This canresult in bruises, rashes, changed moles, or small lesions that gounnoticed and untreated.

Low-vision also impedes good health care by limiting the drivingactivities of the elderly. Many senior citizens prefer to ignorerecommendations to see medical professionals rather than drive totheir appointment or seek alternate transportation.

Impact on Self-Care

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 tasksindependently, but these tasks are commonly impaired by normal,age-related vision loss. The self-care task with the highest physicalrisk involved may be bathing. This risk is compounded by physicalimpairments that prevent the elderly from functioning safely. Poordepth perception can prevent the elderly from accurately judging thedepth of the bathtub. Poor contrast sensitivity can prevent theelderly from accurately judging the edges and the contours of thebathtub. Both of these impairments can cause serious injuries insenior citizens. Young and older people alike have experienced theinjuries caused from misjudging the distance of a stair step. For theelderly, this is even more dangerous because the step into a bathtubis typically deeper than the average stair step and also because thebones of the elderly are more brittle and more susceptible to injury.Bathtub transfer benches, walk-in showers, and caregiver assistancecan all reduce the risk of injury during bathing.

Mobility within the home is also a major part of self-care andalso involves some physical risk. Studies have shown that the elderlyare more confident and less likely to fall in the familiarity of thehome than in unfamiliar environments, but too many senior citizensstill experience falls at home (Abdulrazzak, 1997). While these fallsoften result from physical ailments and disabilities, age-relatedvision loss can certainly increase the risk. Poor contrastsensitivity and poor color discrimination combine to limit theability of the elderly to determine edges. Examples of edges that areimportant to detect are the edges of stair steps or edges between twosurface types, like carpet and tile. Detecting edges is importantwhen the elderly are moving about because the an individual who candetect a change in the surface they are walking on, such as fromcarpet to slick tile, can be prepared for the change and continuemoving safely.

Poor contrast sensitivity and poor color discrimination can alsolimit the ability to perceive obstacles in their path. Modifying theenvironment to meet low-vision senior citizens' needs can reducethese risks. There are specialists trained specifically to evaluatethe home for safety; these services will be discussed in the section,The Need for Additional Services and an InterdisciplinaryApproach.

Senior citizens may also find planning and preparing meals becomesmore challenging with older age. Because of age-related healthproblems, doctors often prescribe special diets that limit substancessuch as sodium, sugar, and cholesterol. Many elderly may also havefood allergies for which they must plan. While the ingredients offood products are required to be printed in a standard format on allproduct labels, this information can be inaccessible to the elderlywith poor acuity. Poor contrast sensitivity affects the ability toread this small print when the labels are printed in low-contrastcolors. Glare can also impair senior citizens' ability to read foodlabels on products with plastic or shiny labels. Unfortunately, themarketing 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 theelderly to do their own cooking. For example, stove and oven knobsare often printed in smaller print and sometimes in low contrast. Thesame is true for cooking instructions on product packaging. Poorcolor discrimination can make it difficult for the elderly todetermine when their food is done. For example, the younger person'smay be able to look through the oven glass to see that bread hasturned a golden color; older individuals may not be able todiscriminate the change between the color of unbaked bread.

Although senior citizens may be physically capable of dressingindependently, choosing clothes that are both attractive to theindividual wearing them and socially acceptable can be a challenge(T. Steadman, personal communication, June 14, 2002). This is theresult of poor color discrimination caused by changes in the variablelens as discussed in Effects of Visual Changes. For clothing toappear attractive to the individual the colors should be brightenough and bold enough that the older person wearing them candistinguish the colors. To be socially acceptable, the differentpieces of clothing should match. Elderly persons with poor colordiscrimination may need assistance when choosing clothing to wearoutside the home.

Personal grooming, including hair and makeup, can be challengingto senior citizens also. The phrase "blue haired" is not as farfetched as some think. Senior citizens who color their hair may endup with strangely tinted hair, and do not notice it, especially ifthe hairdresser is also older or if they color their own hair athome. This is because of age-related impairments in colordiscrimination. The yellowing of the variable lens filters out muchof the color information taken in, so the elderly eye sees the tintas gray.

Cosmetics also challenge elderly women when grooming. As the eyeages, it requires more stimulation for a given response. This meansthat the older eye needs greater intensities of color for perceptionto occur. This need for increased intensities may mean elderly womenwill wear too much make-up, because they cannot perceive less make-upor more appropriate colors. Poor color discrimination adds to theproblem, because elderly women may choose colors that do not matcheach other, resulting in an unusual look. Greater amounts of lightwould normally help in these tasks, but this type of activity in thistype of environment make greater amounts of light more harmful thangood. For the elderly, large amounts of light should be aimed at thetask 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 makethe task harder. Mirrors and porcelain bathtubs and toilets makeextra light problematic as well. Reflection of light from mirrors andshiny porcelain surfaces will add to temporarily blinding glare.While blue hair and unusual makeup will not put senior citizens inany physical danger, it can affect the way people interact with them.Poor interactions can only serve to further the social isolation thatsenior citizens already feel.

While cosmetics and blue hair involve mostly elderly women,elderly men face challenges in grooming as well. Elderly men mayshave less frequently than expected because it may be difficult tosee the stubble growing on the face, especially if facial hair is alight shade of gray or white on light skin or if facial hair is darkon dark skin. This is due to a number of age-related changescombined, including poor acuity, poor color discrimination, and poorcontrast sensitivity, all of which are discussed in Visual Effects ofChanges.

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