Case Study

Mrs. N. is an 82-year-old widow who lived alone in the two-story home that she shared with her husband for more than 50 years. At a visit to her ophthalmologist, she was told that her complaints of blurry vision with reading the mail and newspaper were due to dry macular degeneration, and that new glasses would not help her. The ophthalmologist informed her that there was nothing he could do to correct her condition.

Mrs. N. is now at a subacute rehabilitation facility following a recent knee replacement surgery, and the OTR/COTA team has been ordered to follow her. She tells them that she is a little afraid to be at home alone. She is having trouble seeing her appliance controls and the phone dial. Between her new knee replacement and her vision loss, she does not know whether she can navigate the steps in her home. She is nervous about going outdoors because she is having trouble seeing curbs and changes in walking surfaces, especially at dusk or on hazy days. She feels isolated and lonely. Her children are wondering whether she will be able to return home.

Psychosocial Effects of Vision Impairment

Almost 25% of adults with visual impairment report symptoms of depression compared with 10% of those without visual impairment.⁵ The thought of losing one’s vision is one of the most devastating disabilities imaginable. Without vision, the ability to perform many of the daily activities normally taken for granted is lost. Without vision, a means of social connectedness is lost because it is no longer possible to make eye contact or to read subtle facial expressions. The thought of vision loss conjures up a terrifying world of blackness. However, although most people think of vision loss as total blindness, most individuals with visual impairments are not totally blind. In fact, in one report, 80% of those who reported being legally blind had some degree of usable vision.⁶ It is often difficult for family members, friends, and the general public to understand the limitations and capabilities of those with partial sight.⁷ It is not uncommon for partially sighted individuals to be labeled as “fakes” when others observe that they are capable of one task that requires some degree of vision but are incapable of another task.⁷ This confusion about the abilities of those with partial sight may produce more psychological distress than does total blindness.⁷

In addition to the ambiguity associated with being partially sighted, individuals often find it difficult to adjust to their vision loss because of the uncertainty of their condition. For many, it is difficult to know whether their vision will improve, stay the same, or get worse. There is often an internal struggle with a desire to be independent and the desire to be taken care of. In some situations, elders may want assistance but feel unable to ask for it. Elders struggling with vision loss may experience mood swings. Friedman⁷ describes the stages of coping that individuals with vision loss experience as closely paralleling those that Kubler-Ross⁸ describes in her study on death and dying. These stages include initial shock and denial, then guilt, bargaining, anger, depression, and, finally, adaptation.

Perski⁹ describes a similar response of adaptation when he writes about the five-stage process of being a successful low vision patient. Perski⁹ notes “there are definite psychological stages that many persons go through before they become a successful user of visual aids. Probably the first harsh reality that a low vision person must face is that a single pair of glasses will not help his or her vision. The reality that the person must hold a magnifying glass or use separate reading glasses and hold materials very close to his or her eye is often too much to bear.”

Effects of the Normal Aging Process on Vision

Although elders are more likely to experience visual impairments because of some specific ocular and neurological pathologies, they also experience many age-related changes that affect visual functioning. These normal changes must be taken into consideration when working with this population.

The retina is a multilayered lining of neural tissue on the innermost part of the eye (Figure 15-1). It receives visual messages and transmits them through the optic nerve to the brain.¹⁰ The central area of the retina, or macula, has a concentration of cone cells that enable color vision and fine-detail discrimination. Rod cells are extremely sensitive to light and provide peripheral vision and night vision.¹⁰ As the retina ages, it gradually loses neurons. Central or peripheral vision may be affected, depending on which retinal neurons die. The rate of retinal deterioration and the resultant visual field loss vary among individuals, but, generally, elders experience shrinkage of the peripheral field, experience difficulty with light and dark adaptation, and require increased time to switch from viewing near objects to far objects (accommodation) and to recover from glare. Because pupil size and function decrease with age, elders require more illumination for fine-detail tasks.¹¹ Many elders require three times more light than a person requires in his or her twenties or thirties.¹²

FIGURE 15-1 Anatomy of the eye.

Changes may also occur in the lens of the eye with age (see Figure 15-1). The lens is responsible for properly focusing the image on the retina. It does this by changing shape according to the distance of the object being viewed.¹³ As the lens ages, it loses some of its elasticity, making shape change or accommodation more difficult. This condition, called presbyopia, affects focal ability at near distances, making it difficult to read print or perform close-vision tasks.¹⁴ The greatest change usually occurs between ages 40 and 45 years.¹⁴ Reading glasses or bifocals are often prescribed at this time. In addition to this loss of elasticity, the lens also becomes yellower with age. This deeper yellow can affect the ability to differentiate between colors and discriminate objects with low contrast.¹⁵

Specific Ocular Pathologies

In addition to the natural aging process, specific pathological eye conditions have a more profound effect on functional visual abilities. Four major conditions that affect an elder’s vision are cataracts, age-related macular degeneration (wet or dry), glaucoma, and diabetic retinopathy. Each of these conditions can cause visual impairment when they occur in isolation, but they commonly co-occur in elders, increasing the challenge to remain functionally independent (Table 15-1). More about general intervention ideas for any ocular condition will be presented later in the chapter.

TABLE 15-1 Changes in Visual System Associated with Age

Adapted from Zoltan, B. (2006). Vision, Perception, and Cognition: A Manual for the Evaluation and Treatment of the Adult with Acquired Brain Injury, 4th ed. Thorofare, NJ: Slack.

Glaucoma

Glaucoma is a group of serious ocular conditions that involve excessively high pressure inside the eyeball. This increased pressure results from a buildup of excess fluid in the eye.¹⁰ Increased intraocular pressure can eventually cause damage to the optic nerve or the blood vessels that supply the optic nerve.¹⁰ One of the first effects of this optic nerve damage is usually a loss of vision in the peripheral field (Figure 15-2). This loss of peripheral vision is often not noticed by the individual initially, and the disease frequently progresses substantially before it is noticed.²² If left undetected and untreated, this loss can lead to total blindness. Elders should be encouraged to have routine ophthalmologic visits so that glaucoma may be diagnosed at an early stage. When the diagnosis is early, individuals respond well to medication and, if necessary, surgery to improve the balance of fluid in the eye.¹⁰

FIGURE 15-2 This printout from an automated perimeter test indicates visual loss in points marked with black squares. Note the peripheral distribution.

There are many types of glaucoma, but open-angle is the most common.¹⁰ Other types include closed-angle or narrow angle, traumatic, and low-tension glaucoma.¹⁰ Open-angle glaucoma involves an eye with normal anatomy that, for unknown reasons, is not able to drain the fluid as efficiently as it produces it. This leads to a slow, gradual buildup of intraocular pressure over time.¹⁰

Closed, or narrow-angle, glaucoma is less common. This type of glaucoma progresses rapidly, and symptoms are immediately apparent. Nausea, headaches, severe redness of the eye, and pain may be symptoms of an acute attack of narrow-angle glaucoma.²³ Emergency surgery is often required to reduce the intraocular pressure.

The functional implications of glaucoma vary greatly, depending on the severity of the disease. When diagnosis is early, glaucoma can be treated and many people may have little need to adjust their lifestyles. If the disease is allowed to progress, individuals may experience decreased peripheral vision, difficulty adjusting to changing light, fluctuating and blurred vision, shadow-like halos around lights, and an increased sensitivity to glare.^24,25 If glaucoma goes undiagnosed, a person may lose all of his or her vision beginning with the peripheral field and eventually extending into the central visual field. Mobility and safety can be severely compromised in elders with advanced glaucoma. Referral to an orientation and mobility teacher may be appropriate for an elder experiencing decreased mobility because of vision loss at this stage. COTAs working with elders who have glaucoma should be aware of specific interventions for this diagnosis (Box 15-2).

BOX 15-2 Intervention Gems for Individuals with Glaucoma

Most individuals with glaucoma do not experience problems with their vision until their disease is relatively advanced.

Medication management is vital—train client in nonvisual techniques, labeling, organization, talking labels, and talking reminders or alarms for self-administering oral medicines and eye drops.

Mobility problems (due to reduced peripheral vision)—address by use of contrast, reduce clutter/tripping hazards, train awareness of boundaries, and edges in environment; refer to orientation and mobility specialist for long cane (white cane) and nonsighted techniques for community mobility.

Contrast and glare—Use of yellow, amber, or light plum glasses to increase contrast, decrease glare. Reduce reflective surfaces (glass tabletops, mirrors, highly polished floors, or counters), cover exposed light bulbs, windows, and angle task light sources to decrease glare.

Low-power magnifiers—may help for small print or poor contrast materials.

Increase object size for ease of identification.

Bright colored objects will stand out if client has decreased contrast sensitivity.

Organized scanning patterns—train client to scan in horizontal left to right, zig-zag, and circular patterns to locate obstacles, edges, and objects in their reduced visual field.

Visual Dysfunction After Neurological Insult

The discussion of visual impairments in elders thus far has focused on impairments as a result of ocular conditions. However, the visual system is not composed of the eyeballs alone. To perceive visual information, the data must travel through a complex nervous system and must be processed by appropriate cerebral centers. In addition, effective control of eye movements depends on proper impulses from the brain. This includes feedback from areas that monitor body and head position and movement.²⁶ Thus, successful adaptation to the environment through the visual sense requires the proper functioning of both ocular and neurological components (Box 15-4).

Causes of brain insult can include trauma, cancer, multiple sclerosis, and cerebrovascular accidents (CVA) or strokes. The vision system is vulnerable to strokes and other types of brain insult.²⁷ A host of visual disorders can result from brain insult, including visual field disorders, reduced visual acuity, reduced contrast sensitivity, problems with stereopsis (depth perception), difficulty adapting to changes in light conditions, visual spatial disorders, and oculomotor dysfunction.²⁸

Warren’s Hierarchy for Addressing Visual Dysfunction

Because of the complexity of the visual system, a framework for evaluation and intervention of visual impairments, whether ocular or neurological in nature, may be helpful. Warren²⁷ suggests a developmental model that conceptualizes vision abilities in a hierarchy (Figure 15-3). The abilities at the bottom form the foundation for each successive level. Higher level abilities depend on the complete integration of lower level abilities for their development.

FIGURE 15-3 Hierarchy of visual perceptual skills development in the central nervous system.

(Adapted from Warren, M. L. (1993). A hierarchical model for evaluation and treatment of visual perceptual dysfunction in adult-acquired brain injury, part 1. American Journal of Occupational Therapy, 47, 42-54.)

The highest visual ability in this model is visual cognition. Visual cognition is the ability to mentally manipulate visual information and integrate it with other sensory information to solve problems, formulate writing, and solve mathematical problems.²⁷

Visual memory is the ability directly below visual cognition in Warren’s model. Visual cognition depends on visual memory because mental manipulation of a visual stimulus requires the ability to retain a mental picture.²⁹

To store a visual image, individuals must be able to recognize a pattern. Pattern recognition, the next ability level, involves identification of the salient features of an object.^30,31 An individual must not only be able to identify the holistic aspects of an object such as its shape and contour, but also specific features of an object such as its color detail, shading, and texture.

The ability to scan the environment is necessary for effective pattern recognition. Scanning, therefore, is the fundamental ability required for pattern recognition. The eye must record systematically all of the details of a scene and follow an organized scan path.²⁷

The ability directly below scanning is visual attention. Engagement of visual attention is necessary for proper scanning to occur. If individuals are not attending to visual stimuli in a specific space, they will not initiate scanning into that area. A classic example is the elder with a CVA with left hemi-neglect who requires constant cueing to scan to the left to avoid colliding with objects.²⁷

Visual attention and all of the higher level abilities depend on three primary visual abilities that form the foundation for all vision functions: oculomotor control, visual fields, and visual acuity. Oculomotor control enables efficient and conjugate eye movements, which ensure the completion of accurate scan paths and “teaming” of the eyes for binocular vision. The visual field is the extent of view that a person has in front of each eye. Visual acuity describes the sharpness or clearness of vision.²⁷ Table 15-2 addresses performance skill deficits of all of the discussed visual pathologies, and Box 15-5 is a screen that addresses performance skills with areas of occupation.

TABLE 15-2 Ocular Pathology Related Functional Performance Skills Deficits with Areas of Occupation

Principles of Intervention

When an occupational therapy (OT) visual screen reveals deficits affecting ADL, the client should be referred to an ophthalmologist or optometrist to obtain a comprehensive visual examination. If available records and clinical observation indicate that the client’s visual impairment is caused by an ocular disease, it would be best to refer the client to a low vision specialist (see later discussion of professionals for collaboration). If, conversely, diagnostic and clinical information indicate that the client’s visual impairment is caused by a neurological insult such as head injury or stroke, a consultation with a neuro-ophthalmologist or neuro-optometrist is recommended. If either of these scenarios is not possible, a consultation with a trusted ophthalmologist would be the next choice. Ideally, a good working relationship should be established with low vision specialists and neuro-ophthalmologists in the area to facilitate the speed of referral and communication between professionals.

The information provided by an ophthalmologist or optometrist may vary, depending on the condition and the professional’s area of specialty. A report from these professionals typically includes many of the following visual functions: visual acuity, visual field, contrast sensitivity function (the ability to distinguish subtle gradations in contrast between an object and its background), and oculomotor control. Reports may also include intraocular pressure (the pressure inside the eyeball), best correction for eyeglass prescription, dates and description of any ocular surgeries or procedures, current prescribed ophthalmic medications, and the general heath of ocular structures. Low vision specialists often also make recommendations for special optical devices to access printed materials, computer screens, or detailed eye-guided handiwork if visual acuity cannot be corrected to a functional range. This information and that gathered during the OT evaluation are invaluable in guiding intervention. Box 15-6 is a screening form for the sensory perceptual skill of vision. The following discussion addresses general interventions for many of the deficits that accompany visual loss such as decreased visual acuity, visual field loss, oculomotor dysfunction, reduced contrast sensitivity, and impaired visual attention and scanning.

Decreased Acuity

The input of an eye care specialist is crucial in addressing reduced acuity. Some elders are simply in need of an updated eyeglass prescription. In the case of a head injury or stroke, acuity may be reduced initially but often resolves spontaneously in a few months. (See Chapter 19 on the effects of traumatic brain injury [TBI]/stroke [CVA] for a full discussion of more subtle deficits on acuity and intervention.) Reduced acuity secondary to ocular diseases, such as macular degeneration, cannot be improved through a change in eyeglass prescription. Recommendations for special optical devices may be made in this case. Diabetic retinopathy often not only causes reduced acuity, but also causes fluctuating acuity. It is important to follow the advice of the eye care specialist when planning intervention related to acuity.

As mentioned earlier, one method to compensate for reduced acuity is to use special optical devices to magnify or enlarge print (Figure 15-4). It is recommended that OTRs and COTAs receive specialized training in optical devices before attempting to train individuals in their use. (See listed resources for courses geared to OTRs and OTAs.) There are many unique concepts and techniques involved in the proper use of these devices, and elders typically require very clear instructions and encouragement to become proficient in their use. Other examples of using enlargement to compensate for decreased acuity are the use of large print materials and writing larger letters with a felt tip pen.

FIGURE 15-4 Some common optical aids used by individuals with low vision.

When an elder has decreased acuity, there are other techniques to help maximize function such as the use of proper illumination, reduction of pattern and clutter in the environment, and the use of organizational systems. Proper lighting is usually critical for optimal performance. However, some individuals may be photophobic or sensitive to light, which presents a challenge in finding appropriate lighting. Good, general room lighting (ambient lighting) is necessary for ease and safety in ambulating. Task lighting sources such as a gooseneck lamp or movable track lighting is recommended for fine-detail or low-contrast tasks such as reading, sewing, handyman work, or crafts. Proper positioning of a lamp must be considered to avoid glare. Directing the light from behind the shoulder of the better-seeing eye so that the light source does not create glare often works best. Task lighting with a gooseneck lamp can be positioned closer to the reading material, even in front of it as long as the bulb is not exposed and the shade directs the light downward, concentrating it on the material to be illuminated. Position the light source opposite the dominant hand to avoid shadows when writing.

Patterned backgrounds and clutter in the environment tend to “camouflage “objects that an elder is seeking (Figure 15-5). This can be remedied by using solid colors for background surfaces such as bedspreads, place mats, tablecloths, rugs, and furniture coverings. Care should be taken to reduce clutter where possible by limiting the number of objects in the environment and arranging the remaining objects in an orderly fashion. Once the environment is rearranged and simplified, every effort should be made to keep it organized.

FIGURE 15-5 A patterned background can make it difficult to locate objects.

There are many national and local services available for those with impaired visual acuity (and other visual impairment). Most of these services are free of charge. They can be found by contacting local state services for the blind and visually impaired (search state government website). The American Foundation for the Blind and The Lighthouse are examples of services that provide books and magazines to individuals free of charge (see Appendix). There are also catalogs that offer low-tech adaptive devices for the visually impaired such as talking clocks, large print playing cards and bingo cards, and a variety of other devices for ADL (see Appendix).

Visual Field Loss

Elders who have a visual field loss may be taught to compensate for this loss in daily activities. The first step, however, is to increase the elder’s awareness of the visual field loss. Having accurate information on the extent and location of the field loss is critical for teaching elders proper methods of compensation. The exact type and scope of visual field loss will vary depending on the cause of the disorder or disease and on individual presentation. In general, those with ocular conditions experience relatively “spotty types” of field loss, whereas those with a neurological disorder exhibit more uniform or extensive field loss. Of course, there are definitely exceptions to this rule because some ocular conditions can lead to an extensive and even total loss of visual field. Small, concentrated areas of visual field loss also have been found in those with head injuries.³²

Elders who have central field loss, such as that seen with macular degeneration, must learn to compensate by directing their gaze off-center of the target (either slightly above, below, or to the side of) rather than directly at the target. This technique, called eccentric viewing, enables the individual to place the target outside of the blind spot so that it can be seen. This usually requires professional assistance to identify the best area for eccentric viewing, sometimes referred to as the preferred retinal locus or PRL.³³ Additional training and a conscious effort are required on the elder’s part to override the natural tendency to direct the fovea, the most central area of the retina to the target and instead place the PRL in line with the target. Central field loss usually affects fine-detail tasks but does not significantly interfere with mobility. Those with more peripheral field loss typically require intervention aimed at increasing safety and independence with mobility skills. Elders with a homonymous hemianopsia occurring after a stroke may be taught to compensate for this loss of half the visual field by systematically training them to turn the head and scan into the impaired field during functional activities such as reading, shopping, and mobility.^34,35

Oculomotor Dysfunction

Intervention for oculomotor dysfunction is likely one of the most complex areas for beginning practitioners to comprehend and implement effectively. It is highly recommended that the entry level COTA attend continuing education seminars, develop a mentoring relationship, and establish service competency in this area before attempting any of the intervention strategies suggested. It is also strongly recommended that therapists and assistants work under close supervision of an optometrist or ophthalmologist when treating oculomotor impairments. Oculomotor impairments are seen in individuals who have experienced some type of neurological insult. Ocular conditions do not affect the muscular or neural mechanisms that control eye movements.

A strabismus, or misalignment of an eye,¹⁴ is often seen as a result of extraocular muscle weakness after a stroke or other neurological insult. This misalignment of the eyes results in diplopia, or double vision. The primary intervention methods used to address diplopia include occlusion, eye exercises, application of prisms, and surgery.³⁵

Occlusion is essentially the “patching” of an eye to eliminate the double image.¹⁴ Care must be taken to follow an occlusion protocol that optimizes the elder’s comfort and reduces the likelihood of developing contractures in the muscles opposite the weak ones. Occlusion should not be carried out by simply patching the affected eye during all waking hours because this does nothing to encourage the use of the weak muscles. The protocol is typically directed by an ophthalmologist or optometrist.

Eye exercises can be used in conjunction with occlusion to help strengthen the affected muscles. One basic method would be to patch the unaffected eye and have the client track an object through all ranges of motion.³⁵ Optometrists may suggest additional exercises to be carried out under their direction.

Another strategy to treat diplopia is the application of prisms.¹⁴ Prisms are sometimes prescribed and used to create a single image in the primary direction of gaze. The prism displaces the image to one side, causing the disparate images created by the strabismus to overlap and fuse into a single image. The prism can be permanently ground into the client’s eyeglass lens or can be temporarily applied to the eyeglass lens using press-on prisms. If the strabismus is resolving, the elder should be gradually weaned off of the prism by reducing its strength over time.¹⁴ An ophthalmologist or optometrist determines the strength of the prism and directs the intervention.

In some specific cases, surgery to correct the strabismus may be warranted.³⁵ This is further testimony to the necessity of consulting with appropriate eye care professionals to obtain optimal intervention for the individual. In most cases, the general approach to the surgery is to make the action of one or more eye muscles weaker or stronger by changing its attachment position. This is done by an ophthalmologist who is specially trained in strabismus surgery.³⁵

Reduced Contrast Sensitivity

Contrast sensitivity may be affected by both ocular and neurological conditions. This function is different than visual acuity, which reveals only the size of high contrast black and white letters that the individual is capable of seeing. Contrast sensitivity is the capacity to discriminate between similar shades.¹⁰ In daily life, good contrast sensitivity is necessary to see a gray car on a cloudy day, to detect unmarked curbs and steps, and to distinguish subtle contours on people’s faces to recognize them. Deficits in contrast sensitivity are typically addressed through environmental adaptation. For persons with low contrast sensitivity, the world often loses its definition. The primary technique to compensate for this deficit is to simply add contrast to the environment whenever possible. Many items used in daily activities can be changed to add more contrast and definition (Box 15-7). Proper illumination (as described earlier under “Decreased Acuity”) is also helpful in enhancing contrast. Some individuals find that full-spectrum lighting, either incandescent or fluorescent, provides the best contrast-enhancing illumination. Color filters that may be worn over prescription lenses or alone can also enhance contrast. Light yellow, medium yellow, and light or medium plum are the colors most frequently used to enhance contrast.

Impaired Visual Attention and Scanning

Deficits in attention and scanning are seen in those with neurological involvement, not commonly in those with ocular conditions. One type of impairment in this area is hemi-inattention, or hemi-neglect. This refers to a lack of awareness of one half of a person’s visual space. Neglect of the left half of visual space is more common, but right hemi-neglect is occasionally seen.³⁶ Individuals with hemi-inattention are not able to take in visual information in the orderly, sequential, and comprehensive pattern needed to safely complete many daily activities. Grooming, meal preparation, and functional mobility (especially driving) are common examples of ADL affected. Initial intervention of deficits in visual attention and scanning often involves increasing the elder’s awareness of the deficit followed up with appropriate compensation or remediation techniques, or both. Research has shown that individuals with left visual neglect may be trained to reorganize their scanning strategies by beginning the scan path in the impaired space.³⁷ This is accomplished through intervention strategies similar to those described earlier in treating homonymous hemianopsia. Activities are used that require and encourage a systematic left-to-right scan pattern with a visual anchor (such as a red line or ruler) placed to the left (or right as appropriate) as a visual cue, if necessary. There is some evidence that the effects of this training on patients with hemi-inattention may be task-specific and may not generalize to overall ADL function.^38,39 The presence of hemi-neglect also has been associated with poor rehabilitation outcome.^40-42

Higher Level Visual-Perceptual Deficits

Warren’s²⁷ proposed intervention for higher level visual deficits includes addressing the foundation visual skills that may affect these areas, education of the patient to increase awareness of the deficit, and instruction in the use of compensatory strategies for the deficit. (See Warren²⁷ for a more detailed description of these techniques.) Refer to Box 15-4, Intervention Gems for Individuals with Neurological Visual Impairment.

Settings in Which Visual Impairments Are Addressed

Low-vision rehabilitation is becoming a specialty field for OTRs. OTRs may provide rehabilitation for diagnoses related to visual impairment when prescribed by an ophthalmologist, optometrist, or other physician (as of this writing, regulations vary by state). OTRs work in conjunction with other trained professionals to provide comprehensive services to individuals with vision impairments. The majority of individuals treated in low-vision clinics have impairments caused by ocular pathologies. Macular degeneration accounts for 60% of low-vision cases,¹⁴ whereas glaucoma and diabetic retinopathy are ranked second and third, respectively.⁴³ For this reason, the term low vision is typically associated with visual impairments caused by ocular diseases. However, individuals with visual impairments secondary to neurological insult also may seek intervention in some low-vision clinics.

Because visual impairments are a common result of neurological insult and because ocular diseases are relatively common in the elderly, COTAs working in any geriatric or neurorehabilitation setting should be well educated in visual dysfunction and intervention techniques. Settings may include inpatient and outpatient rehabilitation, subacute rehabilitation facilities, long-term care facilities, and home health agencies.

COTAs working with elders with visual impairments must have specialized training in areas such as optics and use of optical devices, eccentric viewing techniques, blind techniques for ADL, and vision enhancement techniques for ADL, as well as a good working knowledge of the extensive adaptive equipment available for low-vision clients. They also must possess a good understanding of available resources to direct clients to appropriate support groups and other services.

There are many other low-vision rehabilitation professionals with whom the COTA can collaborate to provide the best functional outcomes for their clients. Orientation and mobility specialists address travel needs directly related to vision loss. They typically hold master’s degrees and have a wealth of knowledge in this area. The goal of their services is to develop independent travel skill within the client’s home, neighborhood, or community. These specialists may work in many settings, including public school systems, private agencies, and state-supported programs.

Rehabilitation teachers are professionals who are trained at the university level to address ADL that have been affected by visual impairment. They provide instruction in using adaptive techniques or adaptive equipment to increase independence in areas such as communication, household management, self-care, and other ADL. Rehabilitation teachers may work in private agencies, itinerant state services, residential schools, and independent living centers. The areas addressed and the knowledge base of these professionals may overlap at times with OT professionals. As long as there is open communication and collaboration, each profession will likely learn valuable techniques from the other, and the client will receive an optimal rehabilitation program.

Ophthalmologists and optometrists specializing in low vision ensure that comprehensive low-vision services are provided. They evaluate the client’s visual function and prescribe optical devices and training to compensate for vision loss. They may see low-vision clients in their own broader-based private practice, or they may work in low-vision clinics. (For more information regarding a program using ophthalmology and OT to provide low-vision rehabilitation in an outpatient rehabilitation setting, see Warren.⁴⁴)

Conclusion

Visual impairments in elders may result from either ocular or neurological pathology. Normal physiological changes that may occur with aging include shrinkage of the peripheral field, increased time required to recover from glare, difficulty with light and dark adaptation, increased need for illumination, loss of elasticity in the lens, and yellowing of the lens. The most common ocular diseases that may occur in elders are macular degeneration, cataracts, glaucoma, and diabetic retinopathy. Elders are also at risk for CVAs, which may disrupt any of several neurological components necessary for effective visual functioning.

COTAs can play vital roles in helping elders with visual impairments learn to function as independently as possible. COTAs can provide sources for information about vision loss to help elders understand the specifics of their eye conditions. Encouraging elders to gain knowledge about their eye conditions can be an empowering first step in the process of rehabilitation. COTAs may collaborate with OTRs to provide training to compensate for vision loss in daily activities. COTAs can provide training in community resources and collaborate with other members of the intervention team to provide referral to appropriate agencies and service providers to facilitate community reintegration. Finally, COTAs may collaborate with elders, family members, and/or caregivers to make environmental adaptations, to enhance independence, and to do these safely (Box 15-8).

The loss of vision in elders is a common occurrence, whether it results from the natural aging process, ocular disease, or disruption of neurological components. Vision loss has significant functional implications and can complicate the elder’s rehabilitation process with other physical impairments. This emphasizes the need for COTAs to familiarize themselves with the causes and types of vision loss and effective intervention techniques, whether they are working in general rehabilitation centers or acute care hospitals.

Case Study

Mark is a 67-year-old widower who lives alone and following an amputation below the right knee was just admitted to the rehabilitation unit where you work. He has diabetes mellitus and has had many complications of the disease, including the peripheral vascular disease that led to his amputation and diabetic retinopathy. Mark states that he did not manage his condition well in the past but wants to do everything he can now to keep these complications from getting any worse. He states that he finds it difficult to see the numbers and lines on his syringes when drawing his insulin. He also has some trouble seeing the blood sugar reading on his glucometer. He needs to check his blood sugar three times a day with this machine and adjust his insulin dosage accordingly. The OT visual screen reveals that Mark has moderately decreased visual acuity and decreased contrast sensitivity.

Mark has good upper body strength and uses his walker well on the unit. He will need to use the walker at discharge while waiting for his leg to heal before being fitted for a prosthesis. Fortunately, you will be able to conduct a home evaluation to make recommendations before discharge.