Loss of vision does not mean loss of independence

Medical care, adaptive aides can help

Home health nurses see it all of the time—patients don't want to lose their independence so they don't tell anyone if they experience changes in their mobility, memory or vision. If your patient has problems with vision, there are things that can be done to help him or her maintain independence and handle the vision loss safely.

"Admitting that you are losing your vision has a tremendous impact psychologically on any person," points out Priscilla Rogers, PhD, a vision rehabilitation consultant in Mooresburg, TN. "There are techniques and adaptive equipment that allow a person with vision loss to continue living independently," she says.

There are several different types of vision loss and it is important to diagnose the correct reason for the loss to best identify the assistance your patient needs, says Rogers. "No one should assume that a patient's loss of vision means that they can't do anything for themselves," she adds.

The first step in helping a home health patient with vision loss is to identify the problem, even if the patient won't admit it. "Look for changes in the patient's behavior," suggests Alberta L. Orr, MSW, program manager of the National Aging Program of the American Foundation for the Blind in New York. "If the person stops doing his or her favorite activity, such as knitting, watching television, reading, or playing cards, it might be due to trouble seeing well enough to do these things," she says.

Orr and Rogers suggest a vision component for all initial patient assessments any time that a nurse believes there may be a change in a patient's vision. "Once the type of loss is identified, the patient should be referred to a physician for evaluation and treatment, and environmental changes or adaptive equipment can be used to help the patient manage their daily lives," says Orr.

The most common types of vision loss in older people are central field loss, which is found in patients with macular degeneration; peripheral field loss, which is found in patients with glaucoma and hemianopia, a condition that is caused by a stroke; and overall blurring, which is caused by cataracts and diabetic retinopathy.

Once the problem has been identified, there are a number of techniques to help patients, says Rogers. "There are therapists who specialize in vision rehabilitation and they can provide a wealth of information to patients and their families," she says. There is also federal funding for vision rehabilitation as part of Title VII, Chapter 2 of the Rehabilitation Act, often referred to as the "Older Blind Program," that provides training to older people with vision loss, she points out. Each state agency that is responsible for the aging has information about the program, she adds.

Environmental changes help

There are also simple things that a home health nurse can teach patients and their families to help maintain independence, points out Orr. "Increase lighting in the home by adding lamps throughout the house," she suggests. "We need four times more light as we age than we do in our 20s and, at age 85, we need 10 times more light to see at the same level as we did when we were younger," she says.

Better lighting doesn't mean only increasing the wattage of light bulbs. "Light that comes from different sources, such as an overhead, a floor lamp, and a table lamp, that provides light directly on the area in which I'm working or reading is more effective," says Orr. "Incandescent light is best, and using light bulbs that are described as 'daylight' are good since natural light is best," she says. Use the highest wattage that is recommended by the lamp manufacturer but don't exceed the recommendation, she warns. "Fluorescent lights are problematic because they do flicker, and halogen lights get hot so I don't recommend them," she adds.

In addition to improving light in the home, look for ways to provide contrast to better distinguish everyday items. "If the patient has trouble identifying items on a dinner table, use a dark plate on a light background so it is easy to find the plate, and use contrasting towels and bath mats in the bathroom to easily distinguish the sink and toilet," she says.

Cooking is a major safety concern for older patients with vision loss but there are ways to handle this activity as well, says Rogers. "Larger or contrasting markings for the on and off positions on the stove can be used. Patients can be taught to keep pot handles turned inward, measuring cups can be more clearly marked, a tomato slicer that is just pushed down on the tomato can be used in place of a knife, and pouring devices that signal when a cup is full can be used," she says.

Because a patient is embarrassed or frightened to admit vision loss, approach the issue carefully, suggests Orr. "Ask non-threatening questions and be specific," she says. "I notice that you have difficulty reading that paper" or similar questions can lead to a discussion, she explains. "Nurses need to trust their observations and their judgment because many patients won't admit a problem, even when it is obvious," she says.

Nurses can also bring an item that might adapt the patient's home and say, "Some of my other patients find it helpful when I mark their measuring cups for them," or a similar statement, says Orr. Organizing cabinets or drawers, labeling them with large print, changing a tablecloth, or replacing light bulbs might be a simple first step to get a patient to talk about vision difficulties, she adds.

While ophthalmologists can diagnose and treat the medical conditions that cause vision loss, it is often up to the family and home health provider to find ways to help the patient retain as much independence as possible in the home, points out Rogers. "When a doctor says that he or she has done all that's possible, patients don't realize that there are things that can be done beyond medical treatment to help them make the most of their remaining vision. That's why home health nurses' observations and assessments are so important."