As we age, our sensory systems gradually lose their sharpness. Because our brain requires a minimal amount of input to remain alert and functioning, sensory loss for older adults puts them at risk for sensory deprivation. Severe sensory impairments, such as in vision or hearing, may result in behavior similar to dementia and psychosis, such as increased disorientation and confusion. Added restrictions, such as confinement to bed or a Geri-chair, increases this risk. With nothing to show the passage of time, or changes in the environment, the sensory deprived person may resort to repetitive problem behaviors (calling out, chanting, rhythmic pounding/rocking) as an attempt to reduce the sense of deprivation and to create internal stimulation/sensations.
This article is the first in a series of three articles that discuss the prominent sensory changes that accompany aging, and considers the necessary behavioral adjustments or accommodations that should be made by professional, paraprofessional, and family caregivers who interact with older adults. Though the medical conditions are not reviewed in depth, the purpose of this article is to introduce many of the behavioral health insights, principles, and approaches that should influence our caregiving roles. This article addresses age-related visual changes.
CHANGES IN VISION THAT ACCOMPANY AGING
A. The changes in vision that accompany aging include:
1. A loss of elasticity of the lens; this means the person is no longer able to focus or accommodate to changes in lighting conditions. (Starting in our 40's, glasses are needed to see fine print). It also means the older person cannot adjust to sudden changes in lighting, resulting in an uneasiness when leaving a bright room to enter a dark hallway, or finding seats in the dark in recreation rooms, or theater. Going in the reverse direction can be equally difficult: from a dark room to a bright area.
2. Decreased pupil size; the light reaching the retina is reduced, requiring more light to see. This results in the need for lighting 3x to 4x what younger people need to see clearly
3. A loss of transparency; with age, there is a yellowing of the lens in the eyes, making color discrimination more difficult, especially blue and green. Warmer colors, such as reds and yellows are perceived best, explaining why bright colors are preferred.
4. More susceptibility to glare, and longer time is needed to recover from the effects of glare;
5. Eye diseases and disorders, such as cataracts causing a clouding of the lens; glaucoma, resulting from increased pressure of fluids in the eye, damaging the optic nerve and impairing vision. Glaucoma, the number one cause of blindness in U.S., in advanced stages results in yellow halos around images. Macular degeneration may occur, where vision is distorted, and images appear different sizes or different shapes, and are missing a central element. Visual disorders may be secondary to stroke, in which the eye can see the image but the brain cannot interpret the images. Diabetes may result in disrupted blood flow to the retina, causing diabetic retinopathy and a loss of vision, and blindness, in extreme cases.
B. What are the effects of visual loss on the older adult?
1. An increased dependency on others;
2. A sharply reduced quality of life (changes in activities in daily living and instrumental activities of daily living, reduced connection with outside world);
3. And, a fearfulness and reduced tendency to venture outside.
C. What are the effects of vision changes on demented elderly?
1. With the losses in visual acuity, other problems in cognitive functioning are heightened, such as difficulty processing unfamiliar faces and settings;
2. Because the person with dementia already has difficulty learning new behaviors, he or she is less able to learn new habits to compensate for the visual losses (e.g., learning to use visual aids to identify articles of clothing or other possessions;
3. There is likely to be an increased disorientation and confusion, as the search for structure and external cues is strained.
PRINCIPLES FOR CAREGIVERS
The following principles apply to caregiving approaches with older adults who have diminished sensory function. Increased sensitivity and insight to the needs of these individuals improves their quality of life and improves our effectiveness:
1. Observe the behavior of the person, and look for cues and signs of pain or discomfort;
2. Help the person work through the emotional impact of the sensory changes, allowing expression, acceptance, and support of the grief and sadness accompanying these losses;
3. Do not try to fix the unpleasantness; acceptance and support goes a longer way toward healing than a quick fix or a patronizing attitude;
4. Reduce excess disability by maximizing whatever functioning is still left, such as proper eyeglass prescriptions, or functioning hearing aids;
5. Consider assistive devices (phone amplifiers, large text books, headphones, and the Braille Institute for a variety of useful visual aids).
Approaches for impairments in vision:
1. Address the person before you touch him or her, identify yourself, let him or her know when you are leaving, speak normally, and do not shout;
2. Describe his or her surroundings to help orient and familiarize the person to the environment, tell him or her location of belongings, and if things have been moved;
3. Use as much contrast as possible, e.g., red objects on white background is better than black on a gray background, or blue on green background, (consider switch plates on walls, toothbrushes, combs);
4. Avoid moving quickly from a bright room to a darkened room, or v.v. Make sure the visually-impaired person takes the time for the pupils to adapt to the changes in lighting;
5. Introduce yourself every time you come into contact with the person, and explain what you are going to do because there are no visual cues;
6. Help to identify others in their environment with colored clothing, name tags with large print, etc.
7. Clean eyeglasses regularly, provide adequate lighting, and avoid glare;
8. Provide night lights, and arrange furnishings in the environment for safety and ease of mobility.
Even with normal aging, functioning of our five senses is not like it was when we were younger adults. This article offers caregivers who work with visually-impaired older adults some insights into the special needs and adjustments that will turn unpleasant, frustrating situations into more caring, helpful, and sensitive interactions. By integrating these behavioral approaches in the delivery of the health care with older adults, we can favorably impact the management of these conditions.
Copyright 2008 Concept Healthcare, LLC
Joseph M. Casciani, PhD, is a geropsychologist who has devoted his professional career to working with older adults and their caregivers. His company, Concept Healthcare, http://www.cohealth.org, offers online resources to integrate behavioral health approaches in the health care of older adults.
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