Low Vision: High, Low, No Tech Compensatory Strategies Mountain Central Conference November 9, 2014...

Low Vision: High, Low, No Tech Compensatory Strategies Mountain Central Conference November 9, 2014 Debbie Buckingham, OTR, CVE, CRC, CCM Beth Haerer, MS, Ed, MOTS

Learning Objectives Provide an overview of age related vision loss and the potential impact on occupational performance. Define the assistive technology (AT) concepts of high tech and low tech. Identify and describe various AT and environmental modifications that may be of benefit for individuals with low vision. Provide information on resources for individuals with vision loss. Note: Unless otherwise indicated, images are from Google Images (www.google.com/imghp)

Description & Definitions of Low Vision Scheiman: Low vision can be defined based on either a limitation of visual acuity, visual field, or visual function. A system of defining low vision was developed for the primary purpose of administering financial aid to those who qualify under Title X of the Social Security Act of 1935. The term legal blindness was developed for this purpose and is defined as 20/200 or worse in the best conventionally corrected eye or a visual field diameter of 20 or less in the better eye.

Description & Definitions of Low Vision American Optometric Association (www.aoa.org)www.aoa.org 20/20 vision is a term used to express normal visual acuity (the clarity or sharpness of vision) measured at a distance of 20 ft. If you have 20/20 vision, you can see clearly at 20 ft. what should normally be seen at that distance. If you have 20/100 vision, it means that you must be as close as 20 ft. to see what a person with normal vision can see at 100 ft. National Eye Institute (NEI) a visual impairment that is not correctable by standard eyeglasses, contact lenses, medication, or surgery and that interferes with the ability to perform everyday activities

Lighthouse International & CDC A functional definition of low vision is a vision loss that cannot be corrected and results in severely reduced visual acuity or contrast sensitivity, a significantly obstructed field of vision -- or all three (Lighthouse International, n.d.). In addition to compromising quality of life by reducing ability to perform self-care and instrumental activities of daily living, vision loss may contribute to social isolation (Centers for Disease Control and Prevention [CDC], n.d.).

Normal Visual Changes Associated With Aging Reduced Visual Acuity Presbyopia Luminance/need for more light Sensitivity to Glare Difficulty with Light/Dark Adaptation Reduced Sensitivity to Color Perception & Contrast Reduced Depth Perception Floaters Dry eyes AFB

Reduced Visual Acuity (AFB) Declines to some degree beyond age 50 Reduced visual acuity of 20/30 or 20/40 is typical for person age 50 or older Presbyopia Condition in which near visual acuity is decreased because of age related decline in accommodative ability (Scheiman) Frequently hold reading materials at arms length in order to get print to focus Gradual loss of ability to see close objects or small print Some people may begin to experience headaches or tired eyes while reading or doing other close work Correctable by bifocals, trifocals, reading glasses or continuous range eyeglasses Multifocal lens implants post cataract surgery

Luminance/need for more light (AFB) Amount of light reaching the back of the eye decreases with age Older people receive reduced light through smaller pupil and increased density or haziness with aging lens On average, older person requires 4X more light than a younger person Person age 80 & older requires 10X more light than the average 25 year old Problem can be remediated with improved lighting Vision typically good among older people under conditions of optimal light

Sensitivity to Glare (AFB) Caused by bright light reflecting from shiny surfaces Older person needs brighter light, but too much light that either shines directly or reflects into the eye can reduce vision Ability to recover from glare or bright lights decreases after age 50 due to changes in the lens and retinal sensitivity Natural environment produces a great deal of glare; sunlight often a major cause High gloss paper can be hard to read due to glare

Difficulty with Light/Dark Adaptation (AFB) Ability to adapt to darkness slows significantly with age (secondary to age related changes in pupil size, amount of light reaching the retina, and thickening of lens) Eye adapts more quickly from dark to light than from light to dark Examples: going from brightly lighted lobby into darkened movie theater, or dimly lit restaurant to outdoor sunlight.

Reduced Sensitivity to Color Perception & Contrast (AFB) Greater the difference in contrast between an object & its background, the easier it is to see. Increasingly sharper contrasts & sharper edges around an object to differentiate it from its background is needed. Recognizing faces & objects involves ability to see contrast, textures & patterns. Need high contrast printed material- sharp, crisp black lettering on a white or pale yellow page Ability to identify color diminishes with age

Reduced Depth Perception (AFB) Difficult to determine how near or far away or how high or low something is. Loss of depth perception makes steps or street curbs difficult to manage. Floaters (AFB) Tiny specks that float across the field of vision Generally most aware of them in well-lit rooms or outdoors on a bright day Often normal but sometimes indicate an eye problem. Floaters accompanied by light flashes could mean that the retina is detached, which requires immediate medical attention.

Dry eyes (AFB) Occur when tear glands dont produce enough lubricating fluid Can be uncomfortable, causing itching, burning, scratchy sensation, or even some loss of vision. Eye Dr. may suggest using a humidifier in the home and/or eye drops that compensate for the lack of natural lubrication.

Conditions That Result In Low Vision Four major causes of low vision are directly related to the aging process: Diabetic retinopathy Age related macular degeneration Glaucoma Cataracts (Warren, NEI, & AFB; AMD.org. Kaldenberg)

Diabetic Retinopathy (DR) Diabetes is the leading cause of adult blindness in the US At 20 years after the onset of diabetes, up to 99% of persons with Type 1 diabetes & 60% with Type 2 diabetes have DR to some degree. Affects entire retina & can cause any level of vision loss, including total blindness

Diabetic Retinopathy (DR) Involves a continuum of pathology beginning with non- proliferative form or background diabetic neuropathy Only common eye disease that can cause varying patterns of vision loss because it affects the blood vessels that support the entire retina. Scattered spotty areas of vision loss, called scotomas May have decreased contrast sensitivity & color discrimination, poor night vision & fluctuations in vision May experience diplopia from neuropathy that affects the 3 rd or 6 th cranial nerves (usual resolves spontaneously) (Warren, NEI, & AFB; AMD.org. Kaldenberg)

Age related macular degeneration (AMD) Leading cause of visual impairment among adults in US; Often causes low vision but not complete blindness. Two types "wet" and "dry." Dry is most common. In the dry form, there is a breakdown or thinning of the layer of retinal pigment epithelial cells (RPE) in the macula. Wet AMD occurs when blood vessels growing up from beneath the retina leak blood. Leaked blood pushes on the light receptor cells resulting in damage to the retina.

Age related macular degeneration (AMD) Affects central visual field; does not destroy peripheral vision A vision problem of the retina. Yellowish deposits (drusen) form, resulting in distortion and gradual blurring of vision. In advanced cases, blind spots develop that grow larger as the disease progresses. Causes a clearly demarcated central blind spot (scotoma). Even early loss of central vision causes significant functional problems (Warren, NEI, & AFB; AMD.org. Kaldenberg)

Glaucoma Warren: Group of eye diseases in which the pressure inside the eye is too high for the health of the eye and causes damage to the optic nerve. Increased pressure gradually damages the delicate optic nerve fibers and causes vision loss. Distinctive pattern of vision loss. Begins by reducing vision in the mid-peripheral visual field and then progresses toward the center and the periphery, reducing or eliminating the vision. (Warren, NEI, & AFB; AMD.org. Kaldenberg)

Glaucoma If untreated can leave affected eye with only a narrow tunnel of vision or, in some cases without any vision. Because if affects central vision only in late stages, can be advanced in the presence of near normal acuity on a vision chart. Restricted field can severely affect mobility. No symptoms, persons older than 40 should have eye exams every 2-3 years for early diagnosis (Warren, NEI, & AFB; AMD.org. Kaldenberg)

Cataracts Opacification of cloudiness of the lens of the eye Typically develop slowly; commonly occurs with advanced aging May occur congenitally in newborns; result from hereditary causes in young adult or from trauma Dulls colors & blurs visual detail; eventually compromises distance & near vision (Warren, NEI, & AFB; AMD.org. Kaldenberg)

Charles Bonnet Syndrome Syndrome characterized by visual disturbances usually occurring in people who have experienced visual impairment or sight loss later in life. May see a wide range of images, from simple patterns to people, animals, & buildings. Visual disturbances associated with this syndrome are not signs of mental illness, & people realize that the images they are seeing are not real. No cure for Charles Bonnet Syndrome. However, the symptoms often stop on their own. Should consult with an eye care specialist because treatment for underlying vision disorders may help. (Warren, NEI, & AFB; AMD.org. Kaldenberg)

Projections As noted by the National Eye Institute (NEI), millions of Americans lose some of their sight every year; furthermore, the condition is most common for those over age 65 (NEI, n.d.). Given population aging trends and the chronic nature of age related vision loss, occupational therapists will be increasingly likely to encounter clients with low vision in a variety of practice settings (McGrath and Rudman). www.nei.nih.gov

Impact of Low Vision Older adults with vision loss compared to older adults without vision loss bathing: 27.5% versus 11.7% dressing: 16.6% versus 7.4% preparing meals: 20.1% versus 6.7% managing money: 15% versus 4.2% performing light housework: 18.3% versus 7.6% (Kaldenberg & Berger reference to Crews & Campbell, 2001)

OT Role: In order to provide quality, well informed, evidenced based services for this population, it is important for occupational therapy practitioners to understand the impact of low vision on occupational performance and be able to provide simple adaptations or strategies to maximize participation, safety and quality of life (Weisser-Pike and Kaldenberg).

High, Low, No Tech Intervention Assistive Technology Device any item, piece of equipment, or product system, whether acquired commercially, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities. (Assistive Technology Act of 2004)

Classifying technology Low Technology: (Low Tech) Simple technology, with generalized systems or devices Minimum of capital investment Comprehended easily Requires increased level of clinical reasoning and creativity High Technology (High Tech) Technologies involving highly advanced, specialized systems or devices Large capital investment More advanced training may be required Clinical reasoning driven by systems and protocols (Rakoski & Ferguson)

Low & high technology Distinction between the two is imprecise Low Tech = inexpensive devices that are simple to make and easy to obtain High Tech = expensive, more difficult to make and harder to obtain (Cook, A. & Polgar, J.)

No Tech Environmental modifications Modification - a change in something (such as a system or style) Adaptive strategies Strategies: a careful plan or method for achieving a particular goal www.merriam-webster.com

General considerations for compensation Eight key elements in the home environment that can be utilized and adjusted to enhance the functioning of people with vision loss: lighting; glare; color contrast; labels lettering & marking; organization; use of texture & touch; environmental cues and techniques such as sound and smells; safety issues (Orr & Rogers) Many of the examples included in this presentation fit in several categories and/or overlap. Suggestions and material presented is intended to provide some examples and is by no means exhaustive.

No Tech (AFB; AOTA; Bergman; Caves; DeBrakeleer; Orr & Rogers; Steelman)

Lighting Overhead lighting to help eliminate shadows and keep rooms evenly lit Room should have more than one light source so that lighting is dispersed Light should be aimed at the work not at the eyes Maintain good lighting in the hallways walkway stairwells etc. Use nightlights, flashlight or hall or room lighting if you get up at night Install extra lights in the bedroom closet and other frequently used closets and other rooms Improve task lighting with easily adjustable gooseneck lamps Replace burned-out light bulbs regularly Use adjustable blinds, sheer curtains or draperies to allow adjustment of natural light Note: Home Environment Lighting Assessment (HELA)

Glare Place mirrors so that light doesnt reflect off them Reduce glare by covering windows with shades, mini-blinds or honeycomb blinds If wax floors, use non-glossy wax Avoid using glossy finish paper Position computer monitor away from ambient light sources

Color & contrast (solid colors typically work better than patterns) Bathmat (nonskid) and towels contrast with floor and wall Replaced toilet seat with one contrasting color Place colored tape on edges of stair risers; paint thresholds with a highly contrasting color Use white sheets with dark comforter and pillows Use contrast for place setting or place the plate on a nonskid contrasting surface such as piece of cloth or shelf liner Use a dark colored or striped toothpaste to contrast with white toothbrush bristles or vice versa Avoid using clear glasses with water or clear liquid Drape a contrasting color towel around the shoulders to make the head and hair more visible while grooming; alternately install a high towel bar across from the mirror in the bathroom and hang a contrasting towel

Labels, lettering, & marking Use rubber band to distinguish items such as shampoo & conditioner or use separate pump dispensers Ask pharmacist for large print labels Mark each pill bottle in a distinctive way for easier identification Use large print pillboxes (and contrasting colors) Use large print check registers; banks required to make statements available in large print if requested Large print for other common items such as calendars, magazines, books Large print games such as Monopoly, & Scrabble Fonts that have an equal amount of space allocated for each letters such as Courier

Organization Remove clutter Use organizational strategies & devices such as shower caddy, drawer organizers Use tray dividers to hold items like cosmetics and small tools Organize bills & other important papers in different colored trays or folders Establish a place to put essential small items such as keys, eyeglasses, etc. & keep them in the same easy-to-access location Hang clothes by color Make a list according to where the items are in the grocery aisles Use wall-mounted pegboard to hang frequently used kitchen items (choose safe location)

Use of textures & touch Bathmat that has a different feel than the floor or tub Apply makeup or shaving using facial features such as the nose and chin as landmarks Use clothing tags or sew different shaped buttons to mark clothing Distinguish similar clothes with safety pins Use a multiple compartment wallet and/or system for identifying paper money (e.g. $1 bills unfolded and extended flat, $5 bills folded in half with the short ends together, fold $10 bills in half lengthwise with the long sides together, fold $20 bills in half and then fold in half again)

Environmental cues &/or alternate techniques Place furniture & appliance in traffic patterns to feel comfortable to use; move furniture from the middle of a room to a wall to create an open pathway Shop online or use stores that offer delivery Avoid moving quickly from a dark room to a lighted area and vice versa Pay bills and track accounts online (enlarge font) Use a magnifying mirror for application of make up; hair grooming Try detergent tablets/ premeasured tablets Help to locate items in the room using the clock method Rooms that have color contrast between the walls & furniture may be easier to navigate

Environmental cues &/or alternate techniques Family & friends learn & use sighted guide techniques Use audible medication reminder Install doorknobs of contrasting color with the door or hanging a brightly colored ribbon on the doorknob Avoid upholstery with patterns & patterned carpeting Subscribe for radio reading and news line services NFB news Include video description of TV programs and films & movies Use clock method for locating food on plate Use an electric razor for shaving

Safety issues Note how far you have to rotate faucets to turn the temperature to what you want. Turn on cold water first then add hot turn off hot water first Remove clutter, cords and throw rugs Use the microwave if you feel unsafe using the stove Do not wear long sleeves while cooking Use trailing and protective techniques Use nonskid surfaces in the tub or shower Remind others to close doors and drawers completely Remove flammable or combustible items from around the cooking area Be sure the light switches can be reached from the entrances to each room and from the bed Halogen light is very hot and focused and can cause fire burns; it is not recommended for close up tasks

Low Tech (AFB; AOTA; Bergman; Caves; DeBrakeleer; Orr & Rogers; Steelman)

Lighting Under counter lighting to highlight meal prep area Glare Anti-glare computer screen Color & contrast Large letter computer keyboards, with bright contrast Contrast cutting boards Organization Use of personal digital assistant

Labels, lettering, & marking Pens with a light &/or enhanced visual contrast E-books & newspapers (allow contrast variation & increased font size) Accessible cell phones & tablets Software packages for screen/print enlargement (also can be high tech) Large print heating and air conditioning thermostat

Labels, lettering, & marking Book share (www.bookshare.org ) Once registered (nominal fee), can download up to 100 books per month. Books can be read on a computer with screen enlargement software or a screen reader software program (which book share provides for free) or can be downloaded into a portable device that stores the books and electronically converts them into synthetic speech.)www.bookshare.org US Library of Congress (www.loc.gov/nls), for free, sends audiobooks and magazines to registered users.www.loc.gov/nls

Use of textures & touch &/or auditory cues Writing guides for checks, signatures, letters and envelopes Various shapes for game pieces such as checkers, poker chips Liquid level indicator Beeping &/or musical balls Talking thermometer, glucometer, blood pressure machine, weight scale Tactile bump dots for marking appliances, etc. Boil alert disc Audio books Auditory color ID Voice label scanners that can describe products such as contents of cans

Environmental cues &/or alternate techniques Word prediction & spellcheck utilities Utensils such as a rocker knife and plate guard Talking calculators, electronic bill identifiers, watches, clocks, etc. Use of needle threader; eye drop device Place pot on burner before turning it on Use double spatula to avoid spills when turning food Universal remote control panel with large buttons & speech recognition Handheld or stand magnifiers (non electronic) Note: Rather than attempting to buy any kind of optical device off the shelf, it is better to consult with a low vision specialist to determine what type of magnification if any would be useful for the types of tasks the person wishes to undertake.

Environmental cues &/or alternate techniques Accessibility features on operating systems of computers (e.g. increasing print and pointer size, modifying print and background color, voice input, & Flickr reductions; note: Fonts such as the serif Times Roman and sans serif Arial have features that are more easily distinguishable )

Safety issues Long oven mitts Grab bars in bathroom (contrasting colors) Syringe magnifiers Install smoke alarms, carbon monoxide detectors, and fire extinguishers Remote controls on-off switches

High Tech: (AFB; AOTA; Bergman; Caves; DeBrakeleer; Orr & Rogers; Steelman)

High Tech Home automation & emergency alert systems Keyless entries Script readers (e.g. script talk station - uses radiofrequency identification & text-to-speech technologies) Electronic mobility aids (software uses global positioning satellite) Voice recognition software Refreshable braille displays

High Tech Electronic portable magnifiers (may have capacity to freeze an image; change color contrast) Screen reader software (for computer and/or portable devices) Combined screen magnifiers and readers CCTV, video magnifiers (illuminate and magnify images and words on a screen) Optical character recognition (software that analyzes video data and converts for speech output)

Low to High Tech Variety of mobile apps (AOTA; AFB are resources) Examples: Tap TapSee (Free) Designed to help the blind and visually impaired identify objects they encounter in their daily lives Magnify (Free) Turns a phone into a magnifying glass with flashlight. Brighter and Bigger (Free) Turns your device into a magnification device that will make reading material bigger, brighter, and high contrast. Med Helper (Free) Tracks prescription medication, treatment, and appointment schedules. Alarm reminders and a log of past doses. My Med Schedule (Free) Web-based application that sends text alarms as reminders for taking medications. Read2Go ($19.99) Allows user to browse, search, download, and read books directly from Bookshare and other DAISY book sources.

Note: AFB access world magazine: provides some product evaluations & guides. Example: a comparative review of iPhone magnifier apps

AFB: Center on Vision Loss Student researchers (Haerer & Tuttle) initiated contact with 33 participants who completed a visitor survey after touring the Center for Vision at AFB in Dallas and were successful in obtaining responses from 25 participants. The 6 question follow-up survey included information on low vision strategies implemented by participants after touring the Center. Regarding low vision strategies implemented, participants mentioned both low tech and high tech strategies. Suggested/additional resources mentioned that would be helpful: Support groups, transportation, reading, technology, opportunities to donate

AFB Center on Vision Loss Results RESULTS

Evidence to support OT intervention Sampling of evidence articles included in reference list Kaldenberg, J. & Smallfield, S. Brunnstrom, Sorensen & Alsterstad Eklund & Ivanoff Smallfield, Clem, & Myers Fok, Polgar, Shaw & Jutai Occupational therapy practice guidelines for older adults with low vision (2013, AOTA press)

I wish I might be taken just as a normal person, and my accomplishment treated simply as illustrations of how much more others can do if they only use their five senses with thought and perseverance. Helen Keller

Resource List (separate)

References AFB (2000). To love this life; Quotations by Helen Keller, AFB Press, New York, NY. American Foundation for the Blind. http://afb.org/http://afb.org/ American Occupational Therapy Association: Occupational therapy practice framework: Domain & process, 3 rd ed. (2014) American Occupational Therapy Association: Tips for living life to its fullest: Living with low vision, (2013). American Optometric Association. www.aoa.orgwww.aoa.org Bergman, L. (2012) Out of sight, not out of mind: Personal and professional perspectives on age related macular degeneration. AFB press, New York, NY. Brunnstrom, G., Sorensen, S., and Alsterstad, K. Quality of light and quality of life the effect of lighting adaptation among people with low vision in OPthal. PHysiol. OPT, 2004 274-280 Centers for Disease Control and Prevention. (n.d.) The state of vision, aging, and public health in America. Atlanta: U.S. Department of Health and Human Services Center on Vision Loss - American Foundation for the Blind. (2013). Retrieved from http://www.afb.org/info/programs- and-services/center-on-vision-loss/12 http://www.afb.org/info/programs- and-services/center-on-vision-loss/12 Cook, A. M., Polgar, J. M. (2008). Cook & Hussey's assistive technologies: Principles and practice. St. Louis, Mo: Mosby Elsevier. Eklund, K & Ivanoff, S. (2006) Health education for people with macular degeneration: Learning experiences and the effect on daily occupations. Canadian Journal of occupational therapy

References Kaldenberg, J. & Berger, S. (April, 2008). Essential skills for working with older adults with low vision. Presented at the AOTA annual conference in Long Beach, CA. Kaldenberg, J. & Smallfield, S. (2013). Occupational therapy practice guidelines for older adults with low vision. AOTA press Lighthouse International. (n.d) All about low vision. http://lighthouse.org/about-low-vision-blindness/all-about-low-vision/ http://lighthouse.org/about-low-vision-blindness/all-about-low-vision/ McGrath, C., & Rudman, L. (2013). Factors that influence the occupational engagement of older adults with low vision: A scoping view. British Journal of Occupational Therapy, 76(5). National Eye Institute. (n.d.) Low vision: What you should know. http://www.nei.nih.gov/lowvision/content/know.asp http://www.nei.nih.gov/lowvision/content/know.asp Olson, D. & DeRuyter, F. (2002) Clinicians guide to assistive technology. Mosby, St. Louis, MO Radomski, M. & Latham, C. (2104). Occupational therapy for physical dysfunction, 7 th ed. Lipponcott, Williams, & Wilkins, Philadelphia, PA Rakoski, D. & Ferguson, R. (2013). The virtual context of occupation: Integrating everyday technology into everyday practice. OT Practice, 18(9), CE-8 Scheiman, M. (2011) Understanding and managing vision deficits: A guide for occupational therapists, 3 rd. ed. Slack Inc., Thorofare, NJ. Smallfield, S., Clem, K. & Myers, A. (2013) Occupational therapy interventions to improve the reading ability of older adults with low vision: A systematic review. The American Journal of occupational therapy, Vol 67, #3. Warren, M., & Barstow, D. (2011). Low vision: Occupational therapy evaluation and intervention with older adults. Bethesda: American Occupational Therapy Association Weisser-Pike, O. & Kaldenberg, J. (2010). Occupational therapy approaches to facilitate productive aging for individuals with low vision. OT Practice, 15(3), CE1-8.

Low Vision: High, Low, No Tech Compensatory Strategies Mountain Central Conference November 9, 2014...

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