Adjustment to Aging and Low Vision

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Adjustment to Aging and Low Vision
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Lecture Objectives

• Understands factors affecting adjustment
  physical, emotional, social, cognitive
• Describes interaction between vision loss and
  issues related to aging
• Identifies appropriate intervention strategies

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Stalemate When I was young and in my prime Bill
paying took such little time. One little sheet
with message clear, Pay this amount was written
here. Now Im older, visions poor Hands are
shaky, and whats more, Bills now come
computerized, Page 1 of 4, page 3 of 5. With
digitals that look the same. 5,3, or 8, a
guessing game. When I was young and in my
prime Twas hard to pay my bills on time. Now
Ive got dough but theyre apt to sue Cause I
cant find the balance due Leta Harvey,
Writer and Poet, age 82
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Small Group Activity

• List typical losses associated with aging
• List losses specifically related to vision loss

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Low Vision and Aging Facts

• Older adults make up 2/3rds of low vision
  population
• Age is the single best predictor of vision loss
• Person makes 2 simultaneous adjustments
• To the chronic progressive nature of vision loss
• To the chronic progressive nature of aging

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Low Vision Aging cont

• No two people age the same way
• There is infinite variety among individual
  older persons, whether visually impaired or
  sighted. Neither chronological age nor functional
  disability determines behavior
• Hendricks (1992)
• Persons become more heterogeneous as they age

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Adjustment to aging and vision loss is a product
to many factors
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Adjustment to aging and vision loss is a product
to many factors

• Physical ability
• Cognitive ability
• Sensory abilities
• Psychological make up
• Emotional fortitude
• Family and community support
• Financial resources

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Vision loss does not automatically result in
increased dependency and disability

• Successful adjustment to vision loss depends in
  part on success in handling life crisis in the
  past
• Older adult who has coped with challenges in life
  and arrives in old age with a strong ego and self
  concept likely will accept challenges of vision
  loss and remain independent
• Kleinschmidt 1999

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Vision loss presents a formidable obstacle to
maintaining independence

• Especially when accompanied by other impairments
• Impact of these limitations is compounded by
  other losses that accompany aging

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Vision loss presents a formidable obstacle to
maintaining independence

• Especially when accompanied by other impairments
• Impact of these limitations is compounded by
  other losses that accompany aging
• Death of spouse/diminished family life
• Diminished financial resources
• Reduce social outlets

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Combination of these factors can cause increasing
isolation and inactivity

• Isolation and inactivity are two of the most
  challenging problems facing older adults with
  visual impairment
• Both have been shown to have a negative impact on
  adjustment

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Challenges for Family and Friends

• Persons with low vision present an ambiguous
  social situation for others
• Fletcher et al 1991
• They do not carry outwards signs of disability
• White cane, dark sunglasses, dog guide
• They look no different than when they were fully
  sighted

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• Persons disability is often inconsistent
• Person with AMD may be able to navigate a maze
  of obstacles in a grocery store but be unable to
  identity a can of soup
• Because of ambiguities and contradictions,
  family/friends often dont know how to react to
  the person
• May expect too little or too much
• May attribute limitations to dementia,
  depression, or just not trying

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• Family members may experience fear regarding
  persons safety
• Children may experience desire to reverse roles
  and do everything for parent
• Family members may feel burdened with
  responsibilities and worries
• Family /friends may be uncertain whether to talk
  about the loss with the person
• Becomes the elephant in the room that nobody
  talks about

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Person is also confused by nature of visual
condition

• Often told that they are legally blind but
  realize that they can see
• Often take 2 opposite approaches
• May try to pass as having normal vision to
  avoid social awkwardness
• May stop using vision altogether to prepare for
  further loss of sight in the future
• Conrod and Overbury 1998
• Either approach may result in reluctance to seek
  help from a low vision rehab program

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Emotional Support is an Important Factor in
Adjustment

• Person faces a set of three stressors
• The vision loss is progressive
• Vision loss is irreversible-there is no cure
• Possibility of significant decline in functional
  capacity
• Ability to adjust to these stressors depends in
  part availability of emotional support

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Emotional Support cont.

• Quantity of support is not as important as
  quality
• Do not need a large network
• A single source of emotional support is
  sufficient if support reflects acceptance and
  caring
• Children provide best source of support
• Peer and support groups and telephone contacts
  can be effective (Kleinschmidt 1999)

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Remaining Engaged is also a Key Factor in
Adjustment

• 3 top sources of high morale for adults
• Entertainments and diversions
• Socializing
• Productive activity
• Primary sources of low morale
• Dependency (financial or physical)
• Physical discomfort or sensory loss
• Loneliness
• Bereavement
• Loss of nuturing
• Boredom, inactivity
• Immobility and confinement

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Engagement continued

• Vision loss can limit participation in the
  sources of high morale and exacerbate sources
  that contribute to low morale
• Majority of older adults fill days not with work
  but with leisure
• TV viewing, visiting and reading account for
  greatest share of leisure time
• Consume approximately 6 hrs per day

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Engagement continued

• Older adults are the largest subscribers to daily
  newspapers and use the newspaper to stay informed
  and connect with daily events
• Vision loss can interfere with performance of
  these activities
• Unable to read print, clearly see TV or dial a
  telephone
• Difficulty recognizing faces
• Limited transportation options

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Engagement continued.

• As a result, older adults often have to give up
  activities that were not only a source of
  satisfaction but also a means of staying engaged
  and active in world
• Assisting the person to overcome limitations and
  increase activity level is one of the primary
  issues of low vision rehabilitation

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Dealing with Loss is Another Factor in Adjustment

• Face loss of family and friends with greater
  frequency than younger adults
• Spousal loss can be especially devastating
• Lose companionship and independence if spouse
  performed activities person can no longer do
• Can also lose access to social outlets

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Dealing with Loss cont

• Other losses faced by older adults
• Loss of income and prestige following retirement
• experience identity crisis
• Loss of home when decision is made to move into
  assisted living
• Loss of driving privileges
• Loss of control over personal finances

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Successful Coping

• Each person with vision loss is unique
• Adjustment to any change, even a positive change
  is a process
• Occurs in incremental steps and stages that build
  on one another to restore psychological well being

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Many variables enter into successful adjustment

• Motivation to remain independent
• Cognitive ability
• Personality
• Attitude
• Self concept
• Nature of the visual impairment
• Presence of other disabilities

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Variables continued

• Past experiences
• Vocational and avocational involvement
• Family support
• Financial resources
• Physical environment and resources

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Initial Reaction to Diagnosis

• Shock or denial of the vision loss
• Can take several forms
• Continuing to complete activities despite serious
  difficulty and safety risks
• Doctor and program shopping
• Anger at living longer but not necessarily better
• May direct anger to a situation
• Or to a family member

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Initial Reaction continued

• Feelings of deterioration and vulnerability
• Sense that they are falling apart
• One loss will lead to another in a downward
  spiral
• Despair and hopelessness
• Social isolation/psychological withdrawal
• Fear
• Grief and mourning
• Although painful, a positive sign that person is
  moving through the adjustment process

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Coping

• the process through which people adjust to the
  stressful demands of their daily environments
• Christiansen 1991

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Coping Requirements

• Person engages in specific problem solving
  efforts
• Uses personal resources and competencies to
  create new ways of dealing with problem
  situations and reducing stress

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Three Components of Coping

• Must be able to acquire/process new information
  needed to understand the situation
• Must be able maintain control over emotional
  state
• Identify emotions being experienced
• Express them appropriately
• Control their expression
• Must have freedom of response or realistic
  alternatives for dealing with the situation

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Successful Coping Leads to Adaptation

• Adaptation is the satisfactoriness of fit between
  an individual and the environment
• Equates with quality of life

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Two Classifications of Coping Responses

• Problem focused
• Person makes effort to manage the nature of the
  problem
• Change the circumstances of the situation
• Emotion focused
• Person attempts to regulate the emotions or
  distress accompanying the situation

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Q Which of the two responses is predominantly
used to deal with chronic conditions?
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Q Which of the two responses is predominantly
used to deal with chronic conditions?Emotion
focused because person cant make the problem go
away
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Coping process begins with cognitive appraisal

• Person sizes up a situation and decides how to
  respond
• Very complex process with many factors
• Environmental factors
• Personal characteristics

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Environmental Factors in Coping Process

• Type and nature of stressors
• Long term vs. short term
• Negative vs. positive
• Social network
• Number and quality of supports
• Generally, social support is positive
• Depends on the type of support offered
• Positive material assist, emotional comfort,
  inclusion, encouragement
• Negative irritation, resentment, judging,
  unwilling to hear emotions expressed, pessimism,
  supplying misinformation

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• Availability of social supports does not equate
  with use
• Some persons view support has an indication that
  they are unable to cope without assistance
• Offer of support would threaten self esteem

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Environmental Factors cont

• Economic and educational resources
• Provides more options and choice
• Increases locus of control
• But can also increase frustration when money
  cant solve problems
• Situational ambiguity
• Presence greatly magnifies stress and taxes
  coping ability
• Cant formulate a plan for coping

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Personal Characteristics

• Commitments
• A persons values, motives, goals, the things
  that give meaning to their life
• Point of view
• Powerful influence-can direct a person towards or
  away from certain activities, situations
• Determines perception, appraisal of a situation
• Therapy can be a godsend or a supreme waste of
  time
• Strong commitments can create psychological
  vulnerability
• Create desire for secondary gain

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Personal Characteristics

• Beliefs
• Serve as perceptual lens through which person
  views the environment
• Shapes cognitive appraisal
• Two major categories
• Belief that person has some control over events
• Belief that person is vulnerable and at the mercy
  of fate
• Beliefs play a greater role when the situation is
  ambiguous and are less influential when a
  situation is clear cut

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Personal Characteristics

• Personality disposition
• Optimist vs. pessimist
• Influences the strategy the person chooses to
  cope
• Optimists tend to do better
• Engage in problem focused coping
• Seek social support
• Avoid denial and disengagement
• The most successful personality
• Self confident and easy going

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Personal Characteristics

• Personal history
• If person has faced hard times and survived,
  h/she can often draw on that strength to cope
  with vision loss
• Cultural influences
• Example Midwesterners have a very stoic
  personality
• Less likely to actively solicit help from any
  source

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• Environmental factors and personal
  characteristics affect the way in which a person
  perceives and appraises a stressful situation and
  formulates a response

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Coping Strategies

• Cognitive
• Behavioral
• Avoidant

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Cognitive Coping Strategies

• Attempt to manage appraisal of the situation
• Frame the situation to see it in a certain light
• Example drawing on past experiences to see the
  positive side
• Employ information gathering

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Behavioral Coping Strategies

• Apply information gathering and problem related
  actions aimed directly at the source of stress
• Why am I feeling this way, how can I change my
  emotional response
• Rehearse alternative outcomes
• Request reassurance and emotional support

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Avoidant Coping Strategies

• Reduce emotional attention through diversion or
  conscious efforts to circumvent or sidestep the
  source of stress
• If I cant read, Ill watch TV instead
• Two forms of denial are used
• Denial of fact
• My vision is perfect
• Denial of implication
• My vision is poor but I can continue to live in
  my own home and drive

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• Because western cultures place great value on
  mastery, tend to equate successful coping with
  problem solving and gaining mastery over a
  situation
• Cognitive or behavioral strategies take
  preference over avoidance strategies
• However research suggests avoidance strategies
  may be more useful in the early stages to help
  person avoid being overwhelmed by the situation
• As long as the person also employs active coping
  strategies

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• Avoidance strategies are also most successful for
  dealing with long term disability
• I am a person with a visual impairment
• I am a visually impaired person

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OT Intervention

• Realize there are many coping styles
• Acknowledge the style and work with it unless it
  is maladaptive
• Important to identify the clients style as early
  as possible
• Shapes the plan of care
• Helps you set realistic goals

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• Person will not necessarily experience all of
  these feelings or experience them in any kind of
  order
• See a lot of shifting back and forth

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Improving Coping Strategies

• Use strategies designed to strengthen problem
  solving skills and provide accurate appraisal of
  the situation facing the person
• Provide factual information about the persons
  visual condition
• Assist the person to view the situation
  realistically
• Assist the person to draw on past experiences to
  draw strength

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Facilitate Problem Solving

• Effective problem solving should increase the
  likelihood that the person will select the most
  effective solution
• 5 steps in problem solving
• Problem orientation person develops attitude
  that an effective solution can be found
• Problem definition and formulation person is
  taught to define problem situations in detail

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Facilitate Problem Solving cont

• Generation of solutions various solutions are
  tried out and assessed for success
• Determination of course of action examination of
  the expected consequences of the action
• Verification of the effectiveness of the
  solution person reflects on performance and
  seeks and receives feedback

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• Problem orientation

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• Problem orientation
• Assist person to frame the problem so that h/she
  can see h/she has control over certain
  circumstances
• Show person they have options in completing a
  task

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• Problem definition and formulation

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• Problem definition and formulation
• Assist person to analyze tasks
• Break them down into components
• Address each component
• Can be very successful at dispelling the sense
  that the task is overwhelming and cant be solved
• How do you eat an elephant?

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• Generate solutions

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• Generate solutions
• Direct person towards achievable, feasible
  solutions
• Be creative and flexible
• More than one way to skin a cat
• Have another suggestion ready if one solution
  fails
• Encourage persistence

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• Determine a course of action
• Completed through establishment of the plan of
  care
• Set clear, realistic, achievable goals
• define the patients limitations in a way that
  the patient is able to appraise them properly and
  respond to them as challenges rather than threats
• Solicit the persons commitment by requiring that
  they sign the plan
• If person commits to a goal, motivation will
  increase
• But so will psychological vulnerability
• Person is putting themselves out there
• Critical that the treatment approach is
  structured so that the person experiences early
  success

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• Verify effectiveness of the solution

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• Verify effectiveness of the solution
• Provide objective but compassionate feedback

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Key to Success

• Enlist the person as a partner
• Client centered approach
• Gives person control and increases their
  commitment
• Successful therapy approach as long as there is
  sufficient time to employ it
• Takes multiple treatment sessions

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Utilize Environmental Resources

• Most important resource is social support
• Involve family members in treatment if their
  support is constructive
• Refer to support groups
• Share common experiences
• Gain information
• Provide mutual help and support

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Dealing with Depression

• Many adjustment problems can be addressed with
  a well designed intervention designed to increase
  occupational performance
• Person is not so much depressed as frustrated
• Clinical depression is another matter
• Shown to lead to greater disability
• Can lead to suicide

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Increased Disability

• Rovner et al (Wills Eye Hospital Philadelphia)
• Visual function and self care independence
  declines in persons whose depressive symptoms
  increase
• Discouragement and helplessness drain inner
  resolve and resiliency and anergia, poor appetite
  and sleep impair effortful behaviors
• Archives of Ophthalmology August 2002
• Depression must be recognized as a distinct
  treatable disorder

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Suicide

• Suicide rates are increasing among older adults
• Represent 13 of population but commit 19 of
  suicides
• More likely to be successful if suicide is
  attempted
• Not a plea for help but a way out
• Any mention of suicide should be taken as a
  serious threat
• Contributors to suicide
• Depression, poor sleep quality, limited social
  supports

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Symptoms of Depression

• Persistent, pervasive depressed mood
• Loss of interest or pleasure in usual activities
• Increase or decrease in appetite or weight
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Feelings of worthlessness or excessive,
  inappropriate guilt
• Impaired thinking or concentration

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• Seek professional help for any signs of depression