Vision and perception in people with dementia, Part 1

This series of blogs is excerpted from the March 2009 issue of my publication Wiser Now Alzheimer’s Disease Caregiver Tips which focused on vision and perception in people with Alzheimer’s disease and other forms of dementia. It covers four topics:

1) There are many vision changes associated with aging that probably affect people with AD as much as the general population.
2) Aging-related vision disorders are frequently untreated when people with AD can no longer clearly express their difficulties in seeing clearly.
3) Vision, memory and perception are all linked, so that even when someone can see an object clearly, she may not be able to make sense of it.
4) There are many unknown factors, such as conditions like synesthesia that may contribute to hallucinations.

Vision challenges as we age

As we age, nearly everyone is affected by these changes in vision:

1) A diminished ability to adjust to changes in light. Going from bright sunlight to an indoor space tends to be especially difficult; it may take as long as 10 minutes for an older person’s eyes to adjust fully, so it’s important not to drag someone from an outdoor excursion inside and down the hall to her room without letting her sit just inside the door for a few minutes to give her eyes time to adjust.

2) An increased sensitivity to glare. You may see older people shrink from bright windows, light reflected on metal, shiny floors (that may look wet and unsafe), and direct sunlight. Glare is not only visually uncomfortable, but may actually cause physical pain, such as headaches, in older adults.

3) Aging eyes need much more overall light to see clearly. The average 65-year-old needs two to three times the amount of light as the average 20-year-old. People over 80 or older adults with special visual problems like those we discuss in the next section may need up to 10 times that amount of light. This is especially true when someone is doing a particular task such as needlework or a jigsaw puzzle, but also applies to eating or walking – hallways and stairways need to be well lit. In general, most lighting problems in residential care communities come from a lack of uniformity in lighting – a confusing mixture of “hot spots” and dim lighting.

4) Decreased visual acuity – formally called presbyopia, informally called “Need longer arms syndrome.” As we grow older we have a decreasing capacity to focus on objects at close range, so we either get new glasses or hold reading materials at arm’s length. The need for longer arms is caused by changes in the eye’s lens. When we are young, and shift our focus from a near object to a distant object, it is the lens which changes shape to focus on the new object. As we age, the lens becomes stiffer. It’s like having eyes that go from being an auto-focus camera, which can focus clearly on any object at any range, to a fixed-focus camera that blurs items out of its focal range. Most older adults have reading glasses for this condition, but because this condition tends to get progressively worse with age, people with dementia may no longer be wearing a prescription that meets their needs.

5) A yellowing or dulling of the lens. When we are young, the lens on our eye is nearly clear, but as we edge past 40 we usually begin to notice that our vision isn't as precise as it used to be, and we need more light for reading and close work. Tissue builds up and the lens that used to be almost clear is now distinctly yellow. Colors become muted, so that when we are 80 or older, it can be nearly impossible to tell yellow from peach, or pale lavender from pale blue.

6) Dry, itchy eyes and eyelids. These problems may be caused by eye disorders or by environmental factors such as heating or air conditioning systems, fans, wind, dry climates, air pollution (including cigarette smoke), and hair dryers. Because most older people with dry eyes are women, some think the condition may be estrogen related. Other people believe it may be an acquired allergic reaction to eye make-up in women who continue to use it. This is easily treated with eyedrops, but people with dementia may not be able to express their need for them.

Alzheimer’s disease and group singing

Barbara Jacobs is the creator of the video/CD series, “Front Row Seat” (http://www.frontrowseatvideos.com/) specifically designed for people with Alzheimer’s disease. Her formula for success working with people with AD is to lead a music class, not just a sing-along. She begins with a reminiscing warm-up activity, bringing in a CD, for example, of Nat King Cole or Judy Garland. After playing a song or two, she provides some brief information on the artist’s life (easily found on the CD cover or the Internet), and then encourages participants to share their memories and knowledge. The singing follows, helped along by large print copies of the lyrics, for those who want them.

There are many other ways to enliven group singing. Barb, as demonstrated on her CDs, adds such things as dancing, blowing bubbles and children to the mix. Another idea is to change the words. For example, the song “My Favorite Things” from “Sound of Music,” has been re-written in an aging version that includes these lines:
When the pipes leak,
When the bones creak,
When the knees go bad,
I simply remember my favorite things,
And then I don't feel so bad.

Parodies are fun to sing (and create), but a simpler way to change the words is simply to change the nouns. For example, change the:

• Flowers in “When You Wore a Tulip, and I Wore a Big Red Rose" (lilac and daffodil?)
• Ethnicity in “My Wild Irish Rose” (Mexican?)
• Name in any song that uses one, such as “I’m in Love with Amy,” (why not Nancy or Susie?) or “I’m Just Wild About Harry” (Why not Johnny or Jimmy?)
• Colors in any song that includes them (Why not red suede shoes, purple rose of Texas or blue cliffs of Dover?)

All of these ideas can also be used to start a reminiscence discussion on a musical theme, too. For example:

• Talk about colors participants like by singing songs like "The Little Brown Jug," "When the Red, Red Robin," and "By the Light of the Silvery Moon."
• Talk about the funny things you did when you were younger by beginning with silly songs: "The Flat Foot Floogie," "Mairzy Doats," and "Barney Google."
• Talk about names you like or how you were named by singing "Sweet Adeline," "My Bonnie Lies Over the Ocean" "Alexander’s Ragtime Band," and "When Johnny Comes Marching Home."
• Discuss your courting days and sing, "Love and Marriage," "I Want a Girl," "Let Me Call You Sweetheart," "Makin' Whoopee," and "Get Me to the Church on Time."

There are dozens more songs in each of these categories and dozens more categories that will stir up memories and start the toes tapping. One resource for ideas and trivia games with song titles is ElderSong’s “Say it with Music.” (http://www.eldersong.com/StoreFront.bok)

You can intersperse singing with discussion as Barb Jacobs recommends, whenever you need a change of pace. People with AD tend to be good at filling in the blanks when you say the beginning of a line or title to a song, such as:

• Hail, Hail . . . The Gang’s All Here
• I Wonder Who's . . . Kissing Her Now
• In the Good Old . . . Summertime
• Let Me Call . . . You Sweetheart
• You Must Have Been . . . a Beautiful Baby

You can also ask opinion questions about music: Do you like Big Band music? Do you enjoy close harmony singing like barbershop quartets or the Andrews sisters?

By Kathy Laurenhue, excerpted from Wiser Now Alzheimer’s Disease Caregiver Tips, (June 2008, Vol.9 Issue 5). Available from www.wisernowalz.com or www.wisernow.com.

A chance to talk...

At a conference in New Orleans last week, I had the great privilege of moderating a panel of people with Alzheimer’s disease as they talked about what it’s like to live with this debilitating condition. Even the gentleman whose word-finding difficulties were quite advanced and frustrating for him (He had been an economics professor) was amazingly eloquent as he described how he managed to find a way around the words he could no longer conjure up. All of the panelists described the importance of maintaining a sense of humor. They heartily agreed with what Kurt Vonnegut once said,

“Laughter and tears are both responses to frustration and exhaustion.
I myself prefer to laugh,
since there is less cleaning up to do afterward.”

At the end, the panelists received a well-deserved standing ovation. If you are planning a conference at which dementia is a topic, my advice for the most moving and enlightening presentation possible is to give people who have Alzheimer’s disease a chance to talk for themselves. (For tips on how to prepare the participants, contact mailto:kathy@wisernow.com )