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.

Driving and Dementia, Part 1.

The August issue of Wiser Now Alzheimer’s Disease Caregiver Tips covers Part 1 of the topic of driving and dementia. (What makes people with Alzheimer’s disease unsafe drivers?) As we age, our reaction time slows, our ability to refocus our eyes quickly between close and distant objects diminishes, and we often experience other physical changes that can affect our driving skills.

When people have dementia, they develop a whole new group of much more serious problems that cause them to make mistakes such as these:
•Getting lost going to familiar places
•Stopping in traffic for no apparent reason
•Failure to stop at a stop sign or red light
•Confusing the gas and brake pedals
•Driving at inappropriate speeds (often too slow)
•Moving into the wrong lane and difficulty maintaining lane position
•Easily flustered and distracted while driving
•Poor judgment when making left hand turns
•Hitting curbs

Often their vision is adequate to pass the mandatory vision exam when they are retested, but that short test fails to distinguish the difference between vision and perception. A person with dementia, for example, may see a caution sign but not be able to interpret its meaning, or may see a car approaching as he makes a left hand turn, but not be able to judge its distance and speed.

What is perhaps most dangerous of all is that they lack insight into their difficulties and frequently defend their abilities by saying, “I just have to be careful.”

The deficits are real, but the solutions are complex and often lacking. For example, a person who can no longer drive safely often can no longer manage public transportation safely either, and that’s assuming there is even public transportation available.

Read more about this issue by signing up for Wiser Now Alzheimer’s Disease Caregiver Tips and adding your comments to the debate.

Should I travel with my loved one with dementia?

Here is an edited excerpt from the latest issue of Wiser Now Alzheimer’s Disease Caregiver Tips that focuses on traveling with and without your loved one:

Many years ago I had an offbeat friend from Michigan of Czechoslovakian heritage whose sister married a Texan. At the wedding reception, all the northern guests were taught country line dancing as a way of introducing them to the southern culture and welcoming them into the family. My friend felt that courtesy called for an equal gesture on her family’s part, so she gathered them together, and on the spot made up a Czech folk dance which they dubbed the “Klotzky,” whose chief feature was “a jump step” and flailing arms. It was an immediate success, and I am told is now featured at all family gatherings. If your family is equally spontaneous, consider taking your family member with dementia anywhere you want to go.

Families who have more in common with Auntie Mame than Amy Vanderbilt, who delight in the possibility that anything might happen and can always be counted on to go with the flow are likely to put your loved one with Alzheimer’s disease at ease at many events. The challenge with graduations, weddings, high school reunions, vacations and family reunions is that your loved one is likely to encounter many unfamiliar people, places and situations that your understanding family members may not be able to protect him from.

Before embarking on a trip across time zones or state lines, ask yourself, in what ways will my loved one or others benefit by taking this trip? If your first grandchild is getting married, for example, and your loved one has long been close to his granddaughter, the extra effort required in making the trip may be worth it for everyone involved.

At the same time, set realistic expectations. If your granddaughter wants her grandfather at her wedding, but hasn’t seen him in a year and your gut feeling tells you that he will be more upset than pleased by the event, go with what will be best for his well-being. Will your loved one with dementia be comfortable in this out-of-the-ordinary setting, or will he be frightened by the crowds, bored by the ceremony, and quickly fatigued by the unaccustomed hullabaloo?

Think of your own ease as well. Are you worried that he might speak his mind at inopportune times, that you will have to constantly look out for him in order to protect him from others who are unaware of his limitations, and that in so doing you won’t enjoy the event yourself?

Think of your granddaughter, too. The focus should be on the people getting married, not on your loved one. If you, he or they would ultimately be more comfortable if he were not there, make arrangements for him to stay behind. If you think he could handle the wedding but not the reception, make arrangements for him to attend only what is most appropriate, and be ready to revise your plans as needed if you guessed wrong.

Not everyone lives in a wild and crazy Auntie Mame-style family, and that’s fine. When considering whether or not to take your loved one with dementia to a family affair, weigh what’s fair for all involved.

To subscribe to Wiser Now Alzheimer’s Disease Caregiver Tips, click here.