Seeing it from their side
Adapting older people’s services to
support sight loss
; Why do I need to understand about sight loss?
; What causes sight loss?
; How can I identify sight loss in my service users? ; Sight loss and other health issues
; How can I meet the specific needs of service users with sight
; Changes to your services environment
; Tips for lunch clubs
; Keeping people active
; Moving around your service
; What RNIB and Age UK can do to help
; Contact us
Foreword by Clare Vollum, Head of Service Development, Age UK
Our population is ageing. There are currently 13 million people in the UK aged over 60, and demographic changes will result in a dramatic increase in the number of older people over the next decades. Although it can affect anyone at any time, losing our sight becomes increasingly likely as we get older. Almost two million people in the UK are living with sight loss.
Compared with previous generations, many older people now experience a long period of good health and wellbeing and continue to be active, contributing members of society. People with sight loss should still be able to equally enjoy these benefits in later life.
Older people with sight loss need sensitively designed services that are appropriately delivered by trained staff, and accessible and inclusive activities. They may also need a bit more specialist support to help them maintain good physical health, social and economic wellbeing, and to participate in social, civic and cultural activities.
Services for older people should routinely be well equipped to meet the needs of older people with sight loss. Many local Age UKs and Age Concerns, as the case studies in this guide show, provide such services. Some have adapted existing services and activities, seeking advice from local specialist blind and partially sighted associations and accessing training for staff. Others provide personalised support, such as information and advice, and practical assistance with day-to-day activities, for older people living with sight loss.
Age UK is very pleased to be working in partnership with RNIB to produce this resource, which aims to provide Age UKs with a guide to the issues affecting older people with sight loss. We hope that the case studies will provide ideas and practical examples that can be used to help make your services accessible to blind and partially sighted people.
Why do I need to understand about sight loss? Sight loss isn‟t confined to those who are registered blind and partially sighted. Many older people are living with significant sight loss, and some have vision which is equivalent to people who are partially sighted or blind. This includes people waiting for or having treatment such as cataract surgery to improve their sight. And it includes people whose vision loss could be improved by wearing the right glasses. Any level of sight loss, and the impact on a person‟s day-to-day living is important.
Although it can affect anyone at any time, losing our sight becomes increasingly likely as we get older. It is important to raise awareness of the importance of taking up the free sight test for everyone over 60. Up to 50 per cent of sight loss can be avoided if it is detected early enough. RNIB recommend having a sight test at least every two years.
Currently, sight loss affects:
; one in five people over 75 and
; one in two people over 90.
This means that if you work with or offer services to older people a significant proportion – maybe more than half in elderly services –
will have a degree of sight loss that can have a serious effect on the quality of their lives.
Losing your sight can be a very isolating, lonely experience and you can make a huge difference to ensuring older people with sight loss are able to maintain their independence and wellbeing. We‟ve produced this „refresher guide‟ to raise awareness of the small changes that you can make that will make a big difference to people with sight loss.
What causes sight loss?
Five common causes of sight loss are:
; age-related macular degeneration
; diabetic retinopathy
; refractive error.
To help you and your staff understand these conditions and how they may affect your service users, there‟s a brief description of each one on the following pages. There‟s also lots more detailed information available at www.rnib.org.uk
It is possible to have more than one condition, and for it to be more or less severe. Getting older is one of the biggest risk factors for developing eye conditions which cause sight loss. The impact of each condition on a person‟s sight and life can differ.
Age-related macular degeneration
Also known as ARMD and AMD. It can lead to loss of central vision while side vision remains, and is the most common cause of sight loss in the UK.
AMD occurs when the delicate cells of the macula (a small area at the very centre of the retina) become damaged and stop working. Wet AMD, which can develop very quickly, can sometimes respond to treatment if it is caught in the very early stages. Dry AMD, which develops slowly and causes gradual loss of central vision, can‟t be medically treated.
Loss of central vision can make it difficult for someone to read or recognise facial expressions.
Diabetes can affect the eye in several ways. The most serious affects of diabetes on the eye are the changes it causes to the retinal blood vessels, known as diabetic retinopathy. This happens when diabetes causes the blood vessels in the eye to bulge, leak fluid and blood. This can have a serious affect on vision if left untreated.
Most people with diabetes should have a yearly examination of their retina to check if there are any changes to their blood vessels. This is important because there is a stage of diabetic retinopathy when laser treatment can be used to avoid serious sight loss. Without any treatment diabetic retinopathy can cause very serious loss of vision, affecting both central and side vision.
As well as the yearly examination of their retina, good control of blood sugar (glucose) levels has been shown to help to lower the risk of diabetic retinopathy developing.
This covers a group of conditions in which the optic nerve is damaged at the point where it leaves the eye. This can result in tunnel vision, and may not be noticed until considerable damage to the person‟s side vision has been done.
In some people the damage is caused by raised eye pressure, which can occur when the aqueous fluid doesn‟t drain away
properly. It can also be caused because of a weakness in the optic nerve.
Glaucoma can be medically treated through the use of eye drops, drugs, laser treatment or operations, although any damage already caused by the condition can‟t be repaired.
Cataract is a very common eye condition that affects many people over 60. Age-related cataract is the most common cause of reversible blindness worldwide. Cataract is a frequent cause of visual impairment and blindness in older people. Cataract surgery is a common procedure and in the NHS it is the third most frequent hospital intervention. The average age of cataract patients is 75 years.
The symptoms include blurry or cloudy sight, being dazzled by light and fading colour vision. A cataract is a clouding of the lens. Vision becomes blurred because the cataract makes the usually clear lens cloudy, interfering with sight.
It isn‟t a layer of skin that grows over the eye as is sometimes thought. Cataract can be surgically treated by removing the cloudy lens and replacing it with a clear plastic lens called an intraocular lens implant. Usually this is a simple and quick procedure.
Everyone can play a role in raising awareness of the importance of taking up the free, yearly sight tests for everyone over 60.
Refractive errors are problems like short sightedness (myopia), long sightedness (hypermetropia) and presbyopia (need for reading glasses) which can be corrected using spectacles or contact lens. These problems often go undetected.
Some older people may simply have low expectations of their sight and believe nothing can be done, or, due to other disabilities, symptoms of deteriorating sight can go unnoticed by carers or staff. An eye test is the best way to detect eye conditions and the over 60s receive this free on the NHS. They can get support with the cost of glasses if they receive the Guarantee part of Pension Credit or are on a low income and qualify for help through the NHS low income scheme.
Other causes of sight loss:
Every five minutes someone in the UK has a stroke and stroke is the third biggest killer and a leading cause of disability in the UK.
A high proportion of people (around 70 per cent) who have had a stroke will have some form of visual dysfunction as a result.
Strokes can affect sight and vision in a number of ways. The most common effect is called hemianopia. This occurs when the stroke causes damage to the visual parts of the brain. Hemianopia causes a loss of sight in one side of the visual field, which means
someone would lose all the right or left side of their vision in both eyes. Unfortunately there isn‟t a treatment for this kind of problem, although some people may see a slight improvement over time.
Some people with stroke also have problems with visual perception and neglecting to take notice of parts of their vision (visual neglect). Other visual problems that can occur are eye movement problems and focusing and reading problems.
How can I identify sight loss in my service users? When a service user first comes to your service, we recommend that you ask either the referrers or the service user themselves about their sight.
Do they wear glasses, have they any diagnosed conditions or any self reported sight loss? Bear in mind that:
; total blindness is quite rare: most blind people have some
useful sight even though this may be limited in some way ; most people with serious sight loss have had sight earlier in
their life and so have „sighted mannerisms‟ or appear to look
you in the eye.
It can be difficult to notice if someone is experiencing difficulties with their sight. They might be reluctant to admit it, but some of the signs could be:
; walking slowly and appearing worried about falling ; appearing less confident or very quiet in social situations ; feeling for things even though they appear to be looking at them ; not happy to read or write in front of you
; not recognising people instantly – especially if you have not
; difficulty in bright light, low light or both
; have changed how they read, watch television, drive, walk or
engage in hobbies
; unable to locate food on a plate
; constantly bumping into things, shuffle their feet or steps
; complains that the lighting is inadequate for reading and other
; have less clear writing than before
; difficulty identifying faces or objects
; over-fill their drinking glass when pouring themselves a drink.
Don‟t forget, whether these apply or not, you need to recommend that people aged over 60 have a full eye examination as sight can change quite rapidly.
Sight loss and other health issues
Dementia and sight loss
Most people with dementia are over 60, so there is a high likelihood that they may be living with sight loss. Some forms of dementia have particular effects on vision. When someone has dementia and sight loss, day-to-day living, mobility, wellbeing and communication are all more difficult.
Dementia combined with sight loss can lead to:
; profound disorientation and isolation
; increased risk of falls
; difficulties moving between light and dark
; difficulties learning to use new equipment
; more visual mistakes
; less independence
; misperception and misidentification
; increased worry for carers and relatives.
Visual hallucinations may be associated with dementia or sight loss. They may be distressing for those affected, and for those caring for someone with dementia. More information on visual hallucinations can be found on the RNIB website.
There are practical things you can do to improve people‟s quality of life and independence, such as using effective lighting and design, which can make the most of their vision and reduce disorientation. Ensuring that the environment makes the most of sight and light, supporting people to wear appropriate spectacles, and spending time getting to know the person all help.
Sight loss and falls
Vision plays a direct role in stabilizing balance. Sight problems may predispose a person to trip over hazards in the home and outdoors, for example steps, curbs and uneven pavements. When climbing stairs, a reduction in depth perception might mean you don‟t put your foot down properly.
; If you‟re assessing falls risk, ask about vision.
; If someone has had a fall, advise them to tell their GP and also
to have a sight test.
; Ensure that vision is a part of any health education programme
related to falls and home safety.
; Ensure that high colour contrast is provided through the service
to limit falls.
Sight loss and hearing – dual sensory loss
Over half of all people over 60 have a hearing loss. Combined with the prevalence of sight loss, the likelihood is a high percentage of older people with both.
The daily and ongoing challenges for people who cannot hear and see properly can be hard to understand by the people around them. People with sight loss use their hearing to help them by listening for sound clues, for example someone vacuuming nearby or a car door shutting outside. People with a hearing loss use their sight to compensate by watching people‟s lips and interpreting body
language. If both are impaired then people can very quickly feel frustrated. Hearing and sight loss cause many people to become depressed, angry or withdrawn.
When supporting older people who may have dual sensory loss, it‟s important not to put too great an emphasis on either audio or visual guides. Clarity is the key in all communication.
The charity Sense provide expert advice and information as well as specialist services to deafblind people and the professionals who work with them. Find out more at www.sense.org.uk
How can I meet the specific needs of service users with sight loss?
The Equality Act
The Equality Act became law on 1 October 2010. The changes made by the Equality Act mean you will need to review your organisation‟s policies and practices to make sure they comply with the Act. The Equality Act includes age.
The public sector equality duty is „anticipatory‟, which means you cannot wait until a disabled person wants to use your services, but
must think in advance (and on an ongoing basis) about what disabled people with a range of impairments might reasonably need, such as people who have visual impairment, hearing impairment, mobility impairment or learning disability.
Ensuring your services cater for the needs of blind and partially sighted people can be easy. Consider your environment, your communication materials, the activities you provide, the way people are transported and how all these can be made more accessible. This also applies if you hire out premises, so please be aware of this when making bookings. To find out more about the
www.homeoffice.gov.uk/equalities Equality Act, visit
Changes to your services environment
Not all changes need to be expensive to implement. A few small changes to your Centre‟s environment can make a big difference.
Small changes that make a big difference
; Make sure that all the clocks in communal areas are large and
that they‟re at eye level so that people can see them.
; Improve signage by enlarging print on posters and notices. ; Consider announcements instead of notice boards.
; Encourage everyone to be tidy. Furniture left out of place can
; Buy equipment that can be used by people with sight loss easily.
We will tell you more about this later in this guide. ; When a new person comes to your service, spend some time
showing them how to get from one place to another. It‟s worth
explaining the route you are taking in detail. For those with a
greater degree of sight loss, point out any clues along the way
that will help the person remember the route, such as different
; Use tactile signage like large raised numbers on doors that
people can touch to help them find their way around. If this isn‟t
possible, then large-font-size print outs can also help. ; Introduce colour contrast in the built environment, for example
different coloured doors for the toilet, coloured handrails, or
painted walls. RNIB can provide support and advice on colour
contrast decorations on request.
; Make adjustments when organising activities to be more
inclusive such as large print puzzles, quizzes that are read out
rather than filled out, and activities that involve partners.
Adapting a Day Centre: Saxon Day Centre – Age
The Saxon Day Centre always make an effort to include all clients whatever their ability by making all activities as accessible as possible, and if necessary they alter the way an activity is being delivered.
The manager of the Centre says: “One of our service users is an
elderly blind man who has a guide dog. When we received the referral for this gentleman we were apprehensive that we might not be able to accommodate his needs. This was the first time that we had been asked to have a guide dog at the Centre, where we receive 63 clients each day, including clients who are wheelchair users, some who use Zimmer frames and some who are partially sighted. We contacted RNIB for advice on how to guide a blind client, and all our staff were trained in how to do this. We also sought advice on how to control the guide dog, and gained a better understanding of his role as a working dog.
When we looked at the environment in the Day Centre, we worked out where it would be best for RC to sit so that he would feel included, but also where the guide dog would not be a distraction to any of our other clients. RC was guided around so that he became familiar with the environment and the layout of the Centre and he was included in all activities where appropriate. His guide dog was taken on regular toilet breaks throughout the day by staff or volunteers.”
Buying new products for your service
Many essential day-to-day items that have been adapted for people with sight loss are also excellent for people with limited mobility, problems with touch and with dementia.
There are many aids available such as tools for helping in the kitchen, talking clocks, big button telephones, talking digital televisions, talking microwaves, magnifiers etc, and you can encourage people to use them (see back cover for how to order these products). There are also a variety of aids for leisure activities too, such as playing cards and board games.