Vision Impairment and Older Adult Driving fact sheets for Occupational Therapists

VISION IMPAIRMENT CLINICAL INTERVENTIONS And Older Adult Driving Resources

Tami Levengood December 1, 2016 Philadelphia University OTD 816

TABLE OF CONTENTS BACKGROUND INFORMATION FOR VISION IMPAIRMENT CLINICAL INTERVENTION FACT SHEETS ..................................5 LEVELS OF EVIDENCE.......................................................................6

ADDITIONAL RESOURCES ..............................................................7 Links to Vision Impairment Websites ........................................................................................ 7 Links to Vision Impairment Equipment Catalogs ...................................................................... 7 Links to Local Vision Services and Vision Impairment Support Groups ............................... 7

PHILADELPHIA AND SURROUNDING COUNTY INFORMATION....................................................................................8 FINANCIAL ASSISTANCE RESOURCES ........................................9 VISION IMPAIRMENT CLINICAL INTERVENTIONS FOR READING FACT SHEET .................................................................. 10

VISION IMPAIRMENT CLINICAL INTERVENTIONS FOR ADLS FACT SHEET ..................................................................................... 14

VISION IMPAIRMENT CLINICAL INTERVENTIONS FOR MEAL PREPARATION AND IADL FACT SHEET ................................... 16

VISION IMPAIRMENT AND HEALTH MANAGEMENT AND MAINTENANCE CLINICAL INTERVENTION FACT SHEET .. 20 Additional Health Management Resources.............................................................................. 24

VISION STANDARDS AND RESOURCES FOR DRIVING IN DE, NJ, AND PA........................................................................................ 25 ADDITIONAL DRIVING RESOURCES ......................................... 27 Fox Rehab Driving Services ....................................................................................................... 27 National Resources ..................................................................................................................... 27 Driving Cessation Options ......................................................................................................... 28 Ride Services for PA, NJ, DE ..................................................................................................... 29

AOTA MEMBER RESOURCES........................................................ 30 Critically Appraised Topics on Older Adults with Low Vision ............................................ 30 Critically Appraised Topics on Driving and Community Mobility for Older Adults ........ 30 AOTA Evidence-Based Consensus Statement for Driving and Community Mobility ...... 30

AOTA FACT SHEET: OT SERVICES FOR PERSONS WITH VISUAL IMPAIRMENT ..................................................................... 31

AOTA TIP SHEET: LIVING WITH LOW VISION....................... 33 AOTA TIP SHEET: DRIVING SAFELY AS YOU AGE ................ 36

AOTA TIP SHEET: KEEPING OLDER DRIVERS SAFE .............. 38 AOTA FACT SHEET: DRIVING AND TRANSPORTATION OPTIONS FOR OLDER ADULTS .................................................. 40 ADED DRIVING AND VISION FACT SHEET .............................. 42 ARTICLES REFERENCED IN FACT SHEETS .............................. 43

This document is intended to be a clinical reference tool for the Occupational Therapy Staff at Good Shepherd Penn Partners and Penn Care at Home. The fact sheets provide immediate, evidence based intervention ideas for clients with vision impairment in multiple areas of occupational performance.

As occupational therapists, we field many questions regarding driving. The resources for driving are an additional reference for clinical staff.

All websites in the document can be shared with clients and their caregivers at your discretion.

Background Information for Vision Impairment Clinical Intervention Fact Sheets Vision impairments can detrimentally impact a person’s occupational performance.

Barstow and associates (2015) studied the impact of low vision and additional medical conditions and found that older adults felt vision loss had a greater impact on occupational performance than other co-morbidities. The following fact sheets provide examples of evidence based clinical interventions to improve occupational performance.

The client must be ready to change his/her performance of valued activities and be receptive to new techniques. Mohler, Neufeld, and Perlmutter (2015) describe factors that facilitate readiness for change in clients with low vision. They include desire to maintain/regain independence, positive attitude, and availability of formal social support (Mohler, Neufeld, & Perlmutter, 2015). Factors that prevent change include limited awareness of processes or adaptive equipment and that the impacted activity is not a priority for him/her to complete (Mohler et al., 2015). Informal social support can be a barrier or a facilitator. Know the person’s available resources and if caregivers will support the necessary routine or environmental changes at home prior to continuing interventions. The most important aspect of receptiveness to new information is client centered care. The activity MUST be important to the person (Mohler et al., 2015). The occupational therapist’s role is to learn what areas are important to the client, then assist him/her in regaining or maintaining independence in that activity.

Liu, Brost, Horton, Kenyon, and Mears (2013), Livengood and Baker (2015), and Smallfield, Clem, and Myers (2013) list a combination of interventions provided by occupational therapists that improve occupational performance with clients with vision impairments. They include:  group therapy (also provides social support)  education to the client regarding the visual condition, “low vision,” and available resources (community supports, organizations, equipment)  realistic, individualized goal setting  multiple sessions  training in problem solving strategies to foster participation in meaningful activities/roles  options for environmental modifications (organization, categorization, use of contrast, illumination)  counseling to adjust to vision impairments that can’t be corrected  education in adaptive devices, compensatory techniques, and energy conservation 5

Levels of Evidence

Level of Evidence

“Levels of Evidence” are referenced throughout the fact sheets.

The definition of each evidence level is listed below (Lieberman & Scheer, 2002). The lower the number, the higher the strength of the evidence, or study rigor.

• Level I—systematic reviews, meta- analyses, and randomized controlled trials (RCTs) • Level II—two-group, nonrandomized studies (e.g., cohort, case control) • Level III—one-group, nonrandomized studies • Level IV—single-subject designs, descriptive studies, and case series • Level V—case reports and expert opinion. Textbooks.

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Additional Resources Links to Vision Impairment Websites www.blindness.org www.glaucoma-foundation.org/info www.lighthouse.org www.maculardegeneration.org American Foundation for the Blind www.afb.org/seniorsitehome.asp National Association for the Visually Handicapped www.navh.org Philadelphia Based (919 Walnut St): http://www.afb.org/directory/profile/associatedservices-for-the-blind-and-visually-impaired/12 Comprehensive Resource List for services, transportation, legal counsel, etc.: http://pennsylvania.aoa.org/documents/POA-Resource-List-2004.pdf Links to Vision Impairment Equipment Catalogs www.maxiaids.com www.independentliving.com www.lowvision.com www.lssproducts.com Links to Local Vision Services and Vision Impairment Support Groups On-Line Support Group: https://www.dailystrength.org/group/blindness-visualimpairment Facebook based: https://www.facebook.com/visupportgroup

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Philadelphia and Surrounding County Information Associated Services for the Blind 919 Walnut Street, Philadelphia, PA 19107 (215) 627-0600 www.asb.org Bucks County Association for the Blind 400 New Freedom Drive, Newtown, PA 18940 (800) 472-8775 Delco Blind/Sight Center 100 W. 15th Street, Chester PA 19013 (610) 874-1476 www.cbvi.net Montgomery County Association for the Blind (MCAB) 212 N. Main Street, North Wales, PA 19454 (610)-661-9800 www.MCAB.org Pennsylvania Bureau of Blindness and Visual Services Philadelphia District Office 444 North 3rd Street, 5th Floor, Philadelphia, PA 19123 (215) 560-5700 www.dli.state.pa.us/landi/cwp/view.asp?a=128&Q=190368 Foundation Fighting Blindness Philadelphia affiliate 270 Shadeland Ave., Drexel Hill, PA 19026 610-259-5544 www.blindness.org

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Financial Assistance Resources Links to Financial Assistance Resources for Persons with Vision Impairment: Association of Blind Citizens: Funds cover 50% of retail price of adaptive devices/software. www.blindcitizens.org Co-Pay Relief Program: Assists with copays for pharmaceutical treatments for patients with primary insurance. www.patientadvocate.org EyeCare America: Provides free and low cost examinations to US citizens >65 years old that have not seen an ophthalmologist in the last 3 years. www.eyecareamerica.org Lions Club America: Usually have many local branches for eye care support. www.lionsclub.org

References Barstow, B. A., Warren, M., Thaker, S., Hallman, A., & Batts, P. (2015). Client and therapist perspectives on the influence of low vision and chronic conditions on performance and occupational therapy intervention. American Journal of Occupational Therapy, 69(3), 6903270010. doi:10.5014/ajot.2015.014605 Lieberman, D., & Scheer, J. (2002). AOTA’s evidence-based literature review project: An overview.

American Journal of Occupational Therapy, 56(3), 344–349. doi:10.5014/ajot.56.3.344 Liu, C., Brost, M. A., Horton, V. E., Kenyon, S. B., & Mears, K. E. (2013). Occupational therapy interventions to improve performance of daily activities at home for older adults with low vision: A systematic review. The American Journal of Occupational Therapy, 67(3), 279-287. doi:10.5014/ajot.2013.005512 Livengood, H. M., & Baker, N. A. (2015). The role of occupational therapy in vision rehabilitation of individuals with glaucoma. Disability and Rehabilitation, 37(13), 1202-1208. doi:10.3109/09638288.2014.961651 Mohler, A. J., Neufeld, P., & Perlmutter, M. S. (2015). Factors affecting readiness for low vision interventions in older adults. The American Journal of Occupational Therapy, 69(4), 1-10. doi:10.5014/ajot.2015.014241 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, 67(3), 288-295. doi:10.5014/ajot.2

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Vision Impairment Clinical Interventions for Reading Fact Sheet Reading impairments can detrimentally impact a person’s occupational performance in many ways. They include inability to read prescription medication labels, appliance dials, expiration dates, bills, and financial reports (Smallfield, Clem, & Myers, 2013). The functional consequences of reading impairments ripple through all aspects of ADL and IADL performance.

The evidence-based interventions listed below can help your clients with impaired vision improve occupational performance with reading tasks. Combining education, problem solving strategy training, and instructions in adaptive techniques improve reading abilities (Arbesman, Lieberman, & Berlanstein, 2013).

Critical print size is defined as the smallest size text an individual can read with maximum speed (Warren & Barstow, 2011, p. 151.). This is not reading acuity, which Warren defines as the smallest size print someone can read without multiple errors (Warren & Barstow, 2011, p. 151). Keep in mind that although a person can read small print, a larger font may facilitate sustained, comfortable, successful reading.

References Arbesman, M., Lieberman, D., & Berlanstein, D. R. (2013). Methodology for the systematic reviews on occupational therapy interventions for older adults with low vision. The American Journal of Occupational Therapy, 67(3), 272-278. doi:10.5014/ajot.2013.007021 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, 67(3), 288-295. doi:10.5014/ajot.2013.004929 Warren, M., & Barstow, E. A. (Eds.). (2011). Occupational therapy interventions for adults with low vision. Bethesda, MD: AOTA Press.

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Vision Impairment Acuity

Central Field Loss Central Field Loss/Macular Degeneration Contrast Sensitivity, Central Field Loss/General Vision Impairment Age Related Macular Degeneration Low Vision

Low Vision

Clinical Intervention Electronic text manipulation  Font choice and size: Sans serif such as Arial, Courier, Helvetica, Tahoma, and Verdana at least 16-18 size font  Wide margins, at least 1 inch Hand held magnification Electronic Text Manipulation  Double line spacing, double character word spacing Illumination  Very patient specific, but usually much higher than “normal” lighting conditions  Options of different light sources- halogen, incandescent, fluorescent bulbs.

Apply individualized ergonomic principles to reading stations with vision devices to improve reading speed and comfort Magnification:  Relative size: Make target bigger  Relative distance: Bring target closer  Equipment: stand magnifier, hand magnifier Hand held magnifier  For short term identification: read price tags, menus (Challenging to use if person has tremors)  Smaller lenses have greater magnification power  Person must learn optimal distance to hold magnifier from target. The more powerful the magnification, the closer it should be held to the target  Start by holding magnifier flat against target, then slowly move away.  Note eye to magnifier distance as this can impact clarity.

Level of Evidence 2 Level I, 1 Level V III III 1 Level I, 1 Level V

II

V

V

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Low Vision

Low Vision Low Vision

Low Vision/Glare sensitivity due to glaucoma, cataract, photophobia Page Navigation Limitations

Peripheral Field Loss/Brain Injury

Peripheral Field Loss/Neglect

Stand magnifier  For short-term identification  Image most clear at one specific distance of person’s eye from magnifier  Smaller lenses have greater magnification power  Stand maintains distance from target, promotes faster reading rates and longer duration reading abilities.

1 Level I, 1 Level V

Illumination/Lighting 1 Level I,  Spot lighting or task lighting located at best distance to illuminate text (individualized) 1 Level V Environmental Adaptations V  Establish a “reading station” at home with appropriate lighting source, positioning, ergonomic factors (desk top support, back support in chair, appropriate neck position, minimized sustained grip on reading material and any magnification device), light source with shade on or off Avoid glossy paper Electronic Text Manipulation  Light text on dark background/reversed contrast Strategies to sustain visual fixation on appropriate part of text  Use finger as a guide  Tracing  Book mark  Scanning training where visual stimuli (usually illuminated light/diode) paired with white noise auditory stimulus Scrolling text for impaired visual field  Person sustains central fixation/gaze while text moves right to left Vertical Reading  Turn text 45 or 90 degrees so words are in visual field

V

V

1 Level I, 2 Level II II V

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Unilateral Homonymous visual field loss Scotoma/ Macular Degeneration (cognitive

abilities must support this complex intervention)

Unable to complete sustained reading due to vision impairments

Computer based compensatory training for Reading Training and Visual Field Exploration (GSPP OT’s would need specialized training) Use eccentric viewing strategies, move focus of eye to side of word so scotoma does not block text. Very person specific as to what location of focus is best.  Help person locate area outside of scotoma where target identification is easiest.  May require visual and verbal cuing from therapist. Use results of Amsler grid screening/assessment to guide this.  Once identified, cue person to use eye and head motions to consistently locate target.  Progress to only eye movement, no head movement to locate target. Can use letter or word cards.  Interventions can include fixation, gaze shift, and tracking to and from target.  When this is mastered, move to prereading exercises such as reading specific letters aloud from a letter sheet, finding words on a page, or word searches.  Progress to reading text, simple then more complex reading content (Ex: bill, then recipe, then article.)  Introduce large print materials if needed  Introduce magnification if needed Education regarding print alternatives  Audio books, recordings, podcasts  Large print magazine subscriptions, large print bills, large print medication label  Text to audio options on computers, cell phones, tablets

II V

V

**FYI: Stand-based electronic magnification systems, like a CCTV, promoted faster reading rates and longer reading times (Smallfield, Clem, & Myers, 2013). Dr. Prasad (June, 2016 OT SIG Speaker) can assist clients in obtaining these. Further CCTV information not included due to GSPP OT staff not having clinical access to these devices.

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Vision Impairment Clinical Interventions for ADLs Fact Sheet The OTPF-III (AJOT, 2014) categorizes ADL occupations as bathing, dressing, toileting, bowel/bladder management, eating/feeding, personal hygiene and grooming. Impaired vision impacts occupational performance of ADL tasks. It can require increased time and cause increased errors, which Liu and colleagues (2013) report may lead to lost roles, depression, embarrassment, and limited social participation. If a person cannot see to match clothes, shave thoroughly, or apply make-up evenly, he or she may become more housebound, even if no physical limitations exist. Occupational therapy can assist in these areas and more to promote and sustain participation and engagement in occupational performance.

The person with impaired vision may require overlapping intervention strategies, such as increased use of contrast and adaptive performance patterns. The light source and quality of light should be considered for all adaptations. Some ADLs may require task lighting while others may need standard illumination (Warren & Barstow, 2011).

Background patterns, such as a busy tablecloth or wall-mounted toothbrushes on patterned wallpaper should be minimized (Warren & Barstow, 2011). An organizational strategy for all members of the household should be agreed upon and consistently implemented (Warren & Barstow, 2011).

The evidence-based interventions listed below can help your clients improve occupational performance with ADL tasks. Additionally, in a systematic review, Liu and colleagues (2013) found that various components such as education of low vision, low vision devices, and community resources along with problem solving strategies over multiple sessions are imperative. Repeated sessions allow time for the individual to practice skills and resolve any challenges with the therapist (Liu, Brost, Horton, Kenyon, & Mears, 2013).

References Liu, C., Brost, M. A., Horton, V. E., Kenyon, S. B., & Mears, K. E. (2013). Occupational therapy interventions to improve performance of daily activities at home for older adults with low vision: A systematic review. The American Journal of Occupational Therapy, 67(3), 279-287. doi:10.5014/ajot.2013.005512 Occupational therapy practice framework: Domain and process (3rd edition). (2014). American Journal of Occupational Therapy, 68(Supplement_1), S1-S48. doi:10.5014/ajot.2014.682006 Warren, M., & Barstow, E. A. (Eds.). (2011). Occupational therapy interventions for adults with low vision. Bethesda, MD: AOTA Press.

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Occupation Bathing, Showering

Recommended Clinical Intervention 

Utilize towels and washcloths of contrasting colors of walls or tile



Drape towel over edge of tub in a contrasting color to indicate where to step over and how high Wrap grab bars in tub/shower in bright tape of contrasting color A clear shower curtain allows more light into the area

 

Personal Hygiene and Grooming



Use toothbrush/comb/hairbrush of contrasting color to tile/sink



Use tactile cues to feel toothbrush head for toothpaste Use tactile cues to feel if all areas are shaved Makeup application: Use appropriate task lighting; use magnification mirror; ask others for feedback on amount of makeup applied Place grab bars of different colors next to/surrounding toilet Contrast color of toilet seat/lid; toilet paper holder against background Describe items on plate using a “clock system,” ex: chicken at 12:00, broccoli at 4:00….

Use foods with more solid texture as a buffer for more challenging foods, ex: push peas onto fork by pushing next to potatoes or use a roll

  Toileting

 

Eating

 

Level of Evidence V

V

V

V

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Vision Impairment Clinical Interventions for Meal Preparation and IADL Fact Sheet Home and financial management and meal preparation and clean up are areas of Instrumental Activities of Daily Living (IADLs) as outlined by the OTPF-III (AOTA, 2014). Safe methods of occupational performance can be impacted if vision impairment exists. Hazards remain unidentified. Accidents such as over-seasoning food or tripping over obstacles can occur. Financial mistakes can lead to long standing negative consequences. Scheiman (2002) recommends overarching environmental modifications to enhance household safety of the adult with impaired vision. Specifics include using mini-blinds or vertical shades to control sunlight, sheer curtains to decrease glare, nonpatterned flooring/carpet, consistent lighting throughout the home, and contrasting tape on the first and last steps of a staircase (Scheiman, 2002).

The same principles described for ADL adaptations should be implemented for IADL tasks, including decreasing patterned backgrounds and implementing an organizational strategy to be consistently implemented by all household members (Warren & Barstow, 2011). If possible, clutter should be removed (Warren & Barstow, 2011). Collaboration with the patient and family/household members is imperative. The patient must agree to changes in routine, performance patterns, and habits while the other household members must consistently implement the new organizational strategies (Warren & Barstow, 2011).

Additionally, in a systematic review, Liu and colleagues (2013) found that multiple components such as education of low vision, low vision devices, and community resources along with problem solving strategies over numerous sessions are imperative.

Repeated sessions allow time for the individual to practice skills and resolve any challenges with the therapist (Liu, Brost, Horton, Kenyon, & Mears, 2013).

References Liu, C., Brost, M. A., Horton, V. E., Kenyon, S. B., & Mears, K. E. (2013). Occupational therapy interventions to improve performance of daily activities at home for older adults with low vision: A systematic review. The American Journal of Occupational Therapy, 67(3), 279-287. doi:10.5014/ajot.2013.005512 Occupational therapy practice framework: Domain and process (3rd edition). (2014). American Journal of Occupational Therapy, 68(Supplement_1), S1-S48. doi:10.5014/ajot.2014.682006 Scheiman, M. (2002). Understanding and managing vision deficits: A guide for occupational therapists (2nd ed.). Thorofare, NJ: SLACK. Warren, M., & Barstow, E. A. (Eds.). (2011). Occupational therapy interventions for adults with low vision. Bethesda, MD: AOTA Press.

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Occupation Home Management

Recommended Clinical Intervention Increase use of contrast, different colors with:  cabinet hardware than doors  contrasting color of dishes on table cloth/placemat

 

Financial Management

Clothing Selection for Dressing

measuring utensils and cutting boards with food (ex: dark measuring cup for white flour) pouring dark beverages in light colored cups and opposite (ex: Pour dark coffee into white mug)



Use plain or large, bold-line checks

   

Write on blank, uncluttered surface Use check-writing guide/template Use large print and/or high contrast check register Use talking or large button calculators with large number display

 

Write with a bold marker Try on-line or telephone bill pay incorporating other vision impairment technology skills (screen magnifier, voice to text option) Use different colored folders or file folders for paper organization Organizational strategies agreed upon with client and household members, examples: -Keep all clothes of same color in same drawer

 

Level of Evidence V

V

V

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-Arrange clothing items by color -Consistent organization of clothes by color/style (ex: casual blue, dressy black)

 Meal Preparation and Clean Up

     

 

-Use different brightly colored hangers to denote “dressy” or “casual” clothes -Place different brightly colored labels on inner tag of clothes to discriminate between black/brown/blue shades if other organizational strategies not options -Add bright colored fabric tape on inside label to distinguish similar colors -Sew in a small bump on the label to distinguish similar colors (ex: no bump = blue; one bump = black) Decrease clutter/clothing items no longer worn V Place tactile dots or different colored tape on important dials of stove/oven settings (if patient has sufficient memory) Ensure consistent placement of cooking supplies, from utensils and pans to spices and pantry items Alphabetize cans, jars, and spices and write item name on label in large, bold print Implement auditory adaptive equipment such as liquidlevel indicators and talking kitchen scales If canned items are similar (ex: cut green beans and French green beans) use different numbers of rubber bands to identify differences Utilize a lazy Susan to avoid need to view items at back of dark cabinet

Use recipes in large print or large font on computer Use a funnel to pour liquids to minimize spills

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 

Use elbow length flame retardant oven mitts Use a knife with an adjustable slicing guide

 

Use a pot with a colored interior (not aluminum) Bend metal handles of liquid measuring spoons so spoon can be dipped into liquid, minimizes spilling Minimize use of back burner of stove for safety Use timer for food preparation instead of relying on visual monitoring Color code recipe cards for meat, vegetables, desserts, etc.

Suggest environmental adaptions, if feasible, such as D shaped cabinet and drawer hardware, deep sink (to prevent splashing), lever handle faucet, clear floor space without obstacles, contrasting colors for cabinet hardware, appliance controls, and light switches

   

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Vision Impairment and Health Management and Maintenance Clinical Intervention Fact Sheet Occupational performance for health management, another IADL, can be impacted by vision impairment by inabilities to read medication labels, track blood pressure or blood glucose, or see the appropriate insulin dose (AOTA, 2014). Impaired vision may lead to decreased physical activity and loss of roles as walking partner or yoga friend. Many aspects of health management interventions overlap with previously stated concepts.

Occupational therapy interventions for health management should be part of a comprehensive medical team and be guided by the client’s level of engagement (Cate, 2011, p. 183.) The person, social supports, environment, and habits must be considered along with problem solving skills, coping strategies, and level of behavior change (Cate, 2011, p. 183-186).

Educational materials should be printed in a font size that the individual can read or be provided using auditory resources (Cate, 2011). Any new equipment should be assessed for features that promote or inhibit successful performance. The client should demonstrate appropriate use of any new equipment at least twice over two sessions or once over three sessions to ensure mastery (Cate, 2011, p. 188).

Barstow and colleagues (2015) found that older adults with low vision and additional chronic conditions benefitted from extra treatment sessions, other medical provider referrals, and further strategies to manage co-morbidities. Vision loss was determined to have more impact on occupational performance than other medical conditions (Barstow, Warren, Thacker, Hallman, & Batts, 2015). Compensatory strategies were implemented for vision impairment more than other chronic conditions (Barstow et al, 2015).

References Barstow, B. A., Warren, M., Thaker, S., Hallman, A., & Batts, P. (2015). Client and therapist perspectives on the influence of low vision and chronic conditions on performance and occupational therapy intervention. The American Journal of Occupational Therapy, 69(3), 1-8. doi:10.5014/ajot.2015.014605 Cate, Y. (2011). Evaluation and intervention for diabetes self-management. In M. Warren, & E. A. Barstow (Eds.), Occupational therapy interventions for adults with low vision (pp.179-226).

Bethesda, MD: AOTA Press.

Occupational therapy practice framework: Domain and process (3rd edition). (2014). American Journal of Occupational Therapy, 68(Supplement_1), S1-S48. doi:10.5014/ajot.2014.682006

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Occupation Diabetes selfmanagement

Recommended Clinical Intervention 

Group blood glucose testing supplies and equipment in an organized location or a tray with appropriate lighting



Education in universal safety procedures for handling blood and body fluids, appropriate cleaning solutions for blood glucose testing site Line blood glucose testing area with a plastic tablecloth or use a tray that can easily be wiped off or cleaned Foot/skin inspection: If a client is unable to inspect the skin, family member should be educated on how and what to look for

 





  

Level of Evidence V

If sensation is intact and client can reach feet, foot inspection can be completed tactually by touching all surfaces of each foot and noting any bumps or cuts Utilize adaptive equipment for blood glucose monitoring, including large display or talking blood glucose meters

Place a raised dot on the strip holder of the blood glucose monitor to help client locate strip placement Write expiration date on supplies in large, bold print Write customer service phone number to equipment supplier and device serial number in readable font and store in easily accessible location if service needs arise

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    

Establish a method of documenting legible, readable blood glucose monitoring results with client (some meters have memory function) Utilize large print labels, a rubber band system, or raised dots to identify insulin vials, especially if two types of insulin are used Use a syringe magnifier If vision fluctuates during a day, measure insulin dose when vision is most clear Ensure syringes/sharps can be disposed of appropriately and safely

Examples of syringe assistive devices: “Syringe Support” a half turn draws 1U of insulin https://www.maxiaids.com/syringe-support

“Count-a-Dose” provides audible and tactile click for each 2U of insulin measured https://www.maxiaids.com/search?q=count+a+dose “Fixed Dose Devices” set insulin syringe plunger to only move to pre-measured distance http://www.easierliving.com/syringe-loader-by-safeshot.html “Insulin Pen Injectors” provide prefilled insulin cartridges, doses measured by turning a dial that makes audible click “Insulin Pumps” provide subcutaneous insulin delivery and are programmed to mirror the body’s natural insulin release patterns 22

Medication Routine/ Medication Management

    

Use pill organizers Label pill bottles with large print Label pill bottles with tactual markers like rubber bands or raised dots Implement auditory medication labels Implement a medication log to track/time appropriate doses Use adaptive equipment of talking blood pressure monitor or monitor with large visual display

V

V

Blood Pressure Monitoring



Physical Activity



Adapt walking programs to use familiar landmarks, a sighted guide, or treadmill



Use a hand rail or piece of heavy furniture for support when stretching Try stationary cardiac equipment like a bike or rowing machine Ensure that physical activity does not elevate blood pressure to levels that can harm pressure in orbital/eye areas (May be beneficial to contact physician/medical team for guidelines) Ensure client can prepare nutritious meals, see IADL Fact Sheet Use audio lists Write large print shopping lists

 

Nutrition

  

V

V

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Additional Health Management Resources NFB-LINK: matches client with mentor for living successfully and coping with diabetes and vision loss; sponsored by the National Federation of the Blind. Phone number: 410659-9314, extension 2283.

Diabetes self-care and home management audio and video guides: http://www.milnerfenwick.com/products/db400/index.asp Guidelines for Trainers with Clients with Vision Impairments (from National Center on Physical Activity and Disability): http://www.nchpad.org/929/5073/2010-07-01 Fitness for Individuals who are Visually Impaired, Blind, and Deafblind (from National Center on Physical Activity and Disability): http://www.nchpad.org/110/847/Visually~Impaired~~Blind~~and~Deafblind

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Vision Standards and Resources for Driving in DE, NJ, and PA Driving is the hallmark of independence for many people. The OTPF-III (AOTA, 2014) categorizes driving and community mobility as an IADL. Vision impairments can make driving challenging at best or unsafe at worst. Sandlin, McGwin, and Owsley (2014) found that impaired contrast sensitivity and more than moderate field loss can increase rate of crashes and impair driving performance. Some adults with impaired vision independently decide to decrease miles they drive, only drive in familiar areas, or limit driving to daylight hours (Sandlin, McGwin, & Owsley, 2014).

Dugan and Lee (2013) found that adults who self-report poor vision are less likely to drive or more likely to stop driving than adults with self-reported good vision. Driving restrictions or driving cessation due to vision impairment are delicate topics that require a network of support for the client and his/her caregivers. The occupational therapist can assist by providing resources for driving self-regulation and driving alternatives for sustained community mobility (Golisz, 2014).

In a systematic review, Golisz (2014) describes interventions such as driver and family education, cognitive-perceptual training, interventions geared toward physical fitness, simulator training, and behind-the-wheel training as options for occupational therapists to implement with older adult drivers.

Justiss (2013) found in a systematic review that simulator training, low vision rehabilitation geared to community mobility, driver education programs, and devices for low vision such as prisms and bioptics emerged as themes for occupational therapy interventions. Despite both studies similar results, implementation of these interventions shows limited impact on driver safety and number of accidents (Golisz, 2014; Justiss, 2013). Additional research is necessary.

The chart on the following page outlines vision regulations for driving by state.

References Dugan, E., & Lee, C. M. (2013). Biopsychosocial risk factors for driving cessation: Findings from the health and retirement study.

Journal of Aging and Health, 25(8), 1313-1328. doi:10.1177/0898264313503493 Golisz, K. (2014). Occupational therapy interventions to improve driving performance in older adults: A systematic review. American Journal of Occupational Therapy, 68(6), 662–669. http://dx.doi.org/10.5014/ajot.2014.011247 Justiss, M. D. (2013). Occupational therapy interventions to promote driving and community mobility for older adults with low vision: A systematic review. American Journal of Occupational Therapy, 67(3), 296-302. http://dx.doi.org/10.5014/ajot.2013.005660 Occupational therapy practice framework: Domain and process (3rd edition). (2014). American Journal of Occupational Therapy, 68(Supplement_1), S1-S48. doi:10.5014/ajot.2014.682006 Sandlin, D., McGwin, G., & Owsley, C. (2014). Association between vision impairment and driving exposure in older adults aged 70 years and over: A population�based examination. Acta Ophthalmologica, 92(3), e207-e212. doi:10.1111/aos.12050

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Acuity

Horizontal/ peripheral fields Monocular/ Single eye vision

Bioptic (combination of corrective lenses and small telescope on lenses)

Color Vision

Contrast Sensitivity Steps if Vision Requirements Not Met

PA 20/40 unrestricted

NJ DE 20/50 in better eye, 20/40 unrestricted tested once every license Less than 20/60 10 years corrected both eyes 20/50 restricted to restricted to daylight driving daylight only Worse than 20/50: No driving At least 120 No requirement No requirement degrees combined Must drive with At least 20/50 At least 20/40 outside mirrors that acuity acuity provide view of highway 200’ to the rear Permitted to drive, Yes, with 20/50 Bioptic systems: but not to pass acuity through individualized, licensure test telescope applicant must pass (vague) all driving tests and have Medical Review Section approval and restricted to day time only driving No requirement Tested in new No requirement drivers only; no additional requirement No requirement No requirement No requirement 20/70 to 20/100 requires eye care professional endorsement

If less than 20/50, If vision screen is form from physician failed: issued 60needed day temporary license to be examined by eye care specialist.

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Additional Driving Resources State Specific Regulations http://lowvision.preventblindness.org/daily-living-2/state-vision-screening-andstandards-for-license-to-drive/#Delaware PA Eye Exam Report (to be completed by an optometrist, ophthalmologist, physician assistant, certified registered nurse practitioner, or licensed physician with equipment to properly evaluate vision): http://www.dot.state.pa.us/public/dvspubsforms/BDL/BDL%20Medical-Protected/DL102.pdf PA Low Vision Restricted Driving Website http://www.aging.pa.gov/aging-services/transportation/Pages/Low-Vision-RestrictedDrivers-Licenses.aspx NJ Medical Report (States “emergency report” and focuses on seizures): http://www.state.nj.us/mvc/pdf/Licenses/MVC-Form_MR-4.pdf DE Medical Report (does not specify vision): http://dmv.de.gov/forms/driver_serv_forms/pdfs/dr_frm_mv346.pdf#search=medical% 20reporting Fox Rehab Driving Services Fox Rehab can provide pre-driving and driving assessment services to clients in DE, NJ, and PA. Services vary by county.

Call 1-877-407-3422 and ask for the driving department.

If the patient has a prescription for “community mobility,” the therapist can complete interventions to prepare for the driving assessment. Medicare covers 80% of costs.

If the patient has a prescription for “community integration,” Medicare covers the clinical driving assessment portion at 80%. This may change as of 12/31/16.

On-road driving assessments cost $155 to Fox and $150 for the dual steering wheel car rental. This is not covered by insurance. (as of 12/1/16) National Resources Physician’s Guide to Assessing and Counseling Older Drivers (an AMA publication): http://www.nhtsa.gov/People/injury/olddrive/OlderDriversBook/pages/Contents.html Interesting excerpt from this publication: “Among older drivers, binocular measures of contrast sensitivity have been found to be 27

a valid predictor of crash risk. However, there are presently no standardized cut-off points for contrast sensitivity and safe driving, and it is not routinely measured in eye exams.

Due to its usefulness in predicting crash risk, it is strongly recommended that standardized contrast sensitivity scales be developed, validated, and utilized in the clinical and driver licensing settings.�

AARP Automobile and Driver/Driving Safety Resources http://www.aarp.org/auto/?intcmp=GLBNAV-PL-ATO-ATO Link to National Highway Traffic Safety Administration Resources http://www.nhtsa.gov/Driving-Safety/Older-Drivers Association for Driver Rehabilitation Specialists Resources http://aded.site-ym.com Link to locate Driver Rehabilitation Providers http://aded.site-ym.com/search/custom.asp?id=1984 Link to AOTA Driving Partner Organizations and Stakeholders http://www.aota.org/Practice/Productive-Aging/Driving/Partners-and-Stakeholders.aspx Link to AOTA Self and Family Driving Assessment Tools (Fitness to Drive, Driving Decisions, AAA Resource): http://www.aota.org/Practice/Productive-Aging/Driving/Clients/Self-familyassessments.aspx Bioptic Driving http://www.biopticdrivingusa.com Driving Cessation Options Uber: https://www.uber.com/?exp=home_signup_form Lyft: https://www.lyft.com Taxi

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Ride Services for PA, NJ, DE Pennsylvania Berks/Schuylkill County: http://www.diakon.org/volunteers-serving-seniors/offices/ Delaware County: http://ctdelco.org/disabilities.html Pennsylvania Medical Assistance Transportation Program: http://matp.pa.gov Shared Ride Program: https://www.dot34.state.pa.us/BPTInfo.aspx Lehigh Valley: http://itnlehighvalley.org Montgomery County: http://montgomery.pa.networkofcare.org/mh/services/subcategory.aspx?tax=BT National Resources: https://www.disability.gov/resource/disability-govs-guidetransportation/ Philadelphia: http://victorysupportservices.com/supportive-transportation-of-philadelphia/ Comprehensive Lists: http://www.seniorsresourceguide.com/directories/Philadelphia/search.php?region=PA02 &topic=611 http://www.carepennsylvania.org/list14_PA_disability_transportation_senior_services.ht m New Jersey http://www.njtransit.com/tm/tm_servlet.srv?hdnPageAction=ParaTransitTo Multiple areas of assist for seniors: http://www.adrcnj.org Camden County: http://www.camdencounty.com/health/senior-and-disabledservices/senior-services-transportation Delaware http://www.fcilde.org/transport.html For Medicaid Recipients: http://www.dhss.delaware.gov/dhss/dmma/medical.html

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Pages 31 to 41 are content downloaded with permission from the American Occupational Therapy Association (AOTA). AOTA holds the copyright for these documents. Permission must be granted from AOTA prior to reproducing the Tip Sheets and Fact Sheets.

The links listed below are AOTA members-only documents. AOTA members are welcome to log in and access the publications.

AOTA Member Resources Critically Appraised Topics on Older Adults with Low Vision  Interventions to Improve the Ability to use Optical, Non-optical, and Electronic Magnifying Devices  Interventions to Maintain, Restore, and Improve Performance in Activities of Daily Lving (ADLs) and Instrumental Activities of Daily Living (IADLs) Within the Home  Interventions to Maintain, Restore, and Improve Performance in Leisure and Social Participation  Interventions to Improve Driving Performance and Community Mobility Critically Appraised Topics on Driving and Community Mobility for Older Adults  Clinical and Performance-based Assessments and Performance-based Assessments  Policy and Community Mobility Programs  Cognitive and Visual Function, Motor Function, Driving Skills, Self-regulation/Selfawareness, and the Role of Passengers and Family Involvement AOTA Evidence-Based Consensus Statement for Driving and Community Mobility  http://www.aota.org/~/media/Corporate/Files/Practice/Aging/Driving/evidencebased-consensus-statements-driving-community-mobility.pdf

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AOTA Fact Sheet: OT Services for Persons with Visual Impairment

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AOTA Tip Sheet: Living with Low Vision

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34

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AOTA Tip Sheet: Driving Safely as you Age

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AOTA Tip Sheet: Keeping Older Drivers Safe

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AOTA Fact Sheet: Driving and Transportation Options for Older Adults

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ADED Driving and Vision Fact Sheet

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Articles Referenced in Fact Sheets Article Arbesman, Lieberman, & Berlanstein, 2013 Barstow, Warren, Thaker, Hallman, & Batts, 2015 Berger, Kaldenberg, Selmane, & Carlo, 2016

BlackmoreWright, Georgeson, & Anderson, 2013 Ciuffreda, Han, Kapoor, & Ficarra,

Intervention

Population

Conclusions

Older adults with low vision

Systematic review for effectiveness of 4 areas of interventions for adults with low vision General overview of compensatory strategies that promote occupational participation; used for background information Improved reading performance and visual exploration than without auditory stimuli (moderate evidence, 1 Level I, 2 Level II studies, Ciuffreda, Han, Kapoor, & Ficarra, 2006; Keller & Lefin-Rank, 2010; Passamonti, Bertini, & Ladavas, 2009).

N/a- survey and interview questions

Adults with chronic conditions including low vision

Scanning training where visual stimuli (usually illuminated light/diode) paired with white noise auditory stimulus

Adults with TBI with visual field deficits

Scrolling text for impaired visual field; person sustains central fixation/gaze while text moves right to left Electronic Text Manipulation: -Double line spacing, double character word spacing Scanning training where visual stimuli

Level of Evidence I

V

I (specific articles from systematic review cited to left)

Improved reading saccades and reading speed with 4 weeks of daily intervention (limited evidence, Level II study, Spitzyna et al, 2007)

Adults with Macular Degeneration

This is the optimal spacing to promote reading abilities for adults with macular degeneration

III

Adults w Brain Injury

Improved results compared to 1 Level I, 2 without auditory stimulus Level II

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2006; Keller & LefinRank, 2010; Passamonti, Bertini, & Ladavas, 2009

(usually illuminated light/diode) paired with white noise auditory stimulus

Dugan & Lee, 2013

Study of chronic conditions & risk factors and impact on current/future driving patterns Background information

Adults >65 Almost 18,000

Adults self-reporting “fair/poor” vision were less likely to drive/more likely to stop driving than adults with “very good/excellent” vision

IV

Adult drivers >65

I

Goodrich & Kirby, 2001 Justiss, 2013

Hand held magnification Systematic review

Adults with Low Vision Adult drivers with low vision

Kutintara, Somboon, Buasri, Srettananura k, Jedeeyod, Pornpratoom , & Iamcham, 2013 Liu, Brost, Horton, Kenyon, & Mears, 2013

Environmental adaptations for kitchens

Adults with Low Vision

Systematic review of effective OT interventions with driving for multiple medical conditions (other conditions out of scope of project) Improves reading abilities with central field loss Found 4 interventions appropriate for OT; limited impact on effectiveness in reducing crashes Specific recommendations for kitchens for adults with low vision to promote safety and independence

-Multicomponent interventions should include: Education on low vision, using low vision devices,

Adults with Low Vision (mean age 69-82, majority with AMD)

Systematic review found OT has a strong role in providing effective low vision interventions

I

Golisz, 2014

III I

V

44

Livengood & Baker, 2015

Mohler, Neufeld, & Perlmutter, 2015 RusselMinda, Jutai, Strong, Campbell, et al, 2007 Sandlin, McGwin, & Owsley, 2014

education in problemsolving strategies, education on community resources -Multiple training sessions provide older adults time to incorporate new skills and knowledge into daily routine OT has a strong role in vision interventionsproblem solving strategies, education, and illumination Implementatio n of low vision interventions

Adults with glaucoma

OTs role and evidence based interventions after systematic review of literature

I

Adults with low vision

Activities must be important to client; client must be ready to change, want to maintain/regain independence Sans Serif typefaces (Arial, Helvetica, Verdana, or Adsans) more readable; size 16-18 font

IV

Contrast sensitivity impairments had high correlation with selfregulation of driving; altered driving patterns. Visual acuity not a factor in changing driving habits. Slower visual processing speed also is a

II

Font type and size to promote legibility

Adults with low vision

Population based study exploring relationship between vision impairment and amount of driving

Almost 2000 adult drivers >70 years old with low vision in Alabama

I

45

Schuett, Heywood, Kentridge, Dauner, & Zihl, 2012

Smallfield, Clem, & Myers, 2013

Spitzyna et al, 2007

Watson, Ramsey, De J’Aune, & Elk, 2004

Utilized software based reading and visual exploration programs (Zihl, 2001) in cross-over design study Multiple interventions, systematic review; alternate text font/size; Illumination recommendati ons Scrolling text for impaired visual field; person sustains central fixation/gaze while text moves right to left Reading speed was systematically measured at “regular” reading station and “ergonomically enhanced” reading stations

Adults with unilateral homonymous visual field disorder

factor in changing driving habits.

Visual Exploration and Reading Training compensatory computer based training improve reading ability, but very task specific/task dependent

II

Adults with low vision

Evidence supporting or not supporting OT’s role in low vision interventions

I

Adults with Brain Injury

Improved reading ability with this strategy

II

Adults >70 with ARMD

Using ergonomic principles for environmental set up for use of low vision devices at reading stations improves reading speed and decreases discomfort with reading

II

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Textbooks: Lueck, A. H. (Ed.). (2004). Functional vision: A practitioner’s guide to evaluation and intervention. New York, NY: AFB Press.

Scheiman, M. (2002). Understanding and managing vision deficits: A guide for occupational therapists (2nd ed.). Thorofare, NJ: SLACK. Warren, M., & Barstow, E. A. (Eds.). (2011). Occupational therapy interventions for adults with low vision. Bethesda, MD: AOTA Press.

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