More than 14 million Americans have a visual impairment (National Eye Institute, 1991). It is defined as a loss of vision that cannot be corrected by medical or surgical intervention or corrective lenses. Even though low vision effects all age groups, it is especially prevalent among older adults. One in nine patients age 65 or older has a severe visual impairment and that number rises to one in four among those 85 or older (American Foundation for the Blind, 1999). The four leading causes of vision impairment include macular degeneration, cataracts, glaucoma, and diabetic retinopathy.
One of the greatest challenges in medical compliance for all patients is the understanding and adherence to a consistent medication program. For those patients experiencing a visual loss, instruction in compliance can be daunting. There are a number of care strategies, however, that can be used to help increase compliance and even independence, for patients who are visually impaired.
Understand the Vision Impairment
It is important to understand the type of vision loss a patient is experiencing. With some forms of vision impairment, such as macular degeneration, the patient may have poor central vision. With poor central vision, reading or fine visual tasks, such as color discrimination, may be difficult. Patients with diabetic retinopathy or AIDS-related vision loss, such as cytomegalovirus, may experience fluctuating vision which can impact instruction. For specific visual information, check the patients' chart or speak directly with patients regarding their visual abilities. (For more information about specific eye disorders, a few Web sites are listed in the Sidebar on page 17.)
Encourage the Use of Low Vision Devices
A number of patients with vision impairments will use low vision devices for reading tasks or spot reading (e.g., simple spotting tasks such as color identification of pills or opening a package). These devices range from a common hand magnifier to high-powered electronic devices (Figure 1). It is important to know how these devices work so appropriate use can be encouraged. For instance, some devices are used only for near vision tasks and others just for distance. A low-vision stand magnifier, to be used correctly, must be placed directly on the surface to be read. Therefore, this device may not be helpful to a patient trying to read curved surfaces, such as pill bottles or syringes. Vision rehabilitation professionals can provide more information about low vision devices and their optimal use.
Figure 1 . Examples of low vision devices to help patients read medication labels.
Figure 2. Examples of a gooseneck desk lamp and a tray.
Figure 3. Samples of labeling and marking ideas.
Use Good Lighting
General household lighting may not help patients with a vision impairment use optical devices correctly or use their residual vision to a maximum level. Task lighting, such as a gooseneck desk lamp with a soft white or soft pink light bulb, may be used to reduce glare. This type of lamp can be easily adjusted to focus light where the patient needs it (Figure 2).
Use Color and Contrast
Color and contrast may be used to enhance a patient's residual vision. A dark-colored tray may be used in the medication regime. This tray will contrast with the background to help reduce glare when reading prescription bottles or medication directions. It can also provide contrast against the color and shape of pills and medication containers, which can be an important clue in identifying a medication's use and function. A tray is also a helpful device for catching dropped or spilled medication and can reduce waste (Figure 2).
Encourage the Use of All Senses
Patients should be encouraged to use their senses of touch and smell to help identify medications. Most capsules or tablets have unique shapes and some even have textures that may help distinguish one from another.
Clean the Clutter
To enhance the previously described techniques, patients should be encouraged to set aside an area in their home for the medication regime. It should be free of clutter and allow room for storage of optical devices, a tray, medications, and other medical equipment. To help reduce or eliminate the use of outdated or no-longer-appropriate medications, patients should be instructed to discard such items.
The first items to be organized should be current medications. These should be placed together within the work area. For patients who maintain a back-up or auxiliary supply, it should be suggested that this supply be labeled and stored in a different area. Plastic shoe boxes or zipper sandwich bags make excellent, inexpensive storage containers and can be labeled easily.
Labeling and Marking
When helping patients to label or mark medicines, remember less is better. There are two ways medications can be marked, for content or for use. When marking for content, it may not be necessary to mark each pill container. The patient may be able to safely identify the medication by the size, shape, color or texture of the container. Patients should mark only those containers that are similar in size or shape.
When it is necessary to mark for content or to indicate usage, the patient might use a system of marking that is attached permanently to the medication (e.g., writing a large letter B on the front label with dark marker). Although this solution works in the short term, it will only last for the life of the medication and should be discarded along with the empty container when the medication is finished. To do otherwise would encourage the reuse of containers, which can lead to mislabeling medications and to accidents. For labeling and marking ideas, see the Sidebar. Sample ideas are also demonstrated in Figure 3.
Pill organizers. A number of commercially produced pill organizers are available. These can help a patient remember to take a specific dose of medication at a specific time. They can be found in contrasting colors such as a white or yellow organizer with black print indicating the days of the week or time of day. Some have braille, or raised lettering, on the compartment opening. Using an organizer does not help the patient with identification of medication. The patient must still be able to identify the medication from its original container to fill the organizer. It is helpful to the patient who does not want to figure out their medication doses daily or who may want the family to assist with organizing medications. It is also helpful to the patient who may forget to take a medication at a certain time or day (Figure 3).
Talking or auditory timers. There are a number of talking and auditory feedback timers available on the market. These can be set by the patient or family members to help the patient remember to take medication, especially timed doses. Timers are especially helpful to patients taking multiple doses of medications throughout the day. A number of helpful devices that can be operated independently by the patient can be recommended by rehabilitation teachers who are familiar with adaptive equipment for individuals with vision impairment.
It might be suggested to patients to leave the compartment door or cover open after taking their dose of medication. This helps the patient factually locate the next compartment door for the next dose to be taken and at the end of the day or week when all of the doors are open, making refilling the organizer easier.
It is important to include patients, and when possible, members of the vision rehabilitation team such as rehabilitation teachers or low vision therapists, in the design of a medication program. These professionals are specialists in eye disorders, low vision devices, adaptive equipment, and techniques for individuals who are visually impaired. As the liaison between the physician and patient, gerontologicai nurses need to understand a patient's vision loss and the care strategies necessary to help the patient. By implementing these simple procedures, patients can become more independent, confident, and compliant in the management of their mediation regimes.
- American Foundation for the Blind. (1999). Fact sheet: Facts about aging and vision loss. New York: Author.
- National Eye Institute. (1991). Report of the visual impairment and its rehabilitation panel. Bethesda, MD: National Institutes of Health.