The everyday lives of older adults with visual impairment: An occupational perspective

Abstract

Introduction

In order to live in a world created for the sighted, older adults with visual impairment must adapt to complete vision-dependent activities that require reading, writing, and object identification. The objective of this study was to explore the occupational lives of three older adults with visual impairment.

Method

A qualitative study with four interviews each and two observation sessions each was conducted with older adults with visual impairment. Data were analyzed by participant and across participants using open, axial, and selective coding. Codes were refined throughout the process yielding the themes of the study.

Results

Three themes emerged from the analysis: an occupational life of doing, an occupational life rich with well-being, and an occupational life filled with motivation for independence. Participants were highly motivated to complete their occupations and activities independently. Participation in activities in the home and community environments provided participants with life satisfaction and happiness. Through problem-solving skills, adaptations, and support of family and friends, participants successfully completed their desired occupations.

Conclusion

This study highlights the importance of motivation and support to facilitate participation in occupations in the home and community environments.

Keywords

Occupational lives visual impairment participation independence

Introduction

The World Health Organization (WHO, 2012) reports 285 million individuals with visual impairment and blindness throughout the world. Older adults represent the largest number of individuals with blindness. In the United Kingdom (UK), the number of people with visual impairment will rise to more than 2,250,000 by 2020, and will double to nearly four million people in 2050 due to the aging population (RNIB, 2017). In the United States (USA), there will be 5.5 million people with visual impairment by the year 2020 (National Eye Institute, 2004). In 2050, it is predicted that there will be 88.5 million Americans older than 65 years of age (Khan & Simon, 2011; Sternberg, 2013). As the older adult population increases, the number of individuals with visual impairment will also increase (RNIB, 2017; Nastasi, 2015).

Literature review

While research exists on the effects of visual impairment, low vision, and blindness on specific occupations such as reading (Smallfield et al., 2013) and daily living (Liu et al., 2013; Orellano et al., 2012; Lamoureux et al., 2008), literature addressing the occupational lives of older adults with visual impairment is limited (Alma et al., 2011; Desrosiers et al., 2009; Smith, Ludwig, Anderson, & Copolillo, 2009). Individual occupations do not reflect the life of the person. The literature shows that older adults with visual impairment experience an enhanced sense of risk, which results in shrinking physical and social spaces. These older adults weigh out the benefits and risks necessary to complete an occupation. They struggle to maintain independence in visually dependent occupations and activities, which previously presented no challenges or risks (Rudman et al., 2010). They participate less in daily activities and social roles (Desrosiers et al., 2009) and society (Alma et al., 2011) than older adults without visual impairment do. Barriers include physical and social environments that are not accessible and that create complications that require adaptation (Kaminsky et al., 2014). Common adaptations include addressing lighting (Perlmutter et al., 2013), decreasing patterns and clutter in the environment, increasing contrast, and implementing organizational strategies (American Occupational Therapy Association [AOTA], 2013). The complexity of vision loss and activities requires individualization of adaptive techniques. More information is needed on the occupational lives of older adults with visual impairment in order to understand successful participation in the home and community environments.

Occupational adaptation

Individuals with visual impairment need to learn to adapt to vision loss in order to live and engage in a world created and designed for the sighted (Nastasi, 2015). The model of occupational adaptation (OA) describes a normative process to explain the steps that individuals with visual impairment take to complete occupations successfully. OA addresses the person, the occupational environment, and the interaction between the person and the occupational environment (Schkade and Schultz, 1992; Schultz and Schkade, 1992). Through occupation, individuals with visual impairment develop repertoires of responses that lead to successful participation in desired occupations. They achieve relative mastery of occupations when their abilities and the occupational environment’s demands match (Schkade and McClung, 2001; Nastasi, 2015).

The current study will answer the research question, “What are the occupational lives of older adults with visual impairment?” An occupational life consists of human experiences in everyday occupations. Visual impairment is defined as a visual acuity of 1/3 (20/60) to total blindness (AHRQ, 2004).

The purpose of this study is to describe the occupational lives of older adults with visual impairment. This includes the occupations of older adults with visual impairment, community participation, and challenges and adaptations used for their participation.

Method

Research design

This qualitative research study used a collective case study to gain a better understanding of the occupational lives of three older adults with visual impairment. The collective case study methodology allows for greater depth of understanding of context and process, and understanding and linking of causes and outcomes (Flyvbjerg, 2011). Participants completed four interviews each and two observation sessions each. See Appendix 1 for the interview questions. Semi-structured interviews were used for each of the interview sessions. Participants were observed in a class at a center for blind people to analyze participation in a group in the community. In addition, participants were observed for a 12-hour day to analyze the occupations and activities participated in during a normal day. Data from interviews were open-coded, axial-coded, and selective-coded to refine and yield the themes of the study. Data from observations were recorded as field notes. Participants were recruited from a center for blind people providing programs in the community in order to ensure participants with community participation.

Boundaries of the study

Participants were adults 65 years of age or older who had experienced visual impairment for more than five years. This eliminated working older adults and those newly adapting to vision loss. Participants lived in the same county and participated in at least one program a week at a center for blind people. The center offers transportation and classes in exercise and nutrition, sensory development, and advocacy. In addition, the center offers a movie group, book club, and a client-run club. The study addressed the participants’ participation at the center, their participation in the community, the environments in which they participate, and their adaptation to vision loss.

Selection criteria

Recruitment of participants was coordinated through the center for blind people. Employees of the agency notified their clients of the research study. Clients needed to meet the following eligibility criteria in order to participate in this study: be registered to receive services at the center; have a visual impairment (minimum of best-corrected visual acuity of 1/3 [20/60] in the better eye, to a maximum of total blindness or no light perception); participate in at least one program at the center; have had a visual impairment for more than five years; and be at least 65 years of age. Interested clients notified employees at the center of their interest in participating in the study. Employees then notified the researcher of the clients’ interest and scheduled a time for the clients to meet the researcher. Eligibility was determined during the first session, and three participants with some remaining vision were recruited to participate in the study.

Data collection methods

Prior to collecting data, the study received Institutional Review Board approval, and each participant provided informed consent. Participants were aware that they were free to withdraw from the study at any time with no penalties. All participants were assigned pseudonyms to ensure confidently. During the observation sessions, the participants selected the dates and times for the sessions, knowing the researcher would be following them throughout the day.

Center for blind people

The four interviews and one observation of participation in a group program were conducted at the center. Interviews took place in a private office space, and observations took place in the community room where group programs were held.

Home and community

The observation for a full 12-hour day took place in the participants’ home and community. Participants identified the time in the morning for the researcher to arrive, and the researcher left in the evening after observing the participants for 12 hours. The researcher observed all of the participants’ occupations and activities, with the exception of toileting and dressing. This included activities in the home and the community that the participants completed on the day of the observation.

Data collection and instrumentation

Data were collected over the six sessions of the study. Interviews were audio-recorded and transcribed verbatim, and field notes were taken during the observation sessions. Interviews were conducted for the first, second, fourth, and sixth sessions. The interviews addressed the participants’ vision, changes in vision over time, activities, participation, successful and unsuccessful completion of activities, strategies to solve problems, challenges presented, and any additional information the participants wanted to share. Observations were conducted for the third (participation in a group program) and fifth sessions (a full 12-hour day). All participants completed demographic questions and visual assessments for visual acuity to determine eligibility for the study. During the final interview, participants had their vision reassessed and confirmed the codes/themes emerging from the interviews and observation sessions. The third and fifth sessions did not occur until all participants completed the first two and the fourth session respectively. This allowed the researcher to code and analyze the data for each participant and across participants before completing the follow-up interviews. The final session did not occur until all five sessions were completed by the participants and analyzed to confirm the themes of the study.

Data management

An audit trail was maintained through the study to ensure the proper sequencing, gathering, and analyzing of the data (Gay et al., 2012). To ensure confidentiality, participants were assigned pseudonyms for the study.

Data analysis

The researcher created matrixes for the data from the interviews of the study. Transcripts were placed in the matrixes to code. Codes were refined by participant and across participants using the lens of occupational adaptation. The researcher initially open coded 228 pages of data. Axial coding reduced the data to 101 pages, and selective coding further reduced the data to 45 pages. Overall themes of the study were developed throughout the coding process by merging data to determine common themes. Interviews and the observation sessions were used to validate the themes of the study and were confirmed by the participants.

Comparison of data

The researcher compared codes among interviews. Memos or field notes were created during the coding and served as the first draft of the completed analysis. Themes were refined and built throughout the process. Themes were linked to the participants’ interviews and observations. Each interview was compared to each other and previous interviews.

Trustworthiness

Trustworthiness was established by audio recording and transcribing the interviews verbatim (Gay et al., 2012). Feedback was requested from the participants for the themes of the study. Participants reviewed and concurred with the codes/themes of the study.

Results

In this study, an occupational life consisted of human experiences in everyday occupations. Profiles of the participants’ occupational lives and the overall themes of the study will be discussed.

Participant profiles

One male and two female retired, community-dwelling seniors participated in the study. They all participated in weekly programs at the center for blind people, were independent in activities of daily living (ADL), and participated in leisure activities outside of the home on a weekly basis. They relied on family and friends and various private and public forms of transportation for travel. Familial support contributed to independence in instrumental ADL. The researcher assigned participants with the pseudonyms of Ann, Jane, and Joe. Table 1 provides demographics for the participants, and Table 2 addresses rehabilitation and adaptive techniques used by the participants.

Table 1.

Demographics of the participants.

Participant:	Ann	Jane	Joe
Age (years):	85	87	65
Marital status:	Widow	Widow	Married
Residence:	House	Apartment	House
Diagnosis:	Macular degeneration	Bilateral corneal transplants, and glaucoma	Genetic deterioration of the retinas
Onset of diagnosis:	8 years ago	34 years ago	10 years ago
Visual acuity level (start of study):	Severe visual impairment	Profound visual impairment	Profound visual impairment
Visual acuity level (end of study):	Moderate visual impairment	Near blindness	Profound visual impairment

Table 2.

Rehabilitation and adaptive techniques.

Participant:	Ann	Jane	Joe
Rehabilitation:	No	Yes	Yes
Type of rehabilitation:	n/a	Orientation and mobility	Four formal training periods at two different government facilities in orientation and mobility, computers, and arts and crafts
Adaptive strategies:	Equipment, memory, organization, problem-solving, and family support	Equipment, memory, organization, problem-solving, and family support	Equipment, memory, organization, problem-solving, and family support
Adaptive equipment:	Eyeglasses, over the counter magnifier, closed-circuit television, typoscope, 20/20 pens, digital device to read books on tape, and task lights	Eyeglasses, a closed-circuit television (which she no longer uses), and digital and tape machines for books	Eyeglasses, two closed-circuit televisions, magnifiers, TV glasses, a talking glucose meter, digital and tape devices for books on tape, a scanner, pill containers, prescription label reader, and task lights

Ann

Ann lives alone in a suburb of the city. Ann reports difficulty threading needles, reading recipes and/or package instructions, and using the microwave. Ann is unable to read the Bible and/or standard print books and chooses to listen to audio books. Outside of the home, Ann attends and participates in weekly activities at the center for blind people and two clubs, and attends church on a weekly basis. Ann loves to leave her home and go out in the community. She walks, uses private and public transportation, and relies on friends and family to travel. Ann has strong familial support. Ann’s days, weeks, months, and seasons are structured and routine. Ann attends clubs and completes chores on specified days. She also employs multiple strategies to remain independent.

I use magnification most of all, but I do use different strategies and at one time organization was really my best suit. I don’t say it is any more, but I do the best I can. I try to keep things organized because it is easier to handle things if they are organized. (Ann)

Jane

Jane lives alone in a suburb of the city. Jane has trouble with feeding and slicing. Her daughters complete her clothing care, shopping, meal preparation, and financial management. Jane is unable to write and read print, but enjoys listening to digital books, books on tape, and the television. Jane delegates some tasks to her daughters to complete. Outside of the home, Jane attends and participates in weekly activities at the center for blind people, attends the senior citizen group one for two days a week, and attends church on a weekly basis. Jane is highly motivated to participate in activities and to leave the home. Jane received a few sessions of orientation and mobility so that she could walk down the block to her relative’s house. She has not received any other rehabilitation for her visual impairment. Jane’s family and friends provide her with transportation, and she rides the center for blind people’s van. Jane has extremely strong familial support. She attends clubs on specific days and completes activities with her family at specified times. Jane employs multiple organizational and memory strategies to remain independent.

Memory is mostly what I do things a lot by any more. (Jane)

Joe

Joe lives in the city with his wife. Joe reports that reading recipes and/or package instructions, using the stove top, shopping, playing games, and writing are difficult. Joe’s wife does the clothing care and financial management. Joe is unable to read the telephone directory and uses his computer, scanner, and app reader to read items. Joe listens to books and magazines on digital and tape devices. Outside of the home, Joe attends and participates in activities at the center for blind people and three clubs. Joe is highly motivated to participate in activities and to leave his home. Joe’s wife drives him to places, and he uses various forms of transportation provided by the government. Joe has strong familial support. Joe’s days, weeks, months, and seasons are structured and routine. Joe attends clubs on certain days and goes to the doctor on specific days. He also employs multiple strategies to remain independent. Joe enjoys using humor, organization, and technology to remain independent.

I’m definitely organized. (Joe)

Themes

Ann, Jane, and Joe live full, productive lives. The themes of an occupational life of doing, an occupational life rich with well-being, and an occupational life filled with motivation for independence emerged from the interviews and observations.

An occupational life of doing

The participants’ occupational lives embody a life of doing, as demonstrated in their participation in activities in and out of the home. On the full-day observations, all of the participants traveled into the community and participated in meaningful occupations. In the home, all of the participants prepared meals and enjoyed leisure activities. Ann enjoyed reading, made phone calls, and completed chores. Jane organized her things for going out to the senior center, made calls, and watched television. Joe read the newspaper using his computer and scanner. Outside of the home, Ann used public transportation and traveled to the center to participant in a program and lunch. Jane’s neighbor drove her to the senior center where she participated in activities. Joe and his wife went out to dinner at a local restaurant. The following passages illustrate their occupational lives of doing.

Once a month on Thursday, I go to the [club]. I go to church every Sunday, and if there are church activities within the week, I do … It means a lot to me, it means getting out of the house. It means associating with other people. (Ann)

I go over to the senior center. Oh, I do, and we have a good time with them, we have a good time. We eat and we talk. I just go and sit there and gab with them just like anybody else does. (Jane)

I belong to the [club], I have been with them maybe 25–30 years also, and we have two meetings a month … I love the social part of it, you know, I just love being with people. (Joe)

Participants were observed doing activities in the home and the community. Their visual impairment did not prevent them from doing their desired occupations at home or in the community. The participants went from one activity to another throughout the day. Each activity had purpose and meaning. Additional lighting, organization, and memory were used to compensate for vision loss. Strategies employed allowed the participants to complete the desired occupations and tasks successfully.

An occupational life rich with well-being

The participants rated their overall quality of life as good and their happiness as an eight or a nine on a scale from 1 to 10. Family support facilitated well-being.

Well, I have a daughter nearby and a son nearby. My son stops in every single day, my daughter calls just about every day, and I have another son that calls at least twice a week. My son usually comes in after work, and we’ll have a chat for as long as much time as he can spend with me. I go shopping every Wednesday with my daughter, and I get out in between with my granddaughter. (Ann)

So my life is unique that I can have daughters that make my life as beautiful as it is, that is all that I can say about it … we are family and we do a lot of stuff together. I am not in the house day after day after day after day. I mean, my kids make sure that I go with them wherever we are going. We’re a close family. (Jane)

I have been married for 41 years, so I have one son, I have a granddaughter who is 11 … At home, my wife takes care of it all. (Joe)

During the full-day observations, all of the participants interacted with at least two family members during the day. Ann’s son and daughter visited her in the afternoon. Ann’s son came over to put the air conditioner into the window for Ann, and her daughter brought over some groceries for her. Jane’s daughter, great-granddaughter, and grandson visited her during the day. Her daughter and great-granddaughter took her out to dinner and then took her to the great-granddaughter’s baseball game where her granddaughter met her. Joe had his wife and granddaughter at his house in the early morning. They then left to go shopping. Joe’s wife returned in the early afternoon and then took Joe out to dinner. Throughout the full-day observations, family and friends called the participants, and the participants had access to family and friends, even when no one was with them. All of the participants knew that they could count on and rely on family if needed. Their families supported their overall well-being through their physical presence and availability via telephone.

An occupational life filled with motivation for independence

The participants filled their occupational lives with desire, a drive to problem-solve everyday activities, and the will to remain independent in everyday activities. The participants felt an intense drive to remain independent and to complete activities on their own. It did not matter how small or how large the task, they wanted to do it on their own.

I work it out the best of my ability. If it is something that I need to see, if I am in the kitchen and I was trying to read something there, and I couldn’t read it with the magnified glass in the kitchen, I would go into the living room under that lamp that I can read. Or under the machine or trying to read a recipe or something like that. I try to do the best that I can, you know, with what I have. I take charge that is hard to give up. (Ann)

I do what I want to do, I mean if I want to get something done. Well I try to do them, but I mean there is a lot of stuff that I go ahead and do. I said my eyes aren’t that bad that I can’t do what I really feel like I need to do sometimes. I mean there are things that I have to do. Well, I just kept going until I made sure that I got something that I wanted. (Jane)

No, I feel that I’m a go-getter, and I love to do things and you know as far as traveling as I mentioned before, if I had to crawl I’m still going to travel. (Joe)

The participants had a drive to be independent in the activities that they wanted to do. During the full-day observations, each participant independently completed tasks or delegated tasks to others to ensure success. The participants had insight into their abilities and were able to delegate tasks that would be problematic. The participants had a desire to do something and achieved their goal of completing the task. The participants did what they had to do to be able to complete the activities that they wanted to do. Adaptive techniques and problem-solving skills were used to achieve the desired results. Understanding their abilities and restrictions allowed them to make safe decisions as they participated in desired occupations.

Discussion and implications

The findings of the present study partially support and partially contradict Rudman et al.’s (2010) findings that older adults with visual impairment who did not seek rehabilitation experienced an enhanced sense of risk. Although one participant in this study received comprehensive rehabilitation for his visual impairment, all three participants continued to participate in activities in the home and community environments, and two of the three participants had worse visual acuity than those in Rudman et al.’s (2010) study. The participant who received rehabilitation found the training beneficial. The two participants who did not receive comprehensive rehabilitation did not experience an enhanced sense of risk and continued to live active lives in the community. Insight into their abilities allowed them to make good decisions.

The findings of the current study support the findings from studies on participation in occupations to promote health and wellness for individuals (Eklund et al., 2008; Stav et al., 2012) that found participation in occupations promoted health and wellness. Participation in occupations provided purpose for the participants and kept them going. In addition, the current study supports the findings of previous studies on the act of doing (Erlandsson, 2013; Smith et al., 2009) that found doing allowed individuals to achieve a greater motivation for independence (Tay et al., 2014). The participants were highly motivated to complete activities that they desired, and they adapted in order to complete the activities.

Finally, the findings support a systematic review conducted by Bambara et al. (2009) that found that the majority of literature on family functioning and low vision focused on the unique role that family played in providing instrumental and emotional support to the visually impaired. Family members provided instrumental support by assisting the individual with visual impairment in everyday living tasks, and they provided emotional support by encouraging the individual during difficult times. This held true for the participants in the study who had strong levels of family support on a daily basis.

Occupational therapists need to evaluate the motivation level of their clients and the amount of support available to them. Motivation and support were key facilitators to participation in the home and community for the participants in the study.

Limitations and future research

Little research has been conducted on the occupational lives of older adults with visual impairment. Rudman et al. (2010) discussed the physical and social isolation that occurs with older adults with visual impairment. This study specifically sought older adults with visual impairment who went out into the community to understand what allowed them to participate in the community. In order to explore this topic, the study heavily relied on self-reported data from the participants who participated in the community. Observation sessions were incorporated into the study to corroborate the accuracy of the self-reported data. Thick descriptive quotes were used to allow readers to make decisions about transferability. Participants in the study were highly motivated to remain independent and had family support. Results of the study should not be generalized.

Researchers should continue to explore the occupational lives of older adults with visual impairment who do and do not participate in the community. This study identified adaptations and strategies used by three individuals with visual impairment who participated in the community. Through partnerships with a local center for blind people, occupational therapists can develop a relationship with registered individuals who do or do not participate in center activities. Future studies will provide clinicians and researchers with a greater understanding of the occupational lives of older adults with visual impairment.

Conclusion

The occupational lives of the participants revealed doing, well-being, and motivation for independence. Occupational therapists should explore problem-solving techniques that will allow their clients to adapt to vision loss. The ability to problem solve successfully facilitated the participants’ ability to participate in the community. They did not shrink their physical and social spaces, as indicated by Rudman et al. (2010). They did not fear environments that they could not control. Their insight into their abilities plus their ability to problem solve made them successful in both the home and the community. Observation is also key. The participants often did not verbalize the adaptations or strategies used. Understanding their clients’ repertoire of strategies and techniques will assist in facilitating well-being and independence. Support from family and friends was crucial in facilitating participation in the community for those no longer able to drive. Identifying available family and friends to provide transportation to desired occupations and activities will facilitate the ability to participate in the community. Finally, occupational therapists should identify and address desired occupations that are motivating to the client. Motivation and drive to complete desired occupations empowered the participants to remain independent. Identifying and using desired occupations will facilitate engagement and participation.

Key findings

Support from family and friends played an important role in facilitating participation in the community.

Problem-solving skills and adaptation promoted independence in activities.

What the study has added

This study provides insight into the occupational lives of older adults with visual impairment who participate in the community.

Footnotes

Acknowledgments

I would like to acknowledge Dr. Regena Stevens-Ratchford who served as chair of my dissertation committee. I would also like to thank Dr. Mary Warren and Dr. Thomas Hogan for serving on my committee. Finally, I would like to thank Dr. Debra Pellegrino for her support of my research doctorate.

Research ethics

IRB approval from Towson University: Initial Approval February 24, 2014 Approval Number: 14-A068, modified on March 19, 2014 with the same number, and then renewed March 30, 2015 with Renewed Approval Number: 14-A068R1 and the University of Scranton: Approval on March 10, 2014 OT/PT DRB Application #1402. All participants provided written informed consent.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Appendix 1

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