Helping People with Progressive Memory Disorders »

Chapter 9: Changes of Vision

Changes in ability to see well may be due to changes in a person's eyes or in the brain cells of the visual system. A person with vision changes should check first with the eye doctor. The eye doctor, an ophthalmologist, will check for glaucoma, cataracts, other eye problems, and the need for eyeglasses or a change in eyeglasses. In spite of corrective procedures, some people will continue to have visual problems. Some may not be able to see on one side. For example, they may have limited vision or unable to see things on the left side of their body. One way to help in this situation is to change the furniture around a little to avoid injury. Making the home safer helps these people stay as independent as possible. Toward the end of this chapter the section on Visual Inattention or Neglect discusses this topic more.

LIMITED VISION
Make the house safe with good lighting, smooth floors (no throw rugs), and no accessible hanging plants, fans, or lights. Move furniture so that the sharp edges face the wall. Padding on the edges of kitchen counters can soften a fall. Big, sturdy, well upholstered furniture helps catch and cushion those at risk to fall.

VISION PROBLEMS WITHIN THE BRAIN
If the eyes are healthy and a person still struggles to see, the loss of vision may result from changes in the cells of the visual system within the brain. In other words, the eyes carry clear information from outside the body into the brain but there are problems with the way the information is either stored, processed, or interpreted in the visual systems of the brain.

DIFFICULTY WITH RECOGNIZ-ING OBJECTS (VISUAL OBJECT AGNOSIA)
The eyes may focus on a brown square object and send visual information to the back portions of the brain called the occipital lobes. This visual information is put together in early forms of colored shapes and patterns. These early forms then link to memory and language systems that enable the person to recognize the brown square object by linking to the brain's word bank and finding the name "brown wallet." If a person has brain damage in

the visual system due to a stroke or a degenerative disorder, the brown image may remain sketchy and poorly formed (a perceptual disturbance). Or the image may be fully formed but unable to connect to the meaning and naming area of the brain. Thus the person may not be able to recognize the exact identity of the object.

Some people may be able to recognize objects that are presented to them in other ways. If the person can feel or smell the object, they may be able to recognize it. Or if they can hear the person talk, they may recognize the person. It may help to limit choices. For example, a person should use the same object for a specific activity, such as using the same coffee mug for all beverages. Another suggestion is to color code objects. For example, a red doorknob may indicate the outside door while the green doorknob indicates the kitchen door. Position objects in space so that they are easy to recognize. For example, when a cup is placed on a counter top or on a high cabinet shelf at eye level, it may "look" more like a cup than when it is on the bottom floor-level shelf and seen at a different angle.

Sometimes people try to stare or look very hard at objects or words in order to "see." It may be more helpful to look quickly at the object, close one's eyes, and guess the name of the object. There may be a sense of knowing the identity of the object. This knowing may mean that somehow the visual information quickly entered the brain's word bank but only made a weak impression or incomplete impression. So the person may actually recall the name of the object but at the same time may not feel confident about really knowing the name of the object.

Relax and Look
A different approach is to close one's eyes first, count to three to relax, take a quick look at the object, close the eyes quickly, and say the first name that pops into mind.

Learn a Special Feature
It may be helpful to look at a distinctive or special feature to recognize a person or object. For example, looking at the eyeglasses, the bowtie, or the gap in a person's front teeth instead of the whole face or body may be a way to recognize the person. Seeing a splash of blue may mean a special chair, while a splash of green and orange may mean the flowered curtains next to the door. Other suggestions include listening to a person's distinctive footsteps or the way they clear their throat before speaking.

IMPAIRED READING (ALEXIA - INABILITY TO READ)
People with strokes, tumors, and degenerative disorders may also have problems with reading words. Some can read slowly letter by letter. Others may have difficulty reading some types of words, for example, irregular words such as yacht. People with reading difficulties can be helped by using different methods of sending messages such as through speech or using a tape recorder or books for the blind.

IMPAIRED REACHING AND PLACING (OPTIC ATAXIA)
Some people are unable to reach correctly for objects or put objects in their correct position. For example, they may struggle to pick up a pair of socks from the dresser and struggle to place a glass upright on a coaster or a book back in place on the bookshelf.

It helps to use larger, sturdy objects that are easy to grab and hold. The environment should be arranged such that reaching tasks are simplified with just a few objects. For example, a counter top should have one large plastic cup available, not a whole set bunched together.

Allow plenty of time for the task. Use a background that has a high contrast, for example two pairs of white socks in a drawer lined with dark green or blue shelf paper.

SEEING ONLY A SMALL DETAIL (SIMULTANAGNOSIA)
Some people have changes in the visual system such that they cannot see the "big picture" and instead can see only one object at a time or only parts of objects. They see only the hammer or hammer tip and not the set of tools in the toolbox. When looking at a picture, they may see the apple stem but not the whole apple and definitely not the tree holding many apples. These people may need help learning to scan the whole scene. In looking at a picture, it may help these people to hold one hand on the left edge of the paper while looking at that side of the picture or scene and then using a moving finger as a guide, to look across the whole picture or scene. In real life, it helps if there is less to look at, for example, if there are few objects or people in the room or setting where they are walking.

NOT KNOWING FACES
People with strokes or degenerative dementia may not recognize the faces of people they know well, such as neighbors or even family members. Sometimes it helps for that person to listen carefully to get clues from the voice or to focus on distinguishing marks, such as the nose or curved eyebrow. Around the house, if there are several people living together, some type of nonfacial identification may be used, such as a type of clothing. For example, a blue vest identifies one person as the daughter while the spouse wears an orange vest.

Sometimes smell can help. People sometimes wear a special cologne or aftershave lotion that becomes their trademark. The fragrance gives away their identity.

Sometimes people with dementia have difficulty telling the difference between real people, people on the television screen, and the reflections in a mirror or on other highly reflective surfaces such as glass, waxed furniture, or a glossy floor. They may wonder who the stranger (the reflection) is, may think the reflection is a friend visiting, and try to serve the reflection food or a drink. Sometimes they see the reflection as a robber or killer and become very fearful or angry about the intruder. They may try to overpower or hurt their "killer" (reflection in the mirror) and hurt themselves on cut glass. Dull furniture surfaces, tablecloths, or other covers on shiny surfaces help. Sometimes the only help is for the family to cover the mirror with a sheet, face the mirror to the wall, or remove the mirror completely.

DIFFICULTY WITH DIRECTION
Difficulty with direction shows up as problems finding one's way around and getting lost. Though they may have lived in the same neighborhood for many years, they may get lost halfway down the street or one street over from their home. A companion may be necessary for outside activity. If the person will stay close by the home, a big red ribbon on the front door or around a tree out front may show the way home. The person may even get lost in their own home. They may have difficulty finding the kitchen that is at the other end of the home. Bright tape on the floor with arrows can point the way to a specific room.

VISUAL INATTENTION OR NEGLECT
When there is brain damage to the right hemisphere, neglect of the opposite side of space may result. In other words, the person with a stroke on the right side of their brain not only has difficulty moving the left side of the body but also will ignore objects or people on that side. They may not eat food on the left side of the dinner plate, may ignore people at their left side, may not read the left half of the newspaper, may not comb the left side of their hair, and may bump into furniture on the left side of the pathway.

It helps to put food on the right half of their dinner plate and to put utensils and drinks also on that side. A speaker should be on the right side of the person. The person who is neglecting objects on the left side should be reminded to look from side to side when walking. When they are seated or in bed, their left side should be near the wall. Thus when they get up, they should move to the right of the chair or bed. Thus they use their strong side to get up and reduce the chance for falls.

It may be helpful to train a person to look first to the left before moving. Placing the left arm on the left side of the table may help the person explore. Tapping with the left hand may help draw attention to that side of the table.

SAFETY
Patients with neglect and other visual disorders should not drive a car or work with items, such as knives or staple guns, that may put them or others at risk.

CHAPTER SUMMARY
People may have healthy eyes or good eyeglasses but still have trouble seeing because of changes in their visual brain systems.

Visual problems include not recognizing objects, difficulty reading, inability to reach for or place objects correctly, difficulty selecting one item from a group or bunch, and not recognizing the face of oneself or others. Patients may be unable to spot the difference between an image, such as a reflection in a mirror or people on the television screen, and real people.

Though the person may have lived in the same home or neighborhood for many years, they may get lost. Their view (what they see) may become limited, not seeing things that are high, low, or to the side of them.

Let a person with vision problems take the time they need. Keep things simple, one thing at a time. Store only a few things together, a few clothes in the closet or a few cups in the cupboard. It is easier to see one thing against a plain background, such as one colorful food on a plain dinner plate (broccoli with orange cheese on a white dinner plate).

They should use other sense systems, such as touch, words, or smell, to get the information to the person. The hands should explore surfaces. Verbal instructions help, talking a person through each step of an activity. Listening carefully, sometimes with the eyes closed, or talking to someone on the telephone will help the person understand better. Often a person will not recognize the person they see but will clearly recognize them from their voice on the telephone or speaking to them from the next room.

The Next Chapter contains a discussion of different behaviors, such as inappropriate undressing, sleep disturbances, and wandering. Several ideas are suggested to help family caregivers deal with these challenges.

Go back to the index.

Material taken from

"Helping People with Progressive Memory Disorders: A Guide For You And Your Family, 2nd ed." (University of Florida Health Science Center). Used with permission from the authors: K. M. Heilman, MD, L. Doty, PhD, J. T. Stewart, MD, D Bowers, PhD, & L. Gonzalez-Rothi, PhD. (1999).

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College of Public Health and Health Professions, University of Florida