Occupational Therapy Interventions to Improve Leisure and Social Participation for Older Adults With Low Vision: A Systematic Review

Abstract

This systematic review examined evidence regarding the effectiveness of interventions within the scope of occupational therapy practice to maintain, restore, and improve performance in leisure and social participation for older adults with low vision. We identified and reviewed 13 articles that met the inclusion criteria. Four themes related to interventions to improve leisure and social participation emerged from the literature review: using a problem-solving approach, delivering a combination of services, providing skills training, and making home visits and environmental adaptations. The strongest evidence supports using a problem-solving approach to improve leisure and social participation for older adults with low vision. Evidence was moderate supporting the delivery of a combination of services, either by one professional or through an interdisciplinary approach. Results for the effectiveness of skills training and home visits and home adaptations were mixed. Implications for practice, education, and research are discussed.

Keywords

aged evidence-based practice leisure activities occupational therapy social participation vision,low

Leisure and social participation are within the domain of practice of occupational therapy (American Occupational Therapy Association [AOTA], 2008). Engagement in these important occupations is essential for the health and well-being of all clients. Older adults with low vision are at high risk for social isolation and decreased participation in leisure activities. The objective of this review was to synthesize the research literature to identify interventions within the scope of occupational therapy practice that were effective in maintaining, restoring, or improving leisure or social participation for older adults with low vision. We used the following focused question: What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to maintain, restore, and improve performance in leisure and social participation for older adults with low vision? This review provides evidence for practitioners working with this population to guide intervention and discusses ways to apply the results to clinical practice, research, and education.

Background and Statement of the Problem

Vision loss is prevalent throughout the world (Brouwer, Sadlo, Winding, & Hanneman, 2008) and is expected to increase exponentially as people continue to live longer (Vladeck, 2005). One of every 6 Americans older than age 70 is living with low vision (Dillon, Gu, Hoffman, & Ko, 2010). For people with vision loss, the ability to engage in functional activities is significantly impaired (Crews & Campbell, 2004; Higgins & Bailey, 2000; Horowitz, 2004), as is quality of life (Berman & Brodaty, 2006; Desai, Pratt, Lentzner, & Robinson, 2001). Vision loss can affect participation in every area of occupation, including leisure and social activities.

Evidence has shown that leisure activities are important to health and well-being (Iwasaki, 2007; Lynch, Cerin, Owen, & Aitken, 2007). Social participation is also important because decreased social opportunities can lead to isolation, loneliness, and depression (Newall et al., 2009). Specifically, research has supported the relationship between engagement in leisure and social activities and decreased depression (Wang et al., 2011), decreased mortality (Lennartsson & Silverstein, 2001; Paganini-Hill, Kawas, & Corrada, 2011), delay of onset of cognitive deficits (Karp et al., 2006; Richards, Hardy, & Wadsworth, 2003), and successful aging (Rowe & Kahn, 1998). Evidence has also related leisure and social participation to improved quality of life for older adults (Iwasaki, 2007; Lynch et al., 2007; Tessier et al., 2007).

Participating in leisure activities can be challenging for people living with vision loss. In one study, 70% of participants reported activity loss because of age-related macular degeneration (AMD), and 83% of those participants reported greatly missing the activity (Rovner & Casten, 2002). The activities they missed the most were reading, driving, engaging in craft activities, and watching television. In addition, research has shown that older adults with visual impairments report greater limitations than those without vision loss in going to the movies, attending religious events, visiting outdoor recreational places (e.g., public gardens), and eating at restaurants (Alma et al., 2011; Crews & Campbell, 2004).

This decline in engagement in leisure activities has widespread effects on the daily functioning and quality of life of older adults with vision loss. Older adults reported that leisure participation was vital to their sense of well-being but that their satisfaction with it had decreased (Stevens-Ratchford & Krause, 2004, p. 22). Thus, people experience boredom and sadness after giving up lifetime hobbies and filling the time with other, less-desired activities (Girdler, Packer, & Boldy, 2008).

Along with the difficulties of engaging in leisure activities, social participation can be challenging for older adults with vision loss, and many have fewer social interactions and increased difficulty with interpersonal skills. Specifically, researchers have found that visual impairments are related to social isolation and loneliness (Girdler et al., 2008; King, Gilson, & Peveler, 2006); decreased participation in social roles, particularly in the areas of responsibility, community life, and leisure (Desrosiers et al., 2009); and decreased confidence in social skills because of difficulties following social norms (e.g., shaking hands, acknowledging friends as they walk by; Brouwer et al., 2008; Girdler et al., 2008). In addition, research has indicated that older adults with vision loss spend less time phoning and visiting friends and perceive a decrease in the amount of time they spend socializing compared with their peers without vision loss (Boerner, Wang, & Cimarolli, 2006; Crews & Campbell, 2004). These findings are important because a decrease in social functioning and dissatisfaction with social performance are often associated with depression (Rovner, Casten, Hegel, Hauck, & Tasman, 2007). As the severity of their depressive symptoms increases, older adults with visual impairments often report even greater difficulties in social participation with friends and family (Jones, Rovner, Crews, & Danielson, 2009).

Participation in meaningful leisure and social activities is essential for the daily functioning and psychological well-being of every person, including older adults with vision loss. Leisure and social participation are within the domain of occupational therapy, and occupational therapy practitioners can help older adults with vision loss explore leisure options, plan and prepare for leisure activities, and interact with their community, family, and friends (AOTA, 2008). It is necessary for occupational therapy practitioners to use effective interventions to achieve these goals. Therefore, the purpose of this review was to synthesize the literature related to best practice interventions that are within the domain of occupational therapy and that may facilitate leisure and social participation for older adults living with vision loss.

Method for Conducting the Evidence-Based Review

This systematic review focusing on interventions that address social and leisure participation for older adults living with low vision was completed as a partnership among AOTA, the Boston University Department of Occupational Therapy, and the New England Eye Institute, an organization that provides vision care and vision rehabilitation services to people throughout Massachusetts. Occupational therapy graduate students, a faculty member, and a clinician, all with experience or a strong interest in vision rehabilitation, worked on this review.

The studies included in the review covered a range of leisure and social participation experiences. Although the Occupational Therapy Practice Framework: Domain and Process (2nd ed.; AOTA, 2008) considers leisure and social participation to be separate areas of occupation, they were combined for the purpose of this review because some of the studies considered social participation to be a leisure activity, others used the terms interchangeably, and only a few provided separate outcome measures. In addition, the term leisure is defined slightly differently throughout the studies (e.g., volunteering is considered a leisure activity in some research and a work activity in other research). We included in the review only studies in which the researchers defined the outcome measured as leisure or social participation. An in-depth description of the methodology used in this systematic review can be found in further detail in the article “Methodology for the Systematic Reviews on Occupational Therapy Interventions for Older Adults With Low Vision” in this issue of the American Journal of Occupational Therapy (AJOT; Arbesman, Lieberman, & Berlanstein, 2013).

Results

Of the 605 abstracts reviewed, we read 50 articles for relevance and included 13 in the final review. Nine of the 13 studies included in the review were Level I randomized controlled trials (RCTs) and thus provide strong evidence. One study had a Level II nonrandomized controlled design, and 3 provided Level III evidence. Supplemental Table 1 summarizes all the studies included in this review (available online at http://ajot.aotapress.net; navigate to this article, and click on “Supplemental Materials”). Four themes emerged from the research related to interventions that address leisure and social participation among older adults with vision loss: (1) a problem-solving approach, (2) a combination of services, (3) skills training, and (4) home visits and environmental adaptations.

Problem-Solving Approach

Strong evidence supports the effectiveness of a problem-solving approach; 3 Level I studies found that problem solving is related to increased leisure and social participation in older adults with macular degeneration (Brody et al., 1999; Dahlin Ivanoff, Sonn, & Svensson, 2002; Rovner & Casten, 2008). Rovner and Casten (2008) conducted an RCT in which problem-solving training performed one-to-one in the home was compared with usual care. The training involved helping clients define the problem; establish realistic goals; generate, choose, and implement solutions; and evaluate outcomes. Participants who received problem-solving training were less likely to give up participation in valued activities.

The literature also supported a group problem-solving approach; Brody et al. (1999) compared a self-management group intervention with no treatment. The group consisted of six 2-hr sessions involving educational presentations and problem-solving practice. Specifically, the group solved challenges faced by members with AMD using vignettes and participants’ personal stories. Participants who received the intervention reported an increase in some activities, such as gardening, and continued performance in other activities, such as attending sporting events and engaging in hobbies. Interestingly, participants reported a decline in some occupations (e.g., going to the movies). The authors suggested that participants may have replaced difficult activities with others that were also enjoyable. Likewise, Dahlin Ivanoff et al. (2002) found that a group problem-solving approach was more effective than standard low vision care in increasing confidence in several leisure and social activities. The program consisted of eight 2-hr sessions, all led by an occupational therapist. During these sessions, the participants learned strategies that older adults with low vision typically use to solve varied problems.

Combination of Services

The evidence is moderate that a combination of services, provided by either one or multiple disciplines, is related to an increase in leisure and social participation. Three studies used an interdisciplinary approach (Hinds et al., 2003; McCabe, Nason, Demers Turco, Friedman, & Seddon, 2000; Pankow, Luchins, Studebaker, & Chettleburgh, 2004), and an additional 3 studies had one or more professionals providing a variety of services (Elliott & Kuyk, 1994; La Grow, 2004; Shuttleworth, Dunlop, Collins, & James, 1995). Both Hinds et al. (2003) and McCabe et al. (2000) studied interventions by professionals from multiple disciplines, including ophthalmic nursing, ophthalmology, optometry, social work, occupational therapy, and rehabilitation counseling. Together, these professionals performed assessments and provided low vision aids and training in their use, education, training in adaptive techniques, counseling, and home visits. As a result, Hinds et al. (2003), using a nonrandomized pretest–posttest design, found that participants experienced an increase in leisure reading.

In their RCT, McCabe et al. (2000) provided these interdisciplinary services to two groups but involved family members in the intervention group only. Both groups experienced less difficulty performing leisure tasks such as reading newspapers, sewing, and visiting friends; however, services were not more effective when family members were involved. Pankow et al. (2004) conducted an RCT in which interdisciplinary services, consisting of blind rehabilitation training, orientation and mobility training, driving rehabilitation, and occupational therapy, were compared with no treatment. The exact services that participants received depended on their personal goals, which were set in collaboration with rehabilitation professionals. Participants in the intervention group demonstrated an increase in leisure and social participation.

In a Level III longitudinal study, orthoptists alone provided assessments, counseling, referrals to social services, and training in the use of low vision aids and visual techniques (Shuttleworth et al., 1995). Study participants increased their use of low vision aids for leisure activities, such as reading correspondence, pleasure reading, writing, and engagement in hobbies. In a Level III nonrandomized study, La Grow (2004) compared comprehensive low vision services with typically available services. Both of these groups, however, offered training in the use of low vision devices and home instruction. No significant differences were found between groups in leisure and social participation, most likely because the groups received similar services. Finally, Elliott and Kuyk (1994) conducted a one-group, nonrandomized trial in which veterans with vision loss participated in a residential personal adjustment training program. After approximately 55 days, participants reported significant improvements in social engagement and hobbies. Unfortunately, these authors provided limited information about the treatment protocol.

Skills Training

Mixed results emerged from the literature on the effectiveness of skills training on leisure and social participation. Two Level I studies implemented various types of skills training with older adults primarily with AMD, addressing skills such as scanning, eccentric viewing, focal distance, scrolling, and the use of magnification and other low vision aids (Conrod & Overbury, 1998; Scanlan & Cuddeford, 2004). Scanlan and Cuddeford (2004) found that extended education in skills training increased participants’ independence in reading the newspaper and telephone book and increased their ability to see others’ reactions during conversation.

In another RCT, no significant improvements were observed in the specific outcome measures selected for leisure and social participation among participants who received individual counseling, group counseling, or perceptual skills training compared with the control group (Conrod & Overbury, 1998). However, most participants from each experimental group initiated a new activity or reengaged in a meaningful activity they had relinquished because of vision loss. The authors speculated that the measures selected to assess leisure and social participation may not have been sensitive enough to detect participants’ changes in activity.

Home Visits and Environmental Adaptations

The evidence is mixed that home visits and environmental adaptations are associated with an increase in leisure and social participation among older adults with vision loss. Three Level I studies, in which the most common diagnosis was AMD, explored the effectiveness of interventions provided in the home (Brunnström, Sörensen, Alsterstad, & Sjöstrand, 2004; Reeves, Harper, & Russell, 2004; Rovner & Casten, 2008). Providing task lighting using a standard floor lamp around the reading area of the living room was related to significant improvements in the ability to contact relatives and others (Brunnström et al., 2004), thereby allowing increased opportunities for social participation. Reeves et al. (2004) found that the addition of home-based training in low vision aids was not more effective in increasing leisure and social participation than conventional, clinic-based low vision rehabilitation. However, Rovner and Casten (2008) found that participants who received in-home problem-solving training were less likely than controls to relinquish a meaningful activity.

Discussion and Implications for Practice, Research, and Education

Implications for Practice

The literature provides an abundance of information about the negative effects of low vision on leisure and social participation among older adults. However, few studies have explored interventions to address these limitations. The studies included in this review explored four themes in intervention that promote leisure and social participation among older adults with low vision: (1) using a problem-solving approach, (2) providing a combination of services, (3) teaching specific skills and strategies, and (4) performing home visits and environmental adaptations. Of these themes, the two most promising are incorporating a problem-solving approach and using a combination of services. In addition, one study demonstrated the benefits of a practice that is already widely used by occupational therapy practitioners working in low vision rehabilitation: improving lighting.

The use of active problem-solving strategies in group and individual settings may help clients maintain engagement in occupations of choice, improve self-efficacy, and reduce symptoms of depression. Occupational therapy practitioners have the skills to teach their clients problem-solving strategies, which typically include defining the problem, establishing realistic and measurable goals, developing and implementing solutions, and evaluating outcomes (Rovner & Casten, 2008). For example, an older adult may be frustrated that because of vision loss, he or she no longer enjoys a weekly outing with friends to a neighborhood restaurant. The occupational therapy practitioner first helps the client identify the barriers to participating in this activity; for this scenario, these barriers may include using the telephone and planner to schedule the dinner out, getting to the restaurant, and reading the menu. Often, while exploring barriers, clients report that they want to be able to see better, a desire that may indicate poor insight into and awareness of the permanence of their visual impairment. An unclear understanding of the problem can limit the client’s rehabilitative potential because he or she may be focused on improving vision instead of improving participation. Thus, the occupational therapy practitioner helps the client identify specific problems that can be solved, such as difficulty reading menus.

For a problem-solving approach to be effective, it is essential that the client be involved in setting goals. The occupational therapy practitioner and the client continue to work together to determine solutions and strategies to meet the goals. For the goal of independently ordering food, possible solutions include using a handheld magnifier to increase size, a pocket flashlight to improve lighting, or a filter to decrease glare or contacting the restaurant in advance to see whether it has a large-print menu. Once the client has identified and practiced several options, he or she can implement and evaluate the most appropriate strategy to achieve the desired outcome.

In addition to using a problem-solving approach when working with older adults who have visual impairments, occupational therapy practitioners should engage in a team approach to ensure the most robust treatment outcomes. The evidence shows that an interdisciplinary approach, which can include provision and training in the use of low vision aids, education, and home visits, facilitates improvement in daily living skills, mobility, and leisure participation. Many organizations and practitioners work with older adults with vision loss. The American Academy of Ophthalmology, American Optometric Association, Association for Eduction and Rehabilitation of the Blind and Visually Impaired, and AOTA all support practitioners who work to provide best practices in vision rehabilitation. Understanding the varied roles and skill sets is essential to ensure a proper continuum of care. Occupational therapy practitioners must understand the roles and responsibilities of all the low vision rehabilitation service delivery team members to be able to effectively collaborate and best meet the leisure and social participation needs of their clients.

Shuttleworth et al. (1995) found that the provision of various services (i.e., counseling and training in low vision aids) by only one discipline was effective in improving leisure participation. Although an orthoptist provided a multitude of services in this study, occupational therapy practitioners, who are trained to consider clients’ holistic needs, also have the skills to provide multiple services to address the person, the environment, and the occupation. Specifically, when working with older adults with low vision, occupational therapy practitioners can adapt the environment or task; teach the client adapted visual techniques, such as eccentric viewing or use of magnification; and address the client’s psychosocial needs through facilitating participation in occupations or referring to a support group. However, this ability does not substitute for the benefits and knowledge that can be gained from an interdisciplinary approach; vision impairment can affect all aspects of occupation. Clients’ multifaceted needs frequently go beyond the skill set of any one profession or practitioner.

The evidence also shows that improved lighting enhances social participation and quality of life (Brunnström et al., 2004). Occupational therapy practitioners must address the lighting needs of their older adult clients. The average older adult requires 3–4 times greater illumination than a younger person, and those with visual impairment may require even greater levels of lighting (Figueiro, 2001; Haymes & Lee, 2006). The need for increased lighting is complicated by many issues, including source of light (i.e., task vs. ambient lighting), glare (e.g., exposed light bulb, windows without coverings), contrast, and balanced levels of light.

Effective lighting for older adults must be tailored to the individual, because different visual conditions may require different solutions. General guidelines include increased lighting levels, controlled glare, increased contrast, balanced or uniform lighting levels, and enhanced color perception and color rendering (Figueiro, 2001; Haymes & Lee, 2006). Figueiro (2001) and the Illuminating Engineering Society of North America (Brawley & Noell-Waggoner, 2007) recommended minimum ambient lighting at 300 lux and task-specific lighting at 1,000 lux to support productive aging. By engaging the client in active problem solving, providing a team approach to care, and evaluating and addressing lighting needs, occupational therapy practitioners can have a positive effect on the client’s participation in leisure and social participation.

In summary, best practice guidelines to facilitate leisure and social participation for older adults with vision loss include the following elements:

Use a problem-solving approach in either a group or individual format.

Provide a combination of services, which can include education, skills training, social support, sighted guide training, and home visits. These interventions may be provided through an interdisciplinary team or by a single professional.

Improve lighting, especially task-specific lighting.

Implications for Research

Healthy People 2020 (U.S. Department of Health and Human Services, 2011) and AOTA’s (2007) Centennial Vision clearly emphasize the importance of evidence-based practice and the need for improved access to vision rehabilitation services to support engagement in leisure and social participation. Occupational therapy practitioners must recognize the negative impact of loss of leisure and social participation on the well-being and quality of life of their clients and be aware of interventions to address these needs. Within the realm of low vision practice, the development of specific leisure and social participation outcome measures and additional research specifically focused on leisure and social participation outcomes are needed. Moreover, throughout the literature, authors refer to standard care, low vision teams, vision rehabilitation, and leisure, yet the definitions of each of these terms are unclear and vary between studies. To compare or replicate studies, these definitions need to be clarified and consistent both within and outside the profession.

Implications for Education

It is essential that occupational therapy practitioners working with older adults with low vision expand their focus beyond basic and instrumental activities of daily living. Leisure and social participation are important areas of occupation that are essential for health and well-being. Increased focus within occupational therapy educational programs should be placed on these often overlooked areas of occupation. Moreover, academic curricula should provide educational coursework on the unique needs of older adults living with vision loss, a specialized but growing population. In 2007, the AOTA Ad Hoc Group on Aging found that only a few occupational therapy and occupational therapy assistant programs had a strong focus on gerontology. This committee’s report to the AOTA Executive Board recommended that educational curricula include an increased emphasis on aging and specifically stated the need for graduate occupational therapy programs to implement a stronger focus on aging with a disability, aging into a disability, and living with visual impairment (AOTA Ad Hoc Group on Aging, 2007).

Introducing students and practitioners to the various services available to older adults with visual impairments will likely have increasing importance as the baby boom generation ages. Strengthening partnerships between academic programs and professionals within the field of low vision may provide increased opportunities to educate students on effective assessment and intervention strategies. Last, offering more continuing education workshops to occupational therapy practitioners working with older adults with low vision can promote evidence-based practice and advance current practice.

Limitations

This systematic review has several limitations. Many of the studies used interventions that had multiple components, making it challenging to ascertain which element of the intervention was most important. Particularly in the studies that explored the combination-of-services theme, it is unclear whether specific services, the combination of services, or the interdisciplinary nature of the services was most influential. Additionally, interventions that provided a combination of services often included skill-specific training or home visits and environmental adaptations. Likewise, using a problem-solving approach may lead to the client’s use of low vision aids or environmental adaptations. Therefore, home visits, environmental adaptations, and skill-specific training may actually be more effective than the evidence seems to convey, and thus the results of this review should be interpreted cautiously.

In addition, the studies did not use outcome measures dedicated solely to assessing leisure or social participation. Thus, we identified specific components of outcome measures to determine the effectiveness of the interventions. Unfortunately, many study authors did not report the results of questions related specifically to leisure and social participation. Also, in most studies, many or all of the participants had AMD, making it difficult to generalize this information to clients with other visual impairments. Despite these limitations, this review provides strong evidence that supports specific interventions within the scope of occupational therapy practice as being effective in promoting leisure and social participation for older adults living with vision loss.

Conclusion

More than 15 years ago, Mary Warren (1995) edited a special issue of AJOT on vision. She discussed the emerging role of occupational therapy in working with older adults with visual impairments and the importance of creating a unique and lasting contribution in this area of practice. She stressed the need for research and outcome measures within the profession that address all aspects of occupational performance, including leisure and social participation. The profession of occupational therapy has moved forward in reaching this goal, but more work remains. With the changing demographics and growing aging population, more and more people are living with low vision. Occupational therapy practitioners have the skills to enable these older adults to live productive, healthy, and full lives through participation in social and leisure occupations.

Supplemental Material

Supplementary material for Occupational Therapy Interventions to Improve Leisure and Social Participation for Older Adults With Low Vision: A Systematic Review

Supplementary material, sj-pdf-1-aot-10.5014_ajot.2013.005447.pdf for Occupational Therapy Interventions to Improve Leisure and Social Participation for Older Adults With Low Vision: A Systematic Review by Sue Berger, Jessica McAteer, Kara Schreier and Jennifer Kaldenberg in The American Journal of Occupational Therapy

Footnotes

Acknowledgments

We acknowledge the invaluable guidance and support of Deborah Lieberman and Marion Arbesman through the entire process of this review. Also, Gina Bargioni, Shannon Chovan, Lizabeth Metzger, and Jill Palladino—occupational therapy graduate students at the time—assisted during the initial phase of this systematic review. Portions of this study were presented at the 2011 AOTA Annual Conference & Expo in Philadelphia and the 2012 Gerontological Society of America Annual Scientific Meeting in Boston.

*

Indicates studies that were systematically reviewed for this article.

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