Abstract
Through this Practice Guideline, the American Occupational Therapy Association (AOTA) aims to help occupational therapists and occupational therapy assistants, as well as the people who manage, reimburse, and set policy regarding occupational therapy services, understand the contribution of occupational therapy in providing services to older adults with low vision. This guideline can also serve as a reference for health care professionals, health care facility managers, academic educators, health care regulators, third-party payers, managed care organizations, and those who conduct research to advance care of older adults living in the community.
This guideline was commissioned, edited, and endorsed by AOTA without external funding being sought or obtained. The report was supported financially entirely by AOTA and was developed without any involvement of industry. AOTA aims to update practice guidelines every 5 years to keep recommendations on each topic current according to criteria established by the ECRI Guidelines Trust™. Guideline topics are evaluated for their currency on a 5-year basis by a multidisciplinary advisory group consisting of AOTA member and nonmember content experts and external stakeholders. In addition, a preliminary search of the literature is conducted to determine whether an updated systematic review is warranted.
This Practice Guideline does not discuss all possible methods of evaluation and intervention. Although this document does recommend some specific methods of intervention, the occupational therapist makes the ultimate clinical judgment regarding the appropriateness of a given intervention in light of a specific client’s or group’s circumstances and needs and the evidence available to support the intervention. Specific details regarding evaluation of older adults with low vision are not within the scope of this publication, but example evaluation methods are provided in a case study in the Appendix.
AOTA supported systematic reviews on older adults with low vision as part of its Evidence-Based Practice (EBP) Program. AOTA’s EBP Program is based on the principle that the EBP of occupational therapy relies on the integration of information from three sources: (1) clinical experience and reasoning, (2) preferences of clients and their families, and (3) findings from the best available research. The authors of the systematic reviews and this Practice Guideline have signed a conflict of interest statement indicating that they have no conflicts that would bear on this work.
Clinical Recommendations
Table 1 summarizes the clinical recommendations for occupational therapy practice with older adults with low vision. These clinical recommendations were developed after completion of the systematic reviews and full analysis of the data collected and are to be used to guide practice. AOTA uses the grading methodology provided by the U.S. Preventive Services Task Force (2018) for clinical recommendations:
A: There is strong evidence that occupational therapy practitioners should routinely provide the intervention to eligible clients. Good evidence was found that the intervention improves important outcomes and that benefits substantially outweigh harm.
B: There is moderate evidence that occupational therapy practitioners should routinely provide the intervention to eligible clients. There is high certainty that the net benefit is moderate, or there is moderate certainty that the net benefit is moderate to substantial.
C: There is weak evidence that the intervention can improve outcomes. It is recommended that the intervention be provided selectively on the basis of professional judgment and client preferences. There is at least moderate certainty that the net benefit is small.
I: There is insufficient evidence to determine whether occupational therapy practitioners should be routinely providing the intervention. Evidence that the intervention is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harm cannot be determined.
D: It is recommended that occupational therapy practitioners not provide the intervention to eligible clients. At least fair evidence was found that the intervention is ineffective or that harm outweighs benefits.
Table 1 provides letter grades for the interventions described in this Practice Guideline. The grades can help practitioners understand at what level they can feel confident to use the interventions. Describing the strength of clinical recommendations is an important part of communicating an intervention’s efficacy to practitioners and other users. As always, research evidence needs to be considered in conjunction with client needs and goals as well as sound clinical reasoning from experience.
Clinical Recommendations for Occupational Therapy Interventions for Older Adults With Low Vision: Evidence From 2010 Through 2016
Note. ADLs = activities of daily living; IADLs = instrumental activities of daily living.
Background
The U.S. population is aging, and occupational therapy practitioners who work with older adults need to have the skills to address multiple health issues affecting occupational performance, including vision loss. Although normative aging does not cause low vision, four major causes of visual impairment are age related: (1) age-related macular degeneration (AMD), (2) diabetic retinopathy, (3) glaucoma, and (4) cataracts. Another common cause of visual impairment in this age group is neurological insult, such as stroke or traumatic brain injury.
In 2017, 26.9 million adults in the United States reported a visual impairment that affected their ability to complete everyday activities (American Foundation for the Blind, 2019a). The number of adults diagnosed with AMD is expected to double to 17.8 million by 2050 (Rein et al., 2009), and the number of adults diagnosed with diabetic retinopathy is expected to increase to 9.9 million in the same time frame (Saaddine et al., 2008). The number of people diagnosed with glaucoma is expected to rise from 2.7 million to 6.3 million by 2050 (National Eye Institute [NEI], 2019b). In addition, by 2050 more than 50 million adults are expected to be diagnosed with cataracts (NEI, 2019a). Of clients seen for low vision rehabilitation services, nearly 1 in 3 is age 80 or older (Varma et al., 2016). Clearly, visual impairment in older adults is a significant public health issue that requires attention.
Although no commonly accepted standard definition of low vision exists, the term is used to describe the visual function between “normal” vision and total blindness (Jose et al., 2016). Low vision is typically defined as best corrected visual acuity of 20/60 or worse, visual field loss, or both (Centers for Medicare & Medicaid Services [CMS], 2002). Low vision may be caused not by a single condition but by any of several disease processes that produce decreased visual acuity, bilateral visual field deficits, or both. In addition, by definition low vision cannot be corrected through medication, corrective lenses, or surgery (NEI, 2019c). For medical reimbursement purposes, low vision is limited to visual impairments that meet the International Classification of Diseases (10th rev.; World Health Organization, 2016) diagnostic criteria for reduced visual acuity, visual field, or both (CMS, 2002).
Legal blindness is a severe loss of visual acuity, visual field, or both and is defined as best corrected visual acuity of 20/200 or worse in the better seeing eye or a visual field of 20° or less (Social Security Administration, 2014). This legal definition allows people to qualify for government assistance and programs. Note that 85% of people who meet the criteria for legal blindness have some residual vision (American Foundation for the Blind, 2019b).
Both low vision and legal blindness may result in decreased ability to engage in occupations of choice without adaptation or compensatory strategies. The most prevalent functional complaints among older adults with low vision include difficulty with reading, driving, facial recognition, and in-home activities (Brown et al., 2014). Functional mobility, shopping, meal preparation, cleaning, and activities of daily living (ADLs) may be negatively affected (Taylor et al., 2016). Occupations that involve reading, such as using personal computers or telecommunication devices; taking prescription medications; managing financial statements; and reading product labels, signage, recipes, and menus, all may be limited by low vision or legal blindness (Smallfield et al., 2017). Similarly, leisure and social activities may be challenging (Perlmutter et al., 2010); for example, low vision complicates going out to eat with friends or family by affecting the ability to ambulate safely within the community, read a menu, and see faces across the table to engage in conversation. Even with mild visual impairment (i.e., visual acuity of 20/40 to 20/70), older adults may experience a significant decline in the performance of everyday activities (Perlmutter et al., 2010).
Although the disease process of low vision cannot be reversed by surgery or prescription medication, the functional implications may be mitigated through nonsurgical interventions such as those provided by occupational therapy practitioners as part of a low vision rehabilitation team. This Practice Guideline provides a summary of interventions supported by research to address commonly reported occupational challenges for older adults with low vision.
Systematic Review Methodology
A major focus of AOTA’s EBP Program is an ongoing program of systematic reviews of the multidisciplinary scientific literature using focused questions and standardized procedures to identify occupational therapy–relevant evidence and discuss its implications for practice, education, and research. An evidence-based perspective is founded on the assumption that scientific evidence of the effectiveness of occupational therapy intervention can be judged to be more or less strong and valid according to a hierarchy of research designs, an assessment of the quality of the research, or both.
The guidelines were developed with input from a wide variety of groups. Content experts; a medical librarian; non–occupational therapy professionals; and AOTA EBP staff, including a research methodologist, developed the protocol. A group of internal and external stakeholders comprising multidisciplinary providers, content experts, a research methodologist, professional association representatives, regulatory and policy content experts, and representatives of the target population reviewed the final guidelines. The external review process consisted of a full manuscript review with a feedback form containing question prompts for the following information:
• Each reviewer’s overall rating of the guideline and suggestions for improvements
• Whether any content in the guideline was outdated, irrelevant, or in conflict with the reviewer’s experience and knowledge
• Whether the guideline is representative of client-centered care, effectively communicative of best practice and EBP
• Whether any topics were missing
• Whether the guideline is understandable and accessible
• Whether the guideline provides non–occupational therapy practitioners sufficient information about the role of occupational therapy and the topic.
External reviewers were given the choice to remain anonymous or be identified to the authors, and they were given the option of making additional comments directly on the manuscript.
Evidence Evaluation
AOTA uses standards of evidence modeled on those developed in evidence-based medicine (Sackett, 1989; Sackett et al., 1996). This model standardizes and ranks the value of scientific evidence for biomedical practice as follows:
Level I—Systematic reviews of the literature, meta-analyses, and randomized controlled trials (RCTs). In RCTs, participants are randomly allocated to either an intervention or a control group, and the outcomes for the groups are compared.
Level II—Two groups, nonrandomized studies (e.g., cohort, case control)
Level III—One group, nonrandomized studies (e.g., before and after, pretest–posttest)
Level IV—Descriptive studies that include analysis of outcomes (single-subject design, case series)
Level V—Case reports and expert opinion that include narrative literature reviews and consensus statements.
Previous systematic reviews on occupational therapy interventions for older adults with low vision were completed covering the time frame of 1990 to 2010 (Berger et al., 2013; Justiss, 2013; Liu et al., 2013; Smallfield et al., 2013). Findings from these reviews were used to develop the Occupational Therapy Practice Guidelines for Older Adults With Low Vision (Kaldenberg & Smallfiled, 2013). For the current systematic reviews, the updated literature search covered 2010 through 2016.
The current systematic reviews focused on questions developed and reviewed by the review authors; a multidisciplinary guideline development group of experts in the field that included practitioners, academic faculty, researchers, policymakers, and AOTA staff; and the research methodologist for the AOTA EBP Program. Three focused questions on occupational therapy interventions for older adults with low vision framed the reviews:
What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to maintain, restore, and improve performance in ADLs and instrumental activities of daily living (IADLs) for older adults with low vision?
What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to complete reading required for performance of occupations by older adults with low vision?
What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to maintain, restore, and improve performance and quality of life in leisure social participation, work, education, and rest and sleep for older adults with low vision?
Search Terms and Databases
Search terms for the reviews were developed by the research methodologist for the AOTA EBP Program and AOTA staff, in consultation with the review authors for each question, and by the guideline development group. The search terms were developed both to capture pertinent intervention articles and to ensure that the terms relevant to the specific thesaurus of each database were included. Table 2 lists the search terms related to population, interventions, and study designs included in the systematic reviews.
Search Terms for the Systematic Reviews of Occupational Therapy Interventions for Older Adults With Low Vision
Note. ADLs = activities of daily living; IADLs = instrumental activities of daily living.
A medical research librarian with experience in completing systematic review searches conducted the searches in MEDLINE, PsycINFO, CINAHL, the Cochrane databases, and OTseeker and confirmed and improved the search strategies. The librarian exported the search results into EndNote (Version 8; Clarivate Analytics, Philadelphia, PA). The research methodologist did the first review of the search results, eliminating all citations not relevant to the project on the basis of established inclusion and exclusion criteria. The remaining results were then exported to review authors in EndNote, Microsoft Word (Microsoft Corp., Redmond, WA), and tab-delimited formats. In addition, reference lists from articles included in the systematic reviews were examined for potential articles, and selected journals were hand searched to ensure that all appropriate articles were included.
Inclusion and Exclusion Criteria
Inclusion and exclusion criteria are critical to the systematic review process because they provide the structure for the quality, type, and years of publication of the literature that is incorporated into a review. The reviews were limited to peer-reviewed scientific literature published in English. The intervention approaches examined were within the scope of practice of occupational therapy for older adults. Participants were older adults with low vision with an average age of >55 yr. Studies were excluded if they were dissertations, theses, presentations, or proceedings; were published outside the date range; had participants with a mean age of <55 yr; or were outside the scope of occupational therapy (e.g., required different degrees or licensure). Studies included in the reviews provide Level I, II, and III evidence.
Overview of Search Results
A total of 10,549 citations and abstracts were located in the searches. The research methodologist completed the first step of eliminating references on the basis of citation and abstract, and 2,509 duplicates were removed. This first review reduced the number of citations to 435.
Teams of two or more reviewers carried out the systematic reviews. The review teams completed the next step of eliminating references on the basis of citations and abstracts. The full-text versions of potential articles were retrieved, and the review teams determined final inclusion in the reviews on the basis of the inclusion and exclusion criteria.
A total of 38 articles were included in the final reviews, including 16 Level I, 4 Level II, and 18 Level III studies. Table 3 lists the number of studies included in each review and their levels of evidence. (Note that several included articles addressed multiple outcomes of interest and are discussed in more than one section of this guideline.) The teams reviewed the articles for their focused question according to quality (scientific rigor and risk of bias) and level of evidence. They evaluated the articles and summarized the methods and findings in an evidence table.
Number of Articles Included, by Topic
Note. ADLs = activities of daily living; IADLs = instrumental activities of daily living.
Finally, the review teams synthesized and reported the results of the included articles (see Liu & Chang, 2020; Nastasi, 2020; Smallfield & Kaldenberg, 2020). All three systematic reviews, with evidence tables and risk-of-bias tables, were published in the January/February 2020 issue of the American Journal of Occupational Therapy:
Liu, C.-J., & Chang, M. C. (2020). Interventions within the scope of occupational therapy practice to improve performance of daily activities for older adults with low vision: A systematic review. American Journal of Occupational Therapy, 74, 7401185010. https://doi.org/10.5014/ajot.2020.038372
Nastasi, J. A. (2020). Occupational therapy interventions supporting leisure and social participation for older adults with low vision: A systematic review. American Journal of Occupational Therapy, 74, 7401185020. https://doi.org/10.5014/ajot.2020.038521
Smallfield, S., & Kaldenberg, J. (2020). Occupational therapy interventions to improve reading performance of older adults with low vision: A systematic review. American Journal of Occupational Therapy, 74, 7401185030. https://doi.org/10.5014/ajot.2019.038380
Strength of Evidence
For each systematic review, the evidence was grouped into themes, and the strength of the evidence was determined for each theme. Strength of evidence designations include a synthesis of level of evidence (I–III), quality of evidence (risk of bias), and findings of the studies (e.g., significance, consistency). By synthesizing these three evaluations, the review authors provide important information to practitioners in terms of the level of certainty that the interventions resulted in the outcomes shown. The strength of evidence levels are outlined in Table 4 and are based on the guidelines of the U.S. Preventive Services Task Force (2018).
Strength of Evidence (Level of Certainty) Designations
Note. The determination of the strength of evidence is based on the guidelines of the U.S. Preventive Services Task Force (2018) (https://www.uspreventiveservicestaskforce.org/Page/Name/grade-definitions).
Benefits and Harms
The studies that met the inclusion criteria for the systematic reviews did not explicitly report any adverse events associated with the interventions evaluated in these studies. If harms were noted, they would have been explicitly reported in the summary of key findings and would have been taken into account in determining the recommendations. Before implementing any new intervention, it is always prudent for occupational therapy practitioners to be aware of the potential benefits and harms of the intervention.
Clinical Reasoning
Occupational therapy practitioners exercise clinical reasoning based on a sound evaluation of the client’s strengths and limitations, values, preferences, and goals and an understanding of the intervention to determine the potential benefits and harms of that intervention for the individual client. Clinical reasoning is also required to translate the intervention protocols used in the reviewed studies into client-centered, clinically feasible interventions.
Findings
Interventions to Enhance Performance of ADLs and IADLs
A systematic review was completed to evaluate the effectiveness of interventions to enhance ADL and IADL performance for older adults with low vision (Liu & Chang, 2020). This review was an update to a systematic review completed in 2013 (Liu et al., 2013). Fourteen articles were included in the 2020 review (see Table 3) that discussed interventions categorized into three themes: low vision rehabilitation services (6 studies), problem solving (6 studies), and adapted tango (2 studies).
Low Vision Rehabilitation Services
Six studies (2 Level I, 4 Level III) evaluated low vision rehabilitation services to improve performance of ADLs and IADLs. This theme included 2 Level I studies (Pearce et al., 2011; Stelmack et al., 2012) and 4 Level III studies (Coulmont et al., 2013; Goldstein et al., 2015; Renieri et al., 2013; Ryan et al., 2013). This evidence builds on the 2013 systematic review (Liu et al., 2013), which found strong evidence for the effectiveness of multicomponent interventions that included education about low vision conditions, use of low vision devices, problem-solving training, and low vision resources.
In a Level I study, Pearce et al. (2011) compared participants who received low vision rehabilitation services, which included a low vision assessment and an optician visit (review low vision devices, discuss problems noted at home, and review available community resources) to a control group who received a low vision assessment and a biometric assessment from a nurse. Both groups showed significant improvement on the Massof Activity Inventory (Massof et al., 2007), but no differences were found between groups. In a Level I study by Stelmack et al. (2012), participants with macular diseases received five weekly low vision rehabilitation therapy sessions and one home visit from a certified low vision therapist and were assigned 5 hr of homework each week. Compared with the wait-list control group, the intervention group showed significantly higher visual ability at 4 mo and 12 mo on the 48-item Veterans Affairs Low-Vision Visual Functioning Questionnaire (Stelmack et al., 2004), which includes self-report of ADL and IADL function.
Two Level III studies examined low vision rehabilitation services provided by a multidisciplinary team that included an occupational therapist (Coulmont et al., 2013; Goldstein et al., 2015). Coulmont et al. (2013) found that the number of direct service hours was positively correlated with greater functional improvement. In a one-group pretest–posttest study, Goldstein et al. (2015) found that nearly half of participants receiving multidisciplinary low vision rehabilitation achieved a clinically meaningful difference in overall visual ability on the Massof Activity Inventory.
Two additional Level III studies examined comprehensive low vision rehabilitation services (Renieri et al., 2013; Ryan et al., 2013). Although different in composition, these services included vision assessment and education, fitting and training for magnifying devices and vision aids, advice about lighting and other methods of enhancing vision, suggestions for managing daily activities, and referral for additional services, reassessment, and follow-up. Both studies reported significant positive outcomes on the NEI Visual Function Questionnaire (NEI–VFQ; Ryan et al., 2008).
When considering the 6 articles in the low vision rehabilitation theme of this review, moderate-strength evidence supports the use of multicomponent low vision rehabilitation services provided by a multidisciplinary low vision rehabilitation team to improve ADL and IADL performance. The strength of evidence is weakened by the poor methodological quality of the majority of the articles in the theme, as noted in the risk of bias table accompanying the published systematic review (Liu & Chang, 2020). The results are consistent with those of the 2013 review (Liu et al., 2013), which reported strong evidence for multicomponent low vision intervention to improve ADL and IADL performance.
Problem Solving
The problem solving theme was new to the 2020 systematic review (Liu & Chang, 2020). Six articles—3 Level I studies (Rees et al., 2015; Rovner et al., 2013, 2014) and 3 Level III studies (Alma et al., 2012; Tay et al., 2014; Whitson et al., 2013—reported on the effectiveness of problem-solving interventions to support ADL and IADL performance. Interventions focused on teaching participants specific knowledge and skills to manage challenges related to low vision as problems arose in addition to the usual low vision rehabilitation services participants received. The interventions were either multicomponent (Alma et al., 2012; Rees et al., 2015; Rovner et al., 2014; Tay et al., 2014; Whitson et al., 2013) or single-component (Rovner et al., 2013). Common intervention components included problem-solving skills (Alma et al., 2012; Rees et al., 2015; Rovner et al., 2013), goal-setting or goal-planning skills (Alma et al., 2012; Rees et al., 2015; Whitson et al., 2013), and encouragement of social connection (Alma et al., 2012; Rovner et al., 2014; Tay et al., 2014). These components were delivered weekly in a program format lasting between 6 wk (Tay et al., 2014) and 20 wk (Alma et al., 2012). The programs were delivered in a group format (Alma et al., 2012; Rees et al., 2015; Rovner et al., 2013; Tay et al., 2014), in a one-on-one format (Rovner et al., 2014), or individually with a friend or family member (Whitson et al., 2013).
Two of the 3 Level I studies (Rees et al., 2015; Rovner et al., 2014) combined a problem-solving program with usual low vision rehabilitation services and compared the combined intervention to usual low vision rehabilitation services. Rees et al. (2015) examined an 8-wk program of training in problem-solving skills and goal setting added to usual low vision rehabilitation services, which included an initial assessment by a multidisciplinary team member, an optometric assessment and prescription of optical aids, and further intervention by the multidisciplinary team. Rovner et al. (2014) provided six weekly in-home occupational therapy sessions with a focus on behavior activation, emphasizing the relationship between action, mood, and mastery and promoting self-efficacy and social connection as means to improve mood and function. The intervention was added to usual low vision rehabilitation services, which included assessments of vision function, prescription of devices, and device education. Neither study found the combined intervention to be superior to usual services in improving ADL and IADL performance as measured by self-report questionnaires of visual function.
In another Level I study, Rovner et al. (2013) compared problem-solving therapy to supportive therapy. They found no statistically significant differences between groups on an activity inventory; however, they did find differences in favor of the intervention group in quality-of-life outcomes at 3 and 6 mo postintervention.
In a Level III study, Alma et al. (2012) studied a 20-wk problem-solving intervention delivered by a multidisciplinary group that included two occupational therapists. The intervention program focused on practical skills training; education, social interaction, counseling, and training in problem-solving skills; individual and group goal setting; and a home-based exercise program. They found no statistically significant differences at posttest on the Utrecht Scale for Evaluation of Rehabilitation–Participation (Post et al., 2012); however, frequency of engagement in household chores increased significantly between pretest and 6-mo follow-up, and restrictions in housekeeping decreased significantly at posttest and 6-mo follow-up.
In another Level III study, Tay et al. (2014) examined a 6-wk self-management program delivered by an occupational therapist. The intervention focused on understanding vision loss; maximizing remaining vision and using other senses; staying in touch with others; managing personal care, medications, money, and household; participating in daily activities and hobbies; and maintaining safety and mobility. They found no statistically significant differences in ADL and IADL performance at posttest as measured with the Low Vision Quality-of-Life Questionnaire (Wolffsohn & Cochrane, 2000).
Finally, in another Level III study, Whitson et al. (2013) studied a 6-wk low vision rehabilitation intervention delivered by an occupational therapist for older adults with macular disease who also had cognitive deficits. The intervention was modified to address cognitive deficits by offering frequent and repetitive training sessions, simplifying the training experience, and involving a friend or family member. Significant improvements were found on the NEI–VFQ–25 and on satisfaction with performance of seven IADLs.
In summary, the strength of evidence to support problem-solving training to improve ADL and IADL performance in older adults with low vision is low. These studies did not consistently show benefits of problem-solving training alone or combined with usual low vision rehabilitation services. However, as Liu et al. (2013) reported, strong evidence supports the use of tailored multicomponent and multidisciplinary interventions to improve independence at home for older adults with low vision, and problem-solving training may be a useful component of such interventions.
Adapted Tango
The adapted tango theme, new to the 2020 systematic review (Liu & Chang, 2020), was addressed in 2 studies (1 Level II, 1 Level III) from the same research team (Hackney et al., 2013, 2015). Both studies examined the effects of adapted tango on function as measured by the NEI–VFQ–25. Adapted tango is a dance program delivered in 20 lessons, each 1.5 hr in duration, over 12 wk, and participants are paired with partners without low vision.
In a single-group, repeated-measures, Level III feasibility study, Hackney and colleagues (2013) found significant improvement on the NEI–VFQ–25 after the adapted tango program and at 1-mo follow-up. Subsequently, Hackney et al. (2015) reported on a Level II study that compared the adapted tango program to a standard fall prevention exercise program. Participants in both programs showed significant improvement, but the adapted tango program showed no superior effect relative to the fall prevention program. In summary, low-strength evidence addresses the use of adapted tango to improve ADL and IADL performance in older adults with low vision.
Moving Research Into Practice
Although the systematic review revealed an increasing amount of evidence available to support occupational therapy’s role in addressing the ADL and IADL performance of older adults with low vision, the need to enhance the strength and quality of further research continues. The evidence supports several intervention strategies, but for other strategies small sample sizes, lack of control groups, or limited number of studies make the overall strength of the evidence low.
The 2020 review found 14 studies added to the existing body of literature. Moderate evidence continues to show that low vision rehabilitation should be the primary intervention used on a routine basis to improve ADL and IADL performance because the benefits substantially outweigh the harm. The components of low vision rehabilitation vary but typically include education about low vision conditions, use of low vision devices, compensatory strategies (e.g., lighting, home modifications, sensory substitution, contrast enhancement), and low vision resources. Low or conflicting evidence is available for problem solving and adapted tango, and these interventions should be used on a case-by-case basis.
Interventions to Enhance Reading
A systematic review was completed to evaluate the effectiveness of interventions to enhance reading required for the performance of occupations for older adults with low vision (Smallfield & Kaldenberg, 2020). This review was an update to a systematic review completed in 2013 (Smallfield et al., 2013). Sixteen articles were included in the 2020 review, categorized into three themes according to type of intervention: technology, visual skills training, and multicomponent interventions.
Technology
For the theme of technology to support reading, Smallfield et al. (2013) found moderate-strength evidence to support the use of stand-based electronic magnification, also known as closed-circuit television (CCTV), to enhance reading performance over other types of low vision devices. In addition, as a result of the low methodological quality of the studies, they found low strength of evidence to support use of low vision devices (e.g., high-add spectacles, handheld magnifiers, stand magnifiers, high-plus lenses, telescopes, electronic magnification) to improve reading.
The 2020 review yielded 4 additional studies (1 Level I, 1 Level II, 2 Level III) addressing the effectiveness of technology to enhance reading needed for occupational performance (Smallfield & Kaldenberg, 2020). Two studies tested the effectiveness of vision-specific assistive technology. In a Level I study involving CCTVs, Burggraaff et al. (2012) found no significant differences on measures of reading performance between participants who received standardized training from a low vision therapist to use a CCTV and a control group who received the standard delivery instructions for CCTV use. Both groups showed improvements in reading acuity, speed, and accuracy when using a CCTV. In a small Level III pilot study, Moisseiev and Mannis (2016) found that use of an optical character recognition device, the OrCam (Jerusalem, Israel), significantly increased the reading ability of older adults with low vision compared with baseline and both with and without other low vision devices the participants were already using.
Two studies examined the use of everyday technology for reading. In a Level II study, Gill et al. (2013) compared participants’ reading speeds using an Apple iPad, a Sony eReader, and standardized text on paper. Text sizes were based on each participant’s visual acuity; the International Reading Speed Text (Hahn et al., 2006) was used as the standardized text. Participants who used an iPad with larger text sizes read significantly faster compared with text on paper. Participants also read text on paper significantly faster compared with the eReader. In a Level III study, Kaldenberg and Smallfield (2016) studied the feasibility of group training in use of a tablet to improve occupational performance with four participants. Mean increases of 3.45 for Performance and 3.65 for Satisfaction on the Canadian Occupational Performance Measure (Law et al., 2005) reflected meaningful clinical change.
In summary, low-strength evidence exists for the use of vision-specific assistive technology and everyday technology to improve reading performance. Moderate-strength evidence supports stand-based electronic magnification to enhance reading.
Visual Skills Training
The definition of visual skills training varies in the literature and depends on the underlying visual deficit. In this Practice Guideline, visual skills training is differentiated for clients with central visual field impairment and those with hemianopsia. For clients with central visual field impairment, visual skills training (also called eccentric viewing) includes rapid serial presentation training and controlled eye movement training. For clients with hemianopsia, visual skills training consists of compensatory systematic scanning training, computer-based visual search training, and audio–visual stimulation training.
In addition to the limited literature included in the 2013 review (Smallfield et al., 2013), the 2020 review (Smallfield & Kaldenberg, 2020) found 10 additional studies (5 Level I, 1 Level II, 4 Level III) in the theme of visual skills training. One Level I study (Seiple et al., 2011) and 2 Level III studies (Chung, 2011; Palmer et al., 2010) addressed the effectiveness of visual skills training for central visual field impairment. These studies provide moderate-strength evidence supporting the use of eccentric viewing, with controlled eye (steady eye) movements, to improve reading speed and duration; Palmer et al. (2010) also found significant improvements in reading comprehension. No improvements were found in visual acuity, critical print size measurements, location of the functional preferred retinal locus, or fixation stability (Chung, 2011).
The 2013 systematic review did not address visual skills training for clients with hemianopsia (Smallfield et al., 2013). The 2020 review included 7 studies (4 Level I [Aimola et al., 2014; de Haan et al., 2015; Keller & Lefin-Rank, 2010; Mödden et al., 2012], 1 Level II [Jacquin-Courtois et al., 2013], 2 Level III [Hayes et al., 2012; Schuett et al., 2012]) providing low strength of evidence for the effectiveness of visual skills training for older adults with hemianopsia to improve reading performance. Two Level I studies showed no improvement in reading using compensatory scanning training or computer-based compensatory training (de Haan et al., 2015; Mödden et al., 2012). Two other Level I studies found significant improvement in visual search and reading after 20 or more sessions of reading and visual exploration or audiovisual stimulation training (Aimola et al., 2014; Keller & Lefin-Rank, 2010).
In summary, moderate-strength evidence supports eccentric viewing—specifically, training in the steady eye technique—to improve reading speed and duration for older adults with central visual field impairment. Low-strength evidence supports the use of visual skills training, such as compensatory systematic scanning training, computer-based visual search training, and audiovisual stimulation training, to improve reading performance for older adults with hemianopsia. These studies provided inconsistent results, and many had small sample sizes, increasing the risk of bias.
Multicomponent Interventions
The 2013 review found strong evidence from 5 studies supporting multicomponent low vision programs that included occupational therapy as part of interprofessional services for older adults with low vision (Smallfield et al., 2013). Occupational therapy interventions included group therapy, education about the eye condition and available resources, training in problem-solving strategies, environmental modification, training in the use of low vision devices, instruction in adaptive strategies and work simplification, training in techniques for reading, education regarding adjustment to vision loss, and training in performance of daily occupations. The 2013 systematic review also included 5 studies of multicomponent low vision rehabilitation programs that did not include occupational therapy but provided a low vision examination, prognosis and education about the eye condition, low vision therapy, prescription of low vision devices, eccentric viewing, and home visits. These 5 studies provided low strength of evidence regarding effectiveness in improving the reading required for occupational performance compared with either an alternative intervention or no intervention.
The 2020 review found 2 Level I studies added to the body of evidence for multicomponent interventions addressing the reading needed for occupational performance (Smallfield & Kaldenberg, 2020). Stelmack et al. (2012) led a Level I RCT in which the intervention group received five weekly 2-hr vision therapy sessions, a home visit, 5 hr of homework each week, and low vision device prescription. Compared with a control group receiving no services, the intervention group improved significantly in reading and other visual function skills at 4-mo follow-up. Rovner et al. (2013) completed a Level I RCT that compared an intervention group who received training in problem solving plus goal setting and solution identification with a control group who received supportive therapy with no focus on vision rehabilitation. They found no significant difference in reading performance between the groups.
In summary, strong strength of evidence continues to support multicomponent interventions that include vision therapy, low vision device prescription and training, environmental modification, and homework for older adults with low vision to support reading performance. Low-strength evidence addresses the effectiveness of a problem-solving approach in improving the outcome of reading.
Moving Research Into Practice
Although the systematic review revealed an increasing amount of evidence available to support occupational therapy’s role in addressing the reading needs of older adults with low vision, the need to enhance the strength and rigor of further research continues. The research supported several intervention strategies, but small sample sizes, lack of a control group, or limited number of studies addressing a specific treatment strategy decreased the overall strength of the evidence.
The 2020 review found 16 studies added to the existing body of evidence (Smallfield & Kaldenberg, 2020). Eccentric viewing using a steady eye technique for older adults with central visual field impairment is an intervention supported by moderate-strength evidence and should be used on a routine basis to improve reading performance because the benefits substantially outweigh the harm. In addition, multicomponent comprehensive low vision rehabilitation services that include education about low vision conditions, use of low vision devices, compensatory strategies (e.g., lighting, home modifications, sensory substitution, contrast enhancement), and low vision resources should be used routinely on the basis of strong evidence in the literature. The evidence for vision-specific and everyday technology, visual skills training for older adults with hemianopsia, and multicomponent problem solving is low because of inconsistent results, and these interventions should be used on a case-by-case basis to enhance reading performance.
Interventions to Enhance Leisure and Social Participation
A systematic review was completed to evaluate the effectiveness of interventions to enhance leisure and social participation for older adults with low vision (Nastasi, 2020; see also Nastasi & Blair, 2018; Nastasi & Masci, 2018a, 2018b). This review was an update to a systematic review completed in 2013 (Berger et al., 2013). Eight additional articles were included in the 2020 review, categorized into three themes according to type of intervention: problem solving, multicomponent interventions, and adapted tango.
Problem Solving
The 2013 review found strong evidence from 3 Level I studies to support the effectiveness of problem-solving training to increase leisure and social participation in older adults with macular degeneration (Berger et al., 2013). Training in problem solving was found to significantly improve the ability to establish realistic goals; generate, choose, and implement solutions; evaluate outcomes; maintain or improve participation in valued activities; and perceive greater security in several leisure and social activities.
The 2020 review identified an additional Level I study addressing the effectiveness of problem solving for older adults with macular degeneration. Rovner et al. (2013) compared an intervention group who received problem-solving therapy to a control group who received supportive therapy. The intervention group was taught to systematically identify problems and generate alternative solutions, whereas the control group received structured standardized psychological treatment. The intervention group showed improvement on the Social Functioning subscale of the NEI–VFQ quality-of-life measure (Mangione et al., 2001) compared with the control group and developed more adaptive coping strategies.
Multicomponent Interventions
The 2013 systematic review found moderate-strength evidence to support the use of multicomponent interventions provided by either one or multiple disciplines to improve leisure and social participation of older adults with low vision (Berger et al., 2013). The current review (Nastasi, 2020) identified 5 additional studies (2 Level I, 3 Level III) addressing the effectiveness of multicomponent interventions. Three studies evaluated multicomponent interventions provided by one or more professionals (Girdler et al., 2010, Level I; Renieri et al., 2013, Level III; Rovner et al., 2014, Level I), and 2 studies used a multidisciplinary approach (Alma et al., 2012, 2013, both Level III).
In a Level I RCT, Girdler et al. (2010) compared a control group receiving usual care (vision assessment and multidisciplinary low vision rehabilitation) to an intervention group receiving usual care plus an 8-wk self-management intervention by occupational therapy and social work professionals. The self-management intervention included assessments, prescription of low vision aids, referrals to occupational therapy and social services, training in the use of low vision aids and visual techniques, and group learning sessions and homework. The intervention group showed significant improvements in participation in life situations at posttest and 12-wk follow-up. In another Level I RCT, Rovner et al. (2014) compared behavioral activation to supportive therapy, both of which were provided in addition to standard low vision rehabilitation. Although no statistically significant differences were found between groups, the behavioral activation group showed larger effects for activity inventory scores, changes in social impairment and depression, and improvements in near tasks.
In a Level III study, Renieri et al. (2013) assessed the impact of a minimum of 3 mo of low vision rehabilitation, including prescription of and training with low vision aids, on quality of life. They found that after fitting for low vision devices, participants improved significantly in perceived near tasks, social functioning, and reading ability.
In 2 Level III studies, Alma et al. (2012, 2013) studied the effects of a multidisciplinary approach including social work, occupational therapy, and an exercise coach on leisure and social participation. The intervention included assessments and 2-hr weekly individual and group training sessions over 20 wk that included practical training, education, social interaction, counseling, and training in problem-solving skills. Using a single-group pretest–posttest design, Alma et al. (2012) found that participants experienced improved frequency of outdoor activities, improved satisfaction with partner relationships, and increased satisfaction with outdoor leisure and autonomy with leisure pursuits, although these results were not statistically significant. At 6-mo follow-up, Alma et al. (2013) found significant improvements in adaptation to vision loss, self-efficacy, and helplessness.
Overall, the current review provides moderate-strength evidence for the use of multicomponent interventions to increase leisure and social participation in older adults with low vision. Although the studies provide some support for the use of multicomponent interventions, the lack of outcome measures specific to leisure and social participation and high risk of bias limit the strength of the evidence.
Adapted Tango
The adapted tango theme is new to the 2020 systematic review. The review (Nastasi, 2020) found 2 articles (1 Level II, 1 Level III) addressing the effectiveness of adapted tango as a leisure and social participation intervention. As described earlier, adapted tango is a modified dance program in which an older adult with low vision is paired with a partner without low vision. These studies provide low strength of evidence to support the effectiveness of this leisure intervention to increase physical well-being and quality of life.
In a Level II study, Hackney et al. (2015) found that participants who received 90 min of an adapted tango intervention weekly for 10–12 wk showed improvements in endurance, cognitive dual tasking, and vision-related quality of life compared with a group who received a fall prevention program focused on balance and mobility; however, the differences were not statistically significant. In an earlier Level III study, Hackney et al. (2013) investigated the efficacy of 20 adapted tango sessions of 90-min duration and found significant improvements in physical well-being, dynamic postural control, and general vision-related quality of life at posttest and 1-mo follow-up.
Overall, because of the low quality of study designs and high risk of bias, low strength of evidence exists for the use of adapted tango to increase physical activity and life satisfaction in older adults with low vision. Adapted tango was found to be an easily adapted leisure activity that resulted in some improvement in balance, gait, and mobility, which may help decrease the risk of falls, and it is an interactive way to increase leisure and social participation.
Moving Research Into Practice
Although the systematic review revealed an increasing amount of evidence available to support occupational therapy’s role in addressing leisure and social participation of older adults with low vision, the need to enhance the strength and rigor of further research continues. The evidence supports several intervention strategies; however, small sample sizes, lack of control groups, or limited number of studies addressing a specific treatment strategy made the overall strength of the evidence low.
The 2020 review found 8 studies added to the existing body of evidence. Multicomponent interventions should be used on a routine basis to improve leisure and social participation because the net benefit may be moderate to substantial. These interventions vary, but components include education about low vision conditions, use of low vision devices, compensatory strategies, and low vision resources. Problem-solving and adapted tango interventions were supported by low-strength or conflicting evidence and should be used on a case-by-case basis; moderate certainty exists that the benefit of these interventions for the outcomes of leisure and social participation is small.
Summary
The studies included in this Practice Guideline provide current evidence to inform clinical decision making for older adults with low vision. This evidence can also be used to inform educational curricula and professional development and to guide the future research agenda on older adults with low vision.
Implications of the Evidence for Occupational Therapy Practice
Evidence-based practice involves use of the best available research in combination with practice experience and consideration of the unique values and preferences of the client within the context of service provision. The evidence guides clinical reasoning, justifies services, and promotes best client outcomes. The literature has provided an abundance of information on the negative effects of visual impairment on occupational performance (see Brown et al., 2014; Mohler et al., 2015; Nastasi, 2018; Smallfield et al., 2017; Taylor et al., 2016). However, the evidence supporting the effectiveness of occupational therapy interventions to address the needs of older adults with low vision is in the emerging stage. On the basis of available findings, occupational therapy practitioners are encouraged to routinely use the following interventions with older adults with low vision:
Multicomponent low vision rehabilitation to facilitate ADL and IADL performance, reading for occupational performance, and leisure and social participation
Eccentric viewing for central field impairment using a steady eye technique to enhance reading performance.
Use of the following interventions may be effective on a case-by-case basis:
Problem-solving training to improve ADL and IADL performance, reading skills, and leisure and social participation
Mainstream and vision-specific technology to enhance reading performance
Visual skills training for clients with hemianopsia to improve reading skills.
The Appendix provides a case study describing evidence-based practice with one client.
Implications of the Evidence for Occupational Therapy Education
Although some clients with low vision present with a single diagnosis (e.g., macular degeneration, glaucoma, cataract), many have comorbidities such as stroke, diabetes mellitus, arthritis, and dementia. Older adults with low vision and comorbidities face multiple challenges requiring skilled occupational therapy services, and practitioners must be able to prioritize treatment goals and select appropriate intervention approaches. Therefore, occupational therapy curricula and professional development in this area of practice must include the following topics:
Knowledge of health conditions and age-related changes that influence visual function
Comprehensive information on the visual system as well as neurological, sensorimotor, psychosocial, and cognitive components of human function to prepare students and practitioners to meet the needs of older adults with low vision in a holistic manner
Information regarding contextual influences on occupation, including the physical and natural environment, technology, social determinants, social support, policy, and culture
Exposure to potential members of the low vision rehabilitation team, including optometry, ophthalmology, and low vision rehabilitation professionals, and ability to articulate occupational therapy’s distinct value in low vision rehabilitation
Training in locating and using appropriate assessment tools and outcome measures specific to older adults with low vision to support the value of occupational therapy services
Training in the design of evidence-based and occupation-centered intervention plans for older adults with low vision, including knowledge of both electronic and optical magnification devices, lighting strategies, visual skills training, sensory substitution, contrast techniques, problem solving, and assistive technology
Knowledge about the influence of low vision diagnoses and treatment on the outcomes of interventions for other health conditions and success of the overall therapeutic plan of care.
Implications of the Evidence for Occupational Therapy Research
The systematic reviews provide support for occupational therapy intervention for older adults with low vision; however, continued research of high methodological quality is needed. Researchers in the area of low vision are encouraged to consider the following activities:
Study the composition of multicomponent and multidisciplinary interventions (e.g., specific components, team member roles)
Increase the number of well-designed, high-powered studies that reflect current practice (e.g., environmental modifications, driving and community mobility, compensatory strategies) and allow for generalizability of results
Conduct research involving occupational therapy practitioners as study interventionists
Increase the use of occupation-based outcome measures with adequate sensitivity to detect change to demonstrate intervention effectiveness
Conduct cost–benefit analysis research to examine the potential economic implications of intervention options.
Footnotes
Acknowledgments
The authors acknowledge and thank the following individuals for their participation in the content review and development of this publication:
Deborah Lieberman, MHSA, OTR/L, FAOTA, Vice President, Practice Improvement, and Staff Liaison to the Commission on Practice, American Occupational Therapy Association, North Bethesda, MD
Elizabeth G. Hunter, PhD, OTR/L, Assistant Professor, Graduate Center for Gerontology, College of Public Health, University of Kentucky, Lexington
Beth Barstow, PhD, OTR/L, SCLV, FAOTA; Sarah Blaylock, PhD, OTR/L; Yolanda Cate, MS, OTR/L, SCLV, CDE; Megan C. Chang, PhD, OTR/L; Shaun Kinsella, BA, MS(Geron), LSW, ABDA; Chiung-ju Liu, PhD, OTR/L, FGSA; Julie Ann Nastasi, ScD, OTR/L, SCLV, CLA, FAOTA; Debra S. Ouellette, MS, OTR/L, BCPR, SCLV; Hillary Richardson, MOT, OTR/L; Scott A. Trudeau, PhD, OTR/L; Orli Weisser-Pike, OTD, OTR/L, CLVT, SCLV, CAPS, FAOTA; Monica Wright, CPC, CPMA, CPCO
The authors acknowledge the following individuals for their contributions to the evidence-based systematic review:
Chelsea Blair, MS, OTR/L; Megan C. Chang, PhD, OTR/L; Chiung-ju Liu, PhD, OTR/L, FGSA; Elizabeth Masci, MS, OTR/L; Julie Ann Nastasi, ScD, OTR/L, SCLV, CLA, FAOTA.
Appendix
*
Indicates studies that were systematically reviewed for this article.