Adaptations to Activities of Daily Living to improve participation for those with Low Vision

Picture this: waking up in the morning, getting out of bed, navigating through your bedroom, hallways, and bathroom, completing your grooming and dressing routine, eating breakfast, and heading to work. Sounds like no problem, right? If you are someone with low vision, these simple tasks could feel somewhat impossible.

Low vision is a visual deficit that makes it hard to do daily activities (National Eye Institute, 2024). Individuals with low vision face daily obstacles that can impair their participation in activities of daily living (ADL), such as dressing, toileting, bathing, grooming, and self-feeding. Our job as Occupational Therapists (OT) is to adapt, modify, and change their environment to provide maximum independence in these tasks.

Low vision has a substantial impact on participation in ADLs, increasing symptoms of depression and anxiety (Kempen et al., 2012). I have seen first-hand how low vision impacts interactions with others and their environment. Thus, the creation of this post. Through this, I will provide adaptation ideas for ADL areas that I have found successful with my patients with low vision.

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Self-Feeding

Now, let's think of a typical setup at a table: placemat, plate, silverware, and a cup. But what if all of these items were white? What if the food on the plate was also white or light in color? We may first look at what we can change to provide a better contrast with these items on the table. With the inability to change the colors of the foods on the plate, we may provide a patient with a contrasting-colored plate. This could include red or blue plates with food items that are white or yellow. I have seen high-side dishes to be dependable with patients with low vision to decrease spillage and messes. Depending on the patient, adaptive utensils may be the best fit to ensure proper use and increased color contrast from the background of the placemat or table. Built-up utensils can provide a change in contrast to the light background, as a grey or black handle will be used. If a person does not prefer to use built-up handle utensils, I have found that adaptations such as colored utensils can provide better contrast.

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Dressing

I have found that dressing can be the most difficult ADL to adapt for someone with low vision. While these patients may have problems with the task as a whole- navigating through a bedroom space, retrieving clothing items, doffing previous clothing, and donning new ones, I have found ways to adapt the activity of donning alone. For these patients, I have found success with assisting in the orientation of clothing through the placement of a colored fabric in the back of the clothing, indicating orientation prior to donning. By placing a contrasting color on the back of the clothing, this allows the patient to orient and manipulate the clothing prior to donning. While I have found this one fix, I do believe more research and intervention should be completed on dressing with low vision to better assist patients with low vision through the task.

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Toileting

Toileting can be a challenge for older adults, and safety is a high priority for me as an OT. With the addition of low vision, this task can feel almost impossible. In a standard bathroom, the toilet will be placed near a wall. When living in assisted living, as my patients do, you may notice a white wall, white toilet, and light-colored floor. Oh, the low vision nightmare! This is a great place to put in a horizontal or vertical grab bar to improve orientation to placement near the toilet. An addition of bright colored tape, wrap, or paint can be added to the grab bar to improve contrast from the wall, depending on the wall color and grab bar color. With older adults, we may see the need for adaptations such as raised toilet seats. When choosing a raised toilet seat for a patient with low vision, it is best to choose an option with differing contrast from the toilet itself. For example, if the toilet is white, choosing a raised toilet seat that is a dark grey or blue would be best to enhance orientation to placement on the toilet seat. A raised toilet seat with arms on each side is ideal for an additional improvement in tactile stimulus as well, allowing the patients to feel for their placement prior to a descent to the toilet.

If a patient is not agreeable to a raised toilet seat, I have found success in placing a colored strip of tape on the side of the lid of the toilet to orient to the toilets’ dimensions and placement. Placing a small piece of fluorescent tape or wrap on or near the handle may also assist the person in finishing out the task of toileting by locating the handle. With this simple low-tech adaptation, paying attention to hygiene, cleaning schedules and changing the tape will be important.

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Grooming

Oh, the items at the sink. I don’t know what you think a typical bathroom sink counter should look like, but for someone with low vision, the more minimal the better. I had a patient who would complete their grooming routine standing at the sink but would inaccurately target the items on the counter and choose the wrong containers. For these items, I found success with low-tech adaptations. I placed fluorescent tape on the front of her soap container, labeling “SOAP” in large, capital letters in black ink. This patient in particular enjoyed having a cup to use when brushing her teeth. I labelled this as well, placing “CUP” in large black ink letters across a bright colored strip of tape. As this particular patient also had a diagnosis of dementia, I placed a blue strip of tape on the cold faucet handle, and red on the hot faucet handle. With these easy low-tech adaptations, we would change out the tape or use sanitary wipes often to decrease bacterial growth.

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Bathing

If only aesthetically pleasing bathrooms were also safe and functional. When I think of a standard bathroom shower, I think of an all-white tub shower. An older adult may think of this set up as one of the more challenging tasks in their day. To assist someone in this situation to better navigate the difficulties of a shower, we may add a shower chair or tub bench for decreased fall risk in a wet environment. When suggesting a shower chair, the suggestion of a dark grey or blue shower chair with arms is best to ensure increased contrast to the differing white background. For a person who is independent in transfers, has good balance, and is not agreeable to a shower chair, we may place color-contrasting nonslip grips to improve the figure-ground abilities for the person to orient to floor changes from tub to bathroom floor. If a patient has a step-in shower, placing a red strip at the lip of the shower can assist with indicating a change in height. Large labels on showering items such as shampoo and conditioner can be added to the outside of bottles as well.

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Functional Mobility

There are many adaptations that can be made for functional mobility, which I could fill a whole new post with (possible foreshadowing). Speaking from experience, I will discuss what I have modified with my own patients.

I had a patient living in an assisted living apartment. The setup was simple: kitchenette, bathroom, and a large space for a bed, chair, and TV stand. This patient was running into walls, making turns too soon, not properly getting through doorways due to proximity to walls, and not being able to distinguish a white wall from a white door. I modified his environment by placing blue tape from floor to ceiling on each corner, doorframe, edge of a door, and near handles. This helped the patient distinguish that he was close to the end of a wall or doorway so that he could better navigate through.

While these are all successful and mostly low-tech adaptations that I have personally applied to my patients, there are many ways to easily make an environment more accessible for those with low vision; each being client-centered to the patient and specific environmental setup.  We must begin by finding the barrier that the patient is experiencing to fully assist in adapting and treating (Berger et al., 2013). When providing adaptations, I always make sure to consent with the patient (or power of attorney) before making environmental changes, as the patient could be used to their current setup, causing more of a headache to relearn their environment. Individuals who experience low vision services are shown to have some improvement in their daily activities (Lamoureux et al., 2007). I believe there is still a lot of research to be done on low vision relating to ADL activity, as well as adaptations to be trialed at the clinical level to ensure improvements in independence.

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About the Author

Ashley Denny, OTD, OTR/L is a geriatric Occupational Therapist for FOX Rehabilitation. She is a graduate of Chatham University, receiving her Doctorate in Occupational Therapy in 2023. She has received her First Response Low Vision Certification from the Pennsylvania Occupational Therapy Association (POTA) and her Low Vision Micro-Credential from the American Occupational Therapy Association (AOTA). She also works as a content developer for FOX digital platforms, creating content for clinicians across the United States on topics such as low vision and dementia modifications, arthritis, stroke rehabilitation, and home safety for older adults.

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References

Berger, S., McAteer, J., Schreier, K., & Kaldenberg, J. (2013).  Occupational therapy interventions to improve leisure and social participation for older adults with low vision: A systematic review. The American Journal of Occupational Therapy, 67(3), 303-311. https://doi.org/10.5014/ajot.2013.005447

Kempen, G. I., Ballemans, J., Ranchor, A. V., van Rens, G. H., & Zijlstra, G. A. (2011). The impact of low vision on activities of daily living, symptoms of depression, feelings of anxiety and social support in community-living older adults seeking vision rehabilitation services. Quality of life research, 21(8), 1405–1411. https://doi.org/10.1007/s11136-011-0061-y

Lamoureux, E. L., Pallant, J. F., Pesudovs, K., Rees, G., Hassell, J. B., & Keeffe, J. E. (2007). The effectiveness of low-vision rehabilitation on participation in daily living and quality of life. Investigative Ophthalmology &Visual Science, 48(4), 1476. https://doi.org/10.1167/iovs.06-0610

Occupational therapy practice framework: Domain and process—Fourth edition. (2020). The American Journal of Occupational Therapy, 74(Supplement 2). https://doi.org/10.5014/ajot.2020.74s2001

U.S. Department of Health and Human Services. (2024). Low vision. National Eye Institute. https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/low-vision#section-id-6335

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