Module 3

  Understanding Physical Capabilities and How These Relate to Employment  of Older Persons Who Are Visually Impaired

  Learner’s Goal:

  To understand the physical capabilities of older persons with visual impairments and how these relate to working.

  Learner Objective:

  At the end of the module, you will be able to describe some of the physical losses older persons experience and how these affect their ability to cope with everyday life.

  Understanding Physical Capabilities

“The physical aspects of aging are less important than workers’ ability to maintain good attitudes, safety practices...The positive attitude of older workers and the fact that they do not decrease in productivity or coordinated activities within their physical scope show they can be efficient workers...” (Isernhagen,1991).

  Understanding physical health and limitations of the older worker. (For more information on health and limitations, go to www.aging.unc.edu/ioalearning/mod1Intro.asp and take the course on the Aging Body).

  Experiencing vision loss along with other sensory impairments, particularly hearing loss, intensifies the social impact on the individual.  Vision loss has an even greater impact when it occurs together with acute physical health problems, such as arthritis.  The more  counselors know about the life circumstances associated with the loss of vision as part of the aging process and other concomitant losses, the more successful their interventions can be.

  Most older persons have at least one chronic health condition and many have multiple conditions.  Approximately 30 percent of older people have a significant hearing impairment.

Brain and Cognition

  Normal Chan ges

  With age, decreases normally occur in the number of nerve cells, the weight of the brain, and cerebral blood flow.  These can result in reduced short-term memory loss, slower reaction times, less precision in doing tasks, lengthier time for learning new information, and forgetfulness.  However, most older adults remain mentally alert and capable, even those who live well into their 80's (www.aging.unc.edu/ioalearning/mod1BrainNervousSystem.asp) 

  Disorders of the Brain

  A common brain disorder is dementia, a group of symptoms caused by changes in brain function. Some symptoms include:  becoming disoriented in familiar surroundings, asking questions repeatedly, losing track of time.  One form of dementia which affects approximately 4 million older persons in the U.S. is Alzheimer’s Disease (www.aging.unc.edu/ioalearning/mod1BrainNervousSystem.asp )

Nose and Smell

  The sense of smell generally begins to decline beginning in the 40's and by age 80 approximately 80% of older people experience major loss in ability to smell.  Smell affects the ability to discriminate among tastes such as the difference in chicken and turkey.

  These changes may result in decreased interest in food and inability to determine quality of food and may result in malnutrition.  Also, the older person may lose the ability to detect body odors or warning odors such as gas leaks or smoke (www.aging.unc.edu/ioalearning/modd1NoseSmell.asp)

  Taste

  As a result of age, the number and sensitivity of taste buds declines, resulting in decreased ability to distinguish between salt, sweet, or bitter tastes (www.aging.unc.edu/ioalearning/modd1Oral Health.asp)

Hearing      

  People who are deaf or hearing impaired use vision and touch to compensate for functions of hearing.  Their language is visual and many of the tools and devices they use are also visual.  People who are blind use hearing and touch.  They also use audio cues to orient themselves and to travel.  Persons who are deaf-blind or hearing impaired/visually impaired use the vision and hearing they have.  Their senses of touch and smell act as receptors for information from other people and the environment.

  Individuals experiencing a vision and hearing loss often find access to communication to be quite frustrating and quite challenging. Communication and mobility are obvious challenges to employment.

  The age of onset of the vision and hearing loss will largely determine the communication preference of the individual. For those individuals who are deaf and for whom sign language is the preferred mode, it is critical that the provider either be fluent in sign language, or acquire the services of a certified interpreter. It is important for the rehabilitation provider to be aware that for native signers, English is a second language. Therefore, relying on note writing and/or lip reading for the exchange of important information should be avoided.

  Points to consider when working with an individual with a combined vision and hearing loss:

•   Provide reasonable communication accommodation based on the preference of the consumer.

•  Assist the consumer in determining the most effective way to communicate with a supervisor and peers.

• Determine if the consumer would benefit from amplification in order to hear environmental sounds, as well as to hear and discriminate speech

• Familiarize yourself with visual, auditory, and tactile adaptations needed for the home and work environment (see chart below).

• Ask the consumer how he/she prefers to be approached by others (such as by a tap on the back or shoulder or by flipping the light switch several times to get his/her attention).

•   For consumers who use sign language, using a qualified interpreter for at least the first week or two of training on a new job is highly recommended.

•   Use a qualified interpreter any time when critical information is being exchanged.

•   Determine if there is a TTY (telecommunication device for the deaf) available at the workplace and that staff know how to use it. If for some reason a TTY is not available, staff in the workplace and the consumer should be trained on the use of the state’s relay service.

•   Make certain the rehabilitation provider’s office is TTY accessible.

•   Be aware that placing hard-of-hearing workers in jobs where there is constant exposure to noise might cause further damage to hearing.

•   Avoid work areas where the consumer will experience glare or shadows. 

• Avoid brightly colored and patterned walls, which can disrupt effective communication.

•   Reduce environmental distractions such as noise and movement.

•   Be prepared to repeat and rephrase information.

• Determine what computer technology accommodations are needed (large print; braille access; and amplified voice access).

• Ask the consumer to review key points of the conversation to ensure understanding.

Accommodation Considerations for Individuals with Hearing and Vision Impairments

Accommodat ion Considerations	Needs/ NA	Home	Work	Visual	Auditory	Tactile
Certified interpreter
CART (computer assisted real time captioning)
Assistive listening device (ALD)
Braille Lite
Hearing Aid(s) ___Left ___Right T-switch       Yes___  No___
Telephone __large button __amplified ringer __flashing light __tactile alert __hearing aid compatible __voice carry over __TTY (large/regular print __Braille TTY
Door alert Auditory/visual/tactile
Closed caption decoder
Clock __Braille __Talking __Large numbers Wake up alert __visual (flashing light) __auditory (loud ringer) __pillow vibrator
Smoke Detector __visual __tactile __auditory

For more information or technical assistance in serving individuals who are deaf-blind or hearing-vision impaired, contact the Helen Keller National Center (HKNC) at 111 Middle Neck Road , Sands Point , NY 11050 or visit the HKNC website at: www.helenkeller.org/national/

  Speech

  As a result of aging, the lower face and lips may start to droop.  Weakness in the muscles around the mouth can affect word formation or dentures may not fit properly (www.aging.unc.edu/ioalearning/mod1Oral Health.asp)

Muscle, Nerves, Coordination

  Muscle strength, motion, and reaction time can change. Reaction time can slow but is much less likely to occur in individuals who maintain physical activity. Overall, exercise and activity slow the aging process of muscles and, in some cases, reverse it.

  Coordination is a combined function of brain, nerves, and muscle. With age, speed of coordinated movements can slow but overall accuracy generally does not decrease.  Older workers who are trained and who continue to perform tasks should not experience any decrease in coordination (Isernhagen, 1991).

  Moderate work loads, for the most part, are manageable for older workers.  For the most part, physical demands of jobs are well below the maximum capabilities of older workers. (Meier & Kerr, 1976).

  Bones and Joints

  Women lose bone mass at a much greater rate than men. Exercise is crucial to reducing and even reversing  this bone mass loss.

Osteoarthritis–the process of slow degeneration of the joints–is prevalent in the older population.  Normal activity does not affect osteoarthritis and exercise is important to maintaining full range of motion.  An arthritic joint can functionally limit work, particularly bending low to lift, and job modifications may be necessary based on a medical evaluation (Isernhagen, 1991).

  Arthritis

  Arthritis affects one in every seven Americans and occurs more often as a person gets older. There are more than 100 different types of arthritis and related conditions. Arthritis most often affects areas in or around joints. Studies show that exercise can help reduce the pain and fatigue of many different types of arthritis. Being overweight can worsen the effects of arthritis. (www.arthritis.org/AFStore/Start).

  The Arthritis Foundation’s website at  www.arthritis.org, contains much valuable information about the different types of arthritis, including symptoms and treatment.  The Foundation also offers a valuable brochure entitled Arthritis and Employment which is useful for counselors and consumers and can be ordered from the foundation’s website.

Cardio-Pulmonary Capacity

  Heart

  As we age, the heart wall thickens, arteries lose flexibility, and blood pressure may increase.  However, these changes do not mean that the older person has cardiovascular disease, but can be signs of normal aging and adjustments (www.aging.unc.edu/ioalearning/mod1Cardiovascular.asp)

Maximum heart rate can decrease with age and result in a diminished ability to respond to physical or psychological stress rapidly.  Again, exercise and activity can keep heart capacity from declining significantly. Older workers with diminished heart capacity should not be placed in work situations requiring fast cardiac response (Isernhagen,1991).

Pulmonary Capacity

  The aging process can lead to a reduction in lung capacity due to decreased lung elasticity and less absorption of oxygen into the blood stream.

Aerobic exercise can lessen both heart and pulmonary decline. Older workers should avoid situations which can create severe pulmonary stress such as quick, long, or endurance movements (Isernhagen,1991).

  Balance

  Balance and equilibrium are affected by changes in the inner ear and changes in muscles and tendons which can be worsened by inflammation, osteoarthritic degeneration and trauma.  Balance problems occur particularly when rising from a sitting and kneeling position or when standing on one foot or on uneven surfaces. Individuals with vision loss experience balance problems at times (Saxon and Etten,1987; Isernhagen,1991).  Mobility training may help the older individual with vision loss regain a sense of balance and exercise may mitigate some of the physiological changes which affect balance.

  Digestive and Urinary System

  Diet and lifestyle result in more changes to the digestive system than does normal aging. Kidneys may decrease in size but normally continue to function normally.

Normal aging can result in increased need to urinate and lessened  ability to hold urine and the possibility of incontinence.

  As a result of changes in the digestive and urinary systems, older people may eliminate medications more slowly than do younger people, therefore requiring smaller doses (www.aging.unc.edu/ioalearning/mod1DisgestiveUrinary.asp)

Temperature Regulation

  Older individuals are often sensitive to cold or heat.  Thus, they may require a work environment which is temperature controlled (Isernhagen,1991).

  Diabetes

Diabetes is a disease that affects the body’s ability to produce or respond to insulin.  Diabetes falls into two main categories:  type 1, which usually begins in childhood or adolescence and type 2, which usually occurs after age 45.  The disease prevalence increases with age.  Approximately half of all diabetes occur in people older than 55.  Nearly 18.4 percent of the U.S. population age 65 and older have diabetes.  Certain racial and ethnic groups are at greater risk of type 2 diabetes: African Americans, Latinos, and Native Americans (www.diabetes.org/ada/facts.asp)

  Complications

  Many people do not become aware of diabetes until they develop one of its life-threatening complications. These include heart disease, stroke, vision loss, amputations and kidney disease (www.diabetes.org/ada/facts.asp)

•   Blindness–diabetes is the leading cause of new cases of blindness in people age 20-74. 

•     Kidney disease–diabetes is the leading cause of end stage renal disease.  In 1995, approximately 27,900 people began treatment for kidney failure due to diabetes.

•   Nerve disease and amputations–about 60-70 percent of people with diabetes have mild to severe forms of diabetic nerve damage, which can lead to lower limb amputations.  Each year more than 56,000 amputations are performed on people with diabetes.  Persons with diabetes must take care of their feet. Any injury to a foot or sore must be monitored closely.

•   Heart disease and stroke–people with diabetes are 2-4 times more likely to have heart disease or to suffer from stroke.  Approximately 77,000 deaths occur due to heart disease in diabetics occur annually (www.diabetes.org/ada/facts.asp)

Treatment

Diabetes is one of the most costly health problems in America.  Health care and other costs directly related to diabetes treatment, as well as the costs of lost productivity, run $98 billion annually. It may be possible to prevent or delay the onset of type 2 diabetes by reducing lifestyle risk factors through weight loss and increased physical activity (www.org/ada/facts.asp)

In working with older consumers, the counselor needs to be aware of the warning signs of diabetes, the implications of diabetes, and how these may affect the older individual’s ability to work.  The first priority is obtaining a dilated eye exam to detect eye disease related to diabetes.  Through laser treatment, diabetic retinopathy may be treated quite successfully if caught early enough. 

  Starting in 2001, the Health Care Financing Administration, now known as Centers for Medicine and Medicaid Services (CMS), the Foundation of the American Academy of Ophthalmology, and the American Optometric Association have created a national initiative to address eye care for Medicare beneficiaries, transportation and cost.  In addition to the CMS, FAAO and AOA partners, the initiative has mobilized many other organizations and people at both the national and local levels.  CMS' national network of Peer Review Organizations (PROs) is playing an essential role by sending postcards and brochures to Medicare beneficiaries who qualify for the program to raise awareness of the Diabetes Initiative.  State ophthalmological and optometric societies are partnering with the PROs to help spread the word about the initiative to the local media, celebrity spokespersons have contributed public service announcements and even carriers have helped spread the word to their providers through mailings.  Increasing awareness of the connection between diabetes and blindness as well as the eye exam initiative through the national and local media and professional journals has contributed greatly to the early success of the project.  The PROs are also working to address the transportation issues through state and local groups.  For more information check the American Diabetes Association web site at (www.diabetes.org/ada/preventblindness.asp).

Older individuals with diabetes can work, quite successfully.  It is important for the counselor to educate the older person about complications, treatment, and preventive measures, such as weight reduction and dietary control.  The person who is on insulin may need help working out a system on taking insulin while on the job and to work out problems such as storage of the insulin.

  Learning Activities–You may try these activities to practice what you have learned.

1.         Using simulators for sensory and other losses, try the exercises in Appendix C.

2.         Using the simulators, role play an interview between yourself as consumer and another person as counselor or vice versa.

Congratulations!  

You have finished Module 3. 

Now go on to the key points section to review what you have learned. You will find these at the end of each module.

  Key Points

1.        Older persons experience a number of changes physically which may affect how they work.

2.         The more counselors know about the life circumstances associated with the loss of vision as part of the aging process and other concomitant losses, the more successful their interventions can be.

3.         Diabetes is the leading cause of new cases of blindness in people age 20-74. 

4.         Most older persons have at least one chronic health condition and many have multiple conditions.  Approximately 30 percent of older persons have a significant hearing impairment.

  Self-Check

  You will find a self-check section at the end of each module to allow you to find out what you have learned and help you identify sections you may need to review before moving on to the next module.

 Please answer each True or False and check Appendix A for answers.