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Keeping an Eye on the Rest of the Body
Keeping an Eye on the Rest of the Body IRVING S. WRIGHT, MD
Abstract: The health problems of the elderly are multiplying exponentially with the demographic changes in our aging population. Visual impairment represents one of the most significant of these problems, not only in terms of eye diseases, but because of the associated dangers affecting the rest of the body. The gradual loss of vision, especially if it first affects one eye, is often ignored or denied until it is far advanced with marked functional impairment or causes serious accident. A high percentage of falls, often with resulting fractures, is a direct result of poor vision, but in the elderly this risk is frequently compounded by unsteady gait, osteoporosis, and poor lighting. Misuse of medication, especially with overdose is frequent when directions are in small print. Misuse can be exacerbated by poor memory. The risk of driving accidents is increased. Although notable progress has been made in technical approaches to ophthalmology, many serious problems such as macular and retinal degeneration remain unsolved. The American Federation for Aging Research, which is dedicated to the support of research in all biomedical changes associated with aging, has an active interest in basic research in the field of visual impairment with other changes and diseases in our elderly population. [Key words: falls, fractures, overmedication, reading, vision.] Ophthalmology 94: 1196-1198,1987
It may seem presumptuous for me to have accepted your kind invitation to speak before The American Academy of Ophthalmology. I claim no expertise in this field, but I have had a long experience with what happens to the rest of the body when the vision fails in its appointed tasks. I will try to focus on the impact of failing vision on the lives of our elderly citizens-now numbering 27,000,000 over age 65, the most rapidly increasing segment of our population, and the segment with the greatest percentages of physical and visual impairment. The majority of the elderly over 65 have one or more diagnosable diseases but most consider themselves relatively healthy, and 9% account for 70% of medical expenses. I I will not address the tragic problems of the totally blind. Nor will I discuss the diagnostic and technical details of your speciality. My experience has been with From the American Federation for Aging Research, New York. Presented at the American Academy of Ophthalmology Annual Meeting, New Orleans, November 1986. Reprint requests to Irving S. Wright, MD, President, American Federation for Aging Research, 725 Park Avenue, NY 10021.
1196
the elderly, who are gradually losing their visual acuity, usually over a period of years. This is frequently unrecognized because a good eye compensates for a poor one or it is denied until it leads to an accident or severe incapacitating blindness. The central and peripheral nervous systems together mediate the entire range of man's adjustment as well as the knowledge of himself and the transmission of his culture. Consequently, the pattern, pace, and the texture of the aging nervous system becomes a central issue in human existence. The relevance of this issue is even more pressing at a time when the proportion of the aging population is increasing at an historically unequalled rapid rate. The visual aspect of this complicated change of aging is certainly among the more important since through our eyes flow the images which determine much of our lives. As physicians, our increasing concentration on specialization and high technology tends to limit our consideration of the patient as a whole person. In elderly patients, loss of vision is, however, rarely an isolated disability. Most patients over 65 have multiple diseases, usually three or four. I have seen one patient with 13 distinct diseases. Loss of vision may be directly related
WRIGHT
•
KEEPING AN EYE ON THE REST OF THE BODY
to some of these general diseases, such as diabetes with retinal changes, hypertension with atherosclerosis or hemorrhage, or thrombotic intracardiac or carotid foci producing embolic closure of arteries, either ocular or in visual centers. On the other hand, an unsteady gait due to osteoarthritis or loss of peripheral neuromuscular control when combined with poor vision may produce catastrophic falls. When examining and advising these patients, it is important that the ophthalmologist consider these other factors and the patient as a whole. I ask how often this is done. My experience has been that it is too frequently honored by its omission. This is a challenge to the new generation of ophthalmologists-do not assume that the patient will get complete and comprehensive studies from another physician. Critical problems affecting the total health of individuals related to loss of vision include the following.
FRACfURES FROM FALLS Almost any bones may be involved but it has been reported that approximately 200,000 fractures of the hips occur each year. For our patients, they are among the most common and the most serious. In the elderly, after 1 year one third are up and about, one third are unable to walk, and one third are dead. Over the age of 90, 32% of women and 17% of men have suffered hip fractures. The national cost of hip fractures is estimated from 1 to 3 billion dollars a year. 2 Several causative factors are important: (1) Impaired vision. This resulting in missing steps, curbs, and uneven ground. The combination of unsteady gait and poor vision greatly increases the fear of falling, which is well justified; (2) unsteady gait due to neuromuscular or arthritic disease; (3) poor lighting, lack of night lights; (4) osteoporosis increasing the factor offragility; (5) slippery floors or rugs; and (6) bathtubs without use of suction mats and appropriate support bars. The following factors are commonly associated.
MISUSE OF MEDICATION This is a result of not being able to read the directions on the bottle which are often in fine print or poorly typed. This is compounded when associated with failing memory that is so common in our elderly patients. Many cannot remember the doctor's instructions or even whether they took their pill a few minutes before. Over-dosing is very common and can be serious or even fatal. This is more complicated when the patient has medications for several diseases. In order to minimize this risk, I recommend that either someone else or the patient put the pills prescribed on the bed table and then put all of the bottles in the medicine cabinet for the night.
FINE PRINT ON FOOD PACKAGES MAY PREVENT IDENTIFICATION OF SALT, SUGAR, AND OTHER CONTRAINDICATED CONTENTS Gas range flames are sometimes not visible to the patient preparing food and this has resulted in severe bums, either directly or by igniting clothing.
DRIVING Our society demands mobility. Progressively poor vision as from cataracts, glaucoma, or macular, or retinal degeneration is frequently denied or ignored, especially during the 3- to 5-year period between drivers' licensing examinations. This may create the following deadly hazards: (1) When entering a tunnel from bright sunlight, loss of vision occurs during a period of delayed adjustment. Loss of night vision is most common in blond, blue-eyed people with low-melanin retinal pigmentation. (2) Delayed reading of highway signs indicating turn-offs or other changes in pace or lane until too late to follow them safely. (3) Misinterpreting signal light changes. A few seconds of indecision may mean death! Lack of mobility due to impaired vision curtails the lives of millions of our elderly. Most cannot afford chauffeurs-taxis are often hard or impossible to get when needed, and they frequently will not wait to return the patient. Otherwise spirited and independently minded individuals become dependent on relatives, friends, or organizations that provide special services for the blind. The alternative is isolation, frustration, and sometimes psychologic or physical illness.
READING Although our society seems to be moving into a state of television and computer captivity, reading still remains one of the durable satisfactions of life. It also represents one of the best forms of mental exercise, which is just as important as physical exercise in preventing or retarding the aging phenomena. Gradual or rapid visual loss presents increasing difficulty in keeping up with a person's livelihood, and in enjoying the great minds and lessons of history. Newsprint gets smaller or duller and contrast, especially the pink and orange type, is progressively poorer. Dark print with contrasting light, not glossy background is appreciated. Let me emphasize the importance of large print books-but the paucity of first-class literature and history in their listings in unfortunate. This is probably a reflection of the marketplace, yet this market is rapidly increasing. The publishers should be encouraged to include more classics, historical and other solid reading, for the large 1197
OPHTHALMOLOGY
•
SEPTEMBER 1987
number of elderly whose minds continue to be sharp and who need the challenge of good literature. Auditory techniques for more serious impairment are well known to this audience. However, they frequently fail to challenge the mind to the degree that reading does.
TAKING CARE OF THE PATIENT'S BODY With loss of vision the patient has difficulty in recognizing skin lesions and their changes including keratoses, basal and squamous cell changes, and melanomas. As one interested in the circulation, I have seen many examples of damaged toes as a result of poor clipping of the toenails by the patient. When the circulation is poor as with diabetes or atherosclerosis, this can precipitate gangrene, and if infection occurs, amputation. If the patient cannot see the toenails well enought to cut them safely, a well-trained podiatrist is the best answer, and I emphasize "well trained."
CONCLUSION Blindness in varying degress is one ofthe most serious of all problems of the elderly. It is usually gradual in onset, frequently not recognized, or even denied until an accident or serious impairment occurs. It represents an
1198
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VOLUME 94
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NUMBER 9
integral phenomenon of the aging process or a direct manifestation of specific diseases including diabetes, hypertension, renal disease, and atherosclerosis. It may also be related to the lack or loss of melanin in the retina, especially in blond nordic populations. It is of interest that this is often associated with osteoporosisboth being more common in the blond blue-eyed peoples and rare in the highly pigmented peoples. The results of progressive blindness are extremely serious for many millions of our citizens, and all efforts should be made to prevent, retard, and compensate for these pathologic changes. This requires greater support and research effort by ophthalmologists, internists, and especially basic scientists working in the fields of molecular biology and genetics. The American Federation for Aging Research is committed to the support of research and the correlation of studies in this field with those of other phenomena of aging and its associated diseases. We will welcome your interest and support of our program.
REFERENCES 1. Epidemiological Studies of the Elderly. Resource Data Book. National Institute on Aging. Bethesda: Government Printing Office, 1985. 2. Report of the National Advisory Council on Aging. Administrative Document. Department of Health and Human Services. Washington, DC: Government Printing Office, 1983.
Abstract: The health problems of the elderly are multiplying exponentially with the demographic changes in our aging population. Visual impairment represents one of the most significant of these problems, not only in terms of eye diseases, but because of the associated dangers affecting the rest of the body. The gradual loss of vision, especially if it first affects one eye, is often ignored or denied until it is far advanced with marked functional impairment or causes serious accident. A high percentage of falls, often with resulting fractures, is a direct result of poor vision, but in the elderly this risk is frequently compounded by unsteady gait, osteoporosis, and poor lighting. Misuse of medication, especially with overdose is frequent when directions are in small print. Misuse can be exacerbated by poor memory. The risk of driving accidents is increased. Although notable progress has been made in technical approaches to ophthalmology, many serious problems such as macular and retinal degeneration remain unsolved. The American Federation for Aging Research, which is dedicated to the support of research in all biomedical changes associated with aging, has an active interest in basic research in the field of visual impairment with other changes and diseases in our elderly population. [Key words: falls, fractures, overmedication, reading, vision.] Ophthalmology 94: 1196-1198,1987
It may seem presumptuous for me to have accepted your kind invitation to speak before The American Academy of Ophthalmology. I claim no expertise in this field, but I have had a long experience with what happens to the rest of the body when the vision fails in its appointed tasks. I will try to focus on the impact of failing vision on the lives of our elderly citizens-now numbering 27,000,000 over age 65, the most rapidly increasing segment of our population, and the segment with the greatest percentages of physical and visual impairment. The majority of the elderly over 65 have one or more diagnosable diseases but most consider themselves relatively healthy, and 9% account for 70% of medical expenses. I I will not address the tragic problems of the totally blind. Nor will I discuss the diagnostic and technical details of your speciality. My experience has been with From the American Federation for Aging Research, New York. Presented at the American Academy of Ophthalmology Annual Meeting, New Orleans, November 1986. Reprint requests to Irving S. Wright, MD, President, American Federation for Aging Research, 725 Park Avenue, NY 10021.
1196
the elderly, who are gradually losing their visual acuity, usually over a period of years. This is frequently unrecognized because a good eye compensates for a poor one or it is denied until it leads to an accident or severe incapacitating blindness. The central and peripheral nervous systems together mediate the entire range of man's adjustment as well as the knowledge of himself and the transmission of his culture. Consequently, the pattern, pace, and the texture of the aging nervous system becomes a central issue in human existence. The relevance of this issue is even more pressing at a time when the proportion of the aging population is increasing at an historically unequalled rapid rate. The visual aspect of this complicated change of aging is certainly among the more important since through our eyes flow the images which determine much of our lives. As physicians, our increasing concentration on specialization and high technology tends to limit our consideration of the patient as a whole person. In elderly patients, loss of vision is, however, rarely an isolated disability. Most patients over 65 have multiple diseases, usually three or four. I have seen one patient with 13 distinct diseases. Loss of vision may be directly related
WRIGHT
•
KEEPING AN EYE ON THE REST OF THE BODY
to some of these general diseases, such as diabetes with retinal changes, hypertension with atherosclerosis or hemorrhage, or thrombotic intracardiac or carotid foci producing embolic closure of arteries, either ocular or in visual centers. On the other hand, an unsteady gait due to osteoarthritis or loss of peripheral neuromuscular control when combined with poor vision may produce catastrophic falls. When examining and advising these patients, it is important that the ophthalmologist consider these other factors and the patient as a whole. I ask how often this is done. My experience has been that it is too frequently honored by its omission. This is a challenge to the new generation of ophthalmologists-do not assume that the patient will get complete and comprehensive studies from another physician. Critical problems affecting the total health of individuals related to loss of vision include the following.
FRACfURES FROM FALLS Almost any bones may be involved but it has been reported that approximately 200,000 fractures of the hips occur each year. For our patients, they are among the most common and the most serious. In the elderly, after 1 year one third are up and about, one third are unable to walk, and one third are dead. Over the age of 90, 32% of women and 17% of men have suffered hip fractures. The national cost of hip fractures is estimated from 1 to 3 billion dollars a year. 2 Several causative factors are important: (1) Impaired vision. This resulting in missing steps, curbs, and uneven ground. The combination of unsteady gait and poor vision greatly increases the fear of falling, which is well justified; (2) unsteady gait due to neuromuscular or arthritic disease; (3) poor lighting, lack of night lights; (4) osteoporosis increasing the factor offragility; (5) slippery floors or rugs; and (6) bathtubs without use of suction mats and appropriate support bars. The following factors are commonly associated.
MISUSE OF MEDICATION This is a result of not being able to read the directions on the bottle which are often in fine print or poorly typed. This is compounded when associated with failing memory that is so common in our elderly patients. Many cannot remember the doctor's instructions or even whether they took their pill a few minutes before. Over-dosing is very common and can be serious or even fatal. This is more complicated when the patient has medications for several diseases. In order to minimize this risk, I recommend that either someone else or the patient put the pills prescribed on the bed table and then put all of the bottles in the medicine cabinet for the night.
FINE PRINT ON FOOD PACKAGES MAY PREVENT IDENTIFICATION OF SALT, SUGAR, AND OTHER CONTRAINDICATED CONTENTS Gas range flames are sometimes not visible to the patient preparing food and this has resulted in severe bums, either directly or by igniting clothing.
DRIVING Our society demands mobility. Progressively poor vision as from cataracts, glaucoma, or macular, or retinal degeneration is frequently denied or ignored, especially during the 3- to 5-year period between drivers' licensing examinations. This may create the following deadly hazards: (1) When entering a tunnel from bright sunlight, loss of vision occurs during a period of delayed adjustment. Loss of night vision is most common in blond, blue-eyed people with low-melanin retinal pigmentation. (2) Delayed reading of highway signs indicating turn-offs or other changes in pace or lane until too late to follow them safely. (3) Misinterpreting signal light changes. A few seconds of indecision may mean death! Lack of mobility due to impaired vision curtails the lives of millions of our elderly. Most cannot afford chauffeurs-taxis are often hard or impossible to get when needed, and they frequently will not wait to return the patient. Otherwise spirited and independently minded individuals become dependent on relatives, friends, or organizations that provide special services for the blind. The alternative is isolation, frustration, and sometimes psychologic or physical illness.
READING Although our society seems to be moving into a state of television and computer captivity, reading still remains one of the durable satisfactions of life. It also represents one of the best forms of mental exercise, which is just as important as physical exercise in preventing or retarding the aging phenomena. Gradual or rapid visual loss presents increasing difficulty in keeping up with a person's livelihood, and in enjoying the great minds and lessons of history. Newsprint gets smaller or duller and contrast, especially the pink and orange type, is progressively poorer. Dark print with contrasting light, not glossy background is appreciated. Let me emphasize the importance of large print books-but the paucity of first-class literature and history in their listings in unfortunate. This is probably a reflection of the marketplace, yet this market is rapidly increasing. The publishers should be encouraged to include more classics, historical and other solid reading, for the large 1197
OPHTHALMOLOGY
•
SEPTEMBER 1987
number of elderly whose minds continue to be sharp and who need the challenge of good literature. Auditory techniques for more serious impairment are well known to this audience. However, they frequently fail to challenge the mind to the degree that reading does.
TAKING CARE OF THE PATIENT'S BODY With loss of vision the patient has difficulty in recognizing skin lesions and their changes including keratoses, basal and squamous cell changes, and melanomas. As one interested in the circulation, I have seen many examples of damaged toes as a result of poor clipping of the toenails by the patient. When the circulation is poor as with diabetes or atherosclerosis, this can precipitate gangrene, and if infection occurs, amputation. If the patient cannot see the toenails well enought to cut them safely, a well-trained podiatrist is the best answer, and I emphasize "well trained."
CONCLUSION Blindness in varying degress is one ofthe most serious of all problems of the elderly. It is usually gradual in onset, frequently not recognized, or even denied until an accident or serious impairment occurs. It represents an
1198
•
VOLUME 94
•
NUMBER 9
integral phenomenon of the aging process or a direct manifestation of specific diseases including diabetes, hypertension, renal disease, and atherosclerosis. It may also be related to the lack or loss of melanin in the retina, especially in blond nordic populations. It is of interest that this is often associated with osteoporosisboth being more common in the blond blue-eyed peoples and rare in the highly pigmented peoples. The results of progressive blindness are extremely serious for many millions of our citizens, and all efforts should be made to prevent, retard, and compensate for these pathologic changes. This requires greater support and research effort by ophthalmologists, internists, and especially basic scientists working in the fields of molecular biology and genetics. The American Federation for Aging Research is committed to the support of research and the correlation of studies in this field with those of other phenomena of aging and its associated diseases. We will welcome your interest and support of our program.
REFERENCES 1. Epidemiological Studies of the Elderly. Resource Data Book. National Institute on Aging. Bethesda: Government Printing Office, 1985. 2. Report of the National Advisory Council on Aging. Administrative Document. Department of Health and Human Services. Washington, DC: Government Printing Office, 1983.