Age-Related Macular Degeneration As a person ages their visual feedback can be affected by many factors. A specific condition that can interfere with an individuals occupational performance is age-related macular degeneration (AMD). Macular degeneration is a progressive physical breakdown of the macula, which is part of the retina. There are two forms of macular degeneration, “wet” and “dry”. Eighty to ninety percent of patients have the “dry” form. Both wet and dry AMD can drastically impact an individuals ability to maintain independence, complete daily ADL’s, IADL’s, and BADL’s.
The “dry” form involves deterioration of the macula, that is found in the center of the retina. This form is also associated with the formation of drusen (small yellow deposits) under the macula. The drusen build up leads to thinning and drying of the macula. This form typically progresses slower than the “wet” form. This type of AMD develops gradually, and symptoms can often be mistaken as typical aging. An individual may find they need increased lighting for reading, difficulty adapting to low light levels, increased blurriness, difficulty recognizing faces, and gradually increasing haziness of central vision (Coleman, Chan, Ferris & Chew, 2008).
The “wet” form of AMD effects approximately 10-15% of individuals with this condition. In this type there is abnormal blood vessel growth under the retina and macula. This abnormal growth of blood vessels is known as choroidal neovascularization, or CNV. These blood vessels can bleed and leak fluid, causing the macula to lift up from it’s naturally flat position. This form is more serious and progresses faster than the “dry” form. Severe distortion or destruction of central vision is often the result of this form. The “wet” form causes an individual to see a dark spot(s) in the center of their vision due to the accumulation of blood or fluid. Straight lines may appear wavy to the person because the macula is no longer smooth (Coleman, Chan, Ferris & Chew, 2008).
A person living with macular degeneration is typically able to remain living in their home independently, with proper modifications and supports in place. Decreased visual feedback increases the risk of falling in older adults. Functional mobility may also be affected by decreased balance due to poor visual perception. Functional mobility can be the most drastically impacted, because of a limited visual field it is difficult to maneuver around any clutter/tripping hazards, coffee tables, pets, or other items that may be in the way of navigating one’s own home or the community. A patient with AMD may also have difficulty with self-care ADL’s such as bathing, dressing, and feeding. Due to decreased central vision an individual may have difficulty seeing dangers in the shower, finding soap/shampoos, or adjust the tempature properly when completing bathing/showering tasks. Self-feeding involves setting up, arranging, and bringing food from plate to mouth. AMD can increase the difficultly of this because of the need for primarily central vision during these tasks. Other areas affected include IADL’s communication management, community mobility,health management, home management, meal preparation and cleanup, safety and emergency maintence, shopping, leisure participation, and social participation (Occupational therapy practice framework, 2008).
Three priority areas to address when treating a client with AMD are home safety, home modification/adaptations, and social/leisure participation. The first area to be address would be done so utilzing the HOME-FAST screening tool in the client’s home setting. Due to decreased central vision the client should have a home that is free of clutter or unnecassary dangers. By removing objects such as boxes, papers, unused items from living space and walkways the client will decrease their likilihood of accidently falling. Although, AMD does not typically result in hospitalization, falls do. Carpets and tile should be secured well and free of tears or cracks. Any lose mats or carpet should be fixed to the floor using a slip resistent backing or removed. Other safety issues to consider is furntiture layout; open space to walk is very important to avoid bumping into corners of furntiture or chairs. Lighting is another safety issue that should be addressed within the home. The lighting should be adjusted to suit the needs of the client. Walk ways, stairs, hallways, other frequently used areas need to have adequate lighting.
Home modifications can be recommended to improve sensory perceptual skills such as using contrast (placing light objects against dark backgrounds) and using bright colors to indicate to assist in finding needed items. The hot water heater temperature can also be adjusted to a lower temperature to decrease risk for burns. Kitchen modifications would include labeling with bold contrasting colors, bring most frequently used items to eye level, use high contrast tape to label the stove to label off position easily.
In the area of social and leisure participation the therapist should begin by assessing the client’s priorities, the COPM would be a useful assessment. The COPM will ensure that client centered goals are made. An occupational therapist can assist in community mobility strategies, family supports, and promotion of an active social life. Patients with macular degeneration may isolate themselves due to embarrassment about their condition or avoid leaving home out of fear. It would be important to discuss with the client what they would like to do and develop appropriate supports/adaptations to overcome these fears and apprehension (Eklund & Synneve, 2006). The COPM is also a very useful tool to ensure client-centered goals are made. Support groups for older people with low vision can be set up. An additional assessment that would assist in planning treatment would be the Geriatric Depression Scale (GDS).
It important to assist the client in maintaining the most independence as possible. Client’s with AMD often become depressed and embarrassed by their impairments. It vital to discuss and monitor these areas as the disease progresses. Occupational performance of ADL’s and IADL’s within the client’s natural setting should be assessed to identify limitations and abilities. Environmental supports and barriers should also be identified and discussed with the client and caregivers.
Local and National Resources:
American Macular Degeneration Foundation http://www.macular.org/disease.html Local Resource finder/support assistance for Florida http://www.macular.org/sgroups/flsg.html Media: http://www.macular.org/macdeg.html Animation of “dry” and “wet” macular degeneration. Anatomy and pathophysiology of disease progression. This video provides a brief overview of the progression of the disease to assist in better understanding the impact of age-related macular degeneration.
Discharge: The client should be discharge from therapy when they are able to demonstrate increased safety awareness, present a decreased fall risk, simple home modification have been put in place, patient/caregivers have been educated on considerations for more advanced AE, and social/leisure supports are available to the client despite residual impairments.
LTG 1: In 4 weeks the client will safely complete hot meal preparation in home setting with modified independence.
STG 1: In 2 weeks the client will demonstrate increased safety awareness to cook a hot meal using AE with supervision and no more than 2 verbal cues.
LTG 2: In 4 weeks the client will complete all ADL self-care with modified independence.
STG 2: In 2 weeks the client will safely enter and exit the shower by using contrast tape to perform grooming tasks with modified independence.

References
American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, 625-683.
Coleman, H. R., Chan, C., Ferris, F. L., & Chew, E. Y. (2008). Age related macular degeneration. The Lancet, 372(9652), 1832-1845.
Eklund, K., & Synneve, D. I. (2006). Health education for people with macular degeneration: Learning experiences and the effect on daily occupations. The Canadian Journal of Occupational Therapy, 73(5), 272-80.