Victoria S. Pelak, MD
February 2021
There is not a “one-size-fits all” approach to helping compensate for visual brain dysfunction. We often hear from our patients and their care what helped and what did not and with that information, we put together this document. We also relied upon tips put together by a team at the Multidisciplinary Memory Clinic at the University of Toronto that included Alison Lake OT, Maria Martinez MSW and David F. Tang-Wai MDCM FRCPC. The complete list of those tips are freely available here - PCA Tip Sheet for Patients :
From the Eyes to the Brain: Vision is a complex process that begins in the
eyes. In order to see what our eyes detect, visual signals from the eye must be sent to the brain. One of the most important regions of the brain that receive information directly from the eyes is a region called the thalamus, which is a structure
in the deep center of the brain. From there, information travels to the posterior lobe of the brain called the occipital cortex. The cortex is a special type of brain tissue and regions of the cortex are dedicated to a variety of different functions.
For instance, the cortex helps create our memories, interpret and produce language and speech, processes information from the five senses, and helps control voluntary movements. The occipital cortex is an area that is solely dedicated to vision. After
it receives visual information from the thalamus, the occipital cortex works to provide feedback to the thalamus to control what visual information we pay attention to and it also sends information out to other regions of the brain so we can act upon
what we are seeing or recognize what we are seeing and compare it to our stored memories. Beyond the cortex, the eyes also send information to our brain stem and an area called the hypothalamus; the vital visual information sent to these regions helps
our brain control eye movements, the focusing power of the eye, and the sleep-wake cycle.
Detecting Visual Brain Dysfunction: Testing the basic visual function of the eye and the eye examination do not readily lead to the detection of visual brain dysfunction. Instead, the examiner must be looking specifically for visual brain dysfunction and those types of tests are not part of the routine eye visit. For example, a common test to evaluate cognitive brain processes that rely on vision includes copying a geometric figure or a clock drawing test. When either is abnormal, it is a clue that visual brain dysfunction is likely present. Interpretation of a complex visual image or scene can also be part of the assessment for visual brain dysfunction. This type of testing can reveal decreased visual attention, particularly for objects in the left half of a person’s vision, or abnormal visual detection of the overall scene. In summary, measuring visual brain dysfunction requires specialized tests and assessments usually administered by a neurologist or a neuropsychologist during cognitive testing.
Impact on Everyday Activity:When visual brain dysfunction is present, there are many everyday activities that become difficult or impossible to perform, particularly when the dysfunction is combined with apraxia, which is the inability to properly perform a task that requires purposeful movements (i.e. dressing or using a smart phone). Although many brain processes are important for driving a vehicle, when visual brain activities are disrupted, driving can be impacted early in the course of disease. A person might have difficulty with parallel parking or hug the line on the road too closely; they might misjudge the speed of oncoming vehicles when turning left at stoplights through oncoming traffic. These are distinctive signs of visual brain dysfunction and are important to recognize for safety reasons.
Supportive Approaches: There are ways that might help compensate for these problems and what works best is unique to each person. Thus, suggestions could work for some but not others or you might find some of your own alternative approaches to help you manage everyday activities. Below we review suggestions to help you get started to offset the impact of visual brain dysfunction.
Suggestions to Help
First steps: Eye Care and Prescription Lenses
One of the first steps to improve visual function in the setting of any type of dementia is to make sure your eyes are as healthy as possible and your prescription lenses are up-to-date and appropriate for the various points of focus you use every day (i.e. distance, mid-range, and near). Some eye doctors might not be aware of how the brain impacts vision, but they can provide the type of important eye care health that you need as you age.
General eye care:There are many eye changes that occur as we age. Not only is it difficult to focus up close as we age, otherwise known as presbyopia, but our eyes can become dryer and we can develop age-related eye disorders such as cataracts, macular degeneration, and glaucoma. Schedule annual visits to your ophthalmologist even if you think your glasses are the proper prescription because changes can occur inside the eye before you notice the consequence and early treatment can prevent vision loss. For those with diabetes, routine eye care is critical to preventing blindness.
Prescription lenses: While seeing your eye care provider for prescription lenses, let them know of your diagnosis of visual brain dysfunction and that it might impact your ability to use the lenses they prescribe, particularly those lenses that have corrections for different distances within the lens and these include progressive lenses, trifocals, and bifocals. These types of lenses require small eye movements, sometimes combined with slight adjustments in neck position, to get the eyes to be looking through the proper portion of the lens in order to see things in focus. For those with ocular motor slowing or inaccurate adjustment of the eyes to focus at different distances, these types of multifocal point lenses can be difficult to use. The eyes can also have a hard time moving toward each other and when this happens, which is called convergence insufficiency, it can be difficult to read without blur or seeing double. If convergence insufficiency is causing problems with near reading or other near work, the eye care provider might be able to add prisms to your reading lenses to help improve your near vision. Thus, seeking out proper lenses as soon as visual symptoms become evident when reading or attempting to change focus at different distances is worthwhile.
Visual Hallucinations
Visual Hallucinations can occur and be a challenging problem to cope with throughout the course. If the visual hallucinations are frightening or if a person is having difficulty recognizing the unreal nature of the hallucinations, the use of medication is an important method of treatment to prevent behavioral changes that lead to disruption or safety issues. Non-medication approaches can be tried even in conjunction with medications and these approaches include the following:
Many family members and care partners ask whether gently trying to persuade a person that a visual hallucination is not real is the right thing to do when a person believes the hallucination is real. The answer to this is dependent
upon the circumstance. If a person is asking for reassurance that what they are seeing is not real, then it is appropriate to comfort the person and help them gain insight that the hallucination is not real. In other circumstances,
a person might be more upset by being told or trying to be convinced that what they see is not real than how they feel about the hallucination itself. As an example, a person might create a story regarding a non-frightening visual
hallucination and if they are convinced of the real nature of the hallucination, it might be best to acknowledge the story and simply move on. In another circumstance, a visual hallucination might be frightening, and it then becomes
necessary to make the person feel safe and comfortable and move out of the room or space where the hallucination is being experienced and reassure the person that they are safe and protected. In situations where a person does not
feel safe due to recurrent visual hallucinations, medication treatment is the best approach. In summary, if the act of trying to convince a person with a visual hallucination that it is not real becomes upsetting for the person
to hear or does not provide reassurance or comfort, then it is best to make the person feel safe and consider increasing the lighting, moving to another room, and trying to engage the person in another activity if at all possible.
Room Lighting
Visual brain function can be very dependent on the level of light and the source of lighting. If the room is too bright, it can be difficult to distinguish words on a page or objects from the background. If the room is too dark, the
same problem can occur. Find the best light for the task at hand, whether that is eating, watching TV, looking at photos on a phone or other device, looking at a computer monitor, etc. It is usually somewhere between dim and bright
for most people with visual brain dysfunction. The light source is also important. Overhead lighting from can lights in particular can create a glare that makes it difficult to see, although use of a dimmer on can lighting can
help keep the room well-lit without the brightness that can wash out what is being viewed. Experiment with different lighting environments during the day and evening by bringing different lamps into a room, opening or closing curtains
depending on the time of the day, and changing the brightness of overhead lighting. By increasing the contrast between the background and what you are looking at will be easier to see. See the section on
Contrast.
Contrast and Electronic Devices
On nearly all electronic devices, the level of contrast for text and images can be adjusted. To determine how to do so, you can search the internet for your device and type “how to change contrast”. Once you are able to
adjust the contrast, you can try different levels, but the best for most with visual brain dysfunction is to have the contrast at the greatest level possible, often listed as 100% on devices. The brightness of text can also be
adjusted and the brightness that you want will depend on the background. If the background is white, the brighter the text or image, the harder it is to see because it will blend in with the background. If the background is black,
the brighter image will be easier to see. The best way to determine what is right for the person with visual brain dysfunction is to experiment. In general, increasing the contrast from what is being viewed and the background will
be one way to improve visual function.
Avoid flooring that has grey upon grey or white upon white when adding an area rug to a carpet or flooring. These items can become hazards as they will blend into the background and not be able to be seen.
Finding and Seeing Items
Many people with visual brain dysfunction are not able to find items that are directly in sight or in plain view. At other times, the smallest piece of paper or a very small item can easily be seen. We now understand that the visual brain can miss seeing an item when it is within a cluttered environment or when it is mixed in with a lot of other items such as trying to find a hairbrush on a dresser or bathroom counter that is filled with other items or even a fork on a dining room table. A key to helping to compensate for this problem is to simplify and declutter the environment.
Ideas to help see and find items you need
Focus on the ideas that you believe will make the biggest impact and then give it a try. Invite a family member or friend or grandchild to help you implement them. Others often have ideas that are creative and uniquely suited to
the individual with visual brain dysfunction.
Finding Your Way, Not Getting Lost, and Staying Safe
Wandering and getting lost are common for people with brain dysfunction affecting the visual areas of the brain; these visual areas help create the maps that are stored in your memory and if there is difficulty using vision to
gain access to these memories, wandering and getting lost can be a concern for safety. Some people report that their loved one with visual brain dysfunction was at one moment at their side and then gone the next, especially
in a new location (e.g. at a store with which they are not familiar). Even getting from one location to another in the house can become difficult. Some ways that have helped others are listed below.
When outside the home:
Inside the home:
Getting Dressed with less Frustration
As noted in the Finding and Seeing Items section, keeping closets organized and minimizing the number of clothing items in closets and drawers is the first step in making getting
dressed easier. If necessary, you can add specific and very simple signs or labels on a drawer or in the closet as reminders of what items to expect in a specific location. See Finding and Seeing Items section
for more helpful solutions.
The next step where vision processing can break down is trying to see where the back or the top of a piece of clothing is or perceiving the right from the left sleeve or left from right pant leg. Some people have reported that the use of a safety pin where the tag is located on the back of a piece of clothing, or at the bottom of one sleeve, can decrease the frustration of putting on a piece of clothing. The use of clothing without buttons or zippers when they become difficult to use is also helpful, although for some people the buttons and zippers help them understand how to orient the clothing item when putting it on. Some people report that putting out an outfit for each day in a very specific manner (face down on the bed, for instance) or keeping an entire outfit on one hanger after items are washed (see Finding and Seeing Items section) is extremely helpful. Trying to “re-learn” how to dress as one used to do is most often not helpful nor is it possible. Instead, creating a “new” way to get dress usually takes trial and error and then with progression of dementia, new approaches become necessary.
Smart Phone Applications for People with Visual Impairment
There are many applications that might help a person with visual brain dysfunction, particularly early in the course. Nearly all, however, were designed for people with low vision or with blindness due to eye diseases.
Thus, some of these might not be helpful for a person with cognitive impairments beyond visual brain dysfunction and the list provided is a means to allow one to explore apps with potential to help.