Last week, McKnight’s published a guest editorial by Michael Hass, “Five design decisions you’ll later regret.” In his editorial, Mr. Hass mentioned the errors made in favor of form over function, e.g. hall rails whose color match the walls. In this case, for those with low vision, those hall rails are invisible.

To add to this discussion, form appears to be the underlying decision-maker when new facilities are built or old ones are redecorated, without regard to whether the new environment will facilitate independence and quality of life. When decorating an infant’s nursery, we are told that bright primary colors and definitive black-and-white shapes are the ones a baby’s developing visual cortex can comprehend and assimilate. The concerns with the elderly with dementia and/or low vision are similar.

People with dementia tend to lose their three-dimensional perceptions of space and distance. Because they can’t see depth, they tend to see changes in the floor, e.g. carpet to vinyl flooring, as a cliff, and are hesitant to step off the “cliff.” So they may get stuck in doorways. Their color perception might also change, especially the way they see things that are blue or violet. Those items in their environment may all blend together into a gray two-dimensional surface. Think about the blue table-top with the pretty blue dishes.  A red dish would be more visible.

To reflect further on Hass’s contention that a white rail on a dark wall gives the dementia resident a firm target to grab to propel a wheelchair or to prevent a fall, if the floor is a contrasting color with the wall, the resident can better distinguish the doorway from the rest of the room and thereby prevent falls as well.

More than 80% of people with vision loss can still see, but less than most. Few live in a world of darkness. Adjusting the environment to what these residents are able to see can make the difference between quality functional living and depending on others.

Start with introducing yourself to the low-vision residents every time you meet them, and continue to give verbal directions (not just pointing) and describe what you want them to see and do is the first step toward improving what your resident will be able to do for themselves. Even when seating them for meals, it’s important to tell them where the arm of the chair is, where the plate is, where their utensils lie and even what’s on the plate and how it’s oriented.

I once was asked to offer ergonomic assistance for a luxury assisted living center where suites had two or three bedrooms, garden views, room service and offered guest accommodations for the seniors’ out-of-town visitors. Unfortunately, they equipped the kitchens before I could offer an opinion. The refrigerators that were (already) purchased had the freezers on the top, refrigerator space on the bottom. Think about your seniors and think about which compartment of a refrigerator is used more. I advised that the refrigerators get returned and freezer-bottom units purchased. Bending over daily to get an apple for a 90 year-old would be a chore, and could even contribute to paraspinal muscle strains and vertebral compression fractures. A compression fracture changes everything, and I’ve seen it lead to extended bedrest, pneumonia, and death.

There are three components to balance, and vision is the primary one. Most of our elderly rely on their vision, even if it’s impaired, because their sensorimotor perception (the way the floor feels) is likely impaired, and 80% of people over 65 have vestibular impairment related to a host of issues including neurological history and aging.  Lighting is always important to prevent falls, but so is making sure the environment is visible and appropriate to a resident with dementia or low vision. It may be the most important thing we can do to ensure the safety of our residents.

Jean Wendland Porter, PT, CCI, is the Regional Director of Therapy Operations at Diversified Health Partners in Ohio.