The incidence of sight loss increases dramatically as people get older, and this can also have crucial effects on their overall mental health.
There are plenty of clichés about the ‘time bomb’ that an ageing population embodies, from dementia to care costs. Some conditions, however, go under the radar for many practitioners, even though they impact not just on physical but also on mental health. One condition that’s set to increase dramatically is sight loss.
The number of blind and partially sighted people in the UK is projected to rise to 2.7 million by the end of the decade and to over four million by 2050 – and the majority of these will be over 75. One in five people aged 75 and over and one in two aged 90 and over is living with sight loss.1 This may be the result of a condition like age-related macular degeneration, or it may be part of a wider condition like diabetes or stroke. And alongside the physical effects of vision impairment they are also living with the psychological impact.
Sight loss leads to social isolation
“The top thing people lose is their ability to be independent,” says Rebeca Barr, director of the charity Scottish War Blinded, which has looked at the mental and emotional implications of going blind. “That has a huge effect on confidence. Something that is less obvious is that people are concerned about going out to eat in public, because they’re afraid that they will spill things.”
As a result, many people become increasingly isolated. But the mental effects are compounded hugely because sight loss is the thing many people (in pretty well all cultures) fear above anything else. One poll conducted across Europe found that the only thing people feared more for their old age was memory loss; they were more frightened of going blind than they were about developing heart disease.2
Yet, says Claire Nollett of Cardiff University, “People are being treated for sight loss, but the mental health implications aren’t being covered.” Or alternatively, they are being treated for depression but the effects of their visual impairment are not being taken into account.
Depression and low vision
Nollett and her colleagues screened 1,000 people attending low vision clinics across England and Wales, using the Geriatric Depression scale. “We found that 43% had what we would class as clinically significant depressive symptoms. We also found that people from BME groups were more likely to be depressed. The really worrying thing was that 75% of those people who had significant symptoms weren’t being treated.” Those findings concur with numerous other studies.
In fact the prevalence of depression, anxiety and other mental health comorbidities is probably even higher than the official estimate, says Dr Stephen Orleans-Foli, Consultant Psychiatrist and Honorary Senior Clinical Lecturer (Imperial School of Medicine). “The standardised tests aren’t sensitive to those sub-threshold levels of anxiety and depression which may not meet clinical criteria but affect people profoundly.”
Nollett also found that the people who rated their visual function as ‘poor’ – however much they really could see – were more likely to be depressed.
Simon Labbett, chair of the Rehabilitation Workers Professional Network, agrees. “Psychological makeup is a huge part of it, and it seems not to be related to visual acuity. One of the things that I constantly dwell on is why some people with worse sight cope better than someone with better sight.”
There are also the people whose situation changes suddenly. For instance, people who’ve coped surprisingly well for years may suddenly hit a crisis point when their partner dies; not only are they losing the person they loved, they are also losing the person who provided all the strategies and mechanisms for handling day to day life (including going out and about, so that isolation very quickly becomes another factor in their mental health).
How to help patients cope with visual impairment
Orleans-Foli feels very strongly that clinicians should build in regular questions about vision – both for people who are known to be visually impaired and for those who aren’t – in the same way that they ask about chronic pain. He suggests asking routinely if they have had an eye test in the past couple of years.
“Any risk assessment of someone you already know has visual impairment should always look at the impact of that impairment on their emotional state – and even if their sight hasn’t changed, remember that other stressors or losses may be affecting them.”
Conversely, clinicians also need to remember that someone who presents with a mental health issue may well have vision problems as well. “Ask them about any difficulties they are having – like knocking into things or difficulty reading – as well as checking for any obvious difficulties or eye problems.” There’s also the issue of how people with visually impairments actually manage their medication (for whatever condition). “Some people use the shapes and colours to determine the drugs they are taking, so when they receive a generic form they can’t identify the different medications and that may affect their adherence to their medication regime.”
Rehabilitation that focuses solely on aids and adaptations is clearly not enough for people who’re experiencing serious mental distress as the effect of their sight loss. However, both Orleans-Foli and Barr stress that adapting the physical environment (removing the physical barriers that disable the person) it can make a crucial difference in helping people stay independent.
Blindness made me feel like a 'dimmer candle'
“We’ve found people on the verge of needing support at home, and we’ve enabled them to manage at home again. That is so important,” says Barr. “We’ve gone in, provided equipment and trained people to use it and they are able to stay at home quite happily. Giving them back control of their lives is so important, both mentally and physically.”
“In some ways you can’t separate the psychological from the social,” concludes Thurston (who is registered blind herself (she lost her sight at the age of 40). “And there are people with other comorbidities, like stroke or diabetes, where their depression may appear to be centred around that. Yet their sight loss also has an impact. One participant in my research had survived polio and cancer. She was in an electric wheelchair. But it was blindness that she said made her feel like a ‘dimmer candle’.