The Psychological Challenge of Late-Life Vision Impairment

6 Journal of Ophthalmology
example, because previous joint activities have become more
difficult. AsWang and Boerner [68] observed, two strategies
seem prevalent in visually impaired older adults: namely, to
readjust one’s behavior to maintain relationships or to let
relationships go to some extent. The latter fits in a sense with
Wahl et al.’s [36] finding of lower number of persons in the
periphery of social networks of visually impaired older adults
as compared to visually unimpaired individuals.
Particularly critical features of social partners are
dependence-inducing behavior, the lack of an independencesupporting
attitude, and overprotection [69]. Perceived
overprotection in visually impaired older adults is on the
rise, wherein functional disability and received instrumental
support increases [70]. Also, perceived overprotection
increases over time and has been found to be unaffected by
rehabilitation service use [71]. In general, it seems a challenge
to provide visually impaired older adults with the needed
instrumental support while at the same time avoiding to
underestimating remaining capabilities [72]. Overprotection
may put constraints on the visually impaired older adults’
“true” functional capacity and thereby contribute to loss in
competence in the longer run due to disuse [69, 73].
4.4. Subjective Well-Being-Related Outcomes, Depression, and
Adaptational Processes. Subjective well-being (SWB) is frequently
defined via its cognitive component as degree of
satisfaction with one’s current life.Many studies with visually
impaired older adults have found that with age-related vision
loss comes a significant decrease regarding the cognitive component
of well-being [39, 67]. As has also been observed, the
discrepancy in SWB between visually impaired and visually
unimpaired older adults tends to persist over time [38, 74].
However, Pinquart and Pfeiffer [75] found in their metaanalysis
of 198 studies that the effect size regarding differences
in vision-unspecific measures (such as general well-being
or positive/negative affect scales) was small, whereas larger
negative effects regarding well-being appeared in visionspecific
measures of quality of life (such as the NEI VFQ-
25; [76]). In general, widening the picture of adaptation
to visual impairment with the consideration of everyday
competence, robust evidence underscores that differences in
well-being-related indicators—including constructs such as
self-acceptance, positive relations with others, and tone of
future-time perspective between visually impaired and visually
unimpaired older adults—are clearly less pronounced
than differences in impairment in ADL-IADL status and
leisure activity level [36, 77]. This suggests that although
vision impairment is a pronounced psychological challenge
in late life,many visually impaired older adults seem to adapt
rather well at the level of cognitive well-being, thus also
supporting what has been titled the paradox of well-being in
later life [26].
At the same time, it is critical to acknowledge that visually
impaired older adults represent an at-risk population, in
which the positive impact of human adaptation and the
drawback of reaching the limits of psychological resilience go
hand in hand. Affect balance (ratio of positive and negative
effect) has been found to be more toward the negative
pole in visually impaired older adults [77] and depression
has consistently been found to be significantly increased in
visually impaired older adults [78–80]. Rates identified in
epidemiological studies roughly vary between 15% and 30%
and are particularly high in AMD patients [78].This is also
important, because depressive symptomsmay accelerate both
cognitive decline and decline in everyday competence in
AMD patients [81].
In addition to depressivemood,maintenance and decline
in positive effect are important for adaptation. Schilling
and Wahl [27] found that positive effect goes down in
the period after having received the diagnosis of AMD,
but then also increases again after 2–4 years. Thereafter,
rather constant decrease has been observed, probably due
to the progressive course of AMD in combination with
growing comorbidity and other loss occurrences (such as
widowhood) as people age further. Control regulation, as
argued by Heckhausen et al. [41], also seems important for
positive effect. Wahl et al. [17] observed in a respective
analysis that compensatory control strategies (called “compensatory
primary control” by Heckhausen et al., [41]), such
as involving the help of others as well as strengthening
one’s commitment to important life goals (called “selective
secondary control” by Heckhausen et al., [41]) coincides with
positive effect, whereas the effect of exerting the impact
on one’s environment (called “selective primary control” by
Heckhausen et al., [41]) on positive effect was fully mediated
by ADL-IADL and a vision-specific adaptation measure
(called adaptation to vision loss; [82]). The critical role of
maintaining everyday competence (and not objective vision
impairment) for well-being and adaptation to vision loss in
visually impaired older adults has also been confirmed in
other research [83], including the transition from assimilative
to accommodative coping [19, 20]. Decrease in IADL
competence also seems to drive the transition to modes
of control regulation connected with goal disengagement
and flexible goal adjustment, which Heckhausen et al. [41]
have labeled “secondary compensatory control” ([18]; see also
[84]).
In addition to change in self-regulation as a significant
adaptational process, social resources have been found
to play a critical role in adaptation to vision loss and
other well-being-related outcomes—cross-sectionally as well
as longitudinally—and family and friends provide distinct
contributions to the maintenance of well-being [62, 85].
Perceived overprotection may also lead to negative consequences
in terms of heightened depression and anxiety
over time [73].
4.5. A Glance on Dual Sensory Impairment. Dual sensory
impairment affects one-fifth of those 70 years of age and older
[86] and therefore also deserves attention. Previous research
supports the notion that the overall psychosocial situation
of those with dual sensory impairment is even worse as
compared to those with sole vision impairment, particularly
in the area of everyday functioning [86]. In addition, higher
rates of depression and lowered well-being have also been
found in those affected by dual sensory loss [87].