WhitepaperPublished standard
Print for Macular Degeneration and Low Vision: The Evidence Behind Cognicopia’s Print Standard
Why every Cognicopia page uses large type, strong contrast and a typeface designed for low vision
Written for: Medical directors, Activity directors, Compliance officers
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Key takeaways
- In a study of 380 nursing home residents, 57% saw worse than 20/40 with their better eye, and 10% saw 20/200 or worse.1
- Age-related macular degeneration (AMD) blurs central vision, the vision used for reading and recognizing faces. About 19.8 million people in the US had some form of AMD in 2019.23
- Readers with low vision need more contrast. In a classic study, most low-vision readers needed several times the contrast of fully sighted readers before their reading slowed to half speed.4
- The American Printing House for the Blind treats 18 point and above as large print and recommends sans serif type on matte paper. WCAG sets 7:1 as the enhanced contrast level for text.56
- Cognicopia prints resident activity text at 17 to 26 point, depending on the support tier, in Atkinson Hyperlegible, a typeface designed by the Braille Institute for low-vision readers, as dark text on white.7
At a glance
57%
19.8 million
288 million
18 pt
Vision loss is common in long-term care1 min
In brief: More than half of nursing home residents in one study had impaired vision, so pages should be designed for low vision by default.
In a study of 380 nursing home residents, 57% had distance vision worse than 20/40 in their better eye, and 10% had vision of 20/200 or worse.1 AMD alone affected about 19.8 million people in the US in 20193, and worldwide the number is projected to rise from 196 million in 2020 to 288 million by 2040.8
With vision loss this common, large, high-contrast print cannot be a special request. It has to be the default for every page a resident is given.
How macular degeneration changes reading1 min
In brief: AMD takes the central vision that reading depends on, and readers with low vision need more contrast.
The macula is the part of the eye responsible for sharp, straight-ahead vision. AMD blurs that central vision, making it harder to read, recognize faces and do close work, while side vision usually remains.2
The practical meaning: contrast that seems generous to a fully sighted designer can be the difference between reading and not reading for a resident with AMD. Pale gray text, text over pictures and colored backgrounds all cost contrast.
What the standards say1 min
In brief: Large print starts at 18 point. Use sans serif type on matte paper, and aim for 7:1 contrast.
| Element | Guidance | Source |
|---|---|---|
| Type size | 18 point or larger counts as large print | American Printing House for the Blind5 |
| Typeface | Sans serif or modified serif. Readers with low vision tend to prefer sans serif, though no single typeface has been proven best | APH5; Russell-Minda et al.9 |
| Paper | Matte or dull finish, to reduce glare | APH5 |
| Contrast | At least 4.5:1 for text (AA), and 7:1 for enhanced legibility (AAA) | WCAG 2.26 |
| Spacing | Content should still work with line height of 1.5 times the font size | WCAG 2.26 |
Atkinson Hyperlegible was designed by the Braille Institute for readers with low vision. It makes easily confused characters distinct, for example giving the lowercase l a tail and the number 1 a hook, and it is free under the SIL Open Font License.7
The Cognicopia print standard1 min
In brief: Large type by support tier, one hyperlegible typeface, black on white, and generous writing space.
| Element | Cognicopia | Why |
|---|---|---|
| Activity text | 17 pt (early stage), 20 pt (moderate) and 26 pt (advanced); planner and journal text never below 14 pt | Large print at the stages where vision and attention need it most |
| Typeface | Atkinson Hyperlegible, embedded in every page and PDF | Designed for low-vision readers7 |
| Contrast | Near-black text and pure black line art on white. Meaning never depends on color alone | Low-vision readers need more contrast4 |
| Coloring lines | Pure black on pure white, about 2.25 pt at tier 1, 4.5 pt at tier 2 and 7.9 pt at tier 3; staff can raise line weight for a resident with low vision | Strong outlines separate figure from ground |
| Writing space | Lines 0.5 in apart, at least 2 pt thick | Room for larger, less steady handwriting |
| Margins | A 0.75 in binding gutter and 0.5 in outer margins | Nothing lost in a binder or at the edge of the copier |
Cognicopia’s exact sizes and weights are its own engineering choices, made to meet the published guidance above. No study prescribes these exact numbers.
Print on matte copy paper rather than glossy stock, which adds glare.5
Beyond the page1 min
In brief: Lighting, glasses, magnifiers and eye care matter as much as print.
- Good, even lighting without glare, with a task lamp for close work and the resident seated with their back to bright windows.
- Glasses that are current, clean and actually worn.
- Magnifiers and low-vision services, arranged through the resident’s physician or eye care provider.
- Recording each resident’s visual needs in their profile, so every packet prints to suit them.
These are practical care points, not medical advice. A resident’s eye care provider should guide individual decisions.
What this means for your community
- Make large print the default for every resident page, not an exception.
- Print on matte paper, and check that the copier is not fading the print.
- Record each resident’s visual needs in their profile, and raise line weights where needed.
- Pair print with good lighting and up-to-date eye care.
What this evidence does not show
- The standards rest on expert consensus and laboratory reading studies, not on trials of outcomes in nursing homes.
- No typeface has been proven best for every low-vision reader.9
- Some residents need magnification or audio beyond large print.
References
- Owsley C, McGwin G Jr, Scilley K, et al. The visual status of older persons residing in nursing homes. Archives of Ophthalmology. 2007;125(7):925–930.
- National Eye Institute. Age-related macular degeneration (AMD). National Institutes of Health. Accessed September 30, 2026. https://www.nei.nih.gov/eye-health-information/eye-conditions-and-diseases/age-related-macular-degeneration View source (opens in a new tab)
- Rein DB, Wittenborn JS, Burke-Conte Z, et al. Prevalence of age-related macular degeneration in the US in 2019. JAMA Ophthalmology. 2022;140(12):1202–1208. doi:10.1001/jamaophthalmol.2022.4401 View source (opens in a new tab)
- Rubin GS, Legge GE. Psychophysics of reading. VI. The role of contrast in low vision. Vision Research. 1989;29(1):79–91.
- American Printing House for the Blind. Large print guidelines. APH. Accessed September 30, 2026. https://www.aph.org/resources/large-print-guidelines/ View source (opens in a new tab)
- World Wide Web Consortium (W3C). Web Content Accessibility Guidelines (WCAG) 2.2. W3C Recommendation. W3C; 2023. Accessed September 30, 2026. https://www.w3.org/TR/WCAG22/ View source (opens in a new tab)
- Braille Institute of America. Atkinson Hyperlegible font. Braille Institute; 2019. Accessed September 30, 2026. https://www.brailleinstitute.org/freefont/ View source (opens in a new tab)
- Wong WL, Su X, Li X, et al. Global prevalence of age-related macular degeneration and disease burden projection for 2020 and 2040: a systematic review and meta-analysis. The Lancet Global Health. 2014;2(2):e106–e116.
- Russell-Minda E, Jutai JW, Strong JG, et al. The legibility of typefaces for readers with low vision: a research review. Journal of Visual Impairment & Blindness. 2007;101(7):402–415.
How to cite this page
Cognicopia. Print for Macular Degeneration and Low Vision: The Evidence Behind Cognicopia’s Print Standard. Cognicopia Clinical Science & Research Center. Updated September 30, 2026. Accessed [date]. https://cognicopia.org/resources/research/low-vision-print/
An educational summary for professionals, not medical advice. It reports each source’s findings as the source states them, and was reviewed against its sources on September 30, 2026. Cognicopia makes the tools this page mentions. Found an error? Tell us.