January/February 2020

Fall Prevention: Poor Vision Increases the Risk of Falls
By Michele Deppe
Today’s Geriatric Medicine
Vol. 13 No. 1 P. 6

The Centers for Disease Control and Prevention reports that falling is not an inevitable part of growing older. However, 1 of every 4 older adults falls each year. And while falls are often preventable, they account for roughly 30,000 deaths annually in the United States.1

One of the greatest contributors to falling is blindness or vision impairment. Although 1 in 11 adults older than 65 is affected by a vision problem2 that doubles their risk for falling,3 studies have shown that not enough is being done to treat avoidable vision impairment or support those who experience it.4

Addressing Poor Vision
“There are lots of things that can be done [to prevent falls], but many are specific to visual impairment,” says Jennifer Kaldenberg, DrPH, MSA, OTR/L, a clinical assistant professor of therapy at Boston University School of Public Health. According to Kaldenberg, part of the challenge is that visual health is not prioritized when other health-related problems occur. Therefore, she believes, all people should be encouraged to have regular eye care.

“It’s important to understand what kind of vision loss an individual has,” says Joshua R. Ehrlich, MD, MPH, an assistant professor of ophthalmology and visual sciences at the University of Michigan. “The experience of an individual with peripheral vision loss but intact central vision may be very different from one who has lost central vision. In either case, a referral to vision rehabilitation can be helpful to provide older adults with skills, environmental modifications, and assistive devices that can improve safety and independence both in and out of the home. In some cases, an occupational therapist or other vision rehabilitation professional may even be available to conduct an in-home assessment and suggest modifications to decrease fall risk and maximize independence.”

Glaucoma is a common cause of vision loss in older adults, Ehrlich says. He adds that the most common site of falls in those with glaucoma is the home, and individuals with more peripheral vision loss have a greater risk of falls. Hazards such as dim lighting, unsecured rugs, elevated door thresholds, and a lack of grab bars in the bathroom all may contribute to fall risk in visually impaired older adults. Ehrlich notes that simple environmental changes and vision rehabilitation can help to mitigate some of these risks, though he adds that more evidence is needed to know which interventions are most effective.

Occupational therapists can be a key resource for environmental assessments. Kaldenberg says, “If someone has a visual impairment, they should be referred to vision rehabilitation services. An occupational therapist can evaluate the individuals and come up with strategies to maintain and/or improve function and increase safety. Simple environmental strategies such as lighting can significantly improve someone’s ability to read or safely navigate their home.”

Intrinsic Factors
“Although the rate of falls increases as one ages, many falls are preventable. The evidence shows that a multifactorial approach to falls is the best, addressing the various causes vs looking at one factor,” Kaldenberg says. “So, understanding the risk factors present in any person’s life can be helpful in addressing fall risk.”

There’s more to understanding falls than what meets the eye, quite literally.

In addition to extrinsic factors and vision impairment, mindset may play a role. Older people who report problems with vision also experience fear of falling and may limit their activity due to this fear, according to a 2019 study published in the Journal of the American Geriatrics Society.5 Ehrlich, the study’s lead author, says, “We know that older adults with visual impairment are at higher risk for falls. However, they do not just fall more often; they also have a greater fear of falling and are more likely to restrict their day-to-day activity due to this fear. The cycle of falls and fear of falling may be particularly tough to break in those who have trouble detecting and avoiding obstacles due to their vision.”

Ehrlich and other clinician-scientists are pursuing research that will meet the critical need for evidence-based rehabilitation and treatment approaches to decrease the risk of falls in people with poor vision. “One of our primary goals is to keep patients active and independent, but fear of falling serves to limit these,” Ehrlich says. “Using screening questions to identify the fear of falling can be useful and may prompt referral to an evidence-based rehabilitation or balance training program to improve balance and falls efficacy.”

“Adaptations can certainly be beneficial, but I agree that a person’s interaction with the environment can be a factor in falls,” says Penelope Stanford, PhD, MSc, a researcher and senior lecturer of nursing at the University of Manchester in the United Kingdom. “People who are inherent risk-takers may be more prone to falls,” she says, noting they’re “more likely to climb a ladder without thinking of the potential accident that could occur, or run after a bus they have missed.”

Emotional Health
Evidence suggests that people with a visual impairment take some time to accept their loss of vision and therefore carry on as “normal” and thus risk falls and subsequent injury, Stanford says.

“Those with visual impairment are also at risk for social isolation,” Kaldenberg adds. As individuals become more socially isolated, he says, “they often become less active, and that increases their risk of falls. This can spiral into secondary chronic health problems.”

Exercise as a Preventive Measure
“There is also the wider issue that older people have a value in society and that being older does not mean that a sedentary life is inevitable,” Stanford says. “An ethos of active and healthy aging may help people with vision impairment, and others in their social world, change their views about the inevitability of falling.”

There’s a body of evidence that suggests falls can be prevented by muscle-strengthening exercise. The Otago Exercise Programme from the University of Otago Medical School in New Zealand has shown that even those with visual impairment in their 90s who haven’t been active can improve their leg muscle strength and balance to achieve stability and avoid falls using evidence-based exercises.6

A meta-analysis of four controlled trials based on the efficacy of the Otago Exercise program with 1,016 participants including both men and women aged 65 to 97 estimated that the exercise program reduced the number of falls and the number of fall-related injuries by 35%.7

Screening Considerations and Questions
Blindness and vision impairment disproportionately affect older adults. For that reason, all elderly individuals should be asked about their vision, Ehrlich says.

“Individuals with vision impairment are at greater risk of falls compared to their non–visually impaired peers. There is a lot that can be done to reduce an individual’s risk of falls,” Kaldenberg says. Following are some questions and considerations she says will assist in evaluating older adults with visual impairment and their risk of falls:

• A poorly positioned bifocal can create an increased risk of falls. Ask the individuals whether they wear glasses and whether the glasses help. Do the glasses fit properly?

• Have they experienced a fall? Do they fear falling?

• Do they have a visual field loss? Depending on the visual field cut, they may miss things in their environment.

• Is the environment free of hazards?

• If someone has help in the home, those assisting should work with the individual’s organizational strategies so clients are able to rely on their memory of where things belong. For example, if the client always puts their keys in the basket by the front door, the health care assistant should always put the keys back in the designated place. If that does not occur, rushing may result and increase risk to the client.

• The home or living environment should have good overall lighting. Those older than 60 with normative aging require three to four times more lighting than a 20-year-old does. Factoring in eye disease in addition, they may need even more lighting, but this should be lighting that’s properly positioned and does not create glare.

An Array of Solutions
“We know that when primary care providers talk to older patients about their vision, they are more likely to get an eye exam,” Ehrlich says. “Many cases of vision loss can be corrected with glasses or cataract surgery, while other causes like glaucoma and macular degeneration may require chronic ophthalmologic care.” In either scenario, Ehrlich recommends that older adults who are not receiving regular eye care should be referred for a comprehensive dilated eye exam if they have any visual complaints.

Stanford believes a multifactored problem needs an array of solutions, ranging from public health initiatives, health education, psychological support (to support acceptance), and access to a falls team of health professionals. “Beliefs could be changed or challenged by a robust public health message that falls can be avoided,” Stanford says. “Health care professionals should take the opportunity to reinforce this message at every contact with people in the older age group.”

— Michele Deppe is a freelance writer based in Seattle.

References
1. Centers for Disease Control and Prevention. Keep on your feet — preventing older adult falls. https://www.cdc.gov/injury/features/older-adult-falls/index.html. Updated September 23, 2019.

2. Vision problems in the U.S. — prevalence of adult vision impairment and age-related eye disease in America. http://www.visionproblemsus.org/index.html

3. Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clin Geriatric Med. 2002;18(2):141-158.

4. National Academies of Sciences, Engineering, and Medicine. Making eye health a population health imperative: vision for tomorrow. https://www.nap.edu/read/23471/chapter/1. Published 2016.

5. Ehrlich JR, Hassan SE, Stagg BC. Prevalence of falls and fall-related outcomes in older adults with self-reported vision impairment. J Am Geriatric Soc. 2019;67(2):239-245.

6. Campbell J, Robertson C; Accident Compensation Corporation. OTAGO exercise programme to prevent falls in older adults. https://hfwcny.org/hfwcny-content/uploads/Otago_Exercise_Programme-Revised.pdf.  Published March 2003.

7. Robertson MC, Campbell AJ, Gardner MM, Devlin N. Preventing injuries in older people by preventing falls: a meta-analysis of individual-level data. J Am Geriatric Soc. 2002;50(5):905-911.