ResearchDiscussionPaper12
Fallsinolderpeoplewithsightloss:areviewofemergingresearchandkeyactionpoints
PublishedbyThomasPocklingtonTrustJune2013
Thispublicationoffersasummaryofwhatisknownaboutfallsandfallspreventionamongstolderpeoplewithsightloss.Itdrawsonrecentresearch,includingareviewofqualitativeresearchcommissionedbyPocklingtonfromClaireBallingerattheUniversityofSouthamptonandaforthcoming(2013)CochraneReviewledbyDawnSkeltonattheUniversityofGlasgow.
Itexplorestheimplicationsofresearchfindingsforactiontoaddressandreducetheriskoffallsamongolderpeoplewithsightlossandsuggestskeyissuesforhealthandsocialcareprofessionalstoconsiderwhenworkingwitholderpeople,manyofwhommayhavesightloss,andforsightlossspecialiststoconsiderwhenaddressingindividuals’risksoffalls.
Background
Fallsarethemostcommoncauseofhospitalisationforpeopleagedover65andtheleadingcauseofdeathfrominjuryamongpeopleagedover75(NICE2004).Weknowfromalarge bodyof researchthat fallsin olderpeople resultfrommultipleriskfactors including:increasing age,previoushistoryoffalling,gaitandbalanceproblems,mobilitylimitations,fearoffalling,multiplemedications,environmental/homehazardsandvisualimpairment.Peopleinresidentialcareandnursinghomesareatanincreasedriskoffalls(vanderPolsetal.2000).
Whatisnotsowidelyknownisthatolderpeoplewithsightlossaremuchmorepronetofallsthantheirsightedpeers. Theriskofinjuryfromfallsisnearlytwiceashigh(1.7times)andtherateofhipfracturesisalsonearlytwice(between1.3and1.9times)ashigh(Legood,ScuffhamCryer2002).
TherearealmosttwomillionpeoplelivingwithsightlossintheUK, mostofwhomareolder:1in5peopleaged75yearsand1in2aged90yearsoroverisvisuallyimpaired.
ThemostfrequentcausesofsightlossintheUKarerelatedtoage: macular degeneration (MD), cataract and refractive error.
Thecostoffallsassociatedwithsightloss
RNIB(Boyce2011)estimatedthatthecosttotheNHSoffallsassociatedwithsightlossisatleast£25.1millionperannum.
RNIBusedthefollowingequationtocalculatethecoststotheNHSinalocalarea:
•8%offallsthatresultinhospitaladmissionsoccurinindividualswithsightlossandthesecost21%ofthetotal
NHScostoftreatingaccidentalfalls;
•3.8%offallsresultinginhospitaladmissionscouldbeattributedtosightlossandthesecost10%ofthetotalNHS
costoftreatingaccidentalfalls.
Thesearereasonablecalculationstomakeandareprobablyanunder-estimate.
There isno hardevidenceto showthataction onsight losswillresultinfewerfallsorlowercoststotheNHS-wecannotassumethateveryonewithsightlosswillfall,orthateveryfallresultsincoststotheNHS-butthedevastatingimpactoffallsonpeople’slivesiswelldocumented(NICE2004)andthispublicationshowsthatpeoplewithsightlossareatahighriskoffalling.
Wheredomostfallshappen?
Themostseriousaccidentsinvolvingolderpeopleusuallyhappenonthestairsorinthekitchen(RoSPA2002).Fallsonstairsusuallyhappenasaresultofacombinationoffactors,andmost occur when going down stairsas a result of over-steppingratherthanslipping(Hilletal.2000).Oversteppingmaybecausestairedgesarenotseeneasilyoraremisjudgedbypeoplewithsightloss(Hilletal.2000)becauseperceptionofthedepthofstepsandsensitivityto‘distant-edge-contrast’areaffectedbysightlossandareimportantformaintainingbalanceanddetectingandavoidinghazards(LordDayhew2001).
Adequatelightingcanmakesteps,stairedgesandotherhazardseasiertosee(Percival,2007;ThomasPocklingtonTrust2013).
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Whatresearchtellsusaboutsightlossandfallsamongolderpeople
Thereisaconsiderablebodyofevidenceshowingthatolderpeoplewithsightlossaremorelikelytofallthantheirsightedpeers.Dhital,PeyandStanford(2010)summarisedresearchfindingsonsightlossandfallsandwhereresearchisneededandindicatedthatgapsremaininourknowledgeabouttherelationshipbetweenfallsandsightloss.
Themajorityofresearchonvisualimpairmentandfallshasconcentratedonvisualacuity,contrastsensitivityorvisualfieldlossingeneral.Thereislittleresearchlinkedtoparticulareyeconditionssuchasmaculardegenerationorglaucoma.BecausethecauseoffallsisoftenpoorlyrecordedintheNHS,researchintolinksbetweensightlossandfallsandthedevelopmentofpreventativeactionishamperedbylackofevidence.A2007UKsurveyfoundthatonlyhalfoffallsclinicsassessedvision(Lambetal.2007).
Awarenessofsightlossamongresearchersinvestigatingwhyolder peoplefall maybe limited.A recentarticle inThe Lancetonhowandwhyfallsoccurinolderpeoplewascriticisedfornotmentioningvisualimpairmentorgaitdisordersaspossiblefactors(Zheng2013).
Causesofsightloss
Lossofvisualacuityincreaseswithageto42%ofthoseaged85andolder(Attebo,MitchellSmith1996).
Refractiveerrormayleadtoapersonneedingdifferentspectaclesfordifferenttasks.Itissometimesthecasethatspectaclesgetmixedupandreadingspectaclesareusedforwalkingorvice-versa.
Theuseofmulti-focalglassesisariskfactorforfalls:peoplewhowearmulti-focalsaremorethantwiceaslikelytofallasnon-multi-focalwearers,andthisriskincreaseswhennegotiating stairs(Johnson etal2007; Lord,DayhewHowland2002;Timmisetal.2010;and-falls-prevention-infographic/).Acontributoryfactortothisriskmaybethatsome opticiansgiveadvicethatcompoundsit.BuckleyandElliot(2006)foundthat“Optometriststypicallyencouragepatientswhowearmulti- focalstotucktheirchininwhensteppingoverkerbsorgoingupordownstairssothattheycanlookthroughthetoppartof
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theirspectacles,whichprovidesadistancevisioncorrectionsothatobstacleswillbeinreasonablefocus.Ourownresearchhasshownthatheadflexionsignificantlyincreasesposturalinstability”.
Severalstudiessuggestthatchangesinlensprescriptioncanhaveadramaticimpactonadaptivegait,particularlywhensteppingandonstairs(ElliottChapman2010),andthatlargeandsuddenchangesinrefractivecorrectionshouldbeavoided.
WomenwithMDfallatnearlytwicetherateofwomenwithoutMD(Szaboetal.2008).Woodetal(2011)foundthatreducedcontrastsensitivitywasthestrongestpredictorofincreasedratesoffallsandotherinjuriesandhighlightedtheimportanceofcontrastsensitivityscreening.
Theincidenceofvisualfieldlossalsoincreaseswithage.TheSalisburyEyeEvaluation,whichsurveyed2374peoplebetween65and84years,foundthatperipheralvisualfieldlosswastheprimarycomponentthatincreasedtheriskoffalls(Freemanetal. 2007),probably becauseofits effectonpostural stability andtheabilitytomanoeuvrearoundobjects.Hence,peoplewithglaucomawerefoundtohavethreetimestheriskoffallscomparedtothosewithoutglaucoma(Haymesetal.2007).Blackandcolleagues(2008)alsofoundthatposturalinstabilitymaycontributetotheincreasedriskoffallsamongolderpeoplewithglaucoma.
Diabeticretinopathyhasnotbeenstudiedinrelationtofallsinolderpeople.Howeverthecombinationofdiabetes,ageingandfallshasbeentermedthe“troublingtriad”(Crewsetal.2013)because,regardlessofsightloss,peoplewithdiabetesmayhavepoorbalancecontrol,footproblemsandpoorglycaemic controlthataffectstheirriskoffalls(Nelson,DufrauxCook2007).
Theimportanceofvisiontogoodbalanceandmovement
Visionhelpscoordinateandplanmovement;itisfundamentallyinvolvedingait,balanceandstability.Researchshowsthatpeoplewithsightlossadoptdifferentorunsafegaits,suchassteppingtoohighorfaroverasteporhazard,whichislikelytoleadtoincreasedriskoffalling,particularlywhenavoidingobstaclesandnegotiatingstepsandstairs(Buckleyetal.2005a;2005b;2010).TimmisPardhan(2012)foundthatpeople
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withcentralvisualfieldlossadoptacautioussteppingstrategyinanattempttoreducetheriskoftrippingorfalling.
Wangandcolleagues(2012)foundthatbetween40-50%ofolderpeoplewithsightlosslimittheiractivitiesduetoafearoffalling.Non-activityaffectsmusclestrength,whichmakesfallsmorelikely,andsocompletesaviciouscircle.Research(Lamoureuxetal2010)hasfoundthatpeoplewithsightlosswhodidnottakepartinphysicalactivitywerelikelytofall.
22%ofpeople over60intheUKhavevisualandhearingimpairment(DavisDavis2009).Kulmalaandcolleagues(2008)foundthattheriskoffallsamongpeoplewithsightlosswashigherifthepersonalsohadhearingandbalanceimpairments,probablybecausethispreventedthereceptionofcompensatoryinformationaboutbodypostureandenvironmentbeingreceivedfromtheseothersensorysources.Rantanen(2013)foundthatpoorvisionandhearingmayincreasetheriskofdecliningmobility.
Behaviourplaysalargepartinmanyfalls.Understandingtheolderperson’sperspectiveiscriticalifinterventionstoreducetheriskoffallsaretobesuccessful.Formany,fallsareperceivedtobe,atmost,adistantfuturerisk-peopledonotbelievetheyareatriskoffalling.Weknowthatolderpeopledothingsthatmayincreasetheirriskoffalling,e.g.leavingobjectsonstairsandusingstairsinthedark(Haslametal.2002).Yardleyetal(2006)foundthat“olderpeopledonotrejectfallspreventionadvicebecauseofignoranceoftheirriskoffalling,butbecausetheyseeitasapotentialthreattotheiridentityandautonomy.Messagesthatfocus onthepositivebenefits ofimprovingbalancemaybemoreacceptableandeffectivethanadviceonfallsprevention.”
Themajorityofolderpeoplefearfallsandfracturesandtheeffectsthesemayhaveontheirqualityoflife.Fearoffallinglimitsactivityandmayincreasesocialisolationanddepression,whicharealmosttwiceascommonamongpeoplewithsightlossastheirsightedpeers,evenforthosewithoutahistoryoffalls.
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Preventingfallsinolderpeoplewithsightloss
Thereislittlehardevidencetoshowwhatpreventsfallsinolderpeoplewithsightloss.
Themostrecentsystematicreviewonfallspreventionforolderpeoplefoundevidencetosupport:groupandhome-basedexercise,interventionsthattackledarangeoffactorsandhomesafetyassessment/modification(Gillespieetal.2012).Homesafetyassessmentsandmodificationsandacopingstrategyprogramme delivered byan occupationaltherapist has beenshowntoreducefallsby41%( falls-prevention-infographic/).
ACochraneReviewbySkeltonetal(tobepublishedin2013) lookedattheevidencefortheeffectsof‘environmentalandbehaviouralinterventionsforreducingphysicalactivitylimitationincommunitydwellingvisuallyimpairedolderpeople’andfoundinconclusiveandconflictingresultsandconcludedthatmoreresearchisneeded.
Thereisageneralissueaboutthe“language”offallsand ofoldage:peoplewhofallareperceivedinnegativetermstobeold,frailanddependentand,perhaps,tohaveadrinkproblem.Targetingolderpeople“atrisk”offallscanprovokenegativeornoresponsesamongpeoplewhodonotrelatetoportrayalsofolderage.Studiessuggestthatolderpeoplearemorelikelytotakeupservicesandadvicewhentheemphasisisonmaintainingindependenceandmobility(Yardleyetal.2006).
Actiononsightlossitself,suchasearlycataractremoval,appearstoreducefalls(prevention-infographic/).
Assessingandrecordingsightlossinrelationtofalls
FallsclinicsdevelopedaftertheNationalServiceFrameworkforOlderPeopleidentifiedtheneedtoaddressfallsandtheirconsequencesamongstolderpeople.
In2007areviewofthencurrentpracticewithinfallspreventionclinicsindicatedthe variety ofservices providedand thatassessmentofvisionwasundertakenbyjust58%ofclinics,eitherinformally(egaskingclientsiftheyhadproblemswithvision)orformallyusinganassessmenttool(mostoftenaSnellenchart)(Lambetal2007).Clinicscommonlyoffered
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patientsinformationaboutavarietyofsubjects,includingeyehealthandsightloss,butalmostallreliedonreferringpeopletotheiroptometristorGPforaneyeexaminationoreyehealthissues.In2013theCollegeofOptometristsplanstoinvestigatecurrentpracticeonassessmentofvisioninfallsclinics.
NewNICEclinicalguidelinesontheassessmentandpreventionoffallsinolderpeopleexpectedin2013willreplacethepreviousguideline(NICE2004).Itishopedtheywillincluderecommendationsrelatingtotheassessmentof,andstrategiesfor,addressingvisualimpairment,bothinin-patientsettings,andwithinthecommunity.
Emergingthemes:researchinformingpractice
Preventableandtreatablesightloss
IntheUKwehaveamajorproblemofpreventableandtreatablesightlossinolderpeople:RNIBestimatethatatleasthalfofsightlossispreventable.Researchhasshownthatolderpeoplemaybereluctanttotakeupeyeexaminationsandmaynotseeknewspectacleswhentheirsightchanges(JessaandEvans,2008;Iliffeetal,2009).
Forsomepeople,aspectsoftreatablesightlossarenotrecognisedbecausetheyaremistakenasthesymptomsofotherhealthconditionssuchasdementiawhichmaycauselossofvisualacuity,contrastsensitivityandcolourvision,aswellaspoor spatialawarenessanddepthperception. Weknowthatsomeofthesefactorsarestronglyassociatedwithfalls,yetarecentstudy(McKeefryandBartlett,2010)suggeststhatpeoplewithdementiamaynothaveregulareyeexaminations.
Upto60%ofpeoplewhohaveastrokehavevisualproblems(Roweetal.2009).Despitethis,arecentsurvey(Pollock,HazletonBrady2011)foundthatthevastmajorityofstrokeunitsinScotlandhadnoprotocolforthemanagementofvisualproblems.
Akeystepinreducingtheriskoffallsistoencourageolderpeopletohaveregulareyeexaminations.
Themostrecentsystematicreviewoftherelationshipbetweenvisionandtheriskoffalls(SalonenandKivela,2012)foundthatevidencethatpoordepthperception/stereoacuityandpoor
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low-contrastvisualacuityareriskfactorsforfalls“isquiteconvincing”butthatmorestudiesoftherelationshipsbetweendifferentaspectsofsightlossvisionandtheriskoffallsarerequired.
Factorstoconsiderconnectedwithsightloss
Agrowingbodyofevidenceindicatesthat,inthecontextoffalls,peoplewithsightlosshavesomecharacteristicsthatdifferfromthesightedolderpopulation.Wehavealreadynotedthatsteppingbehaviourandgaitcanbedifferentinpeoplewithsightlossandthatafearoffallingmaycausepeopletolimittheiractivities,particularlyiftheyhavemorethanonesensoryimpairment.CrewsandCampbell(2004)arguedthatolderadultswithpoorvisionmayacquireuniquefallsrisksassociatedwithfunctionallosses,suchasreducedmobilitybecausetheynolongerfeelsafebecauseoftheirvisualimpairment.
Assumptionshavebeenmadethatfallspreventionprogrammeswhichhavebeensuccessfulinthegeneralolderpopulationshouldworkwitholderpeoplewithsightloss.Giventhelackofevidenceforwhatworkswiththisclientgroup,itmaybeeasierforcommissionerstofallbackonthesetriedandtestedprogrammes,especiallyastheycanbeseentobe“evidence- based”andatatimewhenresourcesarelimitedintheNHSandsocialcare. However,Steinman,NguyenLeland(2011)arguethatweneedtoseeaperson’svisualfunctionasadynamicsystemintegratedwithotheraspectsoftheirlifeandthatfallspreventionprogrammesmustviewvisualimpairmentinthatcontext.Forexample,poorvisioncouldindirectlyleadtolossesinupperandlowerlimbstrengthbywayofreducedphysicalactivitywhichisassociatedwithvisionloss.
Differentproblemsrequiredifferentinterventionstopreventfallsamongpeoplewithsightlossandmustbedesignedtomeettheneeds,preferencesandabilitiesoftheindividual.Thisshouldinvolveexploringtheenvironmentinwhichthepersonspendsmostoftheirtime.
TheVisuallyImpairedPersons(VIP)trialcombinedexerciseandhomesafetyprogrammes,bothofwhichareknowntobeeffectiveiftargetedatpeopleatriskoffalls.Itconcludedthat“theVIPtrialresultscastdoubtontheassumptionthatstrategieseffectiveinreducingfallsinolderpeoplewithnormalsightwillnecessarily‘work’inpeoplewithpoorvision,andviceversa.”(Campbelletal,2005;RobertsonCampbell2007).
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Uniquecircumstancesfacedbyolderpeoplewithsightloss
Therearefactorsinadditiontothe“mechanics”ofsightlosswhichneedtobetakenintoaccountindesigningfallspreventionprogrammes.Olderpeoplewithsightlossfacelifecircumstancesthatdifferfromtheirsightedpeers,includinganxiety,depressionandsocialandeconomicexclusion(NazrooandGjonca 2005; Nazroo and Zimdars, 2010; RNIB 2012).
Importanceofautonomyandpersonalchoice
Lifeistoughforpeoplewithsightloss.Theylearntodrawoninnerreservessuchasself-reliance,resilience,stoicismandself- determinationtomeetchallenges(Gosneyetal.2009;Cooper2013).Aqualitativestudyoftheviewsandexperiencesofpeoplewithsightloss(Ballingeretal.2009)reinforcedtheimportanceofautonomyandpersonalchoiceconcerningdecisionsabouttheirenvironmentandrisk.AsYardley’sstudyfound(2006),itisimportantforhealthprofessionalsandcarerstorecognisethisandsupportindependenceratherthanfocusoncheckingforunsafeorinsecurefeatures.Peoplewithsightloss wantto reachdecisionsindependently, particularlyaboutfactorsaffectingthehomeenvironment,“theepicentreoftheirmentalmap”.
Peoplewithsightlosscanviewtheirenvironmentinadifferentwaythansightedolderpeople.Theymayuseitemsoffurnitureorrugs,forexample,toprovide“cues”tocreateafamiliarpaththroughtheirhomeorusetabletopsorbacksofsofastohelptheirbalancetomoveacrossaroomsafely.Whatmayappear toahealthprofessionalasrelativelysmallchangesinfurnishingscandisruptafamiliarenvironment;choosingnottomodifythehomeenvironmentcanbeagoodchoiceintermsofpersonalsafetyandreducingrisk.Reluctancetomoveitemsoffurniturecanbeapositiveassertion,notrecklessness.Interferingwiththeidiosyncraticrelationshipsestablishedovertimebetween peoplewithsightlossandtheirhomeenvironmentscanincreasetheriskoffallsratherthanpreventit(Pynoos, SteinmanNguyen2010).
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Exerciseandbalanceprogrammesforolderpeopleareusuallydesignedforsightedpeople
Exercise isimportant forolder peoplein ordertoretain musclestrength,particularlyinrelationtostairswhereweknowtheyaremostatrisk.However,exerciseandbalanceprogrammesforolderpeopleareusuallydesignedforsightedpeople.Instructorsmayrelyonvisual“cues”orondemonstratingmovements,asinTaiChi,forexample(Steinman,NguyenLeland2011).
Adaptinghouses
Makingthetreadsofstairsmorevisiblemayreducetheriskforfalls(denBrinkeretal. 2005)andappropriate use ofcolourandcontrastandlightingcanmakesteps,stairs,hazardsandotherobstacleseasiertoseeandnegotiate(ThomasPocklingtonTrust,2011and2013).
PracticeRecommendations
Unlessnewwaysofworkingwithpeoplewithsightlossarefound,fallspreventionprogrammesareunlikelytobeeffectiveforpeoplewithsightlossandgapsinourknowledgeofwhatworkswillremain.
Localsightlosssocieties
Localsightlosssocietiescanplayakeyroleinhighlightingtheuniquecircumstancesofpeoplewithsightlossin:
•fallsclinics
•carehomesandshelteredorextracarehousingforolder
people
•strokeservices
•leisurefacilitiesandclubs
•clinicalcommissioninggroups
•exerciseandhomesafetyprogrammesdesignedfor(and
with)peoplewithsightloss
•housingimprovementandmanagementprogrammes.
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Alliedhealthprofessionals
•Join,andcontributecasestudiestoProFaNE,(
professionalscommittedtothepreventionoffalls,whichhasaspecialsectiononvisionandfallsprevention.
•Developclient-centreddecisionmakingandraiseawarenessinfallsclinicsabouttherisksthatsightlossposesforfallsand
theabilitiesandneeds ofpeoplewithsightloss and- conversely-raiseawarenessinsensoryimpairmentandlowvisionservicesoftherisksoffalls(Ballingeretal2009).
•Developcompetenciesinsightlossviaeffectivetraining,coaching,andperformanceassessments.
Recommendationsforresearch
Thereisanurgentneedforrobustresearchaboutthelinksbetweensight lossand falls,and forpeople withsight loss tobedirectlyinvolvedininformingresearchquestions,suchas:
–theeffectivenessofenvironmentalandbehaviouralinterventionsinreducingfallsamongstolderpeoplewithsightloss;
–theviewsandexperiencesofpeoplewithsightlossaboutfallspreventioninterventions;
–theperceivedeffectivenessandacceptabilityofgeneralfallspreventionstrategies(i.e.designedforthegeneralpopulationofolderpeople)amongolderpeoplewithsightloss;
–assessingwhetherincreasedmobility(andconsequentimprovementsin strength,balanceand confidence)reducesfallsorifreducedactivityreducesfallsbylesseningexposuretoriskoffalls(intheshortterm).
Usefulresearchdesignswouldemployrandomisedcontrolledtrialsandqualitativestudies.
MargaretMartin
Medicaljournalistandindependentresearcher
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