Falls Awareness Week 2011
Vision and falls webinar
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Age UK Vision and Falls Webinar
1. An Introduction to vision and falls
2. Vision assessments within falls services
3. Adapting the physical environment for people with visual
impairment
4. Adapting physical activity for people with visual impairment
5. Q&A with panel
Remember: you can submit your questions
at any time during the presentations using
the Q&A box below
Anthony Slater
Lighting Development Manager
Dave Elliot
Professor of Clinical Vision Science
Dawn Skelton
Reader in Ageing and Health
Shelagh Palmer
Health Co-ordinator
Vision and falls – an
introduction
Shelagh Palmer and
Dawn Skelton
Outline
• Extent of the problem
• Impact of eye conditions on vision
• What can be done?
• Can more be done?
of people over 65
fall once a year
20%
of people over 75
have impaired vision
there’s more
to falls than
meets the
eye…
Facts about sight loss
• RNIB estimate 1.8 million in UK are living with sight
loss1
• 50% living with irreversible sight loss1,2
• Only 4% of the visual impaired people see nothing2
• Visual impairment increases with age, especially for
women3
• 80% of visually impaired people are aged over 652
• 88% people with cataract and ARMD were not in touch
with any hospital eye services3
www.visionmatters.org
2 Evans JR, Fletcher AE, Wormald RP, MRC trial,BJO 2002
3. Evans JR, Fletcher AE, Wormald RP, MRC trial,BJO 2004
Visual impairment and falls
• Rate of falls in
older people with
visual impairment
is 1.7 times higher
• Hip fractures are
1.3-1.9 times
higher
(Legood R., Scuffham P, Cryer (2002)
Injury prevention 8(2) 155-60
Sensory Input  Stability
Three main sources of input for
balance
•
Visual information
•
Vestibular information
•
Proprioceptive information
• All three decline with age
• All three show larger declines
in sedentary older adults
Causes and risks
Summary of 12 major
studies of fall causes
•
•
•
•
•
•
•
•
•
•
Accident /Environment
31%
Gait /Balance /Weakness 17%
Dizziness vertigo
13%
Drop attacks
9%
Confusion
5%
Postural hypotension
3%
Visual disorder
2%
Syncope
< 1%
Other
15%
Unknown
5%
Individual risk factors:
16 controlled studies
•
•
•
•
•
•
•
•
Weakness
11/11
Balance deficit
9/9
Mobility limitation
9/9
Gait deficit
8/9
Visual deficit
5/9
Cognitive impairment 4/8
Impaired ADL
5/9
Postural hypotension 2/7
Rubenstein & Josephson 2002
Effects of Eye Conditions on Sight









Loss of central vision
Loss of peripheral vision / reduced visual field
Patchy vision
Poor visual acuity
Poor contrast sensitivity
Loss of colour awareness
Loss of depth perception
Discomfort in bright light or glare
Poor light dark adaptation
OR combinations of the above
Bus normal view
Normal Vision
Bus macular degeneration
Age Related Macular Degeneration
Bus glaucoma
Advanced Glaucoma
Bus cataract
Cataract
Bus diabetic retinopathy
Diabetic retinopathy
Bus normal view
Haemianopia (stroke)
Vision and Falls
Functional Factor
Strength of
association
 Poor contrast sensitivity
***
 Decreased depth perception
***
 Poor visual acuity
**
 Visual field loss
*
(*** is strongest association)
Reproduced / adapted from Lord et al 2007:164
Contrast Sensitivity
How might we intervene?
• Home adaptations (see Anthony’s
presentation)
• Promote eye examinations
• Promote functional vision assessments (final
presentation)
• Change glasses?
• Remove cataract?
• Exercise programmes (second presentation)
Bifocals / Multifocal
• Use of these lenses is associated with an increased
risk of falling.
• Multifocal and bifocal glasses further impair contrast
sensitivity and depth perception.
• Multifocals also cause loss of acuity in the lower
peripheral visual field.
• Protective responses, such as grabbing a rail, may
also be hindered by the peripheral prismatic effect.
Lord et al. 2000, Cambridge University Press
New glasses – be careful!
• Prescription of new lenses should involve careful
instruction in their use.
• In one trial, assessment of vision and prescription of new
glasses significantly increased falls in the intervention
group!.
• One of the reasons suggested for this was the difficulty older
people may have adjusting to sudden change in vision.
Cumming RG et al. J Am Geriatr Soc 2007;55:175-81.
Interventions – cataract surgery
Hazard ratio = 0.95
(95% CI 0.69-1.35)
Hazard ratio = 0.60
(95% CI 0.36-0.98)
.5
.8
.4
Cumulative risk of second fall
1.0
.6
.4
.2
0.0
0
60
30
120
90
180
150
.3
.2
GROUP
r outine
expedited
240
210
GROUP
.1
300
270
r outine
0.0
360
330
expedited
0
390
days in study
60
30
120
90
180
150
240
210
300
270
360
330
390
days in study
RCT - 306 women over 70, cataract surgery expedited (approx 4 weeks or
routine 12 months wait). Showed 40% reduction in risk of recurrent falls.
(Harwood et al 2004)
Interventions specific to VIP

The OT Home Safety Programme alone demonstrated a significant
reduction in falls both inside the home and out with AND equally in
hazard related falls and non-hazard-related falls

The Physiotherapy led OTAGO programme was not so effective
with this specific VIP population. NB. Poor adherence rates

Demonstrates that “One size does not fit all”
Campbell et al 2005
RCT: Exercise vs OT vs Exercise & OT, 391 participants aged 75 and older, one year follow up
Ways forward
 NHS
•
•
•
•
•
•
Promote eye tests
Vision Questions within assessments
Raise awareness of vision and falls
Advice on correct glasses / bifocals / varifocals
Improve communication across services
Promote good mobility
 Falls Services
• Routine vision testing (incl. contrast and depth) and referral to
opthalmology
• Results shared across professionals and patients with appropriate
onward referral
• Refer for home hazard assessment and intervention by an OT,
tailored to individual
Did they ask about vision?
If so, what happened next?
Vision assessment and falls
services
Shelagh Palmer and
Dawn Skelton
NICE 21 Falls Guideline, 2004
Consensus?
• There is no real consensus on vision assessment
within falls prevention settings and little consensus on
subsequent management of visual impairment
Dr Manjit Mehat & Dr Ruma Dutta
• 58% of all falls services consider the assessment of
patients vision either informally or formally by use of
an assessment tool
NIHR ( SDO), Lamb 2007
What visually impaired people said …
“My husband does everything now. I miss being able to go out
myself and doing things for myself. I don’t know how I’d survive if
he wasn’t here”
62% said they don’t go out on their own anymore
“I tripped on the carpet last year and needed stitches. After that the
social work came out and I got an alarm for round my neck and
handrails at front and back of house. I didn’t mention that I have
problems with my eyes but then they didn’t ask”
36% had tripped or fallen
(From: Improving access to specialist services for people who are visually impaired.
Visibility, 2004)
What people said about falls…
‘In the last two years I’ve had four falls and have broken my hip,
pelvis and shoulder. I’ve been taken to casualty every time but they
didn’t ask me anything about my sight’.
‘When I ended up in hospital after my last fall I told them that I was
falling and tripping a lot but they didn’t seem interested. I am terrified
I’ll have a fall which will finish me off.’
Functional vision information not known and /or not shared
(From Deteriorating vision, falls and older people: the links. Visibility 2005)
Four vision related questions
• Are you able to read small print, bills, medicines?
• Can you recognise faces across the street?
• Do you miss or overfill cups when pouring?
• Do you have difficulty judging steps, stairs, kerbs
• Part of single shared assessment
()
Visual Impairment & Falls
• Small study by Department Vision Sciences, Caledonian
University
• N=67 (33 VIP, 33 normally sighted) aged 70-96 years
• Asked number of falls in a year, fear of falling, treatment
• Asked 4 questions on vision
• Controls had a visual acuity of 6/12( 0.3logMAR) or better
in both eyes and no central field loss
• Visually impaired subjects visual field loss within 20
degrees of fixation and / or reduced acuity ( 0.7 logMAR)
or worse in better eye
Age, falls and treatment
77.5
VIP's
79.9
80
%
Control
60
38
40
18
44
25
20
0
age
falls
treatment required
On a scale of 1-5
1=can’t do
Question
5 = no problems
VIP’s Score
Controls
Score
Reading
1.54 ±0.96
4.23 ± 0.74 *
Recognising
faces
1.00 ±0.85
3.77 ± 0.96 *
Pouring
3.15 ±1.47
4.62 ± 0.66 *
Steps/ kerbs
2.69 ±1.21
4.38 ± 0.87 *
4 questions easily differentiate those with
significant visual impairment
* P=<0.0001
Fear of Falling
• Does fear of falling affect your ability to carry out day
to day tasks such as shopping
• 24% of VIP compared to 11% of older people with normal
vision.
• Within those who were fearful
• 38% of VIP had had a fall compared to 25% of older people
with normal vision
• Despite having no falls, 15% of VIP were fearful
Welsh L, BSc dissertation, GCU, 2011
NHS GGC Falls Prevention Programme
Risk Screening Tool
•
•
•
•
•
•
•
Do you wear glasses?
Were you wearing them when you fell?
Any problems with these glasses?
Which types do you wear?
When did you last have your eyes tested?
Are you registered as blind and partially sighted?
Have you ever been seen by the Sensory Impairment
Team?
• Home hazard section, prompted to consider the lighting
around the home.
Vision assessment in falls settings
• Small audit by AgeUk, 26 services responded
• Range of responses from community to hospital
• Most of clinic settings measured visual acuity
measured, eye conditions noted
• Community setting tended to ask very basic vision
questions
• 23 very positive – liked functional/ descriptive aspect
• 4 questions very useful for home visits/assessments
(non specialist assessments)
• Need for VI training and awareness of simple tools
Other audits
• BGS survey - currently ongoing
• Assessing vision and vision function in falls
clinic settings
• Dr Manjit Mehat & Dr Ruma Dutta
• Click below to take part in the survey
• www.surveymonkey.com/s/BJQXFVF
• Visibility is happy to coordinate further
validation of “our” four questions
Interested? - email shelagh@visibility.org.uk
Basic Vision Assessment Tool
• Eyes Right
• A simple and easy-to-use screening tool that
can help you find people living with poor vision
in your community
• Two different formats - a simple computer
programme, which runs on a standard laptop
or computer, or an A4 hand-held book
• Free from RNIB Helpline on 0303 123 9999
Other tools?
Functional Vision Assessment Tool
• A set of checklists to compare peoples vision,
contrast sensitivity, central and peripheral vision etc.
• Specifically for learning disabled but useful for
“observational” testing (eg. in cognitive impairment).
• Free and Downloadable from SeeAbility
• http://www.lookupinfo.org/forms_booklets/functional_vision_ass
esement_pack/default.aspx
Cinderella?
•
•
•
•
Vision is rarely considered in trials
Vision is the “cinderella” on falls risk factors
Vision is also the “cinderella” on falls interventions
Self efficacy and confidence
• Vision impairment then fear of falling....
• Same population group, older adults!
• ++ LUTS, UI, Multiple medical conditions, polypharmacy!!
Unknowns?
• If vision problems identified in falls settings,
what happens next?
• If onward referrals – do people attend?
• What if feedback loops between services?
• What knowledge within falls services of
support services for visual impaired people?
• Mobility training for visually impaired people –
is it offered?
Recommendations
 NHS
•
•
•
•
•
Promote eye tests for public
Vision Questions within all assessments
Raise awareness of vision and falls
Advice on bifocals / varifocals
Improve communication across services
 Falls Services
• Routine vision testing (incl. contrast and depth) and referral to
opthalmology
• Results shared across professionals and patients with appropriate
onward referral
• Refer for home hazard assessment and intervention by an OT,
tailored to individual
• Links with services supporting visually impaired people
Take Home Messages
• Vision is important!
• Vision assessment is the key!
• Falls services should ask about vision
• Vision services should ask about falls
• Audit your service and improve?
• Interventions to promote independence and
mobility in older people with VIP exist, they
work....so what are you waiting for!
Adaptations for people with sight loss
Falls awareness week 2011
Age UK Vision and Falls webinar
Anthony Slater
Thomas Pocklington Trust
Thomas Pocklington Trust

Registered charity founded in 1958
–
To provide quality housing, care and support
services that promote independence and choice
for people with sight loss (nine centres)
–
To fund research into the prevention, alleviation
and cure of sight loss, disseminate findings and
support good practice.
Why focus on sight loss?






Most older people have a degree of sight loss that
affects everyday life
Many eye conditions are age related
Normal ageing of the eye means that, as we age, we
need more light than younger people to achieve the
same vision
Sight loss is a significant factor in 900,000 falls in the
UK per year.
Sight loss is often concurrent with other issues
Housing design, management and maintenance that
is good for sight is good for everyone.
Findings from Pocklington research

Housing outcomes sought by people with sight loss
–
–
–
–

A home that is comfortable, easy to live in and personal
Safety and security – within and outside
Accessibility – within and outside
Opportunities to make the most of sight, in choice of
activities and in daily living.
Good practice for sight loss makes homes safer,
more secure and easier to live in.
Design, management and
maintenance: six key points for sight






Involve people
Improve lighting
Use colour and contrast
Avoid clutter
Reduce glare
Make appliances accessible.
Focus on lighting: seven
characteristics of good lighting
Without light we cannot see
Lighting should always be:
 Appropriate to each person
 Sufficient for activity and orientation
 Even, across different areas
 Adjustable for flexibility
 Energy efficient and sustainable
 Simple to install
 Adaptable for the future.
In practice:

Maximize space and its flexibility, including:
–
–
–

Design to maximize vision, importantly:
–
–

Multiple power points
Multiple and controlled light sources
Storage space (lit and easy to access)
Light, without glare
Colour and contrast
Hazards are designed out, including:
–
–
–
Safe door opening systems
Easy to follow routes
No visual or physical clutter.
Entrances, halls and stairs

General lighting
–
–
–

Task lighting
–

Good level
No glare
Reveal steps
Telephone
Good contrasts
–
Surfaces
Stairs
Halls
Kitchen and utility areas
Kitchens
Living rooms - multiple light sources
Living rooms - traditional
Bedrooms
Wardrobe
Bathrooms
Bathrooms
Outdoors
Individual needs and solutions
Variations within good practice principles reflect

a person’s individual activities and interests:
–
–
–

equipment
reactions to glare and light levels
other conditions: hearing, mobility, dementia
personal needs and priorities:
–
–
–
–
–
choosing clothes
personal care
cooking
safety and security
assistance dog
Guidance



Design guide
Good Practice Guides
Booklet
Checklists
Lighting training






One day workshop
Lamps & fittings
Demonstrations
Practical exercises
Case studies
Design tools
Further information
info@pocklington-trust.org.uk
www.pocklington-trust.org.uk
Adapting physical activity
and advice for exercise
Dawn Skelton
Sensory Input  Stability
Three main sources of input for
balance
•
Visual information
•
Vestibular information
•
Proprioceptive information
• All three decline with age
• All three show larger declines
in sedentary older adults
• 62% of older people with visual
impairment avoided activities due to
fear of falling despite having no falls in
the last year.
Welsh, L. MSc Dissertation, GCU, 2011
Fear of Falling
• Does fear of falling affect your ability to carry out day
to day tasks such as shopping
• 24% of VIP compared to 11% of older people with normal
vision.
Welsh L, BSc dissertation, GCU, 2011
• FoF Prevalance (Tinetti 1994)
• 30-60% in people over age of 65
• 50-65% in previous fallers
Fear of Falling
• Fear and lack of confidence
in balance predict
• Deterioration in physical
functioning (Arfken 1994, Vellas 1997)
• Decreases in physical activity,
indoor and outdoor (Arfken 1994,
Finch 1997)
• Increase in fractures (Arfken 1994)
• Admission to Institutional Care
(Cumming 2000, Vellas 1997)
Fear of Falling
• Implications
• reduction in physical/functional risks may not
reduce fears and activity restriction
• attributing falling to incompetence or ‘risky’
behaviour may
•
•
•
•
discourage activity,
reduce acceptability,
reduce uptake
reduce adherence to prevention programme
Yardley, 2002
Maastricht group
BMJ 2000; 321: 994-8
• RCT of home visits vs usual care for >70 year
old fallers – CBT (Matter of Balance)
• Reduced fear of falling at 12 and 18 months
• Moderate but significant 7% (-2 on scale with 30
points)
• Daily activity at 12 months
• Moderate but significant 4% (1.6 on scale with 39
points)
• ?? works in people with VIP
Environment – a risky place
Personal risk
factors:
• glasses (bifocals
and varifocals)
• footwear and
clothing
Outdoors:
Indoors:
• Poorly lit pathways
• Loose carpets
• Uneven pavements
• Wires and cables
• Slippery surfaces
• Unstable furniture
• Rubbish, building
materials, obstacles
• Change of level
• People flow
• Shadows
• Poor lighting
What do older people (without
VIP!) think?
Difficult and fall inducing dual tasks (doing more
than one thing at a time)
 Stairs negotiation (especially descent) accompanied
by manual upper limb
 Walking and avoiding moving obstacles
 Confusing environment demands with walking
(noise, light, shadows, busy)
Muhaidat, Skelton et al. BJOT 2010
Extrinsic barriers
• Accessible opportunities (transport)
• Safe activity environments (parks, well-lit streets)
• Positive images of older people
Swap bifocals for single
lenses?
• Can providing single lens distance glasses to regular
users of multifocal glasses lower the rate of falls?
• YES - by around 40% in people who regularly took part in
outside activities (incidence rate ratio 0.60, 95% CI 0.42
to 0.87).
• BUT - In frailer people, who spent more time inside, no
significant difference was seen in falls inside and a
significant increase was seen in falls outside.
Haran MJ et al. VISIBLE randomised controlled trial. BMJ 2010;340:c2265
Real life examples
• May not see hazards
• peripheral vision, visual acuity, contrast sensitivity
• May not see the poorly lit bottom step
• depth perception, contrast sensitivity, visual acuity
• May not notice the change from carpet to
slippery tiles
• contrast sensitivity, visual acuity
The VIP Trial: Campbell 2005
•
•
•
•
•
RCT
391 participants
visually impaired
aged 75 years or over
One year follow up
1. Home Safety
assessment and
modification
programme by an OT
2. Home based exercise
programme prescribed
by a Physio + Vit.D
3. Both 1&2
4. Social visits (control)
OT Intervention for VIP
• Assessment tailored to awareness of clients
functional vision
• Home hazard identification with client
• Focus on lighting and lack of contrast
• Removal or adaptation of hazard in agreement with
client
• Changes to risk behaviours also discussed
Campbell et al 2005, La Grow 2006
Mechanisms at play?
• Individually tailored advice by an OT enables VIP to
negotiate environments more safely?
• OT intervention led to reduction in activity (“playing
safe”) and therefore reduction in risk?
• Evidence based home exercise programmes did not
allow full participation due to specific needs of VIP?
La Grow et al 2006
Visual Impairment Rehabilitation
• Monodisciplinary – optometrists
• Low vision aids
• Multidisciplinary – social workers, psychiatrists, OT’s,
• How to cope with VIP in their occupation and with their
preferences/needs
• Practicing daily living skills in the safe environment of the
rehabilitation centre may be different from practicing
these skills in the person's own environment which is
usually not adjusted to visually impaired persons.
• Multidisciplinary VIR improves QoL, mood, self efficacy,
well-being
Langelaan, van Nispen, van Rens 2010, Cochrane
Orientation & Mobility Training
• Orientation is the ability to
recognise one’s position in
relation to the environment
• Mobility is the ability to move
around safely and efficiently
• O & M training can help those
with VI to compensate for
reduced visual information
Virgili & Rubin 2009
O & M Training
• Helps to use remaining vision or other senses to get around
• Canes and optical aids to support.
• 90 mins a week for 10-12 weeks – volunteer-participant
pairs
• Sound localisation, landmarks, tactual discrimination, self protection
positions, cane use, narrow spaces, doorways, changes in level and
obstacle avoidance
• ++ exercise sessions for balance and endurance
• Significant improvements in mobililty and travel in those
with severe VI BUT exercise alone was as good
Virgili & Rubin 2009
Reducing barriers
Walk from Home – Keighley
Senior Peer Mentoring
Mary Moffat - 93
• Referred by physio after a fall
• Loss of confidence and fear of
falling
• Isolated and lonely and
dependent upon others to get out
• Concerned about her vision
• Concerned about her
environment
So to summarise…
• VIP can be supported to be more active
• Who supports PA and exercise for those with
VIP?
• Who in your area supports VIP?
• We hope that this Webinar has stimulated
you and your service into thinking more about
vision
Q&A with Panel