Susan J. Leat, PhD, FCOptom, FAAOProfessor,School of Optometry and Vision Science, University of Waterloo

Amie Peddle, Independent Living Skills Specialist and Orientation and Mobility Specialist,Vision Loss Rehabilitation Ontario, Hamilton

ColleenMcGrath, PhD, OT Reg. (Ont.)Assistant ProfessorSchool of Occupational Therapy, Western University

©Copyright: Susan Leat, Amy Peddle, Colleen McGrath

Goals1) What are the risk factors for falls and what is

the evidence about the association between vision and falls?

2) What should be done to improve vision?

3) What are different types of assessments that can be administered to determine falls risk?

4) What home modifications can I recommend for my client/patient?

5) What technology is available to support people with vision loss that may reduce fall risk?

Falls

“Unintentionally coming to rest at on the ground, floor, or other lower level other than as a consequence of sustaining a violent blow, loosing consciousness, sudden paralysis as in a stroke or seizure”

• 30% of those 65 and older fall at least once per year• 35% are injurious falls• 60% of nursing home residents

• Personal cost• Falls are the leading cause of injury in 65+▫ Hip fractures▫ Wrist fractures▫ Head trauma▫ Increased mortality

The extent of the problem

• Cost to health care system ▫ Among all injuries, falls are the single highest

cause of death, hospitalisation and emergency room visits and cause the highest rate of permanent and total disability

▫ Leading cause of health care costs compared to other injuries >2x the other leading cause of injury

(transportation accidents)

Parachute, 2016 The cost of injury in Canada, Toronto

Biological and medical• Age, female sex • Muscle weakness and reduced physical fitness (4x)• Physical disability• Balance (postural instability), gait or mobility problems• Slower balancing reactions• Chronic medical conditions (history of stroke (especially hemiparesis),

Parkinson’s, arthritis, heart disease, neurological conditions, arthritis, hypotension, COPD)

• Vision changes• Hearing loss• Vertigo• Loss of sensation in feet and limbs (peripheral neuropathy)• Acute infection (immobility → weakness, bone density, • Impaired cognition (delirium and dementia)• Depression• Pain

Interaction of the person with the environmentCause of falls is multifactorial - Risk factors for falls

Environmental Poor lighting Slippery or uneven surfaces Loose carpets Stairs (steep, narrow,

irregular, unmarked edges) Floors (glary, patterned) Poor accessibility (switches,

cupboards) Clutter and obstacles Long distance to washroom

Behavioural History of previous falls Risk taking behaviour (climbing,

sports, rushing, not attending, not using walker etc)

Medications (sedatives, psychotropic, antidepressants, diuretics, antihypertensives)

anticoagulants may risk of damage

Polypharmacy Poor footwear, clothing, bags Fear of falls

Socio-economic Income Education Housing Social connectedness

Rate of falls increase from 27% for those with 0 or 1 risk factor to 78% for those with 4 or more factors

Am Ger Soc, B Ger Soc, Am Acad Orth Sur (2001) Guideline for the Prevention of Falls. JAGS 49; 664

Associations between vision and falls/balance/hip fractures?

▫ Visual acuity (VA) poor VA increases risk of falls by 1.5-2.0 Interocular differences may be more significant than moderate

monocular loss

▫ Contrast Sensitivity (CS) ↓CS is a factor for falls and increased sway

▫ Stereopsis/depth perception/Binocular vision (BV) Poor BV linked to poor balance 25-35% older adults have BV disorders

Lord et al (2010) Clin Geriatr Med 26 (2010) 569–581, Althomali M, Leat SJ, poster, AAO 2013Leat et al (2013) IOVS

• Visual fields binocular field loss associated with increased sway lower field loss in glaucoma more falls and more injurous falls More field loss ⇒ more fear of falling

• Visual impairment 3x higher in fallers than non-fallers 46-76% of patients admitted for fall or hip fracture had VA less than 20/60,

the majority correctable with cataract surgery or spec. change

• Other possible visual risk factors

▫ Visual attention related to mobility, balance, walking tests Decreases significantly with age

Turano et al (1996) IOVS 37, 1483-1491, Black et al (2010) OVS, 85, 489-497, Black et al (2011) OVS 88, 1275-1282,

Ramulu PY. (2012) Ophthalmol; 119(7):1352–8, Tran et al (2011) J Franc d’ophthal 34, 723-728, Elliott D (2014) OVS 91, 593-601. Althomali and Leat, ARVO 2016,

Leat SJ, Lovie-Kitchin JE (2008) OVS 85, 1049–1056, Reed-Jones et al (2013) Maturitas 75, 22– 28

• Falls and spectacle wear

▫ Multifocals are a risk factor Affects CS and stereopsis though the near portion

Increases miss-stepping

Increases mobility errors

2x more likely to fall

Davies et al (2001) Safety Sci 211-226, Lord et al (2002) JAGS 1760-1766, Johnson et al (2007) IOVS 1466-1471, Menant et al (2009) JAGS 1833-1838

• Cataract surgery - ambiguous▫ 2/3 older studies found first eye cataract surgery

reduced falls and fractures

▫ 2nd eye cataract surgery had no effect

▫ Most recent studies Australia; falls increased between 1st and 2nd eye

cataract surgery US; Cat surgery decreased risk of hip fracture

Falls and vision intervention – what is the evidence?

Harwood et al (2005) BMJ 89, 53-59, Brannan et al (2003) BMJ, 87, 560-562, Age Aging 35, 66-71, Elliott D (2014) OVS 91, 593-601.

• No good studies of optometric intervention and falls▫ Cummings et al: Randomised Clinical Trial (RCT)

of eye exam, spectacle correction, referral to ophthalmologist, and OT at home. Falls and fractures more frequent in the intervention

than in the control group in first 6 months But 77% of the control group visited their Optom. Flawed study

▫ Slight trend that greater changes more falls risk

• Haran et al▫ RCT of single vision (SV) specs for outdoor wear. No overall effect But sub-analysis – 40% reduction in falls in those

who regularly exercised outside. But a sig increase in falls in those who did little

outside activity

Haran MJ et al (2010) BMJ 340, 2265

Vision intervention with other components

• Day et al : Vision intervention together with home modifications and exercise gave the largest effect▫ Vision intervention = referral if vision < criterion.

But only 34% had treatment (Tx) who would not have otherwise.

• Two other studies showed that a vision component together with other interventions was successful.

Day et al (2002) BMJ 325, Clemson et al JAGS, (2004) 52, 1487, Dyer et al (2004) Age and Ageing 33, 596

• So the literature on the effectiveness of vision correction/management is very weak.

• The literature on the association with poor vision and falls is strong.

Falls assessment

• For those who have >1 fall per year or reported/demonstrated difficulty or unsteadiness▫ History of falls ▫ Examination of Vision

Vision assessment often does not happen even when referred to hospital after a fall

Seniors often underestimate loss of VA Gait and balance Neurological exam Lower extremity function Cardiovascular Review of meds ADL

JAGS (2011) 59, 148-157 , Boutin et al (2012) JAMDA 13; 187.e15–187.e19

Falls prevention guidelines• Home modifications• Reduction of medications (especially psychotropic

meds) if possible• Management of postural hypotension• Management of footwear and foot problems• Exercise (e.g. Tai Chi, physical therapy)• Education and behavior modification• Treatment/management of vision and visual

deficits (cataract surgery, review of spectacle type)• Tx of cardio and other medical problems• Vit D supplements

AGS/BGS Clinical Guideline (2010) NGC-9165, JAGS (2011) 59, 148-157

Assessment: Person Factors▫ Ask about any recent falls the client has experienced. What

were they doing? Where were they? When did it happen? What do they believe caused the fall?

▫ Ask questions about the client’s routines, roles, and occupations that are meaningful to them.

▫ Consider and assess the client’s strength, dynamic balance, standing tolerance, attention, concentration, memory, comprehension, judgement/reasoning

▫ Inquire about the client’s medication use

Assessment and management: Visual

Glare? adapting to lighting changes? State and fitting of

spectacles In addition to usual full

eye exam/low vision assessment CS BV Visual fields

• Prescribing considerations re falls▫ Try to avoid large power changes (≥0.75D)?? (0.75D of sphere or cyl, axis change of ≥10° with cyls up

to 0.75D or ≥5° with cyls >0.75D, any prism change, intra-ocular change of ≥0.75D)

Although patients with LV may be less susceptible

▫ So partial prescriptions, more frequent examinations▫ More careful, specific counselling regarding

adaptation Magnification effects

▫ Adapt to new glasses in house

• Dispensing considerations▫ Ideally move towards single vision specs. ▫ Or SV for outside house, multifocal inside Haran et al - 40% reduction in falls with additional pair of SV for

outside But for chair bound - no difference

▫ Don’t give new progressive lenses (PALS) or bifocals to the elderly, especially those at risk of falls

▫ For near emmetropes, remove multifocals out of doors▫ For those with high add bifocal, give SV or lower

power add for walking▫ Don’t change lens design unless good reason

▫ Frame that doesn’t impede peripheral vision▫ New frames and lenses▫ Adjust for proper fit

▫ Re-educate about bifocals Emphasis looking over bifocal for stairs

▫ Educate about removing readers when walking

▫ Prescription/selective transmission tint for light adaptation/glare reduction

• Management of disease• Refer/undertake for cat. surgery, especially first eye

surgery• Screen/manage glaucoma, diabetes • Remember that falls linked to

• peripheral neuropathy in diabetes – counseling

• Referrals and reports to circle of care (e.g. OT, O&M, Vision Loss Rehabilitation ON, audiologist, home nurse, community care programmes)

• Communicate with family doctor/gerontologist

Mention environmental modifications Lighting, contrast Ensure that a family member there Refer to an OT or Vision Loss

Rehabilitation Canada

Education and awareness Mohammed’s story One finger contact

Physical Determinants Ax• Timed Up and Go (TUG) (Podsiadlo & Richardson, 1991): A

test that measures the time taken by an individual to stand up from a standard arm chair (approximate seat height of 46 cm, arm height 65 cm), walk a distance of 10 feet, turn, walk back to the chair, and sit down.

• Berg Balance Scale: 14-item scale (15-20 minutes administer) that is designed to measure balance of older adults.

• Dynamic Gait Index (Shumway-Cook & Woollacott, 1995): Measures eights components of gait (15 minutes to administer) to assess likelihood of falls in older adults.

Assessment: Environmental Factors

▫ Determine in which environments the client performs occupation (both within the home and in the community)

▫ Assess the client’s surroundings to determine potential fall risks

▫ Determine the client’s use of assistive devices or equipment

Home Safety Ax• SAFER-HOME (Chiu, Oliver, Marshall & Letts, 2001): 93

items (45 to 90-minute completion time) designed to assess safety of the home across ten domains

• HOME FAST (Mackenzie, Byles & Higginbotham, 2000): 25 items (20 to 30-minute completion time) designed to look at environmental hazards inside and outside of the home.

• Westmead Home Safety Assessment (WeHSA) (Clemson, 1997): 72 items designed to determine how falls history, risky situations, habits, behaviours, and personal characteristics affect safety in the person’s environment.

Assessment: Occupation Factors▫ Assess the client’s ability to perform their desired

occupations within the appropriate environmental context (ex: assess kitchen safety within the client’s home kitchen). Try to choose occupations that require dynamic balance, mobility, and standing.

▫ Consider the physical, cognitive, and affective demands of each occupation and the client’s challenges and resources relative to those domains.

Falls Behaviour Ax• Falls Behavioural Scale (FaB) (Clemson, Cumming &

Heard, 2003): Evaluates behavioural factors that may protect against (or increase the risk of) falling. It includes 30 items (20-30 minutes to complete).

• The Falls Efficacy Scale-International (FES-I): 16 items tomeasure the level of concern (or fear) about falling during social and physical activities.

• Activities-specific Balance Confidence (ABC) Scale (Powell & Myers, 1995): 16-item scale that looks at percentages (0-100%) of self-confidence in completing an activity without loosing balance or becoming unsteady.

Falls in the Home• Home is the most common place for falls• 26% of falls occur on the stairs (44% slip, trip,

and stumble on any surface)• Evidence that home assessment and

adaptations reduce falls is strong• Environmental modifications to the home are

essential

JAGS (2011) 59, 148-157 Public Health Agency of Canada, Report on Senior’s Fall, 2005

What may pose a fall risk?

What may pose a fall risk?

Suggestions for Home Modifications: CLUTTER• Reduce clutter as much as possible –including

visual clutter• Keep all pathways traveled clear and allow for

walls or furniture to be trailed or squared off with• Organization of the home is key -items should be

placed in an appropriate and consistent location so items can be found easily• Chairs should always be kept tucked in and

cupboard drawers and doors should be kept closed

• Carpets and rugs should be secured firmly to avoid tripping• Electrical cords should be tucked away or

secured firmly • Dropped objects should be picked up as soon

as possible• If an individual needs to bend over or is

approaching obstacles at head or waist level, ensure protective techniques are used

Suggestions for Home Modifications: CONTRAST• Rugs or carpets should provide contrast in

comparison to flooring • Rooms and door frames are easier to identify• Inside the kitchen -helps to define space and

identify objects easier

• Colour contrasting, non-slip tape can be placed on the top and edge of stairs and handrails • Non-slip colour contrasting mats in kitchen and

bathroom • Grab bars in bathrooms

http://www.visionaware.org/section.aspx?FolderID=11&SectionID=125&TopicID=504&SubTopicID=282&DocumentID=3236

Suggestions for Home Modifications: LIGHTING

• Closing curtains/blinds, minimizing shiny surfaces, wearing sunglasses or tinted lenses as well as a hat may be useful in reducing glare• Ensure adequate overhead/task lighting in

appropriate locations• Lights on near stairs• Provide extra lighting at night

Suggestions for Home Modifications: CLOTHING

• Proper footwear worn -shoes should have good grip and traction • Shoe laces should be tied securely or wear

shoes without laces• Pants should not be too long so they cannot be

tripped over

Tech to support mobility & reduce falls: BUZZ CLIP• Wearable technology for people who are blind or

partially sighted. It detects obstacles that may be in one’s path and notifies the individual of obstacles through vibrations, allowing the individual to safely negotiate around the object. By attaching the BuzzClip to clothing, it can provide upper body level detection (that may not be identified/recognized by a cane or dog guide). • https://www.indiegogo.com/projects/the-buzzclip-

wearable-mobility-tool-for-the-blind#/

How does BuzzClip work?

https://www.youtube.com/watch?v=8aZECk_uAh0

Tech to support mobility & reduce falls: BlindSquare• An accessible GPS app developed for the blind and partially

sighted. Describes the environment, announces points of interest and street intersections as you travel. You can use it to find a business or search for local points of interest. By shaking the device it will announce your current address. It will also provide you with information about the location of the nearest intersection. Beacons can be set up in buildings to announce the location as well as other relevant information. • http://blindsquare.com/about/

Tech to support mobility & reduce falls: YES CHEF• A hands-free voice controlled accessible app

that allows you to focus on preparing meals. It provides step-by-step recipe instructions, easy for all levels of cooks, ranging from easy to advanced recipes. It provides the ingredient amounts, move through different parts of the recipe and you can ask follow up questions. • http://www.conversantlabs.com/yeschef

How does Yes, Chef work?

https://www.youtube.com/watch?v=9cLgIMmXslU

Moving Forward: Interdisciplinary/ multidisciplinary approach.

• People with normal vision to minimal VI (20/70, 6/21) and with falls risk, who are being managed in the OD/MD’s office

OD/MD

ReferralOT/

VLRehab

ReportOT/

VLRehab

ReferralOD/MD

Report

People with more extensive vision loss (level 3 in Leat model)

• Ideal – multidisciplinary clinic (interdisciplinary)▫ Professions work alongside each other, same

place/time▫ Direct communication▫ Optom/Ophthalmol – LV assessment▫ OTs – home adaptations▫ VLRehab - O&M, education• Second option (multidisciplinary) – reports and

referral between VLRehab, OT and OD/MD

Above all, COMMUNICATION

THANK YOU.

QUESTIONS OR COMMENTS?