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Vision and falls: A multidisciplinary review of the contributions of visual impairment to falls among older adults
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Vision and falls: A multidisciplinary review of the contributions of visual impairment to falls among older adults Rebecca J. Reed-Jones a,b,∗ , Guillermina R. Solis c , Katherine A. Lawson d , Amanda M. Loya e , Donna Cude-Islas f , Candyce S. Berger f a
Department of Kinesiology, College of Health Sciences, The University of Texas at El Paso, United States Physical Therapy Program, Department of Rehabilitation Sciences, College of Health Sciences, The University of Texas at El Paso, United States c School of Nursing, The University of Texas at El Paso, United States d Occupational Therapy Program, Department of Rehabilitation, College of Health Sciences, The University of Texas at El Paso, United States e Cooperative Pharmacy Program, College of Health Sciences, The University of Texas at El Paso, and College of Pharmacy, The University of Texas at Austin, United States f Department of Social Work, College of Health Sciences, The University of Texas at El Paso, United States b
a r t i c l e
i n f o
Article history: Received 19 January 2013 Accepted 21 January 2013 Available online xxx Keywords: Falls Vision Visual impairment Fall prevention Risk factors
a b s t r a c t Falls are a leading cause of mortality among older adults worldwide. With the increasing aging population, falls are rapidly becoming a public health concern. Numerous internal and external factors have been associated with an older adult’s increased risk of falling. Most notably visual impairments are gaining recognition for their critical role in fall events, particularly related to trips, slips and falls due to environmental hazards. This review presents the issue of vision and falls from a multidisciplinary health professional perspective. Discussions include the influence of visual impairment on mobility and activities of daily living, the effects of medications on vision, visual cognitive factors on falls risk and visual training interventions. Finally, implications for multidisciplinary health professional practice and suggestions for future research are offered. © 2013 Elsevier Ireland Ltd. All rights reserved.
1. Introduction 1.1. Definition of a fall A fall is an event where a person inadvertently comes to rest on the ground (floor) or other lower level [1]. Globally, adults over the age of 70 years are at higher risk for fall related mortality [1]. Visual impairment is an independent risk factor for falls among older adults, however; older adults typically underreport visual impairment and it is an underrepresented area of research. The aim of this review is to present the issues surrounding vision and falls in older adults through a multidisciplinary health professional lens, providing a comprehensive picture of the problem, and offering recommendations and thoughts for future research and evidence based practice. 1.2. Falls among older adults Falls among non-institutionalized older adults are growing in epidemic proportions. Given the growth in the elderly population,
∗ Corresponding author at: Department of Kinesiology, College of Health Sciences, The University of Texas at El Paso, 500W University Ave, El Paso, TX 79968, United States. Tel.: +1 915 747 7239. E-mail address: [email protected] (R.J. Reed-Jones).
this represents a major concern for health care providers and health care costs. According to recent census data, 13% of the U.S. population is 65 years of age or older and 1.9% is 85 or older [2]. The growth of older adults has increased at a greater rate (15.1%) than the general population and by 2030, the number of older adults (65 or older) will double to about 71 million [3]. This rapid growth of the elderly has far-reaching implications for public health, placing an unprecedented demand on health care delivery for age-related services. The data on falls among older adults points to significant issues related to mortality and morbidity. Approximately 35–40% of noninstitutionalized adults fall each year, increasing to 50% for those 75 or older [4–6]. Mortality rates for falls among older adults parallels this growth in fall rates. Research has shown that falls are the fifth leading cause of death among the elderly (55+) [5–7], the National Prevention Council (2011) reports that 45.3 deaths per 100,000 older adults are the result of a fall [6]. Falls also contribute to morbidity among the elderly [8]. Nonfatal falls accounts for 1.6 million emergency room visits and 388,200 hospitalizations each year [5,9]. Non-fatal falls have longterm impact on the physical, financial and emotional well-being of older adults accounting for incidence in fractures, internal organ injuries, joint dislocations and closed head injuries [10–13]. Research has identified two major categories of risk factors leading to falls: extrinsic/environmental factors and intrinsic factors
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Please cite this article in press as: Reed-Jones RJ, et al. Vision and falls: A multidisciplinary review of the contributions of visual impairment to falls among older adults. Maturitas (2013), http://dx.doi.org/10.1016/j.maturitas.2013.01.019
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[7,14–18]. Extrinsic risk factors are factors within the individual’s environment. Some examples of extrinsic and environmental risk factors include, use of assistive devices and walking aids, poor flooring, inadequate lighting, area rugs, absence of handrails, and broken or uneven sidewalks and stairs. Intrinsic risks factors relate to characteristics within the individual. Examples of intrinsic risk factors include type and number of medications taken, muscle weakness, age, disease, prior falls history and the number of total risk factors. Another intrinsic risk factor that is gaining increased attention is the area of visual impairment. Of the risk factors that contribute to increased fall risk, vision is one of the most underestimated contributors, despite the implication of vision in a majority of fall events. Visual impairment reduces a person’s ability to detect hazards in the environment. As a predominant number of falls occur due to slips, trips [19,20] and/or interaction with an environmental hazard [21], vision boasts to be a leading issue when evaluating falls risk. In addition, the inclusion of vision in guidelines for fall prevention is limited. Most recommendations for visual health include regular eye evaluations and up to date corrective lenses [22,23], but these do not fully address the complexity of vision and its role in falls. Given the potential importance of vision in events leading to a fall, there is a need for greater awareness of the impact of visual deficits on falls risk. 2. Vision and falls Vision loss in older adults is the third most common chronic condition next to arthritis and heart disease [24]. Impaired vision has been identified as an independent risk for falls associated with decreased postural stability, the occurrence of two or more falls, and fractures during fall events [25–28]. Vision is essential to a person’s ability to plan and coordinate movement in response to environmental hazards as well as assist with balance [29]. Although, visual impairment is a common problem in older adults, it is often an underreported problem [30]. The most prevalent agerelated causes of visual impairment include presbyopia, cataracts, glaucoma, and macular degeneration [24,31]. These conditions are described as follows: • Presbyopia: a problem of seeing objects at close range or small print leads to a need to wear bifocal corrective lenses, a unique problem of aging. Older adults who are required to wear multifocal glasses are twice as likely to fall as older adults who do not wear multifocal glasses [20]. Wearing multifocal glasses increases the risk of falls due to impaired depth perception and edge-contrast sensitivity, which presents a problem when negotiating stairs and settings outside of the home. As such, bifocal lenses may increase risk for injurious outdoor falls in older adults because of greater propensity of tripping and approximation of unexpected objects or barriers [32]. • Cataracts: a cloudiness of the crystalline lens, most commonly occurs as part of the aging process and is one of the significant causes for vision loss with over 50% of older adults 80 years old and older. It is the leading cause of blindness in middle and lowincome world countries (WHO [33]). • Glaucoma: a group of conditions that can potentially damage the optic nerve and lead to blindness. It causes loss of peripheral vision creating a greater risk for falls as visual fields are limited and perception affected. Older age is a major risk factor and approximately 2% of the population is affected [34]. Openangle glaucoma, the most common type of glaucoma, is estimated to double (reaching nearly 3.6 million people) in 2020 due to the aging population. Older adults with glaucoma have reduced postural instability thus contributing to fall risk [35]. • Age-related macular degeneration: caused by deterioration of the retina. It is the major cause of severe vision loss in older adults, its
prevalence due to the aging population with future effect becoming nearly double its current rate. This condition affects central vision causing blurry vision or white spots, distortion of straight lines, and interferes with color perception [36]. The visual impairment is an intrinsic risk factor for falls and injuries, presents an unsafe condition, and creates a potential limitation in activities of daily living. Some of the conditions listed above may be preventable through early detection; however less than 50% of individuals who are eligible for eye exams access these services [37]. By bypassing these preventive services, persons increase their risk of visual impairments. Aside from the risk of falls, visual impairment and blindness can shortern life expectancy, reduce quality of life through limitation in performance of activities of daily living (Table 1), and is rated among the top ten most common causes for disability in the United States [24]. 2.1. Effect of visual impairments on function, quality of life, and psychosocial impact As vision becomes impaired, older adults experience greater problems with mobility. West et al. found that for every line lost of visual acuity, the odds for limitations to mobility increased 10%, while every 10% change in visual field equaled a 20% increase in the chance for mobility limitations [38]. Reduced mobility affects an older adult’s ability to perform Independent Activities of Daily Living (I-ADLs [39]). Disability in one or more I-ADLs occurs in 18% of older adults with minor visual impairment (beginning of glaucoma or ocular hypertensives with normal visual acutity and visual fields). This increases to 25% of older adults diagnosed with moderate visual impairment (glaucoma with visual field deficits and reduction in sensitivity in both eyes), and 43% of older adults diagnosed with advanced macular degeneration (visual acuity loss in both eyes). The top three activities reported to be the most difficult to perform are heavy housework (18.9%), traveling beyond walking distance (14.7%), and grocery shopping (13.6%). Individuals with glaucoma and advanced macular degeneration also report difficulty with preparing meals, managing finances, using the phone, and taking their medications [39]. Reduced ability in these I-ADLs represents significant impact to an older adult’s independence and well-being. Visual deficits also have a significant impact on psychosocial health in older adults. Fear of falling (FOF) is reported more frequently in older individuals with visual acuity impairments than those without [40]. Even after making adjustments for decreased visual acuity, any form of visual deficit produces a greater FOF. Fear of falling limits an older adult’s ability to ambulate, impairing ADL function, and leads to difficulty leaving the home and limited participation in physical activities [40]. Therefore, visual impairments have a multifaceted impact on mobility of older adults, not only impeding I-ADLs directly but by also impeding I-ADLs indirectly through significant psychosocial impact. Finally, the types of medications subjects take in unison can affect vision and as a result fall risk. 2.2. Pharmacological considerations for vision and falls Medication use is a factor associated with falls in older adults [41–43]. Polypharmacy, particularly the use of four or more medications, increases the risk of falling [41]. Additionally, the use of certain classes of medications, including sedatives, hypnotics, anti-psychotics, anti-depressants, and anti-arrhythmics have demonstrated an increased association with falls [43,44]. Although the use of medications may predispose older adults to
Please cite this article in press as: Reed-Jones RJ, et al. Vision and falls: A multidisciplinary review of the contributions of visual impairment to falls among older adults. Maturitas (2013), http://dx.doi.org/10.1016/j.maturitas.2013.01.019
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Table 1 Common types of visual impairments in older adults and their effects on activities of daily living. Condition
Visual effect
Effect on function
Presbyopia Cataract
Inability to see small objects, small print, at close proximity Blurred vision, Glaring of bright light
Glaucoma (open angle)
Affects peripheral vision
Macular degeneration
Affects central vision: distortion of lines, white spots, color perception
Need for multifocal lenses that may interfere in depth perception Limits mobility as may run into objects, limits night driving, limits ability to read instructions Creates “tunnel” vision and limits object perception in visual fields Limits recognition of objects, colors, and visual fields
falls, medications may also cause changes in vision or vision loss, another risk factor for falls in older adults [45,46]. Many medications can lead to ocular adverse events [47,48]. Drugs that possess anticholinergic properties, such as antihistamines, antipsychotics, and tricyclic antidepressants, are associated with visual disturbances including blurred vision, diplopia (double-vision), and cycloplegia (loss of accommodation). Amiodarone is a commonly used anti-arrhythmic agent that can cause dose-dependent corneal deposits that may lead to lens opacities and halo vision. Anti-malarial medications such as chloroquine and hydroxychloroquine also cause corneal deposits in most patients at therapeutic doses. Medications used for the treatment of erectile dysfunction (i.e. phosphodiesterase type 5 inhibitors) have also been associated with visual disturbances. These effects include blurred vision, changes in color perception, and photophobia. Reports of blurred vision have also been reported with the use of benzodiazepines, selective serotonin reuptake inhibitors, and alpha blockers (i.e. doxazosin, tamsulosin, terazosin). Table 2 provides a summary of select medication classes that have been reported to cause changes in vision. It is difficult to ascertain the incidence of ocular adverse effects induced by medications because many other factors play a role in the development of these side effects, including frequency of administration, cumulative dose, and genetic predisposition. Furthermore, the mechanisms for the development of drug-induced visual disturbances are multifactorial and may involve either direct or indirect effects of the drug on ocular structures [47,49]. Early identification of ocular adverse effects caused by medications is an important first step in the management of these disturbances should they occur. Health care providers may take varying approaches to managing these side effects, including dose-reduction, discontinuation of the medication, or increased monitoring through ophthalmic examinations [47,50]. Because medications can contribute to falls by inducing changes in vision and vision loss, it is imperative that health care providers take a detailed medication history when assessing patients who report subjective changes in vision or who have decreased visual acuity noted in vision screening assessments [50]. However, the impact of visual decline on ADLs and falls risk goes beyond visual acuity. Recently, cognitive function specifically related to vision processing (visual cognition), has come under investigation in falls risk. This emerging area of research provides critical knowledge for fall prevention efforts. 2.3. Role of visual cognition in falls and mobility There is increasing evidence that decreased visual cognition also contributes significantly to falling [38,51–54]. Table 3 summarizes the association of visual cognition and falls risk. Visual cognition includes factors such as visual attention, visual-spatial ability and visual processing. These processes are an essential component of adaptive locomotion, the ability to negotiate hazards in the environment (e.g. obstacle avoidance). Vision allows a person to identify a potential hazard in the travel path and triggers a cascade effect
Difficulty climbing stairs and outdoor activities Difficulty with ADL’s and potential isolation Difficulty with IADL’s and ADL’s, Difficulty with IADL’s and ADL’s with high risk for isolation and depression
in the central nervous system to plan a motor response. Reductions in visual processing speed contribute to increased response time in older adults during obstacle avoidance, reducing successful avoidance when available response times are low [55]. Research has shown that lower visual attention (specifically divided visual attention) significantly predicts greater obstacle collisions when walking, over and above visual acuity and cognitive tests alone [51]. Reduced divided visual attention is also associated with increased collision risk while driving, as well as propensity for falls [52,56,57]. These studies used the Useful Field of View (UFOV® ) test, a computer-based test that measures the speed at which an individual can extract visual information at a brief glance [58]. Recent research also indicates the possibility that the association of visual cognitive decline and increased falls risk is independent from general cognitive decline. Nagamatsu et al. studied cortical evoked potentials in fallers and non-fallers and noted that fallers showed no difference in attentional control or cognitive processing when compared to non-fallers but that they did show significant impairments in the ability of attention to modulate visual processing [53]. Furthermore, Martin et al. found that visual constructional ability (a measure of visual-spatial ability) explained most of the variability in a composite falls risk score followed by executive function and memory [54]. Adaptation of vision may also play a key role in falls risk. West et al. conducted an extensive experiment with a number of vision variables. These authors found that visual fields (standard and attentional) and adaptive vision (ability to adjust to lighting differences) played significant roles in self-reported mobility limitations as well as poorer performance on physical tasks such as walking and chair stands [38]. Finally, visuo-motor processing may be disrupted in fall prone older adults. Young and Hollands studied the saccadic eye movements made during visually guided stepping reactions in gait. Older adults who were prone to falling had significantly slower saccades and increased stepping errors when compared to older adults with low fall risk [59]. Together the above studies support that visual cognitive influences on fall risk go beyond those of cognitive influences alone. Given the few studies that have examined visual cognition in association with fall risk (Table 3), there is a great need for future research in this area. Considering that trips, slips and environmental hazards such as obstacles are the most commonly reported cause of a fall [19–21], these visual cognitive variables are a critical aspect of evaluating fall risk. The question then arises, how can we address visual cognitive factors in efforts for fall prevention and management? Declines in visual acuity and visual cognition result from the healthy aging process itself [38,60], however research indicates that exercise may help stave off age related decline. 3. Current interventions for vision and falls among older adults Most research regarding vision and falls among older adults has focused on the issues of visual acuity. Several excellent review
Please cite this article in press as: Reed-Jones RJ, et al. Vision and falls: A multidisciplinary review of the contributions of visual impairment to falls among older adults. Maturitas (2013), http://dx.doi.org/10.1016/j.maturitas.2013.01.019
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Table 2 Summary of medications and the ocular adverse effects of each. Medication or pharmacologic class of medications
Ocular adverse effect(s)
Additional comments
Amiodarone (anti-arrhythmic)
Bilateral corneal deposits may occur, causing lens opacities and/or halo vision. Although rare, optic neuropathy may lead to blindness
Minimal corneal deposits in patients taking <200 mg/day; Almost all patients develop corneal deposits at doses >400 mg/day
Anticholinergics (e.g. antihistamines, antipsychotics, tricyclic antidepressants)
Blurred vision, diplopia, cycloplegia
Anti-malarials (e.g. Chloroquine, Hydroxychloroquine)
Corneal deposits, blurred vision, accommodation disturbances, visual field defects, maculopathy, retinopathy
Corneal deposits occur in nearly all patients at therapeutic doses. Other effects (maculopathy, retinopathy) are rare and associated with long-term, high dose therapy
Anti-epileptics (e.g. carbamazepine, phenytoin, topiramate)
Blurred vision, diplopia, lens opacities, nystagmus
Ocular adverse effects of phenytoin are related to the concentration of phenytoin in the plasma
Corticosteroids (topical or systemic)
Cataracts, increased intraocular pressure (IOP), decreased vision
Risk of cataracts is increased in patients who have been on doses of 15 mg/day of prednisone or its equivalent for more than one year. Elevation of IOP is more common with topical corticosteroids
Cardiac glycosides (e.g. digitalis, digoxin)
Blurred or yellow vision, decreased visual acuity, changes in visual fields, halo vision
Non-steroidal anti-inflammatory medications (e.g. diclofenac, ibuprofen, indomethacin, ketorolac, naproxen)
Blurred vision, abnormal vision including visual field defects, diplopia
Incidence of these effects are rare (<1%) for most of these agents
Phosphodiesterase Type 5 inhibitors (e.g. sildenafil, tadalafil, vardenafil)
Blurred vision, changes in color perception, and photophobia
Ocular effects are dose-dependent
Tamoxifen (antineoplastic, estrogen receptor antagonist)
Corneal opacities, cataracts, color perception changes, retinopathy
More likely in patients taking doses that are higher-than normal
Information from: Lexi-Comp [48], Pellitier [50], Kaakeh [47], Santaella and Fraunfelder [49].
papers have been published on the topic [61–64]. Therefore, recommendations for vision in fall prevention have generally included regular eye exams for appropriate corrective eyewear and diagnosis of visual impairment disorders such as cataracts, glaucoma, and macular degeneration. However, the role of vision in fall events and issues that affect vision go beyond those of regular eye exams. Vision disturbances are a complex issue that includes visual cognitive factors. A large body of research has shown that regular physical exercise improves cognitive function in older adults, including variables of visual cognition (For reviews of this literature see 65,66]. These improvements are possibly the result of brain volume increases from exercise in areas responsible for visual processing and cognition [67]. For example, exercise has shown to increase circulation and function in the hippocampus, an area responsible for visual spatial processing [68]. However, despite the long-standing evidence for the benefits of exercise on visual cognition, few studies have examined interventions for improving visual cognition for fall prevention. Recent research using video game technologies, such as the Nintendo WiiTM , have shown improvement in obstacle collisions in older adults participating in regular physical exercise and video gaming [69]. These researchers have also found that some Wii test scores significantly correlate with divided attention on the UFOV® test, indicating that the Wii may involve processes similar to those of divided visual attention [70]. Preliminary findings
from this group have also shown that divided visual attention, as measured by the UFOV® , and other measures of visual cognition improve following Wii play and exercise [71,72]. Therefore, there are positive prospects for improving adaptive locomotion and visual cognition with exercise and video game play. The Wii could be a tool easily implemented in the home as a visual cognitive training tool. Clearly, this is an area for future research development as video game technologies advance and become increasingly integrated into approaches for fall prevention and management [73–76]. The advantage of these video game approaches is the incorporation of visual training with physical activities such as balance, aerobic, and strength exercises facilitating the inclusion of visual based interventions with interventions already known to improve mobility and function in older adults. In addition, training older adults where to direct their eyes may also benefit fall prevention efforts. Young and Hollands observed improved eye movement patterns and stepping performance following a 3-min instructional training video on where to look when walking and stepping [77]. This research suggests training can be very simple yet effective and is an area of research that would benefit fall prevention efforts both in care facilities and at home. 4. Implications and suggestions for health professionals Visual impairment is an intrinsic risk factor for falls with multiple effects such as limitation of the person’s physical function, fear
Table 3 Association between falls risk and visual cognitive function. Study
Type
West et al. [38]
Cohort
Vance et al. [52] Broman et al. [51] Martin et al. [54]
X-sec X-sec X-sec
N 782 694 1344 300
Falls risk
Visual-cognitive variable
Odds ratio (95% CI)
Self-reported mobility
Visual field-attentional Visual-spatial UFOV divided attention UFOV divided visual attention Visual constructional ability
1.13 (1.04,1.18) 1.11 (1.03,1.19) NA 1.08 (1.04,1.11) ˇ = –0.05 (−0.07, −0.02)
Self reported no. of falls No. of bumps on mobility test Composite falls risk score
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of falling, loss of independence, isolation, and an overall decline in the quality of life. Visual impairment and fall risk form a dyad often difficult to separate, which extends beyond simple recognition of the problem and requires a proactive approach. A comprehensive multidisciplinary health team approach that includes a detailed process for identifying personal and environmental hazards and unsafe behaviors can lead to effective evaluation and management plans for lessening a person’s risk for falls due to visual impairment. For example, the occupational therapist may focus on the status of footwear, immediate home environment, condition and location of furniture for cluttering or unsafe placement. While social workers need to focus on the psychological aspects such as coping mechanisms, presence of depression, perception of problem, family support, and availability of community resources. The pharmacist role, often overlooked, is of high importance in the older adult population who experience a high incidence of medication adverse events because of the physiological changes of aging and the higher incidence of polypharmacy in this age group. Pharmacists can assist in evaluating potential drug (prescribed, non-prescribed, and herbal products) effects and interactions that influence vision and fall risk factors independently. Nurses, who often have frequent interaction with patients, are in a perfect setting for evaluating not just visual acuity and the progression of visual loss but the effects of visual cognition on the ability to function and the existing comorbidities influencing the person’s health state. Nurses need to conduct fall risk evaluation along with other physiological components such as cognition, state of concomitant chronic illness, and treatment adherence. A greatly influential health team member that brings value to the evaluation of visual impairment in older adults with fall risk is the physical therapist who has expertise in balance and motor control deficits and brings greater perspective in the evaluation without merely focusing on visual acuity and strength. Furthermore, management plans for lessening the risk for falls and injuries due to visual impairment requires that the multidisciplinary team design individualized plans of care that are culturally and resource appropriate to address the identified problem. Once the evaluation is completed and problems or issues identified, recommendations need to be made and may include appropriate use of assistive devices, environmental modifications, collaboration with health care providers for consideration of medication modification, appropriate use of herbal products and monitoring of comorbidities as needed. Referral to community resources is crucial for ongoing support and sustainable physical and psychological services. Older adults with visual impairment need to be educated on fall risks and potential injury according to their identified needs with ongoing re-enforcement on a regular basis. Care plans must encompass the scope of care for each participating discipline with possible use of simulated problem solving exercises presented to the person. The multidisciplinary health team must look beyond conventional ways of treatment and seek out validated interventions such as the use of video games and other forms of visual training that can potentially improve visual cognition. Finally, there needs to be greater collaboration between scientists and health professionals to advance research efforts, and provide evidence based approaches for visual training and fall risk management. In conclusion, the high prevalence of vision impairment associated with aging creates a public health concern because of its potentially negative effect in fall risk and injury. Health care providers must be educated in the identification of such problems in a timely manner in order to minimize potential for disability and to maintain an acceptable quality of life as defined by the older adult. Provenance and peer review Commissioned and externally peer reviewed.
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Contributors Rebecca Reed-Jones participated in the organization, writing, and final editing of this paper and approved the final version. Guillermina Solis participated in the writing and editing of this paper and approved the final version. Katherine Lawson, Amanda Loya and Donna Cude-Islas participated in the writing of this paper and approved the final version. Candyce Berger participated in the writing and final editing and approved the final version. Competing interest The authors declare no conflict of interest. Funding Funding for this article was received from the Interdisciplinary Research (IDR) Enhancement Program made available through the Provost and Office of Research and Sponsored Projects, The University of Texas at El Paso. References [1] Violence and injury prevention and disability-falls. World Health Organization (WHO) http://www.who.int/violence injury prevention/other injury/ falls/en/; 2013. [2] Trends in health status and health care use among older men. Centers for Disease Control and Prevention, National Health Statistics Report 2010;24:1–20. [3] Public health and aging: trends in aging—United States and Worldwide. Mortality and Morbidity Weekly Review 2003;52(Feb, 6):101–6. http://www.cdc.gov/ mmwr/preview/mmwrhtml/mm5206a2.htm [4] Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clinics in Geriatric Medicine 2002;18:141–58. [5] Anemaet WK, Krulish LH. Fall risk assessments in home care: OASIS-C expectations. Home Health Care Management & Practice 2011;23(2):125–38. [6] National Prevention Council, Office of the Surgeon General, U.S. Department of Health and Human Services. National Prevention Strategy. Washington, DC: 2011. Available from http://www.healthcare.gov/prevention/nphpphc/ strategy/report.pdf [PDF—4.67MB] [accessed 14.03.2012]. [7] Guideline for the prevention of falls in older persons. Journal of the American Geriatric Society 2001;49:664–72. [8] Cost of falls among older adults. Centers for Disease Control and Prevention http://www.cdc.gov/HomeandRecreationalSafety/Falls/fallcost.html; 2009. [9] Public health and aging: nonfatal injuries among older adults treated in hospital emergency departments-United States. Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report 2003;52:1019–22. [10] Sterling DA, O’Connor JA, Bonadies J. Geriatric falls: injury severity is high and disproportionate to mechanism. Journal of Trauma—Injury, Infection and Critical Care 2001;50(1):116–9. [11] Jager TE, Weiss HB, Coben JH, Pepe PE. Traumatic brain injuries evaluated in U.S. emergency departments, 1992–1994. Academic Emergency Medicine 2000;7(2):134–40. [12] Bell AJ, Talbot-Stern JK, Hennessy A. Characteristics and outcomes of older patients presenting to the emergency department after a fall: a retrospective analysis. Medical Journal of Australia 2000;173(4):176–7. [13] Alexander BH, Rivera FP, Wolf ME. The cost and frequency of hospitalization for fall-related injuries in older adults. American Journal of Public Health 1992;82(7):1020–3. [14] Chou WC, Tinetti ME, King MB, Irwin K, Fortinisky RH. Perceptions of physicians on the barriers and facilitators to integrating fall risk evaluation and management into practice. Journal of General Internal Medicine 2006;21:117–22. [15] Fortinsky RH, Baker D, Gottschalk M, King M, Trella P, Tinetti ME. Extend of implementation of evidence-based fall prevention practices for older patients in home health care. Journal of the American Geriatric Society 2008;56:737–43. [16] Tinetti ME. Preventing falls in elderly persons. The New England Journal of Medicine 2003;348(1):42–9. [17] Tinetti ME, Baker DI, McAvay G, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. The New England Journal of Medicine 1994;331(13):821–7. [18] Tinetti ME, Speechley M, Ginter SE. Risk factors for falls among elderly persons living in the community. The New England Journal of Medicine 1988;319:1701–7. [19] Berg WR, Alessio HM, Mills EM, Tong C. Circumstances and consequences of falls in independent community-dwelling older adults. Age and Ageing 1997;26:261–8. [20] Lord R, Dayhew B, Howland. Multifocal glasses impair edge-contrast sensitivity and depth perception and increase the risk of falls in older people. Journal Aging and Geriatric Society 2002;50:1760–6.
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Contents lists available at SciVerse ScienceDirect
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Vision and falls: A multidisciplinary review of the contributions of visual impairment to falls among older adults Rebecca J. Reed-Jones a,b,∗ , Guillermina R. Solis c , Katherine A. Lawson d , Amanda M. Loya e , Donna Cude-Islas f , Candyce S. Berger f a
Department of Kinesiology, College of Health Sciences, The University of Texas at El Paso, United States Physical Therapy Program, Department of Rehabilitation Sciences, College of Health Sciences, The University of Texas at El Paso, United States c School of Nursing, The University of Texas at El Paso, United States d Occupational Therapy Program, Department of Rehabilitation, College of Health Sciences, The University of Texas at El Paso, United States e Cooperative Pharmacy Program, College of Health Sciences, The University of Texas at El Paso, and College of Pharmacy, The University of Texas at Austin, United States f Department of Social Work, College of Health Sciences, The University of Texas at El Paso, United States b
a r t i c l e
i n f o
Article history: Received 19 January 2013 Accepted 21 January 2013 Available online xxx Keywords: Falls Vision Visual impairment Fall prevention Risk factors
a b s t r a c t Falls are a leading cause of mortality among older adults worldwide. With the increasing aging population, falls are rapidly becoming a public health concern. Numerous internal and external factors have been associated with an older adult’s increased risk of falling. Most notably visual impairments are gaining recognition for their critical role in fall events, particularly related to trips, slips and falls due to environmental hazards. This review presents the issue of vision and falls from a multidisciplinary health professional perspective. Discussions include the influence of visual impairment on mobility and activities of daily living, the effects of medications on vision, visual cognitive factors on falls risk and visual training interventions. Finally, implications for multidisciplinary health professional practice and suggestions for future research are offered. © 2013 Elsevier Ireland Ltd. All rights reserved.
1. Introduction 1.1. Definition of a fall A fall is an event where a person inadvertently comes to rest on the ground (floor) or other lower level [1]. Globally, adults over the age of 70 years are at higher risk for fall related mortality [1]. Visual impairment is an independent risk factor for falls among older adults, however; older adults typically underreport visual impairment and it is an underrepresented area of research. The aim of this review is to present the issues surrounding vision and falls in older adults through a multidisciplinary health professional lens, providing a comprehensive picture of the problem, and offering recommendations and thoughts for future research and evidence based practice. 1.2. Falls among older adults Falls among non-institutionalized older adults are growing in epidemic proportions. Given the growth in the elderly population,
∗ Corresponding author at: Department of Kinesiology, College of Health Sciences, The University of Texas at El Paso, 500W University Ave, El Paso, TX 79968, United States. Tel.: +1 915 747 7239. E-mail address: [email protected] (R.J. Reed-Jones).
this represents a major concern for health care providers and health care costs. According to recent census data, 13% of the U.S. population is 65 years of age or older and 1.9% is 85 or older [2]. The growth of older adults has increased at a greater rate (15.1%) than the general population and by 2030, the number of older adults (65 or older) will double to about 71 million [3]. This rapid growth of the elderly has far-reaching implications for public health, placing an unprecedented demand on health care delivery for age-related services. The data on falls among older adults points to significant issues related to mortality and morbidity. Approximately 35–40% of noninstitutionalized adults fall each year, increasing to 50% for those 75 or older [4–6]. Mortality rates for falls among older adults parallels this growth in fall rates. Research has shown that falls are the fifth leading cause of death among the elderly (55+) [5–7], the National Prevention Council (2011) reports that 45.3 deaths per 100,000 older adults are the result of a fall [6]. Falls also contribute to morbidity among the elderly [8]. Nonfatal falls accounts for 1.6 million emergency room visits and 388,200 hospitalizations each year [5,9]. Non-fatal falls have longterm impact on the physical, financial and emotional well-being of older adults accounting for incidence in fractures, internal organ injuries, joint dislocations and closed head injuries [10–13]. Research has identified two major categories of risk factors leading to falls: extrinsic/environmental factors and intrinsic factors
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[7,14–18]. Extrinsic risk factors are factors within the individual’s environment. Some examples of extrinsic and environmental risk factors include, use of assistive devices and walking aids, poor flooring, inadequate lighting, area rugs, absence of handrails, and broken or uneven sidewalks and stairs. Intrinsic risks factors relate to characteristics within the individual. Examples of intrinsic risk factors include type and number of medications taken, muscle weakness, age, disease, prior falls history and the number of total risk factors. Another intrinsic risk factor that is gaining increased attention is the area of visual impairment. Of the risk factors that contribute to increased fall risk, vision is one of the most underestimated contributors, despite the implication of vision in a majority of fall events. Visual impairment reduces a person’s ability to detect hazards in the environment. As a predominant number of falls occur due to slips, trips [19,20] and/or interaction with an environmental hazard [21], vision boasts to be a leading issue when evaluating falls risk. In addition, the inclusion of vision in guidelines for fall prevention is limited. Most recommendations for visual health include regular eye evaluations and up to date corrective lenses [22,23], but these do not fully address the complexity of vision and its role in falls. Given the potential importance of vision in events leading to a fall, there is a need for greater awareness of the impact of visual deficits on falls risk. 2. Vision and falls Vision loss in older adults is the third most common chronic condition next to arthritis and heart disease [24]. Impaired vision has been identified as an independent risk for falls associated with decreased postural stability, the occurrence of two or more falls, and fractures during fall events [25–28]. Vision is essential to a person’s ability to plan and coordinate movement in response to environmental hazards as well as assist with balance [29]. Although, visual impairment is a common problem in older adults, it is often an underreported problem [30]. The most prevalent agerelated causes of visual impairment include presbyopia, cataracts, glaucoma, and macular degeneration [24,31]. These conditions are described as follows: • Presbyopia: a problem of seeing objects at close range or small print leads to a need to wear bifocal corrective lenses, a unique problem of aging. Older adults who are required to wear multifocal glasses are twice as likely to fall as older adults who do not wear multifocal glasses [20]. Wearing multifocal glasses increases the risk of falls due to impaired depth perception and edge-contrast sensitivity, which presents a problem when negotiating stairs and settings outside of the home. As such, bifocal lenses may increase risk for injurious outdoor falls in older adults because of greater propensity of tripping and approximation of unexpected objects or barriers [32]. • Cataracts: a cloudiness of the crystalline lens, most commonly occurs as part of the aging process and is one of the significant causes for vision loss with over 50% of older adults 80 years old and older. It is the leading cause of blindness in middle and lowincome world countries (WHO [33]). • Glaucoma: a group of conditions that can potentially damage the optic nerve and lead to blindness. It causes loss of peripheral vision creating a greater risk for falls as visual fields are limited and perception affected. Older age is a major risk factor and approximately 2% of the population is affected [34]. Openangle glaucoma, the most common type of glaucoma, is estimated to double (reaching nearly 3.6 million people) in 2020 due to the aging population. Older adults with glaucoma have reduced postural instability thus contributing to fall risk [35]. • Age-related macular degeneration: caused by deterioration of the retina. It is the major cause of severe vision loss in older adults, its
prevalence due to the aging population with future effect becoming nearly double its current rate. This condition affects central vision causing blurry vision or white spots, distortion of straight lines, and interferes with color perception [36]. The visual impairment is an intrinsic risk factor for falls and injuries, presents an unsafe condition, and creates a potential limitation in activities of daily living. Some of the conditions listed above may be preventable through early detection; however less than 50% of individuals who are eligible for eye exams access these services [37]. By bypassing these preventive services, persons increase their risk of visual impairments. Aside from the risk of falls, visual impairment and blindness can shortern life expectancy, reduce quality of life through limitation in performance of activities of daily living (Table 1), and is rated among the top ten most common causes for disability in the United States [24]. 2.1. Effect of visual impairments on function, quality of life, and psychosocial impact As vision becomes impaired, older adults experience greater problems with mobility. West et al. found that for every line lost of visual acuity, the odds for limitations to mobility increased 10%, while every 10% change in visual field equaled a 20% increase in the chance for mobility limitations [38]. Reduced mobility affects an older adult’s ability to perform Independent Activities of Daily Living (I-ADLs [39]). Disability in one or more I-ADLs occurs in 18% of older adults with minor visual impairment (beginning of glaucoma or ocular hypertensives with normal visual acutity and visual fields). This increases to 25% of older adults diagnosed with moderate visual impairment (glaucoma with visual field deficits and reduction in sensitivity in both eyes), and 43% of older adults diagnosed with advanced macular degeneration (visual acuity loss in both eyes). The top three activities reported to be the most difficult to perform are heavy housework (18.9%), traveling beyond walking distance (14.7%), and grocery shopping (13.6%). Individuals with glaucoma and advanced macular degeneration also report difficulty with preparing meals, managing finances, using the phone, and taking their medications [39]. Reduced ability in these I-ADLs represents significant impact to an older adult’s independence and well-being. Visual deficits also have a significant impact on psychosocial health in older adults. Fear of falling (FOF) is reported more frequently in older individuals with visual acuity impairments than those without [40]. Even after making adjustments for decreased visual acuity, any form of visual deficit produces a greater FOF. Fear of falling limits an older adult’s ability to ambulate, impairing ADL function, and leads to difficulty leaving the home and limited participation in physical activities [40]. Therefore, visual impairments have a multifaceted impact on mobility of older adults, not only impeding I-ADLs directly but by also impeding I-ADLs indirectly through significant psychosocial impact. Finally, the types of medications subjects take in unison can affect vision and as a result fall risk. 2.2. Pharmacological considerations for vision and falls Medication use is a factor associated with falls in older adults [41–43]. Polypharmacy, particularly the use of four or more medications, increases the risk of falling [41]. Additionally, the use of certain classes of medications, including sedatives, hypnotics, anti-psychotics, anti-depressants, and anti-arrhythmics have demonstrated an increased association with falls [43,44]. Although the use of medications may predispose older adults to
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Table 1 Common types of visual impairments in older adults and their effects on activities of daily living. Condition
Visual effect
Effect on function
Presbyopia Cataract
Inability to see small objects, small print, at close proximity Blurred vision, Glaring of bright light
Glaucoma (open angle)
Affects peripheral vision
Macular degeneration
Affects central vision: distortion of lines, white spots, color perception
Need for multifocal lenses that may interfere in depth perception Limits mobility as may run into objects, limits night driving, limits ability to read instructions Creates “tunnel” vision and limits object perception in visual fields Limits recognition of objects, colors, and visual fields
falls, medications may also cause changes in vision or vision loss, another risk factor for falls in older adults [45,46]. Many medications can lead to ocular adverse events [47,48]. Drugs that possess anticholinergic properties, such as antihistamines, antipsychotics, and tricyclic antidepressants, are associated with visual disturbances including blurred vision, diplopia (double-vision), and cycloplegia (loss of accommodation). Amiodarone is a commonly used anti-arrhythmic agent that can cause dose-dependent corneal deposits that may lead to lens opacities and halo vision. Anti-malarial medications such as chloroquine and hydroxychloroquine also cause corneal deposits in most patients at therapeutic doses. Medications used for the treatment of erectile dysfunction (i.e. phosphodiesterase type 5 inhibitors) have also been associated with visual disturbances. These effects include blurred vision, changes in color perception, and photophobia. Reports of blurred vision have also been reported with the use of benzodiazepines, selective serotonin reuptake inhibitors, and alpha blockers (i.e. doxazosin, tamsulosin, terazosin). Table 2 provides a summary of select medication classes that have been reported to cause changes in vision. It is difficult to ascertain the incidence of ocular adverse effects induced by medications because many other factors play a role in the development of these side effects, including frequency of administration, cumulative dose, and genetic predisposition. Furthermore, the mechanisms for the development of drug-induced visual disturbances are multifactorial and may involve either direct or indirect effects of the drug on ocular structures [47,49]. Early identification of ocular adverse effects caused by medications is an important first step in the management of these disturbances should they occur. Health care providers may take varying approaches to managing these side effects, including dose-reduction, discontinuation of the medication, or increased monitoring through ophthalmic examinations [47,50]. Because medications can contribute to falls by inducing changes in vision and vision loss, it is imperative that health care providers take a detailed medication history when assessing patients who report subjective changes in vision or who have decreased visual acuity noted in vision screening assessments [50]. However, the impact of visual decline on ADLs and falls risk goes beyond visual acuity. Recently, cognitive function specifically related to vision processing (visual cognition), has come under investigation in falls risk. This emerging area of research provides critical knowledge for fall prevention efforts. 2.3. Role of visual cognition in falls and mobility There is increasing evidence that decreased visual cognition also contributes significantly to falling [38,51–54]. Table 3 summarizes the association of visual cognition and falls risk. Visual cognition includes factors such as visual attention, visual-spatial ability and visual processing. These processes are an essential component of adaptive locomotion, the ability to negotiate hazards in the environment (e.g. obstacle avoidance). Vision allows a person to identify a potential hazard in the travel path and triggers a cascade effect
Difficulty climbing stairs and outdoor activities Difficulty with ADL’s and potential isolation Difficulty with IADL’s and ADL’s, Difficulty with IADL’s and ADL’s with high risk for isolation and depression
in the central nervous system to plan a motor response. Reductions in visual processing speed contribute to increased response time in older adults during obstacle avoidance, reducing successful avoidance when available response times are low [55]. Research has shown that lower visual attention (specifically divided visual attention) significantly predicts greater obstacle collisions when walking, over and above visual acuity and cognitive tests alone [51]. Reduced divided visual attention is also associated with increased collision risk while driving, as well as propensity for falls [52,56,57]. These studies used the Useful Field of View (UFOV® ) test, a computer-based test that measures the speed at which an individual can extract visual information at a brief glance [58]. Recent research also indicates the possibility that the association of visual cognitive decline and increased falls risk is independent from general cognitive decline. Nagamatsu et al. studied cortical evoked potentials in fallers and non-fallers and noted that fallers showed no difference in attentional control or cognitive processing when compared to non-fallers but that they did show significant impairments in the ability of attention to modulate visual processing [53]. Furthermore, Martin et al. found that visual constructional ability (a measure of visual-spatial ability) explained most of the variability in a composite falls risk score followed by executive function and memory [54]. Adaptation of vision may also play a key role in falls risk. West et al. conducted an extensive experiment with a number of vision variables. These authors found that visual fields (standard and attentional) and adaptive vision (ability to adjust to lighting differences) played significant roles in self-reported mobility limitations as well as poorer performance on physical tasks such as walking and chair stands [38]. Finally, visuo-motor processing may be disrupted in fall prone older adults. Young and Hollands studied the saccadic eye movements made during visually guided stepping reactions in gait. Older adults who were prone to falling had significantly slower saccades and increased stepping errors when compared to older adults with low fall risk [59]. Together the above studies support that visual cognitive influences on fall risk go beyond those of cognitive influences alone. Given the few studies that have examined visual cognition in association with fall risk (Table 3), there is a great need for future research in this area. Considering that trips, slips and environmental hazards such as obstacles are the most commonly reported cause of a fall [19–21], these visual cognitive variables are a critical aspect of evaluating fall risk. The question then arises, how can we address visual cognitive factors in efforts for fall prevention and management? Declines in visual acuity and visual cognition result from the healthy aging process itself [38,60], however research indicates that exercise may help stave off age related decline. 3. Current interventions for vision and falls among older adults Most research regarding vision and falls among older adults has focused on the issues of visual acuity. Several excellent review
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Table 2 Summary of medications and the ocular adverse effects of each. Medication or pharmacologic class of medications
Ocular adverse effect(s)
Additional comments
Amiodarone (anti-arrhythmic)
Bilateral corneal deposits may occur, causing lens opacities and/or halo vision. Although rare, optic neuropathy may lead to blindness
Minimal corneal deposits in patients taking <200 mg/day; Almost all patients develop corneal deposits at doses >400 mg/day
Anticholinergics (e.g. antihistamines, antipsychotics, tricyclic antidepressants)
Blurred vision, diplopia, cycloplegia
Anti-malarials (e.g. Chloroquine, Hydroxychloroquine)
Corneal deposits, blurred vision, accommodation disturbances, visual field defects, maculopathy, retinopathy
Corneal deposits occur in nearly all patients at therapeutic doses. Other effects (maculopathy, retinopathy) are rare and associated with long-term, high dose therapy
Anti-epileptics (e.g. carbamazepine, phenytoin, topiramate)
Blurred vision, diplopia, lens opacities, nystagmus
Ocular adverse effects of phenytoin are related to the concentration of phenytoin in the plasma
Corticosteroids (topical or systemic)
Cataracts, increased intraocular pressure (IOP), decreased vision
Risk of cataracts is increased in patients who have been on doses of 15 mg/day of prednisone or its equivalent for more than one year. Elevation of IOP is more common with topical corticosteroids
Cardiac glycosides (e.g. digitalis, digoxin)
Blurred or yellow vision, decreased visual acuity, changes in visual fields, halo vision
Non-steroidal anti-inflammatory medications (e.g. diclofenac, ibuprofen, indomethacin, ketorolac, naproxen)
Blurred vision, abnormal vision including visual field defects, diplopia
Incidence of these effects are rare (<1%) for most of these agents
Phosphodiesterase Type 5 inhibitors (e.g. sildenafil, tadalafil, vardenafil)
Blurred vision, changes in color perception, and photophobia
Ocular effects are dose-dependent
Tamoxifen (antineoplastic, estrogen receptor antagonist)
Corneal opacities, cataracts, color perception changes, retinopathy
More likely in patients taking doses that are higher-than normal
Information from: Lexi-Comp [48], Pellitier [50], Kaakeh [47], Santaella and Fraunfelder [49].
papers have been published on the topic [61–64]. Therefore, recommendations for vision in fall prevention have generally included regular eye exams for appropriate corrective eyewear and diagnosis of visual impairment disorders such as cataracts, glaucoma, and macular degeneration. However, the role of vision in fall events and issues that affect vision go beyond those of regular eye exams. Vision disturbances are a complex issue that includes visual cognitive factors. A large body of research has shown that regular physical exercise improves cognitive function in older adults, including variables of visual cognition (For reviews of this literature see 65,66]. These improvements are possibly the result of brain volume increases from exercise in areas responsible for visual processing and cognition [67]. For example, exercise has shown to increase circulation and function in the hippocampus, an area responsible for visual spatial processing [68]. However, despite the long-standing evidence for the benefits of exercise on visual cognition, few studies have examined interventions for improving visual cognition for fall prevention. Recent research using video game technologies, such as the Nintendo WiiTM , have shown improvement in obstacle collisions in older adults participating in regular physical exercise and video gaming [69]. These researchers have also found that some Wii test scores significantly correlate with divided attention on the UFOV® test, indicating that the Wii may involve processes similar to those of divided visual attention [70]. Preliminary findings
from this group have also shown that divided visual attention, as measured by the UFOV® , and other measures of visual cognition improve following Wii play and exercise [71,72]. Therefore, there are positive prospects for improving adaptive locomotion and visual cognition with exercise and video game play. The Wii could be a tool easily implemented in the home as a visual cognitive training tool. Clearly, this is an area for future research development as video game technologies advance and become increasingly integrated into approaches for fall prevention and management [73–76]. The advantage of these video game approaches is the incorporation of visual training with physical activities such as balance, aerobic, and strength exercises facilitating the inclusion of visual based interventions with interventions already known to improve mobility and function in older adults. In addition, training older adults where to direct their eyes may also benefit fall prevention efforts. Young and Hollands observed improved eye movement patterns and stepping performance following a 3-min instructional training video on where to look when walking and stepping [77]. This research suggests training can be very simple yet effective and is an area of research that would benefit fall prevention efforts both in care facilities and at home. 4. Implications and suggestions for health professionals Visual impairment is an intrinsic risk factor for falls with multiple effects such as limitation of the person’s physical function, fear
Table 3 Association between falls risk and visual cognitive function. Study
Type
West et al. [38]
Cohort
Vance et al. [52] Broman et al. [51] Martin et al. [54]
X-sec X-sec X-sec
N 782 694 1344 300
Falls risk
Visual-cognitive variable
Odds ratio (95% CI)
Self-reported mobility
Visual field-attentional Visual-spatial UFOV divided attention UFOV divided visual attention Visual constructional ability
1.13 (1.04,1.18) 1.11 (1.03,1.19) NA 1.08 (1.04,1.11) ˇ = –0.05 (−0.07, −0.02)
Self reported no. of falls No. of bumps on mobility test Composite falls risk score
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of falling, loss of independence, isolation, and an overall decline in the quality of life. Visual impairment and fall risk form a dyad often difficult to separate, which extends beyond simple recognition of the problem and requires a proactive approach. A comprehensive multidisciplinary health team approach that includes a detailed process for identifying personal and environmental hazards and unsafe behaviors can lead to effective evaluation and management plans for lessening a person’s risk for falls due to visual impairment. For example, the occupational therapist may focus on the status of footwear, immediate home environment, condition and location of furniture for cluttering or unsafe placement. While social workers need to focus on the psychological aspects such as coping mechanisms, presence of depression, perception of problem, family support, and availability of community resources. The pharmacist role, often overlooked, is of high importance in the older adult population who experience a high incidence of medication adverse events because of the physiological changes of aging and the higher incidence of polypharmacy in this age group. Pharmacists can assist in evaluating potential drug (prescribed, non-prescribed, and herbal products) effects and interactions that influence vision and fall risk factors independently. Nurses, who often have frequent interaction with patients, are in a perfect setting for evaluating not just visual acuity and the progression of visual loss but the effects of visual cognition on the ability to function and the existing comorbidities influencing the person’s health state. Nurses need to conduct fall risk evaluation along with other physiological components such as cognition, state of concomitant chronic illness, and treatment adherence. A greatly influential health team member that brings value to the evaluation of visual impairment in older adults with fall risk is the physical therapist who has expertise in balance and motor control deficits and brings greater perspective in the evaluation without merely focusing on visual acuity and strength. Furthermore, management plans for lessening the risk for falls and injuries due to visual impairment requires that the multidisciplinary team design individualized plans of care that are culturally and resource appropriate to address the identified problem. Once the evaluation is completed and problems or issues identified, recommendations need to be made and may include appropriate use of assistive devices, environmental modifications, collaboration with health care providers for consideration of medication modification, appropriate use of herbal products and monitoring of comorbidities as needed. Referral to community resources is crucial for ongoing support and sustainable physical and psychological services. Older adults with visual impairment need to be educated on fall risks and potential injury according to their identified needs with ongoing re-enforcement on a regular basis. Care plans must encompass the scope of care for each participating discipline with possible use of simulated problem solving exercises presented to the person. The multidisciplinary health team must look beyond conventional ways of treatment and seek out validated interventions such as the use of video games and other forms of visual training that can potentially improve visual cognition. Finally, there needs to be greater collaboration between scientists and health professionals to advance research efforts, and provide evidence based approaches for visual training and fall risk management. In conclusion, the high prevalence of vision impairment associated with aging creates a public health concern because of its potentially negative effect in fall risk and injury. Health care providers must be educated in the identification of such problems in a timely manner in order to minimize potential for disability and to maintain an acceptable quality of life as defined by the older adult. Provenance and peer review Commissioned and externally peer reviewed.
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Contributors Rebecca Reed-Jones participated in the organization, writing, and final editing of this paper and approved the final version. Guillermina Solis participated in the writing and editing of this paper and approved the final version. Katherine Lawson, Amanda Loya and Donna Cude-Islas participated in the writing of this paper and approved the final version. Candyce Berger participated in the writing and final editing and approved the final version. Competing interest The authors declare no conflict of interest. Funding Funding for this article was received from the Interdisciplinary Research (IDR) Enhancement Program made available through the Provost and Office of Research and Sponsored Projects, The University of Texas at El Paso. References [1] Violence and injury prevention and disability-falls. World Health Organization (WHO) http://www.who.int/violence injury prevention/other injury/ falls/en/; 2013. [2] Trends in health status and health care use among older men. Centers for Disease Control and Prevention, National Health Statistics Report 2010;24:1–20. [3] Public health and aging: trends in aging—United States and Worldwide. Mortality and Morbidity Weekly Review 2003;52(Feb, 6):101–6. http://www.cdc.gov/ mmwr/preview/mmwrhtml/mm5206a2.htm [4] Rubenstein LZ, Josephson KR. The epidemiology of falls and syncope. Clinics in Geriatric Medicine 2002;18:141–58. [5] Anemaet WK, Krulish LH. Fall risk assessments in home care: OASIS-C expectations. Home Health Care Management & Practice 2011;23(2):125–38. [6] National Prevention Council, Office of the Surgeon General, U.S. Department of Health and Human Services. National Prevention Strategy. Washington, DC: 2011. Available from http://www.healthcare.gov/prevention/nphpphc/ strategy/report.pdf [PDF—4.67MB] [accessed 14.03.2012]. [7] Guideline for the prevention of falls in older persons. Journal of the American Geriatric Society 2001;49:664–72. [8] Cost of falls among older adults. Centers for Disease Control and Prevention http://www.cdc.gov/HomeandRecreationalSafety/Falls/fallcost.html; 2009. [9] Public health and aging: nonfatal injuries among older adults treated in hospital emergency departments-United States. Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report 2003;52:1019–22. [10] Sterling DA, O’Connor JA, Bonadies J. Geriatric falls: injury severity is high and disproportionate to mechanism. Journal of Trauma—Injury, Infection and Critical Care 2001;50(1):116–9. [11] Jager TE, Weiss HB, Coben JH, Pepe PE. Traumatic brain injuries evaluated in U.S. emergency departments, 1992–1994. Academic Emergency Medicine 2000;7(2):134–40. [12] Bell AJ, Talbot-Stern JK, Hennessy A. Characteristics and outcomes of older patients presenting to the emergency department after a fall: a retrospective analysis. Medical Journal of Australia 2000;173(4):176–7. [13] Alexander BH, Rivera FP, Wolf ME. The cost and frequency of hospitalization for fall-related injuries in older adults. American Journal of Public Health 1992;82(7):1020–3. [14] Chou WC, Tinetti ME, King MB, Irwin K, Fortinisky RH. Perceptions of physicians on the barriers and facilitators to integrating fall risk evaluation and management into practice. Journal of General Internal Medicine 2006;21:117–22. [15] Fortinsky RH, Baker D, Gottschalk M, King M, Trella P, Tinetti ME. Extend of implementation of evidence-based fall prevention practices for older patients in home health care. Journal of the American Geriatric Society 2008;56:737–43. [16] Tinetti ME. Preventing falls in elderly persons. The New England Journal of Medicine 2003;348(1):42–9. [17] Tinetti ME, Baker DI, McAvay G, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. The New England Journal of Medicine 1994;331(13):821–7. [18] Tinetti ME, Speechley M, Ginter SE. Risk factors for falls among elderly persons living in the community. The New England Journal of Medicine 1988;319:1701–7. [19] Berg WR, Alessio HM, Mills EM, Tong C. Circumstances and consequences of falls in independent community-dwelling older adults. Age and Ageing 1997;26:261–8. [20] Lord R, Dayhew B, Howland. Multifocal glasses impair edge-contrast sensitivity and depth perception and increase the risk of falls in older people. Journal Aging and Geriatric Society 2002;50:1760–6.
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Please cite this article in press as: Reed-Jones RJ, et al. Vision and falls: A multidisciplinary review of the contributions of visual impairment to falls among older adults. Maturitas (2013), http://dx.doi.org/10.1016/j.maturitas.2013.01.019