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Thursday / April 22.
HomemieyecareStep Up to Prevent Falls: A Looming Public Health Crisis

Step Up to Prevent Falls: A Looming Public Health Crisis

This month (April) is Falls Prevention Month. It’s the perfect opportunity to reflect on the unique opportunity that optometrists, as primary eye care providers, have to help reduce the incidence of falls in the community.

There is a strong relationship between vision and the risk of falls. By screening your patients during an eye examination, or providing them with a short list of questions to take home, you can help reduce their risk of having a potentially life-changing fall.

Falls are a major public health problem around the world. Almost a third of people aged over 65 will fall in any given year,1 making this the second largest cause of injury-related deaths globally.2 Falls may be caused by multiple intrinsic or extrinsic factors (Table 1) and each risk factor is cumulative. One study showed that the risk of falling increased to 78% in one year for a person with four or more risk factors.

It is recommended that to prevent falls, changes to spectacle prescription in older people should be conservative

Case Study: Nancy’s Fall

Nancy* is a 65-year-old Caucasian female who presented for an eye test at the insistence of her daughter. Her previous eye exam had been about a year ago, at which the optometrist informed her she had ‘small cataracts’. She reported that she only ever wears +2.00 glasses from the pharmacy to read. She was in good health and was not taking any medications. One month prior, Nancy had fallen in her garden. Although she wasn’t injured, she had since felt reluctant and nervous to go outside. When queried about the cause of her fall, she was reluctant to comment. Her daughter noted that she seldom liked to go out at night and often complained of lights at night being ‘blinding’.

Nancy’s refraction was: R: -1.50DS, best corrected visual acuity (BCVA) 6/15; L: -0.50/-0.25x 180, BCVA 6/12.

Confrontation visual fields, both pupil reactions and motilities were unremarkable.

Stereopsis was reduced to 200 seconds using the Randot stereotest circles.

Slit lamp examination showed a moderate amount of mixed nuclear and cortical cataracts, worse in the right compared to left. Upon dilation, the retinae, optic nerves and maculae appeared healthy, and Nancy’s intraocular pressures were 15mmHg in each eye, measured with iCare at 1.15pm.

Table 1. Modified with permission from Optometry Australia’s Guidelines for Falls.

The impact of a fall on mental health can be far-reaching, particularly for the elderly. As evidenced in our case study, they may stop exercising or avoid leaving the house due to anxiety over further falls. This can lead to social isolation and a more sedentary lifestyle.4 Falls can also lead to a higher rate of nursing home admissions.5

As a primary eye care provider, asking some simple questions in a case history during a routine examination for any patient over the age of 65, or providing the patient with a short questionnaire to take home, is a valuable way to identify their falls risk.

VISION AND FALLS

Vision impairment is a risk factor for falling because it impedes the ability to see obstacles and judge step edges and kerbs correctly. Good visual acuity is crucial, especially for balance; multiple falls are twice as likely to occur if a patient has a BCVA of 6/9 or worse for both eyes.6 Reduced visual fields, contrast sensitivity and stereopsis may also contribute, although the exact extent is still unclear. Studies have shown that 75% of the visual impairment of most patients who were hospitalised after a fall was correctable with a prescription or cataract extraction.7–11 By improving a patient’s visual acuity, optometrists can significantly reduce the risk of these incidents and the associated burden of care.

On the other hand, optical correction can contribute to falls in older people, due to adaptation problems. In one study, a large change in prescription (defined as 0.75D or greater of sphere or cylinder, axis changes of ≥ 10° up to 0.75DC and ≥ 5° for >0.75DC, any prism change, or an introduced anisometropia of ≥ 0.75DS) caused 74% of participants to fall at least once, while only 53% of those with smaller changes fell.12

Australian data found that large changes to spectacle correction after cataract surgery (0.75D and above) doubled a person’s falls risk.13 These large changes may cause problems, particularly from distortion; laboratory and epidemiological studies have confirmed that changes in magnification can lead to errors in step clearance and increased risk of a fall.14 

Multifocal and bifocal wearers may also have a higher risk of falls as the inferior visual field is blurred and magnified. A study investigating the effect of single vision distance glasses (SVD) on falls for normal multifocal wearers found that the rate of falls was unchanged overall. The rate of falls decreased by 40% in older people who regularly participated in outdoor activities but conversely, increased when outside for the subset of participants who were inactive.15

It is recommended that to prevent falls, changes to spectacle prescription in older people should be conservative, thus avoiding large changes to dioptric power. Further, careful consideration is needed regarding lens types based on levels of outdoor activity, the convenience of multiple pairs of spectacles, and the prescription of tints. Finally, evidence shows that cataract surgery can reduce the risk of falls significantly by restoring visual acuity.16,17 Care needs to be taken afterwards due to likelihood that a large change in prescription is required.

MANAGING PATIENTS

Table 2. A list of questions modified with permission from the Falls Prevention Workshop.20

In light of the prevalence and systemic health implications of falls, and the strong association between falls and vision, optometrists should consider adapting their routine to incorporate falls risk assessment. Thorough case histories (including how and when someone uses their glasses) will aid optometrists in screening for high-risk patients. When prescribing spectacles for these patients, we need to balance the risks posed by adaptation issues with gains in visual acuity to be achieved with an updated prescription. Optometrists might consider gradually increasing the prescription in small increments, or advising patients with prescriptions close to emmetropia to remove their bifocals or multifocals when walking outdoors. Those with ametropia should consider SVD instead of multifocals or bifocals for walking outdoors.

In patients with cataract, earlier intervention is warranted if a patient has multiple falls risk factors. Although there is no guideline for timing of cataract referrals, factors such as the patient’s ability to perform daily tasks, quality of life, and risk/history of falls or other injuries should be considered and specified on the referral, particularly for the public system where delays are common.

COMMUNITY CARE

Ideally, falls are best managed by a multidisciplinary team due to their multifactorial nature. Non-optical interventions have been demonstrated to reduce the risk of falls. For example, Stepping On is an evidence-based community programme, implemented state-wide by the NSW Ministry of Health. It addresses topics such as exercise, hazards, footwear and community safety, and has been shown to reduce falls by 31% in the community.18 Stepping On is managed in each local health district and is a free program for people over 65 years who have had a fall or are concerned about falling.

Low vision services from community organisations, such as Guide Dogs and Vision Australia, can provide hazard assessments around the home and other practical tips for safe mobility. Exercise, which challenges strength and balance, has been shown to prevent falls in this population.19 Your older patients can search for an exercise program in their local area via the Active and Healthy website (www. activeandhealthy.nsw.gov.au) including programs specifically designed to prevent falls. Alternatively, they can contact an organisation such as Guide Dogs, which provides fall prevention programs specifically modified for the low vision population.

For high-risk falls patients, optometrists should be aware that these initiatives exist and recommend them when appropriate. By recognising that falls are a public health problem, with preventable risk factors rather than isolated events, optometrists can play an important role in the multidisciplinary falls team and ultimately improve the quality of life for our patients.

Stephanie Lai practises as an optometrist in Sydney’s Eastern Suburbs. She graduated with a Bachelor of Optometry (Honours) from University of Auckland in 2009. Ms Lai has been engaged as a Clinical Supervisor with University of Manchester, based at Singapore Polytechnic, has practised as an optometrist in Sydney’s Western Suburbs and as a locum throughout regional Australia. 

*Patient name changed for anonymity. 

References 

  1. www.mdfoundation.com.au/content/slips-tripsand- falls 
  2. www.who.int/news-room/fact-sheets/detail/falls
  3. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988;319(26):1701-7. 
  4. Petersen N, König H, Hajek A. The link between falls, social isolation and loneliness: A systematic review. Archives of Gerontology and Geriatrics. Volume 88, May– June 2020, 104020 
  5. Tinetti ME, Williams CS. Falls, injuries due to falls, and the risk of admission to a nursing home. N Engl J Med. 110.1056/NEJM199710303371806. PMID: 9345078. 
  6. Ivers RQ, Cumming RG, Mitchell P, Attebo K. Visual impairment and falls in older adults: the Blue Mountains Eye Study. J Am Geriatr Soc. 1998;46(1):58-64. 
  7. Black A, Wood J. Vision and falls. Clin Exp Optom. 2005;88(4):212-22. 
  8. Elliott DB. The Glenn A. Fry award lecture 2013: blurred vision, spectacle correction, and falls in older adults. Optom Vis Sci. 2014;91(6):593-601. 
  9. Lord SR SC, Menz HB, Close J. Falls in older people: risk factors and strategies for prevention. 2nd ed. Cambridge: Cambridge University Press; 2007 
  10. Jack CI, Smith T, Neoh C, Lye M, McGalliard JN. Prevalence of low vision in elderly patients admitted to an acute geriatric unit in Liverpool: elderly people who fall are more likely to have low vision. Gerontology. 1995;41(5):280-5. 9. Cox A, Blaikie A, Macewen CJ, Jones D, Thompson K, 
  11. Holding D, et al. Optometric and ophthalmic contact in elderly hip fracture patients with visual impairment. Ophthalmic Physiol Opt. 2005;25(4):357-62. 
  12. Cumming RG, Ivers R, Clemson L, Cullen J, Hayes MF, Tanzer M, et al. Improving vision to prevent falls in frail older people: a randomized trial. J Am Geriatr Soc. 2007;55(2):175-81 
  13. Palagyi A, Morlet N, McCluskey P, White A, Meuleners L, Ng JQ, Lamoureux E, Pesudovs K, Stapleton F, Ivers RQ, Rogers K, Keay L. Visual and refractive associations with falls after first-eye cataract surgery. J Cataract Refract Surg. 2017 Oct;43(10):1313-1321 
  14. Elliott DB. The Glenn A. Fry award lecture 2013: blurred vision, spectacle correction, and falls in older adults. Optom Vis Sci. 2014 Jun;91(6):593-601. 
  15. Haran MJ, Cameron ID, Ivers RQ, Simpson JM, Lee BB, Tanzer M, et al. Effect on falls of providing single lens distance vision classes to multifocal glasses wearers: VISIBLE randomised controlled trial. BMJ. 2010;340:c2265. 
  16. Harwood RH, Foss AJ, Osborn F, Gregson RM, Zaman A, Masud T. Falls and health status in elderlywomen following first eye cataract surgery: a randomised controlled trial. Br J Ophthalmol. 2005;89(1):53-9 
  17. Palagyi A, Morlet N, McCluskey P, White A, Meuleners L, Ng JQ, Lamoureux E, Pesudovs K, Stapleton F, Ivers RQ, Rogers K, Keay L. Visual and refractive associations with falls after first-eye cataract surgery. J Cataract Refract Surg. 2017 Oct;43(10):1313-1321 
  18. Clemson L, Cumming RG, Kendig H, Swann M, Heard R, Taylor K. The effectiveness of a community-based program for reducing the incidence of falls in the elderly: a randomized trial. J Am Geriatr Soc. 2004;52(9):1487–94 
  19. Sherrington C, Fairhall N, Wallbank G, Tiedemann A, Michaleff ZA, Howard K, Clemson L, Hopewell S, Lamb S. Exercise for preventing falls in older people living in the community: an abridged Cochrane systematic review. Br J Sports Med. 2020 Aug;54(15):885-891. 
  20. fallspreventiononlineworkshops.com.au/tool

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