Falls Awareness Week 2011 Vision and falls webinar

1. Falls Awareness Week 2011Vision and falls webinar Having technical problems? Please make sure your sound is turned up! Ask for help using the Q&A box below

2. Age UK Vision and Falls Webinar An Introduction to vision and falls Vision assessments within falls services Adapting the physical environment for people with visual impairment Adapting physical activity for people with visual impairment Q&A with panel Remember: you can submit your questions at any time during the presentations using the Q&A box below

3. Anthony Slater • Lighting Development Manager Dave Elliot Professor of Clinical Vision Science Dawn Skelton Reader in Ageing and Health Shelagh Palmer Health Co-ordinator

4. Vision and falls – an introduction Shelagh Palmer and Dawn Skelton

5. Outline Extent of the problem Impact of eye conditions on vision What can be done? Can more be done?

6. 33% of people over 65 fall once a year of people over 75 have impaired vision 20% there’s more to falls than meets the eye…

7. Facts about sight loss RNIB estimate 1.8 million in UK are living with sight loss1 50% living with irreversible sight loss1,2 Only 4% of the visual impaired people see nothing2 Visual impairment increases with age, especially for women3 80% of visually impaired people are aged over 652 88% people with cataract and ARMD were not in touch with any hospital eye services3 www.visionmatters.org 2 Evans JR, Fletcher AE, Wormald RP, MRC trial,BJO 2002 3. Evans JR, Fletcher AE, Wormald RP, MRC trial,BJO 2004

8. Rate of falls in older people with visual impairment is 1.7 times higher Hip fractures are 1.3-1.9 times higher (Legood R., Scuffham P, Cryer (2002) Injury prevention 8(2) 155-60 Visual impairment and falls

9. Sensory Input  Stability Three main sources of input for balance • Visual information • Vestibular information • Proprioceptive information • All three decline with age • All three show larger declines in sedentary older adults

10. Accident /Environment 31% Gait /Balance /Weakness 17% Dizziness vertigo 13% Drop attacks 9% Confusion 5% Postural hypotension 3% Visual disorder 2% Syncope < 1% Other 15% Unknown 5% Weakness 11/11 Balance deficit 9/9 Mobility limitation 9/9 Gait deficit 8/9 Visual deficit 5/9 Cognitive impairment 4/8 Impaired ADL 5/9 Postural hypotension 2/7 Causes and risks Rubenstein & Josephson 2002 Summary of 12 major studies of fall causes Individual risk factors: 16 controlled studies

11. Effects of Eye Conditions on Sight Loss of central vision Loss of peripheral vision / reduced visual field Patchy vision Poor visual acuity Poor contrast sensitivity Loss of colour awareness Loss of depth perception Discomfort in bright light or glare Poor light dark adaptation OR combinations of the above

12. Bus normal view Normal Vision

13. Bus macular degeneration Age Related Macular Degeneration

14. Bus glaucoma Advanced Glaucoma

15. Bus cataract Cataract

16. Bus diabetic retinopathy Diabetic retinopathy

17. Bus normal view Haemianopia (stroke)

18. Vision and Falls (*** is strongest association) Reproduced / adapted from Lord et al 2007:164

19. Contrast Sensitivity

20. How might we intervene? • Home adaptations (see Anthony’s presentation) • Promote eye examinations • Promote functional vision assessments (final presentation) • Change glasses? • Remove cataract? • Exercise programmes (second presentation)

21. Bifocals / Multifocal • Use of these lenses is associated with an increased risk of falling. • Multifocal and bifocal glasses further impair contrast sensitivity and depth perception. • Multifocals also cause loss of acuity in the lower peripheral visual field. • Protective responses, such as grabbing a rail, may also be hindered by the peripheral prismatic effect. Lord et al. 2000, Cambridge University Press

22. New glasses – be careful! • Prescription of new lenses should involve careful instruction in their use. • In one trial, assessment of vision and prescription of new glasses significantly increased falls in the intervention group!. • One of the reasons suggested for this was the difficulty older people may have adjusting to sudden change in vision. Cumming RG et al. J Am Geriatr Soc 2007;55:175-81.

23. Interventions – cataract surgery Hazard ratio = 0.95 (95% CI 0.69-1.35) Hazard ratio = 0.60 (95% CI 0.36-0.98) RCT - 306 women over 70, cataract surgery expedited (approx 4 weeks or routine 12 months wait). Showed 40% reduction in risk of recurrent falls. (Harwood et al 2004)

24. Interventions specific to VIP • The OT Home Safety Programme alone demonstrated a significant reduction in falls both inside the home and out with AND equally in hazard related falls and non-hazard-related falls • The Physiotherapy led OTAGO programme was not so effective with this specific VIP population. NB. Poor adherence rates • Demonstrates that “One size does not fit all” Campbell et al 2005 RCT: Exercise vs OT vs Exercise & OT, 391 participants aged 75 and older, one year follow up

25. Ways forward NHS Promote eye tests Vision Questions within assessments Raise awareness of vision and falls Advice on correct glasses / bifocals / varifocals Improve communication across services Promote good mobility Falls Services Routine vision testing (incl. contrast and depth) and referral to opthalmology Results shared across professionals and patients with appropriate onward referral Refer for home hazard assessment and intervention by an OT, tailored to individual

26. Did they ask about vision?If so, what happened next?

27. Vision assessment and falls services Shelagh Palmer and Dawn Skelton

28. NICE 21 Falls Guideline, 2004

29. Consensus? • There is no real consensus on vision assessment within falls prevention settings and little consensus on subsequent management of visual impairment Dr Manjit Mehat & Dr Ruma Dutta • 58% of all falls services consider the assessment of patients vision either informally or formally by use of an assessment tool NIHR ( SDO), Lamb 2007

30. What visually impaired people said … “My husband does everything now. I miss being able to go out myself and doing things for myself. I don’t know how I’d survive if he wasn’t here” 62% said they don’t go out on their own anymore “I tripped on the carpet last year and needed stitches. After that the social work came out and I got an alarm for round my neck and handrails at front and back of house. I didn’t mention that I have problems with my eyes but then they didn’t ask” 36% had tripped or fallen (From: Improving access to specialist services for people who are visually impaired. Visibility, 2004)

31. What people said about falls… ‘In the last two years I’ve had four falls and have broken my hip, pelvis and shoulder. I’ve been taken to casualty every time but they didn’t ask me anything about my sight’. ‘When I ended up in hospital after my last fall I told them that I was falling and tripping a lot but they didn’t seem interested. I am terrified I’ll have a fall which will finish me off.’ Functional vision information not known and /or not shared (From Deteriorating vision, falls and older people: the links. Visibility2005)

32. Four vision related questions Are you able to read small print, bills, medicines? Can you recognise faces across the street? Do you miss or overfill cups when pouring? Do you have difficulty judging steps, stairs, kerbs Part of single shared assessment ()

33. Visual Impairment & Falls • Small study by Department Vision Sciences, Caledonian University • N=67 (33 VIP, 33 normally sighted) aged 70-96 years • Asked number of falls in a year, fear of falling, treatment • Asked 4 questions on vision • Controls had a visual acuity of 6/12( 0.3logMAR) or better in both eyes and no central field loss • Visually impaired subjects visual field loss within 20 degrees of fixation and / or reduced acuity ( 0.7 logMAR) or worse in better eye Welsh L, BSc dissertation, GCU, 2011

34. Age, falls and treatment

35. On a scale of 1-5 1=can’t do 5 = no problems * P=<0.0001 4 questions easily differentiate those with significant visual impairment

36. Fear of Falling • Does fear of falling affect your ability to carry out day to day tasks such as shopping • 24% of VIP compared to 11% of older people with normal vision. • Within those who were fearful • 38% of VIP had had a fall compared to 25% of older people with normal vision • Despite having no falls, 15% of VIP were fearful Welsh L, BSc dissertation, GCU, 2011

37. NHS GGC Falls Prevention Programme Risk Screening Tool Do you wear glasses? Were you wearing them when you fell? Any problems with these glasses? Which types do you wear? When did you last have your eyes tested? Are you registered as blind and partially sighted? Have you ever been seen by the Sensory Impairment Team? Home hazard section, prompted to consider the lighting around the home.

38. Vision assessment in falls settings • Small audit by AgeUk, 26 services responded • Range of responses from community to hospital • Most of clinic settings measured visual acuity measured, eye conditions noted • Community setting tended to ask very basic vision questions • 23 very positive – liked functional/ descriptive aspect • 4 questions very useful for home visits/assessments (non specialist assessments) • Need for VI training and awareness of simple tools

39. Other audits • BGS survey - currently ongoing • Assessing vision and vision function in falls clinic settings • Dr Manjit Mehat & Dr Ruma Dutta • Click below to take part in the survey • www.surveymonkey.com/s/BJQXFVF • Visibility is happy to coordinate further validation of “our” four questions Interested? - email shelagh@visibility.org.uk

40. Basic Vision Assessment Tool Eyes Right A simple and easy-to-use screening tool that can help you find people living with poor vision in your community Two different formats - a simple computer programme, which runs on a standard laptop or computer, or an A4 hand-held book Free from RNIB Helpline on 0303 123 9999

41. Other tools? Functional Vision Assessment Tool • A set of checklists to compare peoples vision, contrast sensitivity, central and peripheral vision etc. • Specifically for learning disabled but useful for “observational” testing (eg. in cognitive impairment). • Free and Downloadable from SeeAbility • http://www.lookupinfo.org/forms_booklets/functional_vision_assesement_pack/default.aspx

42. Cinderella? • Vision is rarely considered in trials • Vision is the “cinderella” on falls risk factors • Vision is also the “cinderella” on falls interventions • Self efficacy and confidence • Vision impairment then fear of falling.... • Same population group, older adults! • ++ LUTS, UI, Multiple medical conditions, polypharmacy!!

43. Unknowns? • If vision problems identified in falls settings, what happens next? • If onward referrals – do people attend? • What if feedback loops between services? • What knowledge within falls services of support services for visual impaired people? • Mobility training for visually impaired people – is it offered?

44. Recommendations NHS Promote eye tests for public Vision Questions within all assessments Raise awareness of vision and falls Advice on bifocals / varifocals Improve communication across services Falls Services Routine vision testing (incl. contrast and depth) and referral to opthalmology Results shared across professionals and patients with appropriate onward referral Refer for home hazard assessment and intervention by an OT, tailored to individual Links with services supporting visually impaired people

45. Take Home Messages • Vision is important! • Vision assessment is the key! • Falls services should ask about vision • Vision services should ask about falls • Audit your service and improve? • Interventions to promote independence and mobility in older people with VIP exist, they work....so what are you waiting for!

46. Adaptations for people with sight loss Falls awareness week 2011 Age UK Vision and Falls webinar Anthony Slater Thomas Pocklington Trust

47. Thomas Pocklington Trust • Registered charity founded in 1958 • To provide quality housing, care and support services that promote independence and choice for people with sight loss (nine centres) • To fund research into the prevention, alleviation and cure of sight loss, disseminate findings and support good practice.

48. Why focus on sight loss? • Most older people have a degree of sight loss that affects everyday life • Many eye conditions are age related • Normal ageing of the eye means that, as we age, we need more light than younger people to achieve the same vision • Sight loss is a significant factor in 900,000 falls in the UK per year. • Sight loss is often concurrent with other issues • Housing design, management and maintenance that is good for sight is good for everyone.

49. Findings from Pocklington research • Housing outcomes sought by people with sight loss • A home that is comfortable, easy to live in and personal • Safety and security – within and outside • Accessibility – within and outside • Opportunities to make the most of sight, in choice of activities and in daily living. • Good practice for sight loss makes homes safer, more secure and easier to live in.

50. Design, management and maintenance: six key points for sight • Involve people • Improve lighting • Use colour and contrast • Avoid clutter • Reduce glare • Make appliances accessible.