Falls Awareness Week 2011 Vision and falls webinar

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

Age UK Vision and Falls Webinar 1. An Introduction to vision and falls 2. Vision assessments within falls services 3. Adapting the physical environment for people with visual impairment 4. Adapting physical activity for people with visual impairment 5. Q&A with panel Remember: you can submit your questions at any time during the presentations using the Q&A box below

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

Vision and falls – an introduction Shelagh Palmer and Dawn Skelton

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

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

Facts about sight loss • RNIB estimate 1. 8 million in UK are living with sight loss 1 • 50% living with irreversible sight loss 1, 2 • Only 4% of the visual impaired people see nothing 2 • Visual impairment increases with age, especially for women 3 • 80% of visually impaired people are aged over 652 • 88% people with cataract and ARMD were not in touch with any hospital eye services 3 www. visionmatters. org 2 Evans JR, Fletcher AE, Wormald RP, MRC trial, BJO 2002 3. Evans JR, Fletcher AE, Wormald RP, MRC trial, BJO 2004

Visual impairment and falls • Rate of falls in older people with visual impairment is 1. 7 times higher • Hip fractures are 1. 3 -1. 9 times higher (Legood R. , Scuffham P, Cryer (2002) Injury prevention 8(2) 155 -60

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

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

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

Bus normal view Normal Vision

Bus macular degeneration Age Related Macular Degeneration

Bus glaucoma Advanced Glaucoma

Bus cataract Cataract

Bus diabetic retinopathy Diabetic retinopathy

Bus normal view Haemianopia (stroke)

Vision and Falls Functional Factor Strength of association Poor contrast sensitivity *** Decreased depth perception *** Poor visual acuity ** Visual field loss * (*** is strongest association) Reproduced / adapted from Lord et al 2007: 164

Contrast Sensitivity

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

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

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

Interventions – cataract surgery Hazard ratio = 0. 95 (95% CI 0. 69 -1. 35) Hazard ratio = 0. 60 (95% CI 0. 36 -0. 98) RCT - 306 women over 70, cataract surgery expedited (approx 4 weeks or routine 12 months wait). Showed 40% reduction in risk of recurrent falls. (Harwood et al 2004)

Interventions specific to VIP q 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 q The Physiotherapy led OTAGO programme was not so effective with this specific VIP population. NB. Poor adherence rates q Demonstrates that “One size does not fit all” Campbell et al 2005 RCT: Exercise vs OT vs Exercise & OT, 391 participants aged 75 and older, one year follow up

Ways forward q 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 q Falls Services • Routine vision testing (incl. contrast and depth) and referral to opthalmology • Results shared across professionals and patients with appropriate onward referral • Refer for home hazard assessment and intervention by an OT, tailored to individual

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

Vision assessment and falls services Shelagh Palmer and Dawn Skelton

NICE 21 Falls Guideline, 2004

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

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

What people said about falls… ‘In the last two years I’ve had four falls and have broken my hip, pelvis and shoulder. I’ve been taken to casualty every time but they didn’t ask me anything about my sight’. ‘When I ended up in hospital after my last fall I told them that I was falling and tripping a lot but they didn’t seem interested. I am terrified I’ll have a fall which will finish me off. ’ Functional vision information not known and /or not shared (From Deteriorating vision, falls and older people: the links. Visibility 2005)

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

Visual Impairment & Falls • Small study by Department Vision Sciences, Caledonian University • N=67 (33 VIP, 33 normally sighted) aged 70 -96 years • Asked number of falls in a year, fear of falling, treatment • Asked 4 questions on vision • Controls had a visual acuity of 6/12( 0. 3 log. MAR) 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 log. MAR) or worse in better eye

Age, falls and treatment

On a scale of 1 -5 1=can’t do Question 5 = no problems VIP’s Score Controls Score * P=<0. 0001 Reading 1. 54 ± 0. 96 4. 23 ± 0. 74 * Recognising faces 1. 00 ± 0. 85 3. 77 ± 0. 96 * Pouring 3. 15 ± 1. 47 4. 62 ± 0. 66 * Steps/ kerbs 2. 69 ± 1. 21 4. 38 ± 0. 87 * 4 questions easily differentiate those with significant visual impairment

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 a fall compared to 25% of older people with normal vision • Despite having no falls, 15% of VIP were fearful Welsh L, BSc dissertation, GCU, 2011

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

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

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

Basic Vision Assessment Tool • Eyes Right • A simple and easy-to-use screening tool that can help you find people living with poor vision in your community • Two different formats - a simple computer programme, which runs on a standard laptop or computer, or an A 4 hand-held book • Free from RNIB Helpline on 0303 123 9999

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

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

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

Recommendations q 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 q Falls Services • Routine vision testing (incl. contrast and depth) and referral to opthalmology • Results shared across professionals and patients with appropriate onward referral • Refer for home hazard assessment and intervention by an OT, tailored to individual • Links with services supporting visually impaired people

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

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

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

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

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

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

Focus on lighting: seven characteristics of good lighting Without light we cannot see Lighting should always be: ü Appropriate to each person ü Sufficient for activity and orientation ü Even, across different areas ü Adjustable for flexibility ü Energy efficient and sustainable ü Simple to install ü Adaptable for the future.

In practice: l Maximize space and its flexibility, including: – – – l Design to maximize vision, importantly: – – l Multiple power points Multiple and controlled light sources Storage space (lit and easy to access) Light, without glare Colour and contrast Hazards are designed out, including: – – – Safe door opening systems Easy to follow routes No visual or physical clutter.

Entrances, halls and stairs l General lighting – – – l Task lighting – l Good level No glare Reveal steps Telephone Good contrasts – Surfaces

Stairs

Halls

Kitchen and utility areas

Kitchens

Living rooms - multiple light sources

Living rooms - traditional

Bedrooms

Wardrobe

Bathrooms

Bathrooms

Outdoors

Individual needs and solutions Variations within good practice principles reflect l a person’s individual activities and interests: – – – l equipment reactions to glare and light levels other conditions: hearing, mobility, dementia personal needs and priorities: – – – choosing clothes personal care cooking safety and security assistance dog

Guidance l l l Design guide Good Practice Guides Booklet

Checklists

Lighting training l l l One day workshop Lamps & fittings Demonstrations Practical exercises Case studies Design tools

Further information info@pocklington-trust. org. uk www. pocklington-trust. org. uk

Adapting physical activity and advice for exercise Dawn Skelton

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

• 62% of older people with visual impairment avoided activities due to fear of falling despite having no falls in the last year. Welsh, L. MSc Dissertation, GCU, 2011

Fear of Falling • Does fear of falling affect your ability to carry out day to day tasks such as shopping • 24% of VIP compared to 11% of older people with normal vision. Welsh L, BSc dissertation, GCU, 2011 • Fo. F Prevalance (Tinetti 1994) • 30 -60% in people over age of 65 • 50 -65% in previous fallers

Fear of Falling • Fear and lack of confidence in balance predict • Deterioration in physical functioning (Arfken 1994, Vellas 1997) • Decreases in physical activity, indoor and outdoor (Arfken 1994, Finch 1997) • Increase in fractures (Arfken 1994) • Admission to Institutional Care (Cumming 2000, Vellas 1997)

Fear of Falling • Implications • reduction in physical/functional risks may not reduce fears and activity restriction • attributing falling to incompetence or ‘risky’ behaviour may • • discourage activity, reduce acceptability, reduce uptake reduce adherence to prevention programme Yardley, 2002

Maastricht group BMJ 2000; 321: 994 -8 • RCT of home visits vs usual care for >70 year old fallers – CBT (Matter of Balance) • Reduced fear of falling at 12 and 18 months • Moderate but significant 7% (-2 on scale with 30 points) • Daily activity at 12 months • Moderate but significant 4% (1. 6 on scale with 39 points) • ? ? works in people with VIP

Environment – a risky place Personal risk factors: • • glasses (bifocals and varifocals) footwear and clothing Outdoors: Indoors: • Poorly lit pathways • Loose carpets • Uneven pavements • Wires and cables • Slippery surfaces • Unstable furniture • Rubbish, building materials, obstacles • Change of level • People flow • Shadows • Poor lighting

What do older people (without VIP!) think? Difficult and fall inducing dual tasks (doing more than one thing at a time) Ø Stairs negotiation (especially descent) accompanied by manual upper limb Ø Walking and avoiding moving obstacles Ø Confusing environment demands with walking (noise, light, shadows, busy) Muhaidat, Skelton et al. BJOT 2010

Extrinsic barriers • Accessible opportunities (transport) • Safe activity environments (parks, well-lit streets) • Positive images of older people

Swap bifocals for single lenses? • Can providing single lens distance glasses to regular users of multifocal glasses lower the rate of falls? • YES - by around 40% in people who regularly took part in outside activities (incidence ratio 0. 60, 95% CI 0. 42 to 0. 87). • BUT - In frailer people, who spent more time inside, no significant difference was seen in falls inside and a significant increase was seen in falls outside. Haran MJ et al. VISIBLE randomised controlled trial. BMJ 2010; 340: c 2265

Real life examples • May not see hazards • peripheral vision, visual acuity, contrast sensitivity • May not see the poorly lit bottom step • depth perception, contrast sensitivity, visual acuity • May notice the change from carpet to slippery tiles • contrast sensitivity, visual acuity

The VIP Trial: Campbell 2005 • • • RCT 391 participants visually impaired aged 75 years or over One year follow up 1. Home Safety assessment and modification programme by an OT 2. Home based exercise programme prescribed by a Physio + Vit. D 3. Both 1&2 4. Social visits (control)

OT Intervention for VIP • Assessment tailored to awareness of clients functional vision • Home hazard identification with client • Focus on lighting and lack of contrast • Removal or adaptation of hazard in agreement with client • Changes to risk behaviours also discussed Campbell et al 2005, La Grow 2006

Mechanisms at play? • Individually tailored advice by an OT enables VIP to negotiate environments more safely? • OT intervention led to reduction in activity (“playing safe”) and therefore reduction in risk? • Evidence based home exercise programmes did not allow full participation due to specific needs of VIP? La Grow et al 2006

Visual Impairment Rehabilitation • Monodisciplinary – optometrists • Low vision aids • Multidisciplinary – social workers, psychiatrists, OT’s, • How to cope with VIP in their occupation and with their preferences/needs • Practicing daily living skills in the safe environment of the rehabilitation centre may be different from practicing these skills in the person's own environment which is usually not adjusted to visually impaired persons. • Multidisciplinary VIR improves Qo. L, mood, self efficacy, well-being Langelaan, van Nispen, van Rens 2010, Cochrane

Orientation & Mobility Training • Orientation is the ability to recognise one’s position in relation to the environment • Mobility is the ability to move around safely and efficiently • O & M training can help those with VI to compensate for reduced visual information Virgili & Rubin 2009

O & M Training • Helps to use remaining vision or other senses to get around • Canes and optical aids to support. • 90 mins a week for 10 -12 weeks – volunteer-participant pairs • Sound localisation, landmarks, tactual discrimination, self protection positions, cane use, narrow spaces, doorways, changes in level and obstacle avoidance • ++ exercise sessions for balance and endurance • Significant improvements in mobililty and travel in those with severe VI BUT exercise alone was as good Virgili & Rubin 2009

Reducing barriers Walk from Home – Keighley Senior Peer Mentoring Mary Moffat - 93 • Referred by physio after a fall • Loss of confidence and fear of falling • Isolated and lonely and dependent upon others to get out • Concerned about her vision • Concerned about her environment

So to summarise… • VIP can be supported to be more active • Who supports PA and exercise for those with VIP? • Who in your area supports VIP? • We hope that this Webinar has stimulated you and your service into thinking more about vision

Q&A with Panel