British Geriatrics Society
The importance of vision in preventing falls
published November 2003 replaced by Compendium document 4.5
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A joint policy statement by the British Geriatrics Society and the College of Optometrists

Background
Visual impairment is strongly associated with falls and hip fractures ( 1, 2, 3, 4). In addition to poor visual acuity, reduced visual field, impaired contrast sensitivity and cataract may explain this association (2).

Adding treatment of poor vision to exercise and hazard management in the home, produced an additional 14% reduction in the annual fall rate, compared to no intervention (5).

Standard Six of the National Service Framework for Older People has identified a target of reducing the number of falls.There is a major problem of preventable or treatable visual impairment in Britain's older population (6, 7). A North London Study of 1547 people showed that 30% of the sample population aged 65 years and older were visually impaired (less than 6/12) in both eyes and more than 72% of this bilateral visual impairment could potentially be improved by surgery or spectacles (8).Visual impairment is defined as existing when the level of vision is below that which the individual requires for his or her everyday tasks. A common cut off point is taken as a binocular visual acuity of 6/12 or 6/18 as used in the MRC study (9).

Causes of visual impairment
Refractive errors - these can be resolved by the provision of spectacles. Refractive error may be present with or without coexisting eye disease. One UK study found that 17% of visual impairment in the over 65s was solely related to uncorrected refractive error (8) and another that over 30% of visual impairment in the over 75s was due to refractive error (9). Cataracts - are the commonest treatable cause of impaired vision (6, 8). Removal of the cataract from the second eye has benefits in terms of improving visual symptoms and quality of life. Diabetes - is an important cause of visual impairment in older people. Prevalence of diabetic retinopathy requiring treatment among diabetics is estimated to be 1-6% (11). In a sample of diabetic patients who were registered blind, 92% were over 50 and 44% were over 70 (12). The incidence of blindness may be significantly reduced by early and appropriate management 13, 14. It has been found that 9.9% of people in residential or nursing homes had diabetes (15), although the National Service Framework for Diabetes is putting standards into place to ensure regular screening for diabetic retinopathy (16).Glaucoma -causes 2% of visual impairment in the over 65s 8 and 13% of new blindness certifications in one year (1990/1) for those aged 65 or older (17). Optometrists are responsible for detecting 80% of new cases (10). Early detection is important to prevent irreversible visual loss (18).

Significant reduction of visual impairment may be attained with the application of current knowledge in refractive errors, diabetes mellitus, cataract and glaucoma (19).

Macular degeneration - In the UK there are around 500,000 people with age related macular degeneration (AMD) (20). There is a significantly increased incidence of age-related maculopathy lesions with age (more so in women than in men) (21, 22). AMD is present in 13% of those over 85 (23) and causes 30% of visual impairment in patients over 75 and 11-18% of visual impairment in the over 65s (8).

Although treatment options are limited, it is important that these patients are provided with appropriate advice on registration and fall prevention measures.

Visual field loss - Visual impairment is not only caused by visual acuity loss. The incidence of visual field loss increases with age. Visual field loss can contribute considerably to the overall burden of visual impairment and blindness. In a population of adults aged 40-98 years nearly three times as many people were visually impaired because of visual field loss i than visual acuity loss (24).

Problems in take up and provision of services
Since April 1999 people aged 60 and over have been eligible for a regular free NHS eye examination. It is important that older people and health care professionals are aware of this. There may be some residual visual impairment from the period between 1989 and 1999 when some people over 60 had to pay for their eye examination(25).

Prevalence studies demonstrate that in a significant proportion of those older people with visual impairment, eye disease is undetected and untreated (8, 9). In a North London Study, 88% of patients with cataracts and age-related macular disease were not in touch with hospital eye services (8). There is evidence that health inequalities exist and that older people from low socio-economic groups are less likely to avail themselves of primary care ophthalmic services. Severe visual problems are therefore more likely to remain unrecognised and untreated (6, 26). This was specifically mentioned by Sir Donald Acheson in his report published in 1998, "Independent Inquiry into Inequalities in Health" (27). The Government is committed to tackling health inequalities (28).

Older patients who become aware of visual difficulties may be reluctant to attend for a routine eye examination, either for financial reasons or for fear of being told bad news or because they feel intimidated by the eye examination process (29). They may feel that poor vision is an inevitable consequence of ageing. This reticence can be accentuated in some ethnic groups who are more at risk of certain conditions such as diabetes and glaucoma. Up to 64% and 77% of people eligible for blind and partially sighted registration respectively are not registered (30). Blind registration gives access to financial and other benefits. Although partially sighted registration, as such, provides little assistance, it alerts the local authority as to the individual's visual problems. The Department of Health has recently announced new registration procedures for people with Visual Impairment which are aimed at giving people with visual impairment quicker access to support from social services (31).

The Department's Eyecare Services Steering Group has also made recommendations on the provision of services for people with visual impairment (32). People in residential care and nursing homes are at an increased risk of falls (1, 33) and are at risk of having their eye problems overlooked. NHS domiciliary eye examinations are available free of charge to those unable to attend community optometric practice.

Recommendations
All older people undergoing a falls assessment should be screened for visual impairment. The minimum standard is a test of visual acuity using a Snellens chart, and some assessment of the visual field. Visual acuity of 6/12 or worse denotes visual impairment. Those people identified as suffering from visual impairment should have a full eye examination by an optometrist and all older people should be encouraged to have regular eye examinations. The optometry assessment could take place in a variety of community, hospital and voluntary sector settings. The mechanism for achieving this needs to be agreed locally.

People in residential and nursing homes are a particularly high-risk group for falls and this should be reflected in the local arrangements for screening and assessment of visual impairment. The locally agreed policies should include partnerships with voluntary organisations (34). Patient information is produced by the organisations such as RNIB, the Macular Disease Society and the International Glaucoma Association. Involvement of other organisations such as Age Concern and Help the Aged could help in the dissemination of this advice. Such information should also be available in other settings including primary and secondary care, optometry practices and on the NHSNet.

Older people and health care professionals may be unaware of the benefits that are available to the visually impaired. Mechanisms should be developed locally to encourage awareness and uptake of these benefits.

For older people with impaired vision, whether treatable or not, measures should be taken to optimise the visual environment, remove physical hazards, and reduce other fall risk factors.

Audit tools should be developed and used to test the effectiveness of the locally agreed services.

Important areas for future research include the cost-effectiveness evaluation of screening for visual impairment.

Intervention studies of treating visual impairment, including cataract surgery and refractive error correction, in reducing falls, and qualitative studies to identify the barriers that prevent older people accessing eye services are also required.


References

  1. Abdelhafiz, A.H. and Austin, C.A Visual factors should be assessed in older people presenting with falls or hip fracture Age and Ageing, 32, 26-30, 2003
  2. Ivers RQ, Cumming RG, Mitchell P et al. Visual impairment and falls in older adults: the Blue Mountains Eye Study. J. Amer Ger. Soc. 46(1): 58-64, 1998
  3. Cummings SR. Treatable and untreatable risk factors for hip fracture. Bone 18(3 suppl): 165S-167S, 1996
  4. Jack DI, Smith T, Neoh C et al. 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, 41, 280-5, 1995
  5. Day L., Filders B, Gordon I. et al. Randomised factorial trail of falls prevention among older people living in their own homes BMJ, 325: 128, 2002
  6. Wormald RPL, Wright LA et al. Visual problems in the elderly population and implications for services BMJ 304: 1226-122; 1992
  7. Harries V, Landes R, Popay J. Visual disability among older people: a case study in assessing needs and examining services Journal of Public Health Medicine 16(2): 211-8; 1994
  8. Reidy A, Minassian DC, Vafidis G et al, Prevalence of serious eye disease and visual impairment in a North London population: population-based, cross sectional study. BMJ 1998; 316: 1643-1646
  9. Evans JR et al Prevalence of visual impairment in people aged 75 years and older in Britain: results from the MRC trial of assessment and management of older people in the community B J Ophth 86: 795-800, 2002
  10. Laidlaw DA, Harrad RA et al. Randomised trial of effectiveness of second eye cataract surgery. Lancet 353: 925-9, 1998
  11. Bachmann MO, Nelson SJ Impact of diabetic retinopathy screening on a British district population: case detection and blindness prevention in an evidence-based model J Epidemiol Community Health 51(1), 45-52, 1998d
  12. Hamilton AM et al Management of Diabetic Retinopathy BMJ Publishing Group, 1996
  13. Diabetic Retinopathy Research Group. Indications for photocoagulation treatment of diabetic retinopathy:diabetic retinopathy study report no. 14. International Ophthalmol Clin 27:239-253, 1987 (quoted by NSC on Diabetic Retinopathy 2001)
  14. Early Treatment Diabetic Retinopathy Study Research Group. Early photocoagulation for diabetic retinopathy. ETDRS Report no. 9 Ophthalmology 98:766-785, 1991 (quoted by NSC on Diabetic Retinopathy 2001)
  15. Benbow S J, Walsh A, Gill G V. Diabetes in institutionalised elderly people: a forgotten population? BMJ. 1997; 314: 1868-69
  17. Royal College of Ophthalmologists: A national research strategy for ophthalmology, 2002
  18. Fraser S, Bunce C, Wormald R and Brunner E Deprivation and late presentation of glaucoma: case control study BMJ 322:639-643, 2001
  19. VanNewkirk, MR, Weih L, McCarty CA and Taylor HR Cause-specific prevalence of bilateral visual impairment in Victoria, Australia - The visual impairment project Ophthalmology 108(5) 960-967, 2001
  20. Age Related Macular Degeneration Free Information Service (Foresight campaign), AMD alliance Feb 2002.
  21. Klein R, Klein, BE, Jensen, SC and Meuer SM The five year incidence and progression of age-related maculopathy: the Beaver Dam Eye Study Ophthalmology vol 104 7-21 1997
  22. Klein R, et al Ten-year incidence and progression of age-related maculopathy: The Beaver Dam eye study Ophthalmology 109 1767-1779 2002
  23. Smith W, Assink J, Klein R, Mitchell P, Klaver CC, Klein BE, et al. Risk factors for age-related macular degeneration: pooled findings from three continents. Ophthalmology 2001; 108: 697-704
  24. Taylor HR, Livingston, PM, Stanislavsky, YL et al Visual impairment in Australia: distance visual acuity, near vision, and visual field findings of the Melbourne Visual Impairment Project Am J Ophthalmol 123 328-37 1997
  25. Laidlaw DA, Sparrow JM et al, The Sight Test Fee: effect on ophthalmology referrals and rate of glaucoma detection BMJ 309:634-6 1994
  26. Jones H, Yates J, Spurgeon P, Fielder A. Geographical variations in rates of ophthalmic surgery. British Journal of Ophthalmology 80:784-788 1996 quoted in Acheson report 1998
  28. Department of Health, London (ref. 28246/ Tackling Health Inequalities) 2001
  29. Smeeth L, Iliffe S Effectiveness of screening older people for impaired vision in community setting: systematic review of evidence from randomised controlled trials. BMJ 316: 660-663 1998
  30. Royal College of Ophthalmologists Registration and Rehabilitation of the Visually Handicapped. 1994
  31. http://www.info.doh.gov.uk/doh/intpress.nsf/page/2003-0341?OpenDocument (accessed 31/10/03)
  32. Recommendations of the DoH's Eyecare Services Steering Group http://www.doh.gov.uk/ophthalmicservices/draft-pathway-lowv.PDF (accessed 3/11/03)
  33. Van der Pols JC, Bates, CJ, McGraw, PV et al. Visual acuity measurements in a national sample of British elderly people Br J Ophth 84, 165-70, 2000

    i To within 20 degrees of fixation
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