Optometrist Jan Jurkus fondly talks about watching her mother and her mothers friends dance at her mothers 88th birthday party last month.
Its other times that she worries.
Like many elderly people, Dr. Jurkus mother and her friends have suffered falls. Theyre walking and they dont pay attention to where theyre walking, says Dr. Jurkus, a professor at Illinois College of Optometry . Because they cant lift their feet as high, theyll tend to tumble. They also tend to trip more when looking through the bottom portion of their bifocals.
Dr. Jurkus mother and her friends arent the only ones. In fact, one in three adults ages 65 and older suffer from falls each year.1,2 Falls are the leading cause of injury-related deaths and the most common cause of nonfatal injuries and hospital admissions for trauma among older adults.1,3,4
This is a serious public health problem that directly affects our seniors and their family members, says U.S. Sen. Barbara A. Mikulski, D-Md.
Its serious enough that last month, the U.S. Senate passed the Keeping Seniors Safe from Falls Act (S. 1217), sponsored by Sens. Mikulski and Mike Enzi, R-Wyo. The bill seeks to prevent falls among older adults through public education and research initiatives, and calls for a study of health-care costs associated with falls.
Falls among older patients are also serious enough to warrant your attention. While several risk factors for falls are beyond your scope of practice, reduced vision is a significant risk factor that you can address. Thats why weve chosen to focus on the relationship of vision to falls for our Fifth Annual Presbyopia Report.
Research Findings
Several studies have found that reduced visual acuity is at least one factor involved in falls. Researchers have also found that by managing these symptoms, as well as other risk factors, such as stroke, health-care providers might reduce the risk of falls.1,5
Besides visual acuity, contrast sensitivity and depth perception also decrease as patients age. Theyre going to be less able to see some steps or to see a step down that occurs in a room, says James E. Sheedy, O.D., Ph.D., of Ohio State University College of Optometry.
Reduction of depth perception and reduced gait, in fact, are two of the main problems with age. So, even if you have lived and grown up in a house forever, with age, if your step and gait size decreases and depth perception decreases, you dont put your foot down as much. As a result, you may take the second foot step before the first foot has had a chance to stabilize on the step, thereby causing the imbalance and fall, says optometrist Satya Verma, of Pennsylvania College of Optometry. Dr. Verma, who is in private practice in suburban Philadelphia, has lectured nationally on vision and aging issues.
Mark Andre, director of the contact lens service at Oregon Health Sciences Universitys Casey Eye Institute in Portland, Ore., and Patrick Caroline, director of contact lens research at the Oregon Health Sciences University, often see elderly patients who present with decreased vision in one eye secondary to corneal pathology, dystrophic changes, ulcerative scars, trauma, etc., or who have high anisometropia secondary to complications following cataract surgery. So, patients who have spent most of their life with perfect binocular vision, suddenly find themselves thrust into a monocular world. This sudden loss of stereopsis and the subsequent loss of equilibrium leads to unfortunate events such as falls, they believe.
Admittedly, visual function must be considered with other conditions. Consider: The researchers from the Beaver Dam Eye Study found that falls were more commonly reported for all persons who had poorer visual function.6
Five years later, the researchers also found that visual function is associated with the risk of some physical outcomes and limitations of middle-aged and older adults. Still, the authors say it is important to control for other conditions that can confound the relationships between visual functions and outcomes.7
Barbara E. Klein, M.D., M.P.H., professor of ophthalmology and visual sciences at University of Wisconsin-Madison and a principal author of the Beaver Dam Eye Study, is quick to point out that the initial data presented about falls and fractures used cross-sectional visual function data and historical data on falls and fractures, so we cannot infer that reduced visual function caused the falls.
Recent research by Anne L. Coleman, M.D., Ph.D., and colleagues offers further perspective about the relationship between visual acuity and the risk of falls. Dr. Coleman and colleagues studied 2,002 elderly community-residing women whose visual acuity was measured at baseline and four to six years later.8 Women with declining acuity had significantly greater odds of experiencing frequent falls during the subsequent year than women whose visual acuity remained stable or improved.
After adjusting for other variables, the researchers found that a loss of two or more lines (10 or more letters) in visual acuity was associated with 43% higher adjusted odds of frequent falling compared with a loss of less than 10 letters. Even with a decline of one to five letters in visual acuity over a five-year period, the odds of frequent falling increased almost twofold when compared with patients who had no change in visual acuity or whose acuity improved. These findings suggest that elderly people with impaired acuity and/or declining acuity should be prioritized for interventions to evaluate and correct vision to minimize risk for future falls, the researchers say.
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| One in three adults ages 65 and older suffers from falls each year. Falls are the leading cause of injury-related deaths and the most common cause of nonfatal injuries and hospital admissions for trauma among older adults. |
So how can you reduce the risk of falls among your patients? For starters, you can find out if theres a problem. Ask the patient during your initial assessment if mobility is difficult within her home, or if she has problems adapting from outside to inside (light to dark) and vice versa, Dr. Verma suggests.
Make sure there are no physiologic problems, such as cataract, glaucoma or a neurologic defect. If [the patient is] healthy but presbyopic, then you can make a recommendation for a specific lens, says optometrist Richard Clompus. Dr. Clompus is vice president, professional affairs, in the Spectacle Lens Group at Johnson & Johnson Vision Care.
We do not have evidence that any form of optical correction can prevent falls, but some forms may offer slight advantages. A few options:
Single vision (distance) spectacles. These likely place the patient at less risk for falls. If falls are related to the optics were placing in front of people, then they almost certainly involve the multifocal aspects of the lenses that are in the inferior field of view, Dr. Sheedy says. And, I think most clinicians have had the experience of a first-time multifocal wearer saying that they have tripped or fallen on something because of the multifocals theyre wearing.
The disadvantage: Its really not practical in most cases to put them in single-vision, distance-only [glasses] for vision while walking. Usually, patients want one pair of glasses to take care of the majority of their needs, Dr. Clompus says.
Bifocal spectacles. The problem isnt so much the lens itself as how the patient looks through the lens when walking. In other words, the patient should look through the distance portion and avoid looking through the add.
Dr. Jurkus tells her patients to simply remember nose down. In other words, patients should aim their nose downward when walking to ensure that they view through the distance portion of the lens to avoid magnification of images and distortion.
By contrast, Dr. Verma tells patients to behave as they did when they did not have bifocals. People start doing strange things when they get their first bifocal, he says. As soon as they put their new glasses on, they start looking at their feet, which they normally did not do prior to the bifocals. We dont look at our feet while walking. Similarly, while going down the steps, we look at the next step and not the feet. If we follow this we will never look through the bifocal portion of the lens and hence reduce that problem.
PALs. Because progressive addition lenses do offer patients continuous vision from distance to near, PALs may be slightly advantageous over bifocals. This is due to the image jump that occurs at the top portion of the bifocal. The bifocal creates two separate visual worlds, one for distance vision and one for near vision, which are not even connected with one another, Dr. Sheedy says.
The additional range of vision [of a PAL] might help give them a better quality of vision surroundings, Dr. Verma adds.
One caveat, however: You dont want to switch an older patient from a bifocal to a progressive lens or vice versa, Dr. Verma says.
Dr. Sheedy agrees. Once a person has adapted to one type of visual correction, it will be more difficult for them to change to a different optical correction. And, their ability to adapt or change only gets worse with age, he says.
Whatever spectacle lens option you prescribe, patients can greatly benefit from antireflective coating, these O.D.s say. This is especially important for patients who are more mobile, those who still drive and patients who have cataracts. Even the same vision seems a lot better, Dr. Verma says.
Contact lenses. Like single-vision distance glasses, monovision contact lenses do not place the near viewing optics in the inferior field of view. Bifocal, multifocal and progressive contact lenses also may be advantageous in preventing falls. Because the contact lenses rotate with the eyes, the patient continually looks through the center of the contact lenses. The result is fewer spatial distortions than with spectacles, Dr. Sheedy says.
Messrs. Andre and Caroline say that elderly patients with decreased vision in one eye, but who have correctable refractive errors (i.e., irregular corneal astigmatism or surgical aphakia), deserve a trial with contact lenses to see if some semblance of binocular vision can be restored. Despite the many challenges faced by elderly patients related to the care and handling of contact lenses, theyve encountered plenty of individuals who are able to adapt.
When prescribing for elderly patients, youll also want to avoid large prescription changes whenever possible. Patients generally have more difficulty adapting to larger changes than to smaller ones. Dr. Jurkus says.
For example, Dr. Jurkus tries to avoid making more than a 0.50D change whenever possible. So, if a 75-year-old female presents with a distance correction of 1.50D, but refraction yields an error of 2.50D, Dr. Jurkus might correct her to 2.00D. She would still see an improvement, but it wouldnt give her as much magnification, Dr. Jurkus says. Thus, there would be less change in how she sees things, in terms of her depth perception and how large images seem to her. Certainly if the smaller unit change does not give her an improvement, [I would] give the change she can appreciate the most.
Patient Education
In addition to finding the right prescription, you can play a role in your patients safety through education. Try these suggestions about what to tell patients to avoid falls:
Be careful on steps. Patients should be cautious when stepping onto busses or stepping off of curbs, especially when they get their first pair of multifocals. When you are prescribing a first multifocal spectacle correction, patients should be cautioned about steps and other non-level [obstacles] on the ground, Dr. Sheedy says. If they need to step up onto something, at first it would be best for them to tip their head down and look at it through the distance portion of their lenses before they step on it. This will help them get used to the distortions that appear in the lower part of their lens.
Make sure their environment is well lit. Proper lighting, Dr. Verma says, not only improves the visual acuity per se, but also the quality of vision.
Avoid neutral colors. If possible, advise patients to have contrasting colors between rugs and walls, Dr. Verma suggests.
Avoid clutter. Patients with poor contrast sensitivity are more likely to stumble on objects left on the floor, particularly those that are not in bright colors, Dr. Verma says.
Dont forget to remove your reading glasses. Dr. Jurkus has patients who have reported getting up from their chair while still wearing their reading glasses. Then, when they try to walk, everything is magnified for them and they have a greater risk of spatial distortion, she says. I tell my patients who are getting reading glasses, When you stand up from the chair, touch your nose. If you feel your glasses take them off.
Falls among the elderly are a serious public health issue and occur due to a myriad of risk factors. Though all these factors must be considered, you may help reduce your patients risk by improving their visual function and educating them about precautions to follow. Even if theyre not out dancing, this can make a significant difference in their continued mobility and quality of life.
1. National Center for Injury Prevention and Control. Falls and hip fractures among older adults. www.cdc.gov/ncipc/factsheets/falls.htm.
2. Hausdorff JM, Rios DA, Edelberg HK.Gait variability and fall risk in community-living older adults: a 1-year prospective study. Arch Phys Med Rehabil 2001 Aug;82(8):1050-6.
3. Murphy SL. Deaths: final data for 1998. Natl Vital Stat Rep 2000 Jul 24;48(11):1-105.
4. Alexander BH, Rivara FP, Wolf ME. The cost and frequency of hospitalization for fall-related injuries in older adults. Am J Public Health 1992 Jul;82(7):1020-3.
5. Dolinis J, Harrison JE, Andrews GR. Factors associated with falling in older Adelaide residents. Aust N Z J Public Health 1997 Aug;21(5):462-8.
6. Klein BE, Klein R, Lee KE, Cruickshanks KJ. Performance-based and self-assessed measures of visual function as related to history of falls, hip fractures and measured gait time. The Beaver Dam Eye Study. Ophthalmology 1998 Jan;105(1):160-4.
7. Klein BE, Moss SE, Klein R, et al. Associations of visual function with physical outcomes and limitations 5 years later in an older population. The Beaver Dam Eye Study. Ophthalmology 2003 Apr;110(4):644-50.
8. Coleman AL, Stone K, Ewing SK, et al. Higher risk of multiple falls among elderly women who lose visual acuity. Ophthalmology 2004 May;111(5):857-62.
