Step Up to Prevent Falls: A Looming Public Health Crisis

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.³ 

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

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
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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. 
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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