Scottish Government Falls Prevention Strategy consultation

We have responded to a Scottish Government consultation on Falls Prevention Strategy (August 2019).

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1. Do you agree the Strategy will improve services for those who experience Falls?

Yes

2. Do you agree with the outcomes in the Strategy? 

Yes

3. Do you have any comments or additions on topics which are not covered in the Strategy?

N/A

4. Are there any key areas missing or any general amendments you would suggest?

Outcome 9 - We would suggest adding people living with diabetes as a specific group. Diabetes is an important cause of visual impairment in older people as it can increase the risk of conditions such as diabetic retinopathy, cataracts and glaucoma. It has been found that 9.9% of people in residential or nursing homes have diabetes. In addition, people with diabetes who have peripheral neuropathy can have very poor balance control. They also have a greater risk of falls, particularly if they have foot problems.

References 

  • Benbow S J, Walsh A, Gill G V. Diabetes in institutionalised elderly people: a forgotten population? BM. 1997 314 1868-69
  • www.retinalscreening.nhs.uk 
  • Simoneau GG, Ulbrecht JS, Derr JA et al Postural instability in patients with diabetic sensory neuropathy Diabetes Care 1994 17(12) 1411-1421
  • Schwartz AV, Hillier TA, Sellmeyer DE et al Older women with diabetes have a higher risk of falls Diabetes Care 2002 25(10) 1749-54
  • Wallace C, Reiber GE, LeMaster J et al Incidence of falls, risk factors for falls, and fall-related fractures in individuals with diabetes and a prior foot ulcer Diabetes Care 2002 25(11) 1983-1986

Appendix 2 - The Falls and Fracture Prevention Action Plan section currently says that “Interventions may include […] the assessment and management of visual impairment”. We believe that there is now sufficient evidence of the link between poor vision and falls and as such the Strategy should now say that Interventions ‘should’ (rather than ‘may’) include an assessment of visual impairment. Falls are the most common cause of hospitalisation for people aged over 65. Across the UK, one in three people aged over 65 will fall every year, and it remains the biggest cause of accidental death in people aged over 75.

References 

  • Abdelhafiz, A.H. and Austin, C.A Visual factors should be assessed in older people presenting with falls or hip fracture Age and Ageing 2003 32(1), 26-30
  • Ivers RQ, Cumming RG, Mitchell P et al. Visual impairment and falls in older adults: the Blue Mountains Eye Study. J. Amer Ger. Soc. 1998 46(1): 58-64
  • Cummings SR. Treatable and untreatable risk factors for hip fracture. Bone 1996 18(3 suppl): 165S-167S
  • 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 1995 41(5), 280-5
  • Patino CM, McKean-Cowdin R, Azen SP et al Central and peripheral visual impairment and the risk of falls and falls with injury  Ophthalmology 2010 117(2) 199-206
  • Knudtson MD, Klein BE, Klein R  Biomarker of aging and falling: the Beaver Dam eye study Arch Gerontol Geriatr 2009 49(1) 22-26  
  • Kuang TM, Tsai SY, Hsu WM et al  Visual impairment and falls in the elderly: the Shihpai Eye Study J Chin Med Assoc  2008 71(9) 467-72
  • Kulmala J, Era P, Parssinen O et al  Lowered vision as a risk factor for injurious accidents in older people  Aging Clin Exp Res  2008 20(1) 25-30
  • Lamoureux El, Chong E, Want JJ et al  Visual impairment, causes of vision loss, and falls;  the Singapore Malay eye study  Invest Ophthalmol Vis Sci  2008 49(2)  528-33
  • de Boer MR, Pluijm SM, Lips P et al  Different aspects of visual impairment as risk factors for falls and fractures in older men and women  J Bone Miner Res 2004 19(9) 1539-47
  • Coleman AL, Stone K, Ewing SK et al  Higher risk of multiple falls among elderly women who lose visual acuity  Ophthalmology  2004 111(5) 857-62
5. Please comment your thought on how best to support the implementation of the Strategy.   

We believe optometrists have a major and influential role to play in supporting the implementation of the Strategy. Optometrists are in a good position to identify people who are at an increased risk of falling, for example elderly patients who have a change in their prescription and/or wear multifocal lenses. Wearing bifocal or varifocal glasses can affect the ability to gauge distance and depth perception, and wearers are twice as likely to fall as other elderly people. Optometrists can help to reduce that risk by offering advice on prevention to patients and carers, and colleagues in other medical and care professions. They can also identify problems that cause sight loss and prevent/manage these.

Outcome 1 - Awareness of Falls Services among relevant primary care clinicians is a fundamental factor in the service seeing the appropriate patient at the appropriate time. Links between falls and community optometrists could be improved. Falls Services would benefit from having the ability to communicate with and/or refer to an optometrist. Optometrists are also in a good position to identify people who are at risk of falling. Methods of reciprocal referral between Optometry and falls services should be explored. A system should be devised whereby falls services can easily select and contact each patient’s preferred choice of local optometrist for onward referral. Connections between the specialist vision services, such as those for low vision, and Falls Services should be nurtured and encouraged.

The College of Optometrists is pursuing solutions to support both optometrists and falls teams in linking up services for the benefit of the patient. We have been working with Falls teams across the UK and developed a Falls Directory. We encourage optometrists to make contact with their local Falls Team when they identify risk. Falls teams with concerns about a patient’s eye sight, should encourage them to book an eye examination by using our Member Directory to find a College Member practising in their area. Many have dementia-friendly practices.

Outcome 2 - Optometrists have a vital role in supporting falls prevention programmes. Thanks to the frontline nature of the profession, and the high levels of patient coverage, optometrists are in a good position to help deliver public health messages on lifestyle choices.

Schemes exist in other countries where optical practitioners can offer health and lifestyle-related advice and, if necessary, referral into other support services. One such example is the Healthy Living Optician (HLO) initiative started in England. The HLO scheme allows practitioners to offer a range of health-related advice, including NHS health checks. As part of the initiative patients also receive lifestyle advice and if necessary, referral into other support services. These schemes should be considered in Scotland.

The College has developed resources to help optometrists in examining patients at risk of falling, including training sessions on The Ageing Eye: Vision and Falls.

Outcome 3 - Vision is fundamental to coordinating our movement –balance and postural stability are directly affected by vision. In addition, vision is fundamental to adapting gait to enable safe travel through the environment, avoiding obstacles and negotiating steps and stairs. However, emerging evidence shows that standard falls rehabilitation strategies may not be effective for people where vision was a factor. We feel that vision should be a consideration in all aspects of a patient pathway through falls services – including prevention and rehabilitation programmes.

The message that generic falls rehabilitation exercise programmes may not be effective for people with sight loss should be highlighted to the relevant professionals. We would stress the importance of ensuring that physical activity programmes are tailored to people with sensory impairment. Research shows that older people with eye diseases are 3 times more likely than those with good vision, to limit activities due to fear of falling.

Optometrists also have a role in identifying those adults with poor vision who have fallen or who have a fear of falling and signposting them to services and resources for crucial strength and balance exercise training to prevent falls. Joined up services should be in place.

References 

Outcome 4 - 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. Adding treatment of poor vision to exercise and hazard management in the home has been shown to produce an additional 14% reduction in the annual fall rate, compared to no intervention.

There is also a need to raise awareness of the domiciliary optometry service; if a patient is housebound and unable to access a community practice an optometrist can provide a sight test at home.

References 

  • Day L., Filders B, Gordon I. et al. Randomised factorial trial of falls prevention among older people living in their own homes BMJ 2002 325 128

Outcome 5 – We would like to see increased visibility of and emphasis on interventions that encourage regular eye examinations with an optometrist as an important healthy lifestyle behaviour. Encouraging older people to have regular eye examinations should help reduce falls caused by visual problems. Visual impairment is associated with a significant increased risk of falls and a reduced ability to live independently.

As mentioned in our comments under Outcome 2, optometrists are in a good position to help deliver public health messages on lifestyle choices thanks to the frontline nature of the profession, and the high levels of patient coverage.

References 


Outcome 6 - See our comments under Outcome 5 above.


Outcome 7 - All older people undergoing a falls assessment should be screened for visual impairment and those found to have a visual impairment should have a full eye examination by an optometrist. All older people should be encouraged to have regular eye examinations.

As mentioned in our comments under Outcome 2 above, optometrists are in a good position to have “falls conversations” with patients thanks to the frontline nature of the profession, and the high levels of patient coverage. Optometrists have expertise on visual factors that cause falls and how to manage them, such as the need for cautious prescribing of multifocal lenses to older people.

Outcome 8 - n/a

Outcome 9 - 850,000 people are living with dementia in the UK, with two-thirds living in private households, and one-third living in some form of institutional care setting. The risks of visual impairment and dementia both increase with age, and the UK’s ageing population will lead to many more people living with both dementia and sight loss. The impact on quality of life of having both sight loss and dementia are much more severe than those resulting from either dementia or sight loss alone.

The government-funded Prevalence of Visual Impairment in Dementia project (PrOVIDe) led by the College of Optometrists  found that the prevalence of visual impairment (VI) in those with dementia is generally higher than for the overall population, indicating that the lives of many people with dementia could be improved by regular sight tests and taking appropriate action.

The College’s research also found that almost 50% of those living with dementia and VI were no longer classified as visually impaired when wearing their up-to-date spectacle prescription, highlighting the importance and impact of eye examinations in this group of people.

This research will help professionals and family members to understand the importance of vision to those with dementia. If they are unable to access a community practice unaccompanied, people living with dementia can have eye examinations in their home but PrOVIDe showed that many carers were not aware of this. Our research showed that it was possible to conduct key components of an eye exam with more than 80% of PrOVIDe participants.
 
Awareness on how good vision will help people with dementia live better, and possibly slow their decline should be raised.

References 

  • Bowen M, Edgar DF, Hancock B, Haque S, Shah R, Buchanan S, et al. The Prevalence of Visual Impairment in People with Dementia (the PrOVIDe study): a cross sectional study of 60-89 year old people with dementia and qualitative exploration of individual, carer and professional perspectives. Health Serv Deliv Res 2016;4(21)
  • New research shows vision and hearing loss may raise risk of dementia in older adults, Alzheimer’s Society. 

Outcome 10 - Care homes: People in residential care and nursing homes are at an increased risk of falls, and it has been estimated that the falls incidence in nursing care facilitites is three times that in the community. These people are at risk of having their eye problems overlooked.

Awareness of the link between falls and vision should be raised with carers and carers’ organisations.

Again, there is a need to raise awareness of the domiciliary optometry service; if a patient is unable to attend community optometric practice because of physical or mental disability an optometrist can provide a sight test at home.

References 

  • Van der Pols JC, Bates, CJ, McGraw, PV et al. Visual acuity measurements in a national sample of British elderly people Br J Ophthalmol 2000 84 165-70
  • Nurmi I, Luthje P. Incidence and costs of falls and falls injuries among elderly in institutional care. Scandinavian Journal of Primary Health Care 2002 20(2) 118-22
  • Luukinen H, Koski K, Hiltunen L, Kivela SL. Incidence rates of falls in an aged population in northern Finland. Journal of Clinical Epidemiology 1994 47(8) 843-50.
  • Rubenstein LZ, Josephson KR, Robbins AS. Falls in the nursing home. Annals of Internal Medicine 1994 121(6) 442-51

Hospitals: Falls are the most common cause of hospital admission for the over 65’s. All older people undergoing a falls assessment should be screened for visual impairment and those found to have a visual impairment should have a full eye examination by an optometrist.

Outcome 11 - n/a

Outcome 12 - The link between hip fractures and poor vision should be highlighted, as they have been linked to visual impairment.  Evidence found that in hip fracture patients, 33% were visually impaired (6/18 or worse in both eyes) and 58% had a distance visual acuity of 6/18 or worse in at least one eye.

References

  • De Boer MR, Plujm SM, Lips P, et al. Different aspects of visual impairment as risk factors for falls and fractures in older men and women.  J Bone Miner Res 2004; 19(9) 1539-1547
  • Squirell DM, Kenny J, Mawer N et al. Screening for visual impairment in elderly patients with hip fracture: validating a simple bedside test Eye 2005 19 55-59
  • Abdelhafiz, A.H. and Austin, C.A Visual factors should be assessed in older people presenting with falls or hip fracture Age and Ageing 2003 32(1), 26-30
  • Ivers RQ, Cumming RG, Mitchell P et al. Visual impairment and falls in older adults: the Blue Mountains Eye Study. J. Amer Ger. Soc. 1998 46(1): 58-64
  • 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 1995 41(5), 280-5
  • Patino CM, McKean-Cowdin R, Azen SP et al Central and peripheral visual impairment and the risk of falls and falls with injury  Ophthalmology 2010 117(2) 199-206
  • Kuang TM, Tsai SY, Hsu WM et al  Visual impairment and falls in the elderly: the    Shihpai Eye Study J Chin Med Assoc  2008 71(9) 467-72
  • Kulmala J, Era P, Parssinen O et al  Lowered vision as a risk factor for injurious accidents in older people  Aging Clin Exp Res  2008 20(1) 25-30
  • Lamoureux El, Chong E, Want JJ et al  Visual impairment, causes of vision loss, and falls;  the Singapore Malay eye study  Invest Ophthalmol Vis Sci  2008 49(2)  528-33
  • de Boer MR, Pluijm SM, Lips P et al  Different aspects of visual impairment as risk factors for falls and fractures in older men and women  J Bone Miner Res 2004 19(9) 1539-47
  • Coleman AL, Stone K, Ewing SK et al  Higher risk of multiple falls among elderly women who lose visual acuity  Ophthalmology  2004 111(5) 857-62
6. Do you have any further general comments on the Falls and Fragility Fracture Prevention Scotland Strategy? 

The College of Optometrist welcomes the Strategy as it rightly focuses on falls related in particular to visual impairment.

The complex links between eye health and the broader public health agenda are strong and often overlooked. One in five people aged 75 and on in two aged 90 and over are living with sight loss. Sight loss is a severe disability and can have a devastating pervasive effect on all aspects of life. There is a link between sight loss and reduced wellbeing. The chances of having reduced vision greatly increases with age and older people with reduced vision are more likely to fall. Visually impaired people have been found to be three times more likely to fall if they were physically inactive. The Strategy should emphasise the greater role of optometrists to help ensure Scotland has joined up, effective falls initiatives that will reach people through multiple touchpoints.

References

  • Access Economics (2009) Future Sight Loss 1.
  • Lamoureux E, Gadgil S, Pesudovx K et al The relationship between visual function, duration and main causes of vision loss and falls in older people with low vision Graefes Arch Clin Exp Ophthalmol 2010 248(4) 527-33

Submitted: August 2019

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