What’s New in the Patient Safety World
June 2014
New Glasses and Fall Risk
The most common
cause of gait instability in the elderly is the “multiple sensory deficit”
syndrome. That means that disturbances of proprioception, vision, vestibular
function, and maybe even hearing, each of which may not be enough to affect
gait become severe enough collectively to affect gait. So, as a neurologist, we
are often recommending to our patients with gait disturbances that they get
their vision corrected.
But in our June 2010
What’s New in the Patient Safety World column “Seeing
Clearly a Common Sense Intervention” we noted that sometimes new glasses
may paradoxically result in increased falls.
Recently we came
across an outstanding paper in the optometry literature (Elliott
2014) that nicely summarizes the physiological links between vision and gait,
the epidemiology of falls and vision disturbances, and the evidence base
linking falls to changes in patients’ corrective lenses.
The author notes
that 57% of falls in older adults are due to trips, slips, and stumbles and
that steps, stairs and curbs are the most common environmental hazards contributing
to falls. He also notes that falls with injury are 3 times more likely when
descending stairs compared to ascending them. He goes on to describe how
corrections to vision that involve magnification and/or changes in astigmatism
may affect their function during such activities as descending stairs.
Elliott describes
the literature linking visual impairment to falls and notes this is likely an
underestimate. But he then goes on to describe the literature on the impact of
optometric interventions and/or cataract surgery on the fall rate. One of the
most striking studies cited was a randomized controlled trial (RCT) in which
community-dwelling patients aged 70 and older were given an optometric
intervention (most often new glasses) compared to those receiving just usual
care (Cumming
2007). Surprisingly, the fall rate
was higher in the intervention group in the first year (65% vs. 50%).
Elliott also notes
the literature on the relationship between bifocals and progressive lenses and
falls (see also our June 2010 What’s New in the
Patient Safety World column “Seeing
Clearly a Common Sense Intervention” regarding bifocals).
Elliott concludes
with several practical recommendations for optometrists:
- First, identify patients at high risk of falling
- Be conservative in changes made to new glasses (he provides
suggested limitation metrics for such changes)
- “If it ain’t broke don’t fix it” (i.e. if
the patient has no problems with his/her vision but wants new glasses,
just give him/her new frames)
- Where possible, keep the lens type the same (i.e. don’t change among
bifocals, progressive lenses, or single-distance lenses)
- Don’t prescribe bifocals or progressive lenses to any patient at
high risk for falls who has been using single-vision glasses
- When you do change glasses educate the patient on potential
complications
We don’t expect that
you’ll read through all the optometric details in the paper. But you should be
cognizant of the practical recommendations in the paper to be conservative with
any changes made to correct your patients’ vision. We’d actually go as far as
recommending that, for your patients who have multiple fall risk factors, you
provide them a copy of this paper to take with them to their ophthalmologist or
optometrist visit!
References:
Elliott DB. The Glenn A. Fry Award Lecture 2013: Blurred
Vision, Spectacle Correction, and Falls in Older
Adults. Optometry & Vision Science 2014; 91(6): 593-601
Cumming RG, Ivers R, Clemson L,
Cullen J, Hayes MF, Tanzer M, Mitchell P . Improving
vision to prevent falls in frail older people: a randomized trial. J Am Geriatr Soc. 2007; 55: 175–81
http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2007.01046.x/abstract
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