Rnib care Homes Falls Prevention Project: a review of the Literature icon

Rnib care Homes Falls Prevention Project: a review of the Literature

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2.1.3 For the care home business

The key objective of any care home must always be to provide high quality care for all residents however underlying that is the need to be and remain a business and secure appropriate funding for that purpose.

The recent health reforms are moving healthcare towards a service driven by patient outcomes and patient choice rather than a service which is provider driven. Care homes are closely aligned to healthcare and patient choice is becoming increasingly important as more and improved service information is shared with a better informed population with higher service expectations. The impact of this could potentially result in care homes with more recorded falls not being the preferred choice of the informed resident and the number of residents reducing with the subsequent reduction in business.


3. Risk factors relating to falling in older people with visual impairment in residential settings

There are numerous reasons why people fall. NICE (2004) identified over 400 risk factors that could increase the risk of falling. Woolf and Akesson (2003) divided the main risk factors into eight categories:

  1. Age-related deterioration

  2. Visual Impairment

  3. Problems with balance, gait and mobility

  4. Cognitive Impairment

  5. Blackouts

  6. Incontinence

  7. Drug therapy

  8. Hazards – personal and environmental

Although ‘visual impairment’ has been listed as a separate category, numerous studies emphasise how reduced vision either from normal ageing or specific eye conditions are linked to the other seven risk categories. For example, impaired vision has been shown to adversely affect postural stability and increase the risk of falling in older people (Lord: 2006). Incontinence issues might result from an individual’s lack of ability to identify a toilet because of their vision problems and/or affect their capability of walking easily to its location.

There is a higher prevalence of visual impairment in older people who live in nursing or residential homes compared with people of a similar age living in the community (Tielsch et al: 1995; West et al: 2003; Horowitz: 1994; Van de Pols et al: 2000; Van Newkirk et al: 2000; Evans et al: 2008). Much of this impairment is due to correctable conditions such as refractive error or cataract. Owsley et al (2007) advised that the reasons are not fully understood but that a variety of factors might contribute to the high rates of visual problems in this population. A number of possibilities for this have been suggested:

  • Visually impaired people may be more likely to be admitted to residential care, although a recently completed UK study by Evans et al (2008) suggested that visual impairment did not add significant extra disadvantage leading to nursing home admission and that other co-morbidity factors may be more significant.

  • Eye care services may be more difficult to access for this population. Such difficulties have been observed in a number of studies (Goetzinger et al: 1996); and

  • Residents living in care homes are frailer with increased levels of co-morbidities. Consequently, eye care interventions may be overlooked or thought to be unnecessary for this client group with spectacle usage or vision assessments for those with cognitive impairments being underutilised.

4. The impact of vision impairment on falls

4.1 Normal age related vision changes and visual impairment

Campbell (2005) emphasised that it was important to understand the difference between normal vision changes due to aging and visual impairment. As individuals get older they experience age-related differences in a number of visual functions. These can include increased glare sensitivity as well as reduced visual acuity; contrast sensitivity; accommodation; depth perception and visual field. The extent to which the pupil dilates also decreases with age resulting in an older person needing two or three times as much light as younger people (Pool: 2007). Such changes can predispose a person to the risk for falling through declined visual functioning. For example, a person may have difficulty walking at night or be unable to see an object in their path due to a greater sensitivity to glare or a reduction in their visual field. These difficulties would increase the likelihood of a person experiencing a slip or trip.

Historically, public awareness of preventable or treatable visual problems in the older population of the UK has been poor (Wormald et al: 1992). Often individuals’ sight loss problems remain undetected. Research has shown that the majority of people have vision problems which could be improved by surgery or spectacles. One UK study found that 17 per cent of visual impairment in people over 65 years was solely related to uncorrected refractive error which could be resolved by the provision of spectacles (Reidy et al: 1998) whilst another stated that over 30 per cent of visual impairment in the over 75s was due to refractive error (Evans et al: 2002).

Studies have demonstrated that people in residential facilities can experience difficulties in accessing regular eye assessments (de Winter et al: 2004), not wear their spectacles or use out of date prescriptions or wear inappropriate spectacles. For example, multifocal spectacles have been shown to impair distant depth perception and contrast sensitivity and can increase the risk of trip incidents and falls in older people. Haran et al (2010) in a study to determine whether the provision of single lens distance glasses to older wearers of multifocal glasses reduced falls, noted that such wearers (i.e. wearers of multifocal glasses) had a high risk of falls when outside their homes and when walking up or down stairs.

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