Falls-Prevention Interventions for Persons Who Are Blind or Visually Impaired (2024)

Abstract

The purpose of this article is to describe four main areas of falls-prevention intervention for older adults who are blind or visually impaired. When integrated into multifactorial programs, interventions pertaining to education, medical assessment, exercise and physical activity, and environmental assessment and modification have been shown to be effective in falls reduction. These areas of intervention are discussed with respect to specific concerns of older adults who are blind or visually impaired. In describing these areas of intervention, the increasing need for cross-disciplinary falls-prevention programs designed specifically for older persons with vision loss, as well as research demonstrating the efficacy of multidisciplinary programs designed for this group, are emphasized.

Keywords: multifactorial falls prevention, older adults, blindness, vision impairment

Introduction

Varying degrees of vision loss, including blindness and visual impairment, often appear near the top of lists indexing the many factors that place older people at greater risk for falling. The association between vision loss and falls has often been discussed in terms of various clinical measures of poor vision status that could independently influence falls risk, including visual acuity, contrast sensitivity, depth perception, and loss in visual fields (De Boer et al., 2004; ; ). Nevertheless, blindness and visual impairments rarely operate completely independently of other systems to increase the likelihood of a fall. For instance, Lord, Smith, and Menant (2010) described the important relationships between the visual system and systems that control and coordinate balance and gait. Similarly, Steinman, Pynoos, and Nguyen (2009) described an integrated effects view by which self-reported poor vision could indirectly lead to losses in upper and lower limb strength, by way of reduced physical activity associated with vision loss. These views recognize the potential for vision loss to dynamically affect and be affected by other health dimensions that contribute to falls risk. Furthermore, the range of visual functioning that is possible—from total blindness to vision impairments—is wide, and different problems often require different interventions. Some diseases and conditions that result in vision impairments may be progressive leading even to blindness, so interventions associated with vision loss may need to be reevaluated over time. Thus, in thinking of visual functioning as a dynamic system that is integrated with other systems, effective interventions aimed at reducing falls would need to consider blindness and visual impairment in their context among other falls risk factors.

Among researchers and practitioners who are interested in developing effective falls-prevention programs for older adults, there is marked consensus that integrated risk-management programs emphasizing multiple interventions, including educational programs, medical risk assessment, exercise and physical activity, and home hazard assessment and implementation of modifications, are most effective for improving function and reducing falls among community-dwelling older people (Close et al., 1999; Day et al., 2002; Gillespie et al., 2003; Tinetti et al., 1994). Studies that have compared single interventions to those that address multiple falls risk factors have found the greater efficacy of multifactorial programs compared to most singular interventions on their own. For example, Day et al. tested the effectiveness of three interventions separately and together, including vision improvement, group-based exercise, and home hazard management. Whereas statistically significant effects were reported for exercise alone, and for the other interventions when combined with exercise, neither management of home hazards nor treatment of poor vision alone were statistically significant in reducing falls.

In its national action plan to reduce or prevent falls, the National Council on Aging (NCOA; 2005) set goals that would prioritize multiple areas of concern by encouraging collaboration among diverse stakeholders, including older adults themselves, health care providers, policy makers, aging service professionals, representatives of building and construction industries, and community health professionals. Indeed, the “no wrong door” approach to falls prevention, in which older adults who are found to be at risk of falls in medical or community settings are linked to a standard falls risk evaluation (), reiterates the importance of establishing strong network connections between organizations that provide services to persons who are blind and visually impaired and other agencies that serve older people ().

The purpose of this article is to describe four main areas of falls-prevention intervention that, when integrated into multifactorial programs, have been shown to be effective in reducing falls among the older population at large. Interventions pertaining to education, medical assessment, exercise and physical activity, and environmental modification are discussed with respect to specific concerns of older adults who are blind or visually impaired. In describing these areas of intervention, we hope to emphasize the increasing need for cross-disciplinary collaboration in the development of falls-prevention programs designed specifically for older persons with vision loss, as well as more research testing the efficacy of multifactorial programs for this group who are at high risk for falls.

Education

Improving knowledge of older adults about falls and falls risk was among the primary goals developed by NCOA in its national action plan (2005). An important aspect of falls prevention for older persons who are blind or visually impaired is educating individuals about specific risk factors that can increase their likelihood of experiencing a fall. For example, older adults with poor vision may acquire unique falls risks associated with functional losses (such as an inability to walk from one room to another; ), in part, because they no longer feel safe due to their difficulties seeing. These types of functional losses may be reduced or avoided through the provision of training in daily living activities, which have the potential to make up a large portion of an older individual’s daily physical activity. Vision rehabilitation services, such as those provided by state/federal independent living programs for older individuals who are blind, can serve a vital role in training older adults to maintain their ability to safely perform activities of daily living and instrumental activities of daily living that are crucial to health maintenance and for preserving independence. In particular, public and private agencies that serve older people who are blind or visually impaired under the Older Blind Independent Living program (Title VII, Chapter 2, of the Rehabilitation Act of 1973, as amended—hereafter, VII-2) may have much to contribute in efforts to prevent falls. VII-2 independent living services that are available (but not necessarily provided) under the program include services to help correct blindness (including visual screening and surgical or therapeutic treatment); hospitalization related to such services; the provision of visual aids (such as magnifiers or eyeglasses); and other specific services that are designed to assist older individuals to adjust to blindness, maintain independence, and become more mobile and more self-sufficient (Orr, 1998). These services have been shown to be effective in helping older adults complete meaningful activities independently, including preparing meals for themselves and continuing to participate in the lives and activities of family, friends, and their communities (). Although VII-2 programs serve only a fraction of the number of older adults who could benefit from vision rehabilitation services, the program’s access to older persons who are blind or visually impaired makes VII-2 a potentially effective agent for provision of training in falls-prevention techniques and for disseminating information about falls and falls prevention to the individuals they serve.

Older persons who are blind or visually impaired can also benefit from educational materials that are created and disseminated by nonprofit organizations and government agencies, whose collective mission is to prevent falls among older adults. For example, there are a range of materials available from the Fall Prevention Center of Excellence (FPCE), located at the University of Southern California. Materials are made available on the FPCE website (http://www.stopfalls.org) for service providers and researchers, as well as for individuals and their families. Information is available regarding falls risk factors (including vision loss), assessment tools for evaluating environments, and programs and services that are available, aimed at preventing falls.

Checklists are another educational tool available to older adults who are blind or visually impaired. Because of their relative ease of use, checklists can provide older adults with a practical and inexpensive basis for evaluating risk related to the presence of hazards that may be present in their homes. In addition to being easy to administer, checklists usually require little or no training to conduct and may be disseminated directly to older adults via facilities where older people may congregate to receive services (such as senior centers and health clinics), by way of programs that serve older adults who are blind or visually impaired (including the VII-2 program), or through Internet sites that target older adults in need of services. An example of a home assessment checklist is Check for Safety: A Home Fall Prevention Checklist for Older Adults, disseminated by the Centers for Disease Control and Prevention (CDC; 2005) and attainable in large print from the CDC’s website (http://www.cdc.gov). It should be noted, however, that checklists may vary greatly with respect to their comprehensiveness, and suggested solutions may be generic or may not apply in all cases (). For example, checklists that are designed for older people in general may overlook some problems that are especially important for individuals who are blind or visually impaired. By contrast, the American Foundation for the Blind (AFB) disseminates a House Survey Tour and Checklist on its website (www.afb.org/seniorsite/homesurveychecklist). This checklist focuses on specific safety issues within the homes and apartments of individuals who are blind or visually impaired, which may be addressed very briefly or omitted from other checklists. The AFB checklist also provides room-by-room suggestions about adaptations that could be implemented to address specific hazards (such as the application of color and/or texture contrast to mark edges on stairs and entrance thresholds. Finally, the adoption of recommendations presented by checklist assessments may also vary according to the willingness of older adults to change aspects of their homes and their beliefs as to whether making changes would influence their likelihood of falling (Cumming et al., 1999). Therefore, educational materials for older adults who are blind or visually impaired may be more effective when accompanied by research-validated materials emphasizing the efficacy of making specific changes to reduce falls risk.

Medical Risk Assessment

Customarily, older people may begin to seek out redress for age-related vision loss or related health conditions through consultations with physicians who are trained to address vision loss on the basis of a medical examination. Physicians and other health care professionals are an important source of information for older individuals who are blind or visually impaired and concerned about the possibility of falling. Increasingly, geriatricians have begun to integrate falls prevention into practices that have traditionally focused on treating chronic and acute conditions, including falls-related injuries, after they occur. Many of the most common chronic conditions often experienced by older people who are blind or visually impaired have been associated with falls, including stroke, diabetes, osteoarthritis, cardiovascular problems, and cognitive impairments (; ). Furthermore, among older adults in general, the risk of mobility loss and falls increases relative to the degree of frailty and to the number of chronic conditions that are experienced by individuals (Guralnik et al, 1993; ).

Chronic disease and vision loss have a unique association that is directly relevant to an individual’s falls risk. Identifying integrated relationships between vision and other health dimensions during a formal assessment of falls risk has the potential to inform effective interventions designed to reduce falls and to improve overall health of persons who are blind or visually impaired. A formal medical risk assessment should include a visual examination, as well as an assessment of the individual’s eyewear prescription for currency. Uncorrected refractive errors have been shown to be a significant cause of vision impairments among people of all ages (), as well as a falls risk for older people (Day et al., 2002). In addition to evaluating vision status, additional risk factors can be identified by conducting a detailed history of the patient’s health, including his or her medical conditions and medications, and inquiries about mobility and functioning and about the environments in which the older person spends his or her time (Tideiksaar, 1998). According to Rubenstein, Robbins, Josephson, Schulman, and Osterweil (1990), much can also be learned by conducting post-fall medical assessments designed to identify underlying and possibly modifiable falls risk factors that could inform preventive and therapeutic interventions. Even when falls do not result in injuries, reviewing the circ*mstances that lead up to falls episodes with physicians may be informative, as these discussions may elucidate symptoms of underlying disease or functional losses that, if addressed early on, could prevent more serious health problems, functional losses, and falls in the future.

Exercise and Physical Activity

It is well known and documented that persons with vision loss have greater risk of acquiring functional difficulties that, in part, may reflect age-related losses in the musculoskeletal system (). For this high-risk group of individuals and for older adults in general, exercise may serve to prevent, slow, or reverse the progress of many negative health outcomes commonly experienced by older people (Campbell et al., 2005; ). Even minimal doses of regular exercise by older adults have been shown to modify many of the most prevalent chronic medical conditions experienced in old age, including arthritis, heart disease, stroke, and pulmonary disease (). Studies that have assessed the effects of exercise on the musculoskeletal system have reported positive effects on muscle strength, neuromuscular performance, and bone mineral density (), in addition to improving balance and mobility () and increasing flexibility and joint range of motion (Fatouros et al., 2002). Studies that have directly assessed the impact of exercise in reducing falls risk have generally confirmed the efficacy of various exercise regimens alone and in conjunction with other interventions for reducing falls (Day et al., 2002; Province et al., 1995; ). In the review conducted by Province and colleagues, which assessed effects of various exercise interventions administered as part of the Frailty and Injuries: Cooperative Studies of Intervention Techniques trials, general exercise programs were found to reduce falls by about 10 percent, whereas balance exercises reduced falls by 17 percent. Thus, all exercise programs are not equal in their beneficial effects with respect to falls prevention, and it appears that the greatest benefit is achieved when exercises are chosen to address specific decrements experienced by older individuals—that is, when exercises are tailored to address the individual’s specific functional limitations. For example, Lord et al. (2001) described resistance or strength training as a means to increase the ability of muscles to generate force, such as that needed to stand from a chair or to climb stairs. Various studies have demonstrated that resistance training, including weight training, can reduce falls risk by increasing muscle strength and improving functioning and performance in daily tasks (). Lord et al. noted, however, that strength training for isolated muscle groups that are not used in everyday tasks may do little to improve functional capacity because carryover to muscles that are not directly trained may be limited. Greater improvement may be possible by practicing particular functional activities in which individuals have deficits. For example, older persons who have trouble climbing a flight of stairs may benefit most by training that practices stair-climbing or exercises that simulate stair-climbing. In addition to formal exercise classes, older persons who are blind or visually impaired could potentially acquire valuable physical training in programs (such as VII-2, described previously) that teach orientation and mobility—a protocol that focuses on training specific skills needed for safe and effective travel through the environment ().

Although evidence overwhelmingly supports the need for all older people to remain physically active to maintain optimal health, older persons who are blind or visually impaired are often at a decided disadvantage in their ability to easily participate in formal exercise programs, even when they are available to them in their communities. Older adults with vision loss may have many reasons for not participating in formal exercise programs. For example, practical considerations such as procuring transportation may be of greater concern for older adults who are blind or visually impaired. Some agencies, such as the Braille Institute in Los Angeles, provide limited door-to-door transportation from the homes of participants to their classes; however, expenses associated with overhead costs, including paying for fuel and drivers, as well as general maintenance of a fleet, make this option impractical and prohibitive to many agencies that serve older people. In addition to transportation concerns, vision impairments may also result in motivational difficulties that could arise due to health disparities related to blindness and vision impairments. Chronic conditions, which are often experienced disproportionately by people with vision impairments (), may limit the types of exercise that can be performed and the duration of time that they are able to participate. Older people who have mobility difficulties due to their vision loss may feel that their safety is threatened by venturing beyond their homes, or they may feel uncomfortable or unstable while participating in formal exercise programs. Finally, older people with visual impairments may have greater difficulty following instructors, who may rely heavily on visual cues while leading classes. Some exercise regimens that have been adapted specifically for falls prevention, such as tai chi for older adults, may involve a complex series of choreographed movements, which are not easily replicated without being able to see them demonstrated by an instructor. In this case, older adults who are blind or visually impaired would likely forgo attending exercise classes if special provisions were not available to address their concerns.

Those who instruct older adults in physical fitness classes should become knowledgeable about the unique circ*mstances that older people who are blind or visually impaired may face when attempting to participate in groups where others have normal vision. In addition, instructors as well as physicians should become aware of techniques and strategies available to older people who are blind or visually impaired for maintaining or increasing physical activity levels, to avoid unduly limiting activities due to vision loss (Lieberman, 2002). Morgenthal and Shephard (2005) provided some basic recommendations and modifications that would foster participation by persons with vision impairments, including making sure that exercise areas are well lighted and that instructions are provided in large print or are spoken clearly and slowly, with enough detail to ensure comprehension. Exercise areas should be kept clear of objects that can cause trips or stumbles. If possible, the provision of external support devices, such as chairs or wall bars, should be provided to individuals who have a history of falls. For individuals who are blind, who are visually impaired, or who have dual sensory impairments, an array of techniques and adaptations have been developed to help improve access to fitness alternatives, including the use of sighted guides, guide wires, tethering, and cueing techniques, which allow persons of all ages to participate in walking, running, bicycling, swimming, exercise training in a health club, aerobics, and fitness at home (such as jumping rope, yoga, and basketball; see Lieberman, 2002). Despite the availability of techniques, there is a clear need for continued development of exercise regimens specifically designed for older people who are blind or visually impaired to target their unique balance, strength, and coordination problems, while providing structure, motivation, and social support to this group.

Home Hazards and Home Modifications

The settings in which older people who are blind or who have vision impairments live often contain many hazards and problem areas or lack supportive features that could reduce falls risks if they were present (; Pynoos et al., 2010; Stevens, 2002/2003). To compound these problems, the oldest old, those who are most likely to experience vision loss, may become less mobile due to their functional losses and spend more of their time in and around their homes (), thus increasing the potential for environmental factors to influence falls risk. Among older adults in general, the majority of falls-related injuries (55 percent) occur inside the home, including falls on stairs and in rooms throughout the house. An additional 23 percent of injuries experienced by older adults due to falls occur outside but near the home, such as in the driveway, on the patio, or in the back yard. The remaining 22 percent occur out in the community, in public spaces such as parking lots and sidewalks (Kochera, 2002), as well as in the built environment (Pynoos et al., 2005). According to Li et al. (2006) risk profiles for indoor and outdoor falls are different, with increased leisure-time physical activity being associated with outdoor falls and a greater number of physical difficulties and indicators of poor health associated with indoor falls. In all, it is estimated that around 40 percent of falls result from factors that are related to the environment ().

According to Lawton and Nahemow’s (1973) theory of environmental press, well-designed environments and effective home modifications should function to reestablish equilibrium between a person’s abilities, which may have declined due to vision loss and the demands of the environment. The concept of universal design (UD) has been employed to create products, buildings, and exterior spaces that reduce sensory, cognitive, and environmental demands for people of all ages, sizes, and abilities to the greatest extent possible, without the need for adaptation. Effective UD minimizes barriers and increases supportive features to facilitate participation in daily living activities (). Among many other possibilities, UD features that may be especially helpful for reducing falls among older persons who are blind or visually impaired include a zero-step entrance with flush or low-profile threshold, high contrast trim and glare-free or textured floor surfaces, curbless or roll-in showers in bathrooms, and motion sensor lighting that automatically turns on and off when individuals enter or exit a room (Pynoos, 1992; Young, 2006).

In older homes or homes that have not been well designed for older persons who are blind, are visually impaired, or have other related disabilities, home modifications can be employed to address hazardous areas that could increase falls risk. Home modification refers to the converting or adapting of environments to make everyday tasks easier, reduce accidents, and support independent living (Pynoos et al., 2005). Just as visual functioning and health status of older individuals is dynamic, environments also can change over time, as homes become older and keeping up with repairs may become more difficult. The range of available home modifications is wide and expenses vary from low-cost adaptations to more expensive renovations (Pynoos et al., 2010). Home modifications that are particularly germane to older adults who are blind or visually impaired include improving lighting throughout the home, removing hazards (e.g., clutter and throw rugs), adding special features or assistive devices (e.g., grab bars that provide color contrast with the surrounding decor), moving objects and furnishings to create clear pathways, placing contrasting nonskid textured mats in showers and tubs, and painting door frames in bright solid colors (Duffy, 2002; Pynoos et al., 2005).

Researchers generally agree that home modifications are important for promoting safety and independent living; however, research findings are inconsistent and sometimes counterintuitive in their reports of the impact of hazard reduction and home modification on falls rates. For example, Steinman et al. (2009) analyzed data from the Health and Retirement Study and reported that persons whose homes had been modified to accommodate someone living with a disability were more likely to fall than persons who lived in homes that had not been modified. This finding was interpreted to reflect the greater likelihood of acquisition of home modifications by those who need them, whether due to chronic conditions, functional difficulties, or vision loss—that is, that those who were at greater risk of falls were more likely to invest in home modifications to prevent a fall.

When hazard reduction and home modifications have resulted in significant reductions in falls, it has usually been described as a combined effect in which environments interact with other falls risk factors. The general removal of home hazards without consideration for interactions of physical and behavioral traits with specific aspects of the environment may not only be ineffectual for reducing falls but also has the potential to increase falls risk by interfering with idiosyncratic relationships established over time between individuals and their home environments (Pynoos et al., 2010). For instance, a common recommendation is to clear all walkways and paths of obstacles that may be viewed generally as trip hazards. On the surface, this recommendation seems sensible; however, many older adults who are blind or visually impaired may have adopted personal strategies based on environmental features to improve mobility and compensate for decrements in their vision. Older people who are blind or visually impaired may use large pieces of furniture as cues to orient themselves as to their location in a room or relative to other known but less salient environmental hazards. Similarly, older people with balance impairments may use table tops or the backs of sofas to support themselves as they make their way across a room. By exploring unique forms of support that environments afford and observing how persons carry out tasks, recommendations by occupational therapists and/or vision rehabilitation therapists can be better tailored to address specific combinations of intrinsic (including vision-related) factors experienced as a function of age, behavioral attributes, and environmental falls risk factors.

Conclusion

This article highlights multiple interventions that address the specific needs of older individuals who are blind or visually impaired, which when integrated into multifactorial programs are effective for reducing falls. The most effective intervention strategies consist of multiple components that address relationships between vision loss and other falls risk factors that are intrinsic, extrinsic, and behavioral in origin (; ). Programs that hold the greatest potential for reducing or preventing falls among this high-risk group require exploration of dynamic interactions between the health and functional abilities of older adults who are blind or visually impaired and their surrounding environments. In accordance with this view, AGS Clinical Practice Guideline: Prevention of Falls in Older Adults established by the American Geriatrics Society (AGS; 2010) recommends that older adults who are at high risk of falling (including those who are blind or visually impaired) undergo multifactorial falls risk assessments that could serve to identify factors that may be uniquely associated with blindness and visual impairment in late life. Implicit in the recommendation of AGS is the acknowledgment that any single intervention is likely to be less effective than when complex relationships between multiple falls risk factors are considered together. Thus, there is a concerted need for continued development of cross-disciplinary multifactorial falls-prevention programs specifically targeting older adults who are blind or visually impaired. To deal most effectively with the problem of falls among this population, an array of medical and rehabilitative services including providers from the aging network will need to be enlisted, and collaborative relationships strengthened between public agencies and private agencies that serve older adults who are blind or visually impaired. Given projections of a growing number of older individuals with vision loss, it is clear that practitioners across numerous fields who are interested in preventing falls among older adults will need to become increasingly aware of issues related to medical, functional, and rehabilitative aspects of blindness and visual impairment, especially as they relate to falls prevention. In addition, new and continued research is needed to demonstrate the efficacy of programs and to establish a body of evidence on which to base programs aimed at improving health and functioning, enhancing independence, and reducing falls among older persons who are blind or visually impaired.

Acknowledgment

This manuscript was completed with support from a training grant provided by the National Institute on Aging (#5T32AG0037); the Agency for Healthcare Research and Quality National Research Services Awards Post-doctoral fellowship training grant (5T32HS000011-24), and the Archstone Foundation.

Contributor Information

Bernard A. Steinman, Brown University, Providence, RI.

Anna Q.D. Nguyen, University of Southern California, Los Angeles, CA.

Jon Pynoos, University of Southern California, Los Angeles, CA.

Natalie E. Leland, Brown University, Providence, RI.

References