Link between eye examinations and fall prevention in older adults

Falls by older adults can kill and are widely recognized as a public health crisis in the U.S., the American Public Health Association’s (APHA’s) new policy statement says.

“Falls are the leading cause of injury-related deaths among (community-dwelling) adults 65 years and over and lead to premature mortality, loss of independence, and placement in assisted-living facilities,” reads the Falls Prevention in Adults Aged 65 and Over: A Call for Increased Use of an Evidence-Based Falls Prevention Algorithm.

Two years in the making, the policy statement continues, “Each year, falls result in more than 32,000 deaths, with 3 million older adults requiring emergency treatment” and hospital admissions for traumatic brain injuries and hip fractures. The economy saw an estimated $50 billion in medical costs in 2015 for fatal and nonfatal falls.

Many of these injuries and deaths surely are avoidable, says Andrea P. Thau, O.D.

“Falls are one of the greatest health risks over age 65,” says Dr. Thau, policy chair and governing councilor of the vision care section of the APHA. “Over 25% of adults over age 65 report at least one fall in the past year. They can lead to injury, loss of independence and death. Importantly, many falls can be prevented.”

Whereas kids are typically like rubber bands—bouncing back after a fall—older adults don’t necessarily bounce back when multiple and complex body systems are involved, says policy statement co-author Andrew Morgenstern, O.D. Then, a fall is not just a fall.

“The only way we’re going to prevent falls is to detect early,” says Dr. Morgenstern, a member of the policy committee of the APHA’s vision care section. “You can’t have prevention without detection.”

The co-authors say the purpose of the policy statement’s development is three-fold: (1) to educate health care providers about fall screenings, risk assessments and interventions, (2) to promote a multidisciplinary approach to providing care for patients at risk and (3) to highlight the merits of the underutilized national initiative called Stopping Elderly Accident, Deaths & Injuries (STEADI).

That multidisciplinary approach to care was also highlighted in a previous APHA public policy statement on diabetes’ care whose co-authors also included Drs. Morgenstern and Thau. The lead author was podiatrist and researcher Rachel Albright, DPM.

APHA action steps to prevent falls by older Americans

Interventions could save millions of dollars if mobility/balance issues are addressed and home hazard evaluations are undertaken, the statement says in citing studies. Attending to vision problems and mitigating falls among older adults alone could save $237-$423 million, the authors write.

Among its 17 action steps, the APHA calls for:

• Professional societies to educate their members and promote use of an evidenced-based algorithm such as STEADI that includes fall screening, assessment and interventions in patients 65 years and older.
• State licensing organizations (e.g., the Accreditation Council for Continuing Medical Education, the American Osteopathic Association, the Commission for Continuing Education Provider Recognition, the American Academy of Family Physicians, the American Podiatric Medical Association, the American Optometric Association, state boards of pharmacy) to include STEADI and other falls prevention education as mandatory for initial licensing and recertification.
• The American Optometric Association and the American Academy of Ophthalmology to advocate for annual, in-person, comprehensive eye examinations for all adults 65 years and older.
• The Centers for Disease Control and Prevention (CDC) to alter the STEADI algorithm to mirror the recommendation of the CDC falls prevention webpage (“have your eyes checked by an eye doctor at least once a year and be sure to update your eyeglasses if needed”) instead of using a Snellen eye chart for screening as the CDC suggests.
• Accredited continuing education organizations make STEADI-related education available for continuing education credits.
• Medicare, Medicaid and private insurers include coverage with no or low-fee cost sharing and reimbursement to providers for fall prevention exercise programs for adults 65 years and older, including gait, balance and functional training.
• Emergency departments and health care facilities that treat patients for acute falls to provide discharge instructions to obtain a comprehensive eye examination, a physical therapy assessment and a podiatric assessment to reduce the risk of future falls.

“Doctors should find a way to implement these programs in their regular exams,” says Dr. Morgenstern, referring to STEADI. “For example, if a patient comes in to an eye doctor with mild macular degeneration, even though it’s mild, there is still a significant increased risk for a fall. Part of the eye exam should be ‘you’re an increased fall risk, here’s the reason why and here are some ways we can actually help you reduce that risk’.”

He adds, “All health care providers, at every touch point, have to have that conversation with that patient. We also have to continually advocate for comprehensive, dilated eye exams, especially in this population, especially annually, if necessary. It’s also not unreasonable to have a list of referral points if a patient, for instance, has diabetes and they’re feeling any numbness in their feet.”

See the entire list of action steps here (list is three-quarters of the way down the page).

Falls and eye care

A decline in vision—and its subsequent impact on mobility—can contribute significantly to falls among adults 65 and older, whether it is from a decrease in visual acuity, visual fields, depth perception or contrast sensitivity, the statement says.

“In fact, the risk of falling doubles if an elderly adult has any level of vision impairment,” the authors write.

“Optometry plays a vital role in falls prevention,” Dr. Thau says. “Macular degeneration, cataracts, diabetic retinopathy and glaucoma are strongly associated with falls because they cause poor contrast sensitivity, reduced depth perception and visual field loss. As doctors of optometry, we can diagnose and treat these conditions and maximize patients' visual function and decrease the risk of falls.”

Adds Dr. Thau, “We should educate our patients about fall risks, encourage compliance with annual, comprehensive eye examinations, treat underlying conditions and maximize maintenance of visual function. For example, when prescribing glasses, we should consider single-vision lenses rather than progressives or bifocals for those at high risk of falling. We should help our patients maximize visual function.”

What can cause a fall?

According to the APHA, most falls are preventable. Among the causes cited:

• Medications
• Physical inactivity
• Dementia
• Metabolic disorders
• Gait disorders
• Foot deformity
• Lower extremity amputations
• Built environment
• Nutrition
• Vision impairments