Think sight with falls and older people CPD Session Aim: To provide resources for a hour group/individual session that explores the impact of sight loss on older people, how sight loss may increase the risk of falls and some implications for occupational therapy practice Introduction: This resource comprises a PowerPoint presentation and notes to go with it to explain how to run an hour’s workshop or complete it as an individual The PowerPoint and the accompanying notes are grounded in evidence The session is designed to equip members to develop their practice in working with service users with sight loss The session will facilitate members to improve their understanding of the link between falls and sight loss in line with the stated learning outcomes below There is a short text included after the notes with a reference list and some links to further reading The learning outcomes for the session By the end of this module you should understand: • • • • the factors that contribute to people with sight loss being at a greater risk of falls and falls related injuries the different vision problems and their impact on moving around the benefits of vision assessment, diagnosis and rehabilitation in falls prevention and how occupational therapists can contribute how to modify the environment to support falls prevention CPD Think sight with falls and older people ©2017 Royal College of Occupational Therapists This CPD Session may be copied and adapted for non-commercial use by RCOT members only Page Notes to accompany the PowerPoint entitled Think sight with falls and older people Slide 1: This is the title slide, which reminds people to read these notes while looking at the slide show There is more room in the notes to expand on ideas conveyed briefly or alluded to by implication on the slides and these slides are not designed to stand alone Slide 2: All professionals working with older people should be thinking about sight and falls All occupational therapists who work with older people should bear in mind the likelihood that older people will have some degree of sight loss The RCOT practice guideline entitled Occupational Therapy in the prevention and management of falls in adults makes the point that fall-related injuries are the leading cause of death among older people (COT 2015, p9) Slide 3: This slide headlines two significant facts relating to age and sight loss The risk of having reduced sight greatly increases with age, with in people aged 75 and in aged 90 and over living with sight loss (Access Economics 2009) As we age we require more light to see in the same detail People aged over 60 need on average three times more light to see in the same detail as when they were 20 years old This is without the impact of an eye condition Slide 4: Sight loss can occur as a result of eye conditions that affect different parts of the eye, damage to the optic nerve that carries visual information to the brain or damage to parts of the brain where visual information is processed e.g due to stroke, head injury and some types of dementia Slide 5: This slide highlights a reference giving the evidence for sight loss and falls being linked and a reference that highlights the consequences of falls Further to this is the fact that is mentioned in the RCOT practice guideline (COT 2015, p 9), cited in the notes to slide 2, that falls are the most frequent cause of fatalities in older people CPD Think sight with falls and older people ©2017 Royal College of Occupational Therapists This CPD Session may be copied and adapted for non-commercial use by RCOT members only Page Slide 6: Activity: Why might someone with sight loss be more likely to fall? Possible answers • Wearing the wrong spectacles • Wearing spectacles with an outdated prescription • May not see edges clearly • Difficulty judging distance on stairs • Difficulties seeing detail • Not seeing obstacles • Difficulties with adaptation between dark and light environments • Poor balance • Adopting unhelpful movement patterns such as high stepping or shuffling • Reduced confidence when moving around • Where a familiar environment has been changed without asking the person • Sight loss may combine with other health conditions such as diabetes, dementia and frailty to further increase the risk of falls • They may have an acute illness for example urinary tract infection or chest infection There are many reasons why someone with sight loss might fall Older people with sight loss may have a combination of different eye conditions and/or uncorrected refractive error Sight loss varies between individuals even where they have the same condition For some people sight loss can be gradual and they may not notice the changes For others it can happen much faster Slide 7: The images on the following four slides show some examples of how problems with vision affect what we see and increase the risk of falls These simulated images can only give an impression of what it is like to live with sight loss Slide 8: Reduced depth perception is shown on the first image as it would appear on descending a set of stairs This commonly occurs with individuals who have an eye condition that affects only one eye Even a small reduction of depth perception can lead to trips over obstacles or overstepping on stairs Slide 9: Poor contrast sensitivity can reduce the individual's ability to see detail in poor or difficult lighting conditions CPD Think sight with falls and older people ©2017 Royal College of Occupational Therapists This CPD Session may be copied and adapted for non-commercial use by RCOT members only Page Slide 10: The distorted lines on this image of a window illustrate where someone has difficulties seeing the object in its correct form Slide 11: The image of the outside scene shows the effect of the loss of peripheral vision, which may cause individuals not to see obstacles Slide 12: Older people living with sight loss may experience a fear of falling They may be concerned about the embarrassment or shame associated with falling as well as the physical harm As a result, older people living with sight loss may restrict their activity which can then lead to a spiral of decline in strength and balance and future increased risk of falls A recent study found that between 40-50% of older people living with sight loss limit their activities due to a fear of falling (Wang et al 2012) Furthermore, fear of falling can lead to social isolation as people become wary of leaving the home Slide 13: It is recommended, in the practice guideline entitled Occupational Therapy in the prevention and management of falls in adults (COT 2015, p32), that occupational therapists are aware of interventions that may be available from other members of the multidisciplinary team such as vision assessment Knowing how to access a vision assessment is important as over 50% of sight loss is avoidable through, for example, correctly prescribed spectacles, cataract surgery or timely treatment (RNIB 2012) A sight examination by an optometrist is essential for detecting sight loss CPD Think sight with falls and older people ©2017 Royal College of Occupational Therapists This CPD Session may be copied and adapted for non-commercial use by RCOT members only Page Slide 14 Activity: It is important to remember that sight loss can be masked by other health conditions Possible answers include: • Impaired communication skills e.g where a person has word finding difficulties which prevent them describing the symptoms of sight loss • Sight loss is mistaken as perceptual problems e.g thought to be as a result of the brain incorrectly processing visual information rather than an eye condition • Visual hallucinations such as those that occur with Charles Bonnet Syndrome may be thought to be related to dementia rather than sight loss • Having a learning disability can prevent people from knowing and telling others that they have sight loss Where a person has dementia, learning disability or has experienced stroke, vision assessment and treatment are still possible The optometrist and/or ophthalmologist may need to adapt their examination to suit the needs of the person Again it is important to undertake a comprehensive falls risk assessment to be able to ascertain why a person has fallen or is at risk and to determine if sight is a contributory factor Sometimes the person themselves can assume that they fell due to their sight loss when for example getting up to go to the toilet However, on further questioning, it becomes apparent that they may have low blood pressure and so they are dizzy on rising Slide 15: An occupational therapist can look out for the signs of sight loss by asking questions such as those on the slide These questions enquire about activities which involve close focus work as well as activities that rely on long distance or peripheral vision It is worth noting that people can adapt to changes in their sight, and asking questions about and observing function may not pick up on declining vision; whereas an eye examination will It is important to check whether a person has had an eye examination within the last year and, if not, recommend that they arrange one See the further information at the end of this document after you have completed the slide show CPD Think sight with falls and older people ©2017 Royal College of Occupational Therapists This CPD Session may be copied and adapted for non-commercial use by RCOT members only Page Slide 16: It is also helpful to look out for the condition and use of spectacles Consider the three easy checks on the slide when a person wears spectacles Where there are concerns regarding spectacles e.g adjusting to a new lens prescription, recommend that the person visits their optician or optometrist for further advice Slide 17: Assess home hazards: Where a person has sight loss the RCOT practice guideline recommends that an occupational therapist should offer a home safety assessment as part of falls prevention Working with the person, consider using assessment tools such as the Home Falls and Accident Screening Test (HOME FAST) and Westmead Home Safety Assessment (WeHSA) to look at factors such as clutter, edges, lighting and balance all of which are important to consider when minimising risk and maximising independence for older people with sight loss Slide 18: Assess risk of falling: As part of the multifactorial risk assessment, occupational therapists should be aware of individuals restricting activity due to fear of falling The Falls Behavioural Scale (FaB) is an assessment tool designed to identify the awareness, and practice, of behaviours that could potentially protect against falling It is particularly useful if someone has sight loss The assessment tool explores protective behaviours around vision and the use of lighting (examples of the questions can be seen on the slide) Individuals are asked to rate the statements on the slide according to how often they occur (never, sometimes, often or always) Where a person does not have enough useable vision to self- complete the assessment the occupational therapist will need to consider other ways of administering it Where a person raises concerns with their vision they may need an eye examination as detailed in slide 13 It should also prompt an occupational therapist to consider modifications to the home e.g improving lighting and advice on colour and contrast CPD Think sight with falls and older people ©2017 Royal College of Occupational Therapists This CPD Session may be copied and adapted for non-commercial use by RCOT members only Page Slide 19: What should occupational therapists consider when planning interventions for those with sight loss? Consider modifications to the home Often small changes to the home environment can make a big difference to older people with sight loss It is important to work with the person when problem solving and exploring solutions We have already looked at how tools such as WeHSA, HOME FAST and FaB can help identify environmental and personal risks Below are some principles to consider when minimising these risks and maximising independence • • • • • • • Involve people – people usually know what they would like improved in their home They usually appreciate information, advice and discussion Encourage use of lighting on stairs and when getting up to go to the toilet at night Use colours that reflect light and contrasting colours to differentiate an object from its surroundings Avoid materials that are shiny and increase glare Advise that clutter is removed from inside and outside the home, including making cupboards and storage space more accessible Be aware that a person with sight loss may have anchor points/landmarks that appear to clutter the environment but serve a function in orientation and way finding Make frequently used appliances accessible, consider how appliances and everyday items can be made easier to locate and use Often practice and repetition of tasks can build confidence with ADL tasks and reduce the risk of falls Consider technology-enabled care and support, for example telecare to assist the person to summon help Practise a falls emergency plan For more information on adapting homes for people living with sight loss take a look at Pocklington’s good practice guides (see further reading section below) CPD Think sight with falls and older people ©2017 Royal College of Occupational Therapists This CPD Session may be copied and adapted for non-commercial use by RCOT members only Page Consider lighting As mentioned in the notes to Slide 3, people need more light to see by as they age and so lighting deserves a specific mention in relation to home modifications How often on a home/access visit you turn the lights on in different rooms, hallways and outside to check the bulbs are working and bright enough for the task in hand? A simple check like this will help an occupational therapist decide whether a full lighting assessment is necessary Before making lighting modifications to a home, a lighting assessment needs to be carried out by an occupational therapist who is competent to so or through joint working with a Rehabilitation Officer for Visual Impairment (ROVI) Different eye conditions may benefit from different use of lighting Whilst light is important for navigation, mood and activity it may need to be controlled according to individual preference Below are some general lighting principles: • Minimise glare from lamps and the sun through lamp shades and blinds • Ensure even lighting throughout the home • Make lighting flexible with dimmer switches, and movable lights • Consider task lighting for close up work Further information on lighting can be found on Thomas Pocklington's website and the CPD Session "Light for Sight" on RCOT’s Learning Zone (see further reading section) Strength and balance A final intervention that occupational therapists could recommend is improving strength and balance As previously mentioned, fear of falling can lead to inactivity and a reduction in strength and balance This may mean incorporating strength and balance into ADL tasks or prescribed exercise It is important to consider how a person with sight loss can engage in exercise programmes either at home or in a community setting When introducing a person with sight loss to a strength and balance class, an occupational therapist needs to consider how the person is integrated and feels accepted by the group, appropriate supporting material with demonstration, sensitive explanation, carer involvement and individually tailored interventions (Skelton et al 2013) Where strength and balance classes are not available, or suitable, an occupational therapist may consider other interventions such as the Lifestyle Integrated Functional Exercise (LiFE) approach (see p48 in the COT practice guideline) It is important to remember that, where information is provided, it needs to be in an accessible format Further information on accessibility can be found on the NHS England website (see further reading section) CPD Think sight with falls and older people ©2017 Royal College of Occupational Therapists This CPD Session may be copied and adapted for non-commercial use by RCOT members only Page We would like to thank Visibility, a charity working with people with sight loss in Glasgow and the West of Scotland, for kindly supplying the set of questions on Slide 15 Further information that expands upon the notes from the slides, please read this after you have gone through the slideshow Recommendations that relate to sight loss within the RCOT practice guideline entitled Occupational Therapy in the prevention and management of falls in adults • • • Be aware of other interventions that may be available from other members of the multidisciplinary team e.g vision assessment (p32) Offer a home safety assessment and modification for older people with a visual impairment (p2) Falls prevention and management information should be available in different formats and languages to empower and engage all populations e.g web based support, written information leaflets (p3) Further to the notes on slides 8-11 above For some people sight loss can be gradual and they may not notice the changes For others it can be much quicker For more information on different eye conditions refer to RNIB's guides to eye conditions:www.rnib.org.uk/eye-health/eye-conditions The Eyes Right Toolkit An occupational therapist may choose to use an assessment like Thomas Pocklington's Eyes Right Toolkit (ERT) ERT offers simple vision screening tools which have been shown to be effective in identifying symptoms of refractive error and some common eye conditions Using the ERT is not an alternative to a full eye examination by an optometrist Using ERT, and asking questions about sight, can help determine whether a person needs a full eye examination Where signs of sight loss are detected, an occupational therapist should recommend that a person visits an optometrist for an eye examination CPD Think sight with falls and older people ©2017 Royal College of Occupational Therapists This CPD Session may be copied and adapted for non-commercial use by RCOT members only Page Professionals with particular expertise in vision and sight loss Optometrists mainly operate out of ‘high street’ practices with no set catchment area, though some work in hospital eye departments, GP practices or community hospitals and some are available to carry out domiciliary eye examinations Anyone who cannot access a ‘high street’ optometrist may arrange a domiciliary eye examination by asking their local optometrist, or contacting their local Clinical Commissioning Group (CCG) for information on local services An Ophthalmologist is a specialist eye doctor who can examine, diagnose and treat diseases and injuries in and around the eye Orthoptists usually work in the NHS as part of the ophthalmic team and specialise in visual development, binocular vision (how the eyes work together) Rehabilitation officers for visual impairment (ROVIs) are specialists in providing support to people with vision problems with orientation, mobility, activities of daily living or communication skills The ROVI and the occupational therapist can work together and carry out a joint assessment CPD Think sight with falls and older people ©2017 Royal College of Occupational Therapists This CPD Session may be copied and adapted for non-commercial use by RCOT members only Page 10 References Access Economics (2009) Future sight loss UK1: economic impact of partial sight and blindness in the UK London: RNIB Available at: http://www.rnib.org.uk/knowledge-and-research-hub/research-reports/generalresearch/future-sight-loss-uk-1 Accessed on 22.06.15 Clemson L (1997) Home fall hazards: a guide to identifying fall hazards in the homes of elderly people and an accompaniment to the assessment tool, the Westmead Home Safety Assessment West Brunswick, Victoria: Coordinates Publication Clemson L, Cumming RG, Heard R (2003) The Falls Behavioural (FAB) Scale for the older person: instruction manual Sydney: University of Sydney Available at: http://sydney.edu.au/health-ciences/staff/docs/lindy_clemson/FaB_manual_2003.pdf Accessed on 22.06.15 College of Occupational Therapists (2015) Occupational therapy in the prevention and management of falls in adults: practice guideline London: COT Legood R, Scuffham P, Cryer C (2002) Are we blind to injuries in the visually impaired? A review of the literature Injury Prevention, 2002 (8),155-160 Mackenzie L, Byles J, Higginbotham N (2000) Designing the Home Falls and Accidents Screening Tool (HOME FAST): selecting the items British Journal of Occupational Therapy, 63 (6), 260-269 Available at: http://www.bhps.org.uk/falls/documents/HomeFast.pdf Accessed on 22.06.15 National Institute for Health and Care Excellence (2013) Falls: the assessment and prevention of falls in older people (Clinical Guideline CG161) London: NICE Available at: http://www.nice.org.uk/guidance/cg161/evidence Accessed on 23.06.15 RNIB (2012) Preventing avoidable sight loss: developing an evidence base to build better eye care services London: RNIB Available at: http://www.rnib.org.uk/sites/default/files/Preventing_avoidable_sight_loss_August_20 12.pdf Accessed on 09.07.15 Skelton DA, Howe TE, Ballinger C, Neil F, Palmer S, Gray L (2013) Environmental and behavioural interventions for reducing physical activity limitation in communitydwelling visually impaired older people (Cochrane Review) Chichester: John Wiley and Sons Ltd Available at: CPD Think sight with falls and older people ©2017 Royal College of Occupational Therapists This CPD Session may be copied and adapted for non-commercial use by RCOT members only Page 11 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009233.pub2/pdf Accessed on 22.06.15 Wang MY, Rousseau J, Boisjoly H, Schmaltz H, Kergoat M.-J, Moghadaszadeh S, Freeman EE (2012) Activity limitation due to a fear of falling in older adults with eye disease [Online] Investigative Ophthalmology & Visual Science, 2012; 53 (13), 79677972 Available at: doi:10.1167/iovs.12-10701 Accessed on: 22.06.15 CPD Think sight with falls and older people ©2017 Royal College of Occupational Therapists This CPD Session may be copied and adapted for non-commercial use by RCOT members only Page 12 Further reading Boyce T (2011) Falls: costs, numbers and links with visual impairment London: RNIB Available at: http://www.rnib.org.uk/knowledge-and-research-hub-research-reports/travel-mobilityand-living-skills-research Accessed on 22.06.15 College of Optometrists (2014) Focus on falls 2014 London: The College of Optometrists Available at: www.college-optometrists.org/en/utilities/document-summary.cfm/docid/86C37E3CD48E-47A4-B5ED2471074F641A Accessed on 22.06.15 College of Occupational Therapists www.rcot.co.uk Accessed on 21.07.15 BAOT members can access a further CPD Session entitled “Light for Sight” on the RCOT website NHS England (2015) Accessible information Redditch: NHS England Available at: http://www.england.nhs.uk/ourwork/patients/accessibleinfo-2/ Accessed on 14.07.15 Thomas Pocklington Trust www.pocklington-trust.org.uk Accessed on 21.07.15 You will find useful further reading on vision and lighting here, including Good Practice Guides, research publications and the Eyes Right Toolkit Thomas Pocklington Trust (2015) Research publications London: TPT Available at: http://www.pocklington-trust.org.uk/researchandknowledge/publications Accessed on 22.06.15 Thomas Pocklington Trust (2015) Eyes Right Toolkit London: TPT Available at: http://www.pocklingtontrust.org.uk/researchandknowledge/publications/EyesRightToolkit Accessed on 22.06.15 End of document CPD Think sight with falls and older people ©2017 Royal College of Occupational Therapists This CPD Session may be copied and adapted for non-commercial use by RCOT members only Page 13