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Falls Prevention through the Visual Impairment Detection Program


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This article introduces the Visual Impairment Detection Program, developed in Montreal to reduce the risk of falls in persons with vision impairment. The goal of the program is to teach home health care professionals to screen for early vision loss among persons 75 years and older living on the Island of Montreal. Screening for early vision loss is intended to prevent more severe vision impairment, as well as better identify, orient, and refer persons to the appropriate resources and ensure improved access to existing vision rehabilitation services. This, in turn, serves to prevent and/or reduce the number of falls. Health care professionals are provided with Visual Impairment Detection Training Sessions and taught how to administer a Visual Impairment Screening Questionnaire. To date, more than 975 health care professionals have been specially trained to detect vision impairments, resulting in 227 referrals for vision rehabilitation services. The implementation of the program is discussed, along with the implications for practice and research.
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Falls Prevention through the Visual
Impairment Detection Program
Cathy McGraw, MSW
MAB-Mackay Rehabilitation Center
Montreal, Canada
Lise De
Institut Nazareth et Louis-Braille
Longueuil, Canada
Walter Wittich, PhD*
MAB-Mackay Rehabilitation Center
Montreal, Canada
This article introduces the Visual Impairment Detection Program, developed in Montreal to reduce the
risk of falls in persons with vision impairment. The goal of the program is to teach home health care
professionals to screen for early vision loss among persons 75 years and older living on the Island of
Montreal. Screening for early vision loss is intended to prevent more severe vision impairment, as well
as better identify, orient, and refer persons to the appropriate resources and ensure improved access to
existing vision rehabilitation services. This, in turn, serves to prevent and/or reduce the number of falls.
Health care professionals are provided with Visual Impairment Detection Training Sessions and taught
how to administer a Visual Impairment Screening Questionnaire. To date, more than 975 health care
professionals have been specially trained to detect vision impairments, resulting in 227 referrals for
vision rehabilitation services. The implementation of the program is discussed, along with the
implications for practice and research.
Keywords: falls prevention, clinical program, service delivery, referral, training program
In 2008, the MAB-Mackay Rehabilitation Centre
(MMRC) and the Institut Nazareth et Louis-Braille
(INLB), under the sponsorship of the Quebec
government, l’Agence de sante
´et des services
sociaux de Montre
´al, designed and implemented the
Visual Impairment Detection Program. This program
was developed in response to the priorities identified
by the government, subsequent to a National Fall
Prevention Program within a Continuum of Services
to Seniors Living at Home (Gouvernement du
´bec, 2004). As of 2006, 1,854,442 persons
resided on the Island of Montreal, of which 15
percent are over the age of 65 (Ville de Montre
2006). Of those, 46 percent are over 75 years old. By
2026, it is estimated that more than one of five
residents of the Island of Montreal will be at or over
retirement age. In Quebec, one of nine residents
over the age of 65 and one of four over the age of
* Please address correspondence to
Practice Report
74 | Received November 9, 2010; Accepted February 9, 2011
75 years experiences vision loss, while 80 percent
are not familiar with or referred to vision rehabilitation
centers (Gresset & Baumgarten, 2002). Demograph-
ic trends also forecast a substantial increase in the
number of Canadian seniors living with a visual
impairment over the next 20 years (Statistics
Canada, 2002). Moreover, the number of blind and
visually impaired Canadians is expected to increase
by 52 percent by the year 2026. Among seniors aged
75 and over, this represents a 72 percent increase
(Gresset, 2005).
Over the 1999–2004 period, the incidents of falls
resulting in hospital admissions for Montreal resi-
dents was 340 per 10,000 for persons aged 85 years
and over, 138 per 10,000 for persons between the
ages of 75 and 84, and 50 per 10,000 for those
between the ages of 65 and 74. According to Ivers,
Norton, Cumming, Butler, and Campbell (2000), 40
percent of hip fractures are associated with a visual
impairment. Support for this association between
impaired visual function, measured or otherwise, and
increased risk of hip fractures is reported in the
findings of previous research studies (Cummings et
al., 1995; Grue, Kirkevold, & Ranhoff, 2009; Jack,
Smith, Neoh, Lye, & McGalliard, 1995). According to
the study by Grue et al., nearly half of the patients
with hip fractures had impaired vision. These findings
are supported by Jack et al., who found 76 percent of
older patients admitted to hospital after a fall had
impaired vision. Thus, we most certainly can
anticipate a rise in the incidents of falls, as well as
hospitalizations, as the population ages. Given these
demographic and statistical projections, the Visual
Impairment Detection Program has been implement-
ed specifically to identify individuals at risk for falls
due to a visual impairment.
The Island of Montreal is divided into 12 regions
where service delivery is provided by their respective
health and social services establishments (Centre de
la sante
´et des services sociaux, CSSS). The 12
CSSS regions have been strategically divided in
proportion to the ratio of English- to French-speaking
clientele with each rehabilitation center having the
mandate to jointly establish, implement, and develop
the Visual Impairment Detection Program. The goal
of the program is to teach home health care
professionals to screen for early vision loss among
persons 75 years and over living on the Island of
Montreal. Screening for early loss is intended to
prevent more severe vision impairment, as well as
better identify, orient, and refer persons to the
appropriate resources and ensure improved access
to existing vision rehabilitation services. This, in turn,
serves to prevent and/or reduce the number of falls,
among other serious occurrences that are detrimen-
tal to a person’s health and well-being. Similarly,
persons are better assisted to live safely at home or
in any other living environment, while circumventing
the need for premature institutionalization and
possible morbidity.
As a primary objective of the program, health care
professionals are provided with Visual Impairment
Detection Training sessions and taught how to
administer a Visual Impairment Screening Question-
naire. The target audience primarily consists of
occupational and physical therapists, social workers,
nurses, psychologists, and nutritionists and dieticians
employed through the 12 CSSSs and working
directly in home-care programs in neighboring local
community service centers (CLSCs).
Visual Impairment
Detection Training
The training session consists of a 2-hour Power-
Point presentation and corresponding brochure of
course material, provided in either English or French.
The trainers are experienced vision rehabilitation
specialists from the MMRC or INLB, with advanced-
level training in areas such as social work or low
vision rehabilitation (i.e., activities of daily living).
Training is provided on-site at the CLSC and includes
a maximum of 12 participants. These sessions are
experiential and interactive as participants engage in
exercises using simulators that demonstrate visual
impairments associated with the most common age-
related ocular pathologies. Participants voluntarily
take part in a role-play exercise to demonstrate how
the Visual Impairment Screening Questionnaire is
administered and are given a scored copy of the
questionnaire for reference purposes. These exer-
cises serve to sensitize participants to the implica-
tions of living with impaired vision. Participants are
also educated about the referral process using a
graphic outline and given an overview of vision
rehabilitation services offered by the two centers.
The session concludes with comments and ques-
tions generated from the participants’ experiences
Visual Impairment Detection Program
Volume 4, Number 2, Spring 2011 | 75
and course outline. They are asked to complete a
Training Session Appraisal Form, which is later used
for program planning purposes.
Questionnaire Background
To increase the utilization of vision rehabilitation
services among older persons, Horowitz and Cassels
(1985) validated the 15-item Functional Vision
Screening Questionnaire (FVSQ) used to identify
older persons with a visual impairment as potential
candidates for rehabilitation services. The question-
naire, inspired by existing assessment instruments
(Gurland et al., 1977; Gurland & Wilder, 1984), was
developed to allow gerontology professionals to
screen individuals that experience vision loss. The
FVSQ was translated, modified, and validated in
French and named Questionnaire de de
´pistage des
`mes de vision fonctionnelle, consisting of 20
items (Gresset & Baumgarten, 2003). The additional
5 items, questions 1, 2, 17, 18, and 20 (Figure 1),
were included for descriptive purposes to facilitate
the resulting referral. The final score is established
only from answers derived from questions 3–16 and
19. Both the English and French version of the 20-
item questionnaire was renamed the Visual Impair-
ment Screening Questionnaire/Questionnaire de
´rage des incapacite
´s visuelles for the purpose
of the program. Both the English and French
versions and accompanying test manual (Gresset
& Baumgarten, 2009) are extremely useful standard-
ized instruments that can be utilized by health care
professionals and nonspecialized persons alike, to
identify individuals requiring further clinical evaluation
and/or specialized vision rehabilitation services.
Questionnaire Format
and Administration
The measure consists of a total of 20 questions, 15
of which have a response code of either 0 or 1, with a
higher total score indicating more severe visual
impairment. The remaining 5 qualitative questions
provide descriptive information for the purpose of
directing clients to the appropriate resources or
services, as needed. The final score is calculated
using a mathematical formula located at the bottom of
the questionnaire. Upon completion of the training, the
health care professional is required to administer the
questionnaire systematically to persons 75 years and
over whose need for home-care services is being
evaluated or reevaluated by the CLSC.
When the score is 6 and over, the person is
directed to the admission services of the MMRC/
INLB. With the person’s consent, the health care
professional is expected to forward the Visual
Impairment Screening Questionnaire, along with an
interestablishment referral form, to the rehabilitation
center. For those persons who have not consulted an
optometrist or ophthalmologist, the health care
professional collaborates with the rehabilitation
center to facilitate and ensure that the person
undergoes an optometric or ophthalmologic exami-
nation. In the case in which the health care
professional makes the referral to a vision care
specialist, he or she conveniently provides the
person with an eye report form to be completed at
the time of the examination. Further, all information
pertinent to the person’s overall functioning, such as
being at risk for falls, depression, or social isolation,
are documented on the interestablishment referral
form. If needed, a home visit by a community
optometrist may be arranged. When the score is less
than 6, persons who have not been seen by an eye
care specialist in the past 2 years are encouraged to
undergo an eye examination as a preventive
measure. In cases in which the person does not
have an optometrist or ophthalmologist, a referral is
recommended. An optometrist mailing list, subdivid-
ed by the 12 CSSS regions, and the eye report form
are provided to the health care professionals.
All referrals are processed by admissions services
at either MMRC or INLB who work collaboratively
with the health care professionals to obtain the
necessary eye report and nominative information.
Once admitted to the MMRC/INLB, a rehabilitation
specialist is assigned accordingly. The role of the
rehabilitation specialist is to evaluate the person’s
needs for vision rehabilitation services in collabora-
tion with the health care professionals as part of the
person’s individual service plan. Not only does the
MMRC/INLB have the mandate to provide direct
individualized vision rehabilitation services but they
are available for consultations.
As per the government’s directives, the 12
regional CSSSs and the MMRC/INLB are all required
to keep records for statistical purposes. For their
part, the 12 regional CSSSs are required to report on
the number of Visual Impairment Screening Ques-
Visual Impairment Detection Program
76 | Insight: Research and Practice in Visual Impairment and Blindness
Fig. 1. Visual Impairment Screening Questionnaire. Printed with permission from l’Institut Nazareth
et Louis-Braille and MAB-Mackay Rehabilitation Centre within the framework of the Visual
Impairment Detection Training Program.
Visual Impairment Detection Program
Volume 4, Number 2, Spring 2011 | 77
Fig. 1. Continued.
Visual Impairment Detection Program
78 | Insight: Research and Practice in Visual Impairment and Blindness
tionnaires that are systematically administered. The
MMRC/INLB are required to submit a biannual
assessment, citing the number of health care
professionals trained on how to administer the Visual
Impairment Screening Questionnaire, the number of
person’s referred and admitted to its respective
rehabilitation center, and information on the offer of
services to those individuals admitted. Thus, these
government directives function as a built-in incentive
that renders all parties responsible and accountable
for the success of the program.
Program Status
From April 1, 2008 to March 31, 2010, 975 health
care professionals from 10 of the 12 CSSS regions
have been specially trained to detect vision impair-
ments. Participants completed the Training Session
Appraisal Form, which contains specific items
evaluating the content of the program and its relevance
to the detection of visual impairments. Having acquired
practical knowledge and skills, they now have the
ability to recognize the critical link between early
detection of vision impairment and falls prevention.
Moreover, they recognize the benefits of referring
persons for vision rehabilitation services. Further, 227
persons were referred forvision rehabilitation services.
Eighty-seven were referred to the MMRC, while 140
were referred to INLB, depending on service language
preferences and/or geographic location. Of the 87
persons referred to MMRC, 54 (62 percent) were
admitted to the center. Similarly, 101 (72 percent) of
those referred to INLB were admitted. Most persons
admitted to either center met the following govern-
ment’s visual aids loan program criteria: visual acuity in
each eye is less than 6/21 (20/70) or a visual field in
each eye less than 60 degrees in the 180-degree and
90-degree meridians after correction by appropriate
ophthalmic lenses (Regie de l’assurance maladie du
Quebec/RAMQ, 2006). Coinciding with the implemen-
tation of the program has been the change of
admission criteria to the MMRC/INLB. The new criteria
include persons with a diagnosis ofa degenerative eye
disease who, after correction, experience significant
difficulties in executing one or more activities of daily
living, notwithstanding the person’s visual acuities and
fields. This change in admission criteria is based on
the conceptual model, Processus de production du
handicap (Fougeyrollas, Cloutier, Bergeron, Cote, &
St. Michel, 1998). Further, it is coherent with the
principles of the government’s Improvement, Access
and Continuity Plan (Ministe
`re de la Sante
´et des
Services Sociaux, 2008) that serves to optimize,
harmonize, and manage the organization and delivery
of services. Hence, had the new criteria been applied
from the onset, most persons, if not all, would have
been admissible to receive vision rehabilitation
services, increasing the number of persons admitted
to both centers.
Although some persons admitted to the MMRC/
INLB may not meet the RAMQ criteria for dispensing
visual aids and technical devices, most are expected
to be eligible to receive vision rehabilitation services.
As such, both rehabilitation centers need to further
develop and tailor their offer of services to meet the
needs of this emerging and increasing clientele.
Such services might include information sessions,
peer support groups, and rehabilitation workshops
that address various psychosocial and rehabilitation
issues. More specifically, the topic of falls prevention
and low vision could be a specific theme for
discussion with the support of an orientation and
mobility specialist. Further, innovative, creative, and
resourceful measures and partnerships will need to
be explored. This includes networking with commu-
nity partners who share a common goal.
Implications for Practice
The main beneficial effect of this program is the
systematic screening and early detection of persons
75 years and over, whose visual needs would likely
not have been detected had the questionnaire not
been administered. In other words, 227 persons
might not have been referred had they not been
systematically screened. Rather, most of those
referred were admitted to MMRC/INLB and are
eligible to receive a global evaluation and vision
rehabilitation services consistent with their individu-
alized needs. In keeping with the goals of the
program, regularly scheduled training sessions need
to be firmly in place within the 12 CSSS regions to
ensure the ongoing administration of the question-
naire. Furthermore, given staff turnover, it is
imperative that new health care professionals be
equipped with the necessary knowledge to contribute
to the success of the program.
An important implication for practice involves the
problems administering the questionnaire to persons
with cognitive impairments. Health care professionals
Visual Impairment Detection Program
Volume 4, Number 2, Spring 2011 | 79
report problems identifying the origins of their
handicapping situation(s). As such, health care
professionals are less likely to administer the
questionnaire to persons experiencing cognitive
impairments, in accordance with their clinical
judgment. Therefore, it is particularly important that
the MMRC/INLB and CLSCs adopt an interdisciplin-
ary and collaborative approach to service delivery.
Certainly, partnerships between primary health care
professionals and secondary rehabilitation specialists
are an essential component in the development and
success of the program. Evidence of such is already
seen in the increased number of referrals received
by the rehabilitation centers and the concerted effort
to jointly coordinate individualized service plans.
Also of particular importance to practice is the
recent change to the admissibility criteria. As such,
both rehabilitation centers are further exploring the
needs of persons meeting the new criteria. The goal
is to develop and harmonize the offer of services
consistent with this clientele’s need to access
information, resources, support (individual and
group), and rehabilitation services. It is intended that
preventative vision rehabilitation and intervention will
serve to reduce not only the prevalence of falls but
also other handicapping situations. Conversely, the
rehabilitation centers’ efforts and measures to better
respond to this emergent clientele is also expected to
place a greater demand on the MMRC/INLB’s
material and human resources. Notably, it is
expected to place a greater strain on vision
rehabilitation specialists, many of whom are in short
supply. This increase in the demand for services will
likely have implications on existing waiting lists and
the delivery of services. With systematic screening,
improved access, and partnerships, along with
harmonization of services, the MMRC/INLB will need
to be responsive to these anticipated challenges.
Implication for Research
Unfortunately, due to gaps in data entry into the
statistical coding system, it is presently not possible
to extract complete summary statistics on the total
number of questionnaires administered across the 12
CSSS regions. Had all the questionnaires been
administered and entered into the system, more
detailed summary statistics on the number and
proportion of those classified with a score of 6 and
over, and referred to the MMRC/INLB, would be
available. Using information obtained through the
program’s statistical database, we would have
compiled more information on each individual’s
demographic profile, along with other valuable data
such as the individual’s visual diagnosis, activities of
daily living, comorbid conditions such as hearing
loss, and cognitive function.
It will be possible to ascertain a complete
demographic profile, given the plans to improve the
coding system and the process of statistical data
entry. Likewise, the effectiveness of the questionnaire
will also need to be established. These data will be
of particular interest when examining the Visual
Impairment Detection Program questionnaire’s sen-
sitivity (74 percent) and specificity (86 percent) for
detecting the presence or absence of moderate-to-
total clinical visual impairment at a cut-off score of 6
(Gresset & Baumgarten, 2003, 2009). Such data will
also be useful when comparing our data to the
information collected by the Lighthouse Vision
Education and Outreach/Demonstration Project,
whereby a similar questionnaire was used to identify
and evaluate aging persons with vision problems in
community settings (Horowitz, Teresi, & Cassels,
1991). The authors reported that the vision scale had
an 80 percent overall accurate classification rate
(sensitivity) at a cut-off point of 9. By using a score of
6, detection of mild impairment is more likely to
increase; however, the most appropriate cut-off score
will need to be investigated further in light of the new
admission criteria in the context of this program.
Important to research is the administration of the
questionnaire to persons with cognitive impairments.
According to Chertkow et al. (2008), between 25 and
75 percent of older persons are reported to have
memory problems, depending on its definition. The
comorbidity between the visual and cognitive deficits
is probably more prevalent than the suspected 3 to 9
percent among persons 75 years and over. Given the
anticipated needs of this clientele, a study is being
undertaken by INLB in collaboration with its partners,
with the objective of adapting and developing
effective visual impairment screening methods.
Another important implication for research is
whether the Visual Impairment Screening Program
is effectively reducing the number of falls associated
with visual impairments. This will need to be re-
evaluated within the established parameters of Ivers
et al. (2000) who associated 40 percent of hip
Visual Impairment Detection Program
80 | Insight: Research and Practice in Visual Impairment and Blindness
fractures with a visual impairment. Ideally, this
association would hopefully be significantly reduced
once the program is fully operational. To establish
whether this beneficial outcome is present, the
National Fall Prevention Survey would need to be
repeated within the context of the program. Grue et
al. (2009) report that there is a potential for
improvement for persons with visual impairments,
given that half of their study population had not had
an eye examination or adjustment in their glasses for
the past 2 years. A recent systematic review on the
topic of prevention of falls and fall-related injuries
acknowledged that visual impairment, together with
poor balance and dementia, is among the main risk
factors for falls in the elderly, whereby cataract
surgery in the first eye was associated with a
reduction in falls rate (Gillespie & Handoll, 2009).
The authors reported that most prevention programs
studied in randomized clinical trials highlight the
protective effects of exercise; however, the multifac-
torial nature of fall risk factors makes it difficult to
isolate the contribution of a vision impairment
detection program in such a context.
The present article, introducing the Visual Impair-
ment Detection Program, is an innovative and
collaborative interestablishment initiative, aimed at
detecting visual impairment and reducing the risk of
falls among persons 75 years and over. Its goal is to
be accomplished by training home health care
professionals to screen for signs of early vision loss
and to properly orient and refer those persons to the
appropriate resources and vision rehabilitation servic-
es. Given the consequences of falls and fall-related
injuries, it is hoped that the training program presented
will reach its full potential and inspire others.
The authors would like to acknowledge the
contribution of Paulette Arsenault, Christiane Pfeiffer,
Nadia Girard, Pierre Rondeau, Martyne Audet,
Cheryl Quinn, and Christine Trudel for the prepara-
tion of this manuscript.
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Visual Impairment Detection Program
82 | Insight: Research and Practice in Visual Impairment and Blindness
... Indeed, this bilingual 20-item measure has been adopted as part of the Visual Impairment Detection Program, which was developed in response to the priorities identified by the provincial government subsequent to the National Fall Prevention Program within a Continuum of Services to Seniors Living at Home (Gouvernement du Québec-Direction générale de la santé publique, 2004). It was implemented across the Island of Montreal and sponsored through the Agence de santé et des services sociaux de Montréal as a screening tool for home health care professionals to detect vision loss among persons 75 years and older (McGraw, Dery, & Wittich, 2011). This detection program is primarily aimed at fall prevention but also results in the prevention of further vision loss and referral to the appropriate services. ...
... Development. Two authors (WW and AT) developed the preliminary survey content in English based on Dillman, Smyth, and Christian's (2008) tailored design method, the authors' methodological (Thomas & Law, 2014) and content expertise (McGraw et al., 2011;Wittich et al., 2012), and the empirical literature on sensory screening. The survey was reviewed by three content experts working in vision, hearing, and dual sensory loss from two Canadian universities and one American university. ...
Full-text available
Background The goal of occupational therapy education is to train generalists who can refine their knowledge after graduation according to the requirements of the professional environment. However, it is currently unclear to what extent sensory screening should be included in the educational curricula. Purpose The purpose of this study was to examine the sensory screening education for and practice by occupational therapists working with older adults. Method A cross-sectional survey was used to collect data from members of the Quebec Order of Occupational Therapists. Descriptive statistics were used in the analysis. Findings Data from 102 respondents indicated that training on sensory impairment–related topics was minimal and in stark contrast to the proportion who reported serving clients with a visual (92%), hearing (84%), or combined impairment (53%). Implications Occupational therapy considers numerous aspects of physical, cognitive, and emotional well-being. The question remains as to what extent vision and hearing health should take their place among these priorities.
... The assessor is a social worker with over 30 years of direct clinical experience in the context of sensory rehabilitation, and has developed and implemented a sensory screening program (13,20). Her work experience and her professional interactions with sensory rehabilitation professionals allowed her to develop extensive expertise on how to interact and communicate with persons living with different levels of sensory impairment., and how to explore and assess their functional abilities and needs. ...
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Purpose: Service providers must identify and assess older adults who have concurrent vision and hearing loss, or dual sensory impairment (DSI). An assessment tool suitable for this purpose is the interRAI Community Health Assessment (CHA) and its Deafblind Supplement. This study's goal was to explore this assessment's administration process and to generate suggestions for assessors to help them optimize data collection. Methods: A social worker with experience working with adults who have sensory loss, who was also naïve to the interRAI CHA, administered the assessment with 200 older adults (65+) who had visual and/or hearing loss. The assessor evaluated the utility of the instrument for clinical purposes, focusing on sections relevant to identifying/characterizing adults with DSI. Results: Suggestions include the recommendation to ask additional questions regarding the person's functional abilities. This will help assessors deepen their understanding of the person's sensory status. Recommendations are also provided regarding sensory impairments and rehabilitation, in a general sense, to help assessors administer the interRAI CHA. Conclusions: Suggestions will help assessors to deepen their knowledge about sensory loss and comprehensively understand the assessment's questions, thereby allowing them to optimize the assessment process and increase their awareness of sensory loss in older adults.
... Occupational therapists embarking on a mobility-aids assessment may find screening questions about functional daily activities, such as television viewing, reading, and recognizing people, to be a nonthreatening mechanism for inquiring about vision skills, along with standard questions regarding use of eyeglasses and frequency of accessing eye care. If problem areas are indicated, the use of the Visual Impairment Screening Questionnaire (McGraw et al., 2011) may be appropriate, as a score of 6 or greater out of the total possible score of 15 indicates that the client is in need of further in-depth vision testing and, possibly, low-vision rehabilitation. The use of screening questions and questionnaires presents an opportunity for occupational therapists to obtain a rapid understanding of clients' perception of their visual abilities in functional activities, while obtaining background information to inform their mobility-aids prescription. ...
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Background.: Co-occurring mobility issues and vision loss are prevalent in older adults. Vision loss can cause ambulation difficulties and falls. Community-dwelling older adults frequently require mobility-aids assessment by occupational therapists. However, therapists often lack access to medical documentation on vision or training in vision assessment to ensure that clients have adequate vision for safe mobility-aid use. Purpose.: This study aimed to identify screening and assessment approaches to identify functional vision loss to guide mobility-aid prescription. Method.: A scoping review following Arksey and O'Malley's five stages was undertaken using Medline and CINAHL databases. A data-charting form was used for extraction of information about each article, including the population, vision diagnosis, and the methodology for vision screening. The data regarding vision loss and mobility of older adults were summarized for each article. Findings.: Twenty-three papers were included in the study, describing screening questions and questionnaires or assessment tools to screen for vision loss in community settings. Implications.: The various tools identified can better prepare therapists to prescribe mobility aids appropriate for seniors' level of functional vision and to refer clients for further assessment and intervention if warranted.
... Comparable efforts are currently underway in Quebec in terms of systematic screening for visual impairment at first-line health service organisations, in order to identify individuals that are potentially at risk for falls due to visual impairment. 25 Clinically if we can identify people that are at risk and begin providing information and referrals at an earlier stage we may be able to increase the number of people who make a positive personal choice. Additional research following individuals in clinical settings with the VF-14, pre-and post-vision rehabilitation is needed. ...
Purpose: The goal of the current study was to examine the critical factors indicative of an individual's choice to access low vision rehabilitation services. Methods: Seven hundred and forty-nine visually impaired individuals, from the Montreal Barriers Study, completed a structured interview and questionnaires (on visual function, coping, depression, satisfaction with life). Seventy-five factors from the interview and questionnaires were entered into a data-driven Classification and Regression Tree Analysis in order to determine the best predictors of awareness group: positive personal choice (I knew and I went), negative personal choice (I knew and did not go), and lack of information (Nobody told me, and I did not know). Results: Having a response of moderate to no difficulty on item 6 (reading signs) of the Visual Function Index 14 (VF-14) indicated that the person had made a positive personal choice to seek rehabilitation, whereas reporting a great deal of difficulty on this item was associated with a lack of information on low vision rehabilitation. In addition to this factor, symptom duration of under nine years, moderate difficulty or less on item 5 (seeing steps or curbs) of the VF-14, and an indication of little difficulty or less on item 3 (reading large print) of the VF-14 further identified those who were more likely to have made a positive personal choice. Individuals in the lack of information group also reported greater difficulty on items 3 and 5 of the VF-14 and were more likely to be male. Conclusions: The duration-of-symptoms factor suggests that, even in the positive choice group, it may be best to offer rehabilitation services early. Being male and responding moderate difficulty or greater to the VF-14 questions about far, medium-distance and near situations involving vision was associated with individuals that lack information. Consequently, these individuals may need additional education about the benefits of low vision services in order to make a positive personal choice.
... In addition, persons with a progressive degenerative eye disease, such as age-related macular degeneration, are eligible for services (not assistive technology) if they experience problems in their activities of daily living. 24,25 For hearing, impairment is generally determined on the basis of the average hearing detection thresholds dB HL measured at four audiometric frequencies (i.e., 500, 1000, 2000, and 4000 Hz) in the better ear, without assistive technology. 23 However, for children under the age of 12 years, notwithstanding the degree of hearing loss, services are provided whenever the impairment is deemed sufficient to be a potential threat to language development. ...
  Demographic changes are increasing the number of older adults with combined age-related vision and hearing loss, while medical advances increase the survival probability of children with congenital dual (or multiple) impairments due to pre-maturity or rare hereditary diseases. Rehabilitation services for these populations are highly in demand since traditional uni-sensory rehabilitation approaches using the other sense to compensate are not always utilizable. Very little is currently known about the client population characteristics with dual sensory impairment. The present study provides information about demographic and sensory variables of persons in the Montreal region that were receiving rehabilitation for dual impairment in December 2010. This information can inform researchers, clinicians, educators, as well as administrators about potential research and service delivery priorities. A chart review of all client files across the three rehabilitation agencies that offer integrated dual sensory rehabilitation services in Montreal provided data on visual acuity, visual field, hearing detection thresholds, and demographic variables. The 209 males and 355 females ranged in age from 4months to 105years (M=71.9, S.D.=24.6), indicating a prevalence estimate for dual sensory impairment at 15/100000. Only 5.7% were under 18years of age, while 69.1% were over the age of 65years, with 43.1% over the age of 85years. The diagnostic combination that accounted for 31% of the entire sample was age-related macular degeneration with presbycusis. Their visual and auditory measures indicated that older adults were likely to fall into moderate to severe levels of impairment on both measures. Individuals with Usher Syndrome comprised 20.9% (n=118) of the sample. The age distribution in this sample of persons with dual sensory impairment indicates that service delivery planning will need to strongly consider the growing presence of older adults as the baby-boomers approach retirement age. The distribution of their visual and auditory limits indicates that the large majority of this client group has residual vision and hearing that can be maximized in the rehabilitation process in order to restore functional abilities and social participation. Future research in this area should identify the specific priorities in both rehabilitation and research in individuals affected with combined vision and hearing loss.
The aim of this study was to review the current literature on falls prevention in people with visual impairment and to estimate the applicability of methods of fall prevention for people with visual impairment and intellectual disability. A scoping review was performed according to the Arksey and O’Malley framework. Relevant studies were collected from PubMed, Web of Science, and the Cochrane Register of Controlled Trials (CENTRAL). All records covering the time span from January 1980 until November 2017 were collected. Studies were included if the participants had a visual impairment according to objective ophthalmic assessments, the article described interventions to reduce falls or risk factors for falls, and the study was written in English and published in a peer-reviewed journal. The methodological quality of the studies were determined by consensus of the authors on the PEDro scale. Fifteen articles were included in this scoping review. Three articles focused on screening and intervention programmes, five articles addressed the effectiveness of environmental adjustments, and seven articles involved training programmes for physical improvement. Environmental adjustments emerged as having the best evidence for falls prevention for people with a visual impairment. Physical training programmes improved balance in those with a visual impairment but could not reduce the number of falls. Environmental adjustments also may be effective for persons with a visual impairment and intellectual disability. In addition, multifactorial screening and intervention programmes are recommended as an important new research direction with important clinical implications.
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In this analysis of data from the Canadian Longitudinal Study on Aging, vision loss (in men) and dual sensory loss (in 65- to 85-year-olds) were independently associated with low social network diversity. Vision loss and dual sensory loss (in 65- to 85-year-olds) were independently associated with low social participation. Hearing, vision, and dual sensory losses were each independently associated with loneliness and reduced availability of social support, respectively. These findings are concerning because social support facilitates positive coping mechanisms that mitigate the effects of sensory loss and other chronic disabling conditions. Living with a chronic health condition often entails relying on others for help with instrumental tasks and emotional support. Unfortunately, individuals with clinically diagnosed sensory loss typically receive little, if any, relationship and communication counseling.
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As part of a case-control study, the Auckland Hip Fracture Study (1991-1994), the authors examined associations between impaired vision and risk of hip fracture. Subjects (911 cases and 910 controls aged 60 years or older) completed a questionnaire and had vision measurements taken, including measurements of visual acuity and stereopsis (depth perception). Binocular visual acuity worse than 20/60 was statistically significantly associated with increased risk of hip fracture after adjustment for age, sex, proxy response, hours of activity per week, and height (odds ratio (OR) = 1.5; 95% confidence interval (CI): 1.1, 2.0), as was having poor vision (less than 20/100) in both eyes (OR = 2.4; 95% CI: 1.0, 6.1). Having no depth perception was associated with increased risk (OR = 6.0 95% CI: 3.2, 11.1), as were categories of decreasing stereopsis (trend p = 0.0001), self-reported poor vision (OR = 1.4; 95% CI: 1.0, 1.9), not wearing glasses at the time of the fall (OR = 1.2; 95% CI: 1.0, 1.6), and increasing time since the last eye examination (trend p = 0.03). The population attributable risk of hip fracture due to poor visual acuity or stereopsis was 40%. Visual factors are important fall-related factors which influence risk of hip fracture. Risk of hip fracture may be decreased by correcting refractive error, improving stereopsis, and administering regular eye examinations.
This paper reports on the research findings of The Lighthouse Vision Education and Outreach Research/Demonstration Project. The research objective was to design and evaluate a brief vision screening questionnaire which could be used in community settings to identify aging persons with vision problems. A 15-item questionnaire was tested with 369 senior center participants and 69 home care clients; 195 persons met the follow-up criterion and were contacted by telephone by professional staff in order to assess need for further clinical vision evaluation. Expectancy table analyses were performed with the professional assessment as criterion and indicated that the vision scale had an 80% overall correct classification rate at a cut-score of 9. Implications regarding the future use of the vision screening questionnaire and the need for education on vision and aging are discussed.
As people get older, they may fall more often for a variety of reasons including problems with balance, poor vision, and dementia. About a third of community-dwelling people over 65 years old fall each year, and the incidence of falls, and fall-related injuries, increases with age.1 Although less than 10% of falls in community-living older people result in a fracture, these are a significant source of morbidity1 and mortality.2 More commonly, falls result in minor injuries such as bruising and lacerations. They can also result in fear of falling and loss of confidence, and admission to a nursing home. Many risk factors appear to interact in older people who suffer fractures,3 and it is possible that fall-prevention strategies have limited effect on falls that result in injuries, or are ineffective in populations at a higher risk of injury.4 Interventions designed to reduce falls would require large effects to have an impact on the incidence of fractures. In the past, fall-prevention trials have not been adequately powered to detect effect on injury outcomes, and variation in the definition of these outcomes has hindered meta-analysis.5 The Prevention …
To examine the prevalence of hearing and vision impairments in 65+ year-old patients with hip fractures. Many older people believe sensory problems are inevitable and thus avoid medical assessment and assistance. Furthermore, health professionals often overlook sensory problems, though it is known that sensory impairments can increase the risk of falling and sustaining hip fractures. A prospective, observational study. We admitted 544 consecutive patients to an orthogeriatric ward from October 2004-July 2006; 332 were screened for study inclusion with the Resident Assessment Instrument for Acute Care (InterRAI-AC) and a questionnaire (KAS-Screen). We conducted patient interviews, objective assessments, explored hospital records and interviewed the family and staff. Impairments were defined as problems with seeing, reading regular print or hearing normal speech. Sixteen per cent of the patients had no sensory impairments, 15.4% had vision impairments, 38.6% had hearing impairments and 30.1% had combined sensory impairments. Among the impaired, 80.6% were female, the mean age was 84.3 years (SD 6.8), 79.9% were living alone, 48.0% had cognitive impairments, 89.6% had impaired activities of daily living, 70.6% had impaired instrument activities in daily living, 51.0% had bladder incontinence and 26..8% were underweight. Comorbidity and polypharmacy were common. Delirium was detected in 17.9% on day three after surgery. Results showed the prevalence of combined sensory impairments was: 32.8% none; 52.2% moderate/severe; and 15.1% severe. Patients with hip fractures frequently have hearing, vision and combined impairments. We recommend routine screening for sensory impairments in patients with hip fractures. Most sensory problems can be treated or relieved with environmental adjustments. Patients should be encouraged to seek treatment and training for adapting to sensory deficiencies. This approach may reduce the number of falls and improve the ability to sustain independent living.
The Comprehensive Assessment and Referral Evaluation (CARE) is a new assessment technique which is intended to reliably elicit, record, grade and classify information on the health and social problems of the older person. The CARE is basically a semi-structured interview guide and an inventory of defined ratings. It is designated comprehensive because it covers psychiatric, medical, nutritional, economic and social problems rather than the interests of only one professional discipline. The style, scope and scoring of the CARE makes it suitable for use with both patients and non-patients, and a potentially useful aid in determining whether an elderly person should be referred, and to whom, for a health or social service. The CARE can also be employed in evaluating the effectiveness of that service if given.
This paper introduces a series on a method of systematically assessing the health and social problems of elderly adults, the Comprehensive Assessment and Referral Evaluation (CARE). An overview is given of the conceptual approach and development of the care and its principle features including clinical relevance, semistructured format, criterion-based diagnosis, and psychometric properties as established on a probability sample of the elderly population. The reduction of the CARE is described, from a 1500-item instrument covering a wide range of problem areas and taking 90 minutes to administer, to shorter, more efficient and selective versions, the CORE-CARE and SHORT-CARE. The subsequent papers give details of the properties, reliability, validity, and reduction of the CARE.
Many risk factors for hip fractures have been suggested but have not been evaluated in a comprehensive prospective study. We assessed potential risk factors, including bone mass, in 9516 white women 65 years of age or older who had had no previous hip fracture. We then followed these women at 4-month intervals for an average of 4.1 years to determine the frequency of hip fracture. All reports of hip fractures were validated by review of x-ray films. During the follow-up period, 192 women had first hip fractures not due to motor vehicle accidents. In multivariable age-adjusted analyses, a maternal history of hip fracture doubled the risk of hip fracture (relative risk, 2.0; 95 percent confidence interval, 1.4 to 2.9), and the increase in risk remained significant after adjustment for bone density. Women who had gained weight since the age of 25 had a lower risk. The risk was higher among women who had previous fractures of any type after the age of 50, were tall at the age of 25, rated their own health as fair or poor, had previous hyperthyroidism, had been treated with long-acting benzodiazepines or anticonvulsant drugs, ingested greater amounts of caffeine, or spent four hours a day or less on their feet. Examination findings associated with an increased risk included the inability to rise from a chair without using one's arms, poor depth perception, poor contrast sensitivity, and tachycardia at rest. Low calcaneal bone density was also an independent risk factor. The incidence of hip fracture ranged from 1.1 (95 percent confidence interval, 0.5 to 1.6) per 1,000 woman-years among women with no more than two risk factors and normal calcaneal bone density for their age to 27 (95 percent confidence interval, 20 to 34) per 1,000 woman-years among those with five or more risk factors and bone density in the lowest third for their age. Women with multiple risk factors and low bone density have an especially high risk of hip fracture. Maintaining body weight, walking for exercise, avoiding long-acting benzodiazepines, minimizing caffeine intake, and treating impaired visual function are among the steps that may decrease the risk.
The prevalence of visual impairment among elderly patients admitted to hospital is unknown. This group of patients may be particularly at risk from poor vision which could jeopardise their independence. A prospective study of visual imapairment and its aetiology in acute geriatric admissions assessed after the acute illness had settled was performed. Subjects were all patients aged 65 years or over, excluding those chronically confused, admitted to the Department of Geriatric Medicine at the Royal Liverpool University Hospital with an acute medical illness. After the acute illness had settled visual impairment, as defined by the American criteria (best acuity 6/18), was assessed on the ward with a Snellen chart read at 6 m using binocular vision and current glasses. Those patients identified with impaired vision on initial screening were formally assessed in the ophthalmology department to identify the cause. 200 patients were examined. 101 patients (50.5%) had impaired vision. In these patients, correctable refractive errors were present in 40%, cataract in 37% and senile macular degeneration in 14%. Of the 101 patients with impaired vision 79% had a reversible cause. Comparing these results with a recent study in the community showed a much higher incidence for patients admitted to hospital. There was a particularly high prevalence in those elderly patients who were admitted with falls (76%, p = 0.0003). In conclusion, elderly patients, especially those presenting with falls, admitted to hospital have a high prevalence of visual impairment. Visual impairment may be compounding or causing falls.(ABSTRACT TRUNCATED AT 250 WORDS)
Data on the prevalence of reported visual impairment and on the utilization of rehabilitation services were collected on a sample consisting of 1777 community-residing people aged at least 65 years. A visual disability was considered to be present if the answer to at least one of the following two questions was positive: Do you have trouble reading ordinary newsprint with glasses (if normally worn)? Do you have trouble clearly seeing the face of someone 12 feet away with glasses (if normally worn)? Prevalence of a reported near disability was 7.6%, prevalence of a reported distance disability was 4.4%, and 3.5% of subjects reported both types of disability. In a subsample of the surveyed population, the positive predictive value was 21% and the negative predictive value was 100%, using moderate or worse visual impairment as the gold standard. Among those answering yes to both questions, 11.4% received services from a rehabilitation center and 10.0% from a nonprofit agency. The utilization rates (adjusted to apply only to those whose visual impairment was confirmed by visual examination) reached 20% for rehabilitation centers and 17.5% for nonprofit agencies. Low utilization of rehabilitation services raises questions concerning the role of general eye care practitioners, community-based health centers, and rehabilitation centers in the rehabilitative process of the visually impaired elderly.