Falls Prevention through the Visual Impairment Detection Program

Abstract

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.

Full text

Falls Prevention through the Visual
Impairment Detection Program
Cathy McGraw, MSW
MAB-Mackay Rehabilitation Center
Montreal, Canada
Lise De
´ry
Institut Nazareth et Louis-Braille
Longueuil, Canada
Walter Wittich, PhD*
MAB-Mackay Rehabilitation Center
Montreal, Canada
Abstract
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
Introduction
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
Que
´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
´al,
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
wwittich@ssss.gouv.qc.ca.
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
proble
`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
repe
´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.
Acknowledgments
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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