According to the U.S. Census (2020), adults 65 years of age and older comprise 16% of the population, and this number is increasing. Visual impairment can result from a variety of common etiologies during the aging process. By 2050, the number of visually impaired adults aged 70 to 79 is predicted to increase 211%, and the number of visually impaired adults who are 80 years and older will increase 280% (Kelly et al., 2020). Although visual impairment can negatively impact multiple areas of older adults' lives, the contribution to fall risk and falling is one of the greatest threats.

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Many factors contribute to fall risks and falling in addition to visual impairment. Fear of falling and poor balance were recently cited as common factors (Gashaw et al., 2020). Other researchers identified that the most common causes for a tripping fall are lack of attention to one's surrounding, unexpected obstacles, or misjudging distances or angles (Manduchi & Kurniawan, 2011). Visual impairment may also contribute to each of those common causes. Research indicates that older adults with visual impairment have significant mobility deficits (Swenor et al., 2013). In another study, 46% of people who had a fall-related hip fracture attributed the cause of their fall to poor vision (Cox et al., 2005). Among those who attributed their fall to poor vision, 49% had untreated cataracts, 21% had macular degeneration, 17% had uncorrected refractive error, and 3% had glaucoma (Cox et al.). Fewer participants with visual impairment reported regular ophthalmology care compared with participants without visual impairments (Cox et al.).

Costs and fall-associated fatalities increase with aging and are higher among women than men. In 2015, the cost of fatal falls and nonfatal falls among older adults was estimated to be approximately $50 billion (Florence et al., 2018). Falls are the first leading cause of death from unintentional injury in the older adult population (Kramarow et al., 2015). The Centers for Disease Control and Prevention (2019) reported that fall-related death rates among older adults are escalating annually and increased by 30% between 2007 and 2016 (Figure 1). The purpose of this article is to provide a review of the common types of visual impairment, their etiology, and treatment and to present strategies to reduce falls among visually impaired older adults.

Figure 1. Fall death rate in the U.S. from 2007-2016.

Common Visual Problems and Fall Risk Implications for Older Adults

The most common visual problems among older adults are presbyopia, cataracts, macular degeneration, diabetic retinopathy, glaucoma, and vision loss due to cerebrovascular accident. The pathology of the vision problem determines the residual visual deficit as summarized in Table 1. Presbyopia occurs from changes to the anatomy of the eye structure by hardening the lens and decreasing the eye's elasticity; the changes decrease visual acuity. Cataracts decrease the transparency of the lens. Aging, genetic predisposition, other medical conditions such as diabetes, medication use such as long-term steroid use, and lifestyle behaviors such as smoking and ultraviolet light exposure (Chua et al., 2017) lead to opacification, which causes cloudy vision. Macular degeneration is caused from the overgrowth of new fragile blood vessels leading to rapid vision loss. Changes in the retinal microvasculature of the eyes in the presence of diabetes causes vision loss. Glaucoma is due to increased intraocular pressure, leading to nerve and blood vessel compression. Vision losses due to cerebrovascular accidents are a result of nerve and vascular injury that impairs information interpretation in the brain.

Table 1. Common Visual Impairments Among Older Adults

The prevalence of refractive errors, glaucoma, cataracts, and macular degeneration increases with aging. Refractive errors require corrective lenses (glasses, contacts) or surgical correction to reduce fall-associated risk and improve daily functioning and quality of life. Cataracts, macular degeneration, and glaucoma are progressive diseases that decrease visual acuity and can lead to blindness if untreated (Lee et al., 2020; Saftari & Kwon, 2018). Surgery is the most effective treatment for cataracts; however, the lens needs to become a certain thickness before surgery can be scheduled. Cataracts that are not yet operable create an increased fall risk due to visual impairment (Palagyi et al., 2016). Macular degeneration and glaucoma tend to develop gradually, and older adults may be unaware that they have these conditions. Screening and early diagnosis are critical because treatment is more effective early in the disease process (Scott et al., 2016). Additionally, early diagnosis helps to decrease fall risk in patients with glaucoma, macular degeneration, and cataracts (Palagyi et al.; Wood et al., 2011; Yuki et al., 2015).

Vision impairments from diabetic retinopathy and cerebrovascular accidents (CVAs) are considered secondary disease-related conditions. With diabetic retinopathy, the treatments focus on diabetes management (Liu et al., 2019). Incretin therapy is an option to control postmeal glucose levels (Wang et al., 2018). Unfortunately, diabetic retinopathy is usually asymptomatic in its early stages and treatment is not as effective at later stages, which is when vision loss occurs. Therefore, prevention through optimizing blood glucose control and regular vision exams for early detection are essential for people with diabetes. Vitreoretinal surgery can help improve the condition in certain cases (e.g., nonclearing vitreous hemorrhage and/or tractional retinal detachment; Rami et al., 2017). For visual impairment caused by CVAs, the vision deficits generally have an acute onset in conjunction with the CVA (Rowe et al., 2019), and the vision deficits vary depending on the area of the brain affected (Rowe et al.). The most common vision deficits are homonymous (sees only one side of visual world in each eye), quadrantanopia (loss of vision in a quarter of the visual field), and bitemporal hemianopia (blindness in the outer half the visual field). Early intervention to restore blood flow may prevent permanent visual deficits (Speirs & Graves, 2018). Vision impairments from diabetic retinopathy or from a CVA also increase fall incidents (Gupta et al., 2017; Maeda et al., 2015).

Interventions to Reduce Vision-Related Fall Risks in the Home

Vision Assessment and Referral

Home healthcare clinicians working for organizations that are certified by the Centers for Medicare and Medicaid Services are required to document patients' vision as part of the Outcome and Assessment Information Set (OASIS). The assessment is often completed by asking patients about their vision rather than doing any type of visual examination. Unfortunately, many older adults have undiagnosed vision problems or are unaware of their visual deficits (Scott et al., 2016), and healthcare providers tend to underestimate the impact vision loss has on patients' functional status and quality of life (Chaudry et al., 2015; Zhang et al., 2015). Cues that older adults may have a visual deficit include difficulty reading certain size print or manipulating small objects such as replacing batteries, clearly viewing a television screen, and/or slower walk speed or gait hesitancy (National Academies of Sciences, Engineering, and Medicine, 2016).

Visual exams can be done by home healthcare clinicians (Gudgel, 2021). Home vision assessment may be particularly important now because many older adults have foregone healthcare services, including vision care, during the COVID-19 pandemic (Ung et al., 2021). There are several different types of home eye exams, both tangible and digital. One of the easiest involves having the person sit 10 feet away from the vision chart in a chair, with one eye covered and a flashlight shining in each line of the chart while the person reads the letters on the chart out loud (Gudgel). Clinicians should also educate patients and caregivers about the importance of regular vision exams from an ophthalmology health professional to both maintain optimal visual health and to prevent the secondary consequences of untreated visual deficits such as falling.

Standard Fall Prevention Interventions

Prior research identified several barriers that contribute to falls during the hospital-to-home transition, including not receiving fall information at discharge, sedentary behaviors, and lack of assistance with activities of daily living (Shuman et al., 2019). Standard fall prevention includes education and other interventions that address environmental safety and reduce physiologic risk factors (Paliwal et al., 2017). It is essential for home healthcare clinicians to routinely evaluate environmental risk factors and provide education to patients and caregivers to improve safety. For example, safety can be enhanced in stairways and hallways by having secure handrails on both sides. Adequate lighting and clear pathways in all rooms improve safety, as do firmly fixed carpeting and an absence of throw rugs or small area rugs (Chacko et al., 2017). Securely mounted grab bars near toilets and on the inside and outside of bathtubs and showers, and nonskid bathmats can reduce falls in the bathroom (Chacko et al.). Another common cause for falls is poor lighting in the living room, bedroom, and bathroom. Light switches that can be reached from the bed, such as a lamp on a bedside table may reduce falls (Swenor et al., 2016). Home healthcare patients can benefit from a more detailed evaluation and a plan of care developed by an occupational therapist (Cumming et al., 1999). However, it is not home modification alone, but also behavioral changes that help older adults live more safely.

Behavioral changes include older adults' use of adaptive or safety equipment that has been installed in the home to appropriately manage physiologic factors that can increase fall risks. Physiologic factors include disease-specific conditions that may impair balance and mobility (e.g., CVA, Parkinson's disease, Meniere's disease), side effects from medicines (e.g., dizziness, hypotension, confusion), and healthy lifestyle behaviors such as physical activity. Assessing patients' current behaviors and then tailoring educational and behavioral interventions to patient-specific fall risk is essential. For example, education about how medications to manage specific conditions such as diabetes may protect vision, and, conversely, how medication effects or side effects (e.g., diuretics) may increase fall risk. Physical therapy to improve strength and balance, and proper fitting and use of walking aids, are often appropriate intervention for home care patients (Gallo et al., 2018). In addition to these standard interventions, specific interventions are warranted for older adults with vision deficits (Table 2).

Table 2. Fall Risk Prevention Interventions for Specific Visual Impairments

Technology to Prevent Fall Risk

Several recent technological advances can be used to prevent fall risk. Research from our team and others suggests that virtual home assistants (e.g., Amazon Echo, Google Home) connected to smart light bulbs for voice-activated lighting control may be useful for fall prevention (Corbett et al., 2019; O'Brien et al., 2020). Low-intensity lighting (e.g., night light) does not provide enough light to perform tasks that require near vision, such as identifying an object on the floor (Butler, 2017; James et al., 2017). Voice-activated lighting avoids the need to use a light switch, so this may be particularly effective for people with visual impairment (Ho, 2018; Pradhan et al., 2018), because the light can be turned on by voice prior to getting out of bed and then turned off by voice once the older adult has returned to bed.

Exergaming devices, such as Nintendo Wii/Switch or Xbox Kinect, may be used to improve physical strength and balance and cognitive function in older adults (Choi et al., 2017). Wii sport games require balance and strength to perform movements (Skjaeret et al., 2016). A study that used a fall prevention exergaming technology system demonstrated a reduction in fall risk among all users, except those who had a very high baseline physical activity (Ogonowski et al., 2016). However, all participants reported a perception of decreased fall risk. Improving strength, balance, and cognition can help reduce falls in those with and without visual deficits.

Both wearable sensors and ambient sensors that are placed in older adults' homes are being tested in fall prevention. Changes in gait, walking speed, and activity patterns detected by ambient sensors have been shown to predict falls several days in advance of a fall (Khanuja et al., 2018). Another project is testing delivery of subsensory vibration noise to improve balance and gait (Lipsitz et al., 2015). Wearable sensors may increase fall risk awareness and the ability to develop tailored fall risk interventions (Danielsen et al., 2016). Technology to prevent falls is an emerging area that requires more research and testing. However, technological advances hold great promise for fall prevention among older adults with and without visual deficits.

Conclusion

Vision impairment is highly prevalent among older adults. Alarmingly, many vision problems are undiagnosed, as many older adults do not recognize symptoms. Vision problems increase the risk of falls and other injuries, leading to further complications and decreased life quality. Therefore, prevention and early treatment are paramount. Greater awareness of, and attention to, potential vision deficits among older adult home care patients will enable clinicians to implement appropriate safety interventions. Home healthcare clinicians can play a critical role in preventing falls for older adults with and without vision problems. Traditional and newer technology-enabled fall risk strategies can improve older adults' safety and may be especially important for older adults with vision deficits.

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