Treatable vision problems predispose older patients to falls

Nearly two-thirds of visually impaired older patients fell one or more times over a five-year period. Many lacked access to vision care.

Almost half of patients aged 65 years and older admitted to four Scottish hospitals with femoral neck fractures proved visually impaired and unwilling or unable to receive necessary ophthalmic services, a new study shows.

Additionally, about two-thirds of those visually impaired patients had fallen one or more times during the previous five years compared with half of patients admitted with normal vision.

Despite apparent connections, researchers remained cautious about suggesting a causal relationship between vision impairment, falls and femoral fractures, stating that falls arose from many factors or combinations of causes. However, they did draw one clear conclusion: Visually impaired patients generally are not in touch with ophthalmic services.

“Social deprivation appears to be associated with this group’s inability to access ophthalmic care," the study authors said. Only 16% of patients in the visually impaired group were under the care of eye services at the time of their fall, they noted.

“The purpose of this study was to document the level and cause of visual impairment in this population and [it] has identified that the visual function is much poorer than would be expected compared to the general population of the same age,” the authors said in the study, published in the journal Eye.

In both groups, 97% of the fractures were traumatic. Nine percent of visually impaired patients fractured their fellow hip, while 5% of the non-visually impaired patients fractured their fellow hip, according to the study.

Visual status results

The study evaluated 518 patients, 239 (46%) of whom comprised the visually impaired group and had a binocular visual acuity (VA) of 6/18 or less. The non-visually impaired group included 279 (54%) patients with a binocular VA of 6/12 or better.

“To our knowledge, this study represents the poorest level of vision documented in a sample of elderly patients with fall in the Western world,” the authors said.

The researchers measured uniocular and binocular VA using a Snellen chart without corrective lenses. They defined binocular vision on presentation as the vision obtained with the patient's current refractive correction.

In the visually impaired group, cataracts were the principal cause in 118 patients (49%), refractive error in 40 patients (17%) and macular degeneration in 51 patients (21%). Visually impaired patients were older, having a mean age of 85 years, compared to a mean age of 79 years for non-visually impaired patients.

Visually impaired patients were also more likely to be admitted from long-term institutional care; 28% compared to 6% of non-visually impaired patients. Additionally, visually impaired patients had a higher rate of severe cognitive impairment; 15% vs. 3% of non-visually impaired patients.

Researchers found that 136 (58%) visually impaired patients complained that impaired vision affected their quality of life, while 73 (26%) of non-visually impaired patients admitted such problems.

Using the Scottish deprivation index, the researchers also found that visually impaired patients were more likely to reside in areas of social deprivation, with 40% having a score greater than nine compared to 26% of non-visually impaired patients. Patients with a deprivation score greater than nine were also less likely to have sought optometric assistance in the three years prior (71% vs. 82%, P<0.01), according to the study.

This study follows a similar U.K. study conducted two decades ago, in which 0.8% of patients with a femoral neck fracture had no vision and 21% had only partial sight, the authors noted.

For more information:
Cox A, Blaikie A, McEwan CJ, et al. Visual impairment in elderly patients with hip fracture: causes and associations. Eye. 2004. (00) 1-5.