Connecting Falls to Elder Vision

We are repeatedly reminded that the populations around the world are aging, and national reports from some countries have documented this for some time. In a recent news item, I read that the number of people older than 60 years will be a surprisingly large percentage of most populations. Although it varies by country, it is in all cases growing from today’s percentage. The implications for societies are broad and quite serious. In our own professional field, we have become much more aware of the changes in vision that accompany aging, quite separately from the fairly dramatic increase in aging eye diseases, like diabetic vision loss (primarily associated with diabetic retinopathy), and age-related macular degeneration, glaucoma and cataract. On the latter, in North America, it is being effectively ameliorated with surgical treatment. In many countries, cataract remains the leading cause of vision loss among the older populations. It is apparent from a survey of the literature that falls among the elderly are a most serious threat to an individual’s health. Also, the literature on vision changes in the elderly, published in many journals, is a rich one. It documents the deterioration of vision with age. Let me briefly remind our readers of some publications in Optometry and Vision Science (OVS) that highlight the kind of vision changes that may contribute to falls among the elderly. Even from our own OVS publications, one might “connect the dots” on how vision is a factor in falls by the elderly. About 9 years ago, OVS published an article that followed an Award-giving Lecture (The Glenn A. Fry Lecture 2003) by Gunilla Haegerstrom-Portnoy1; it followed a 1999 article by her.2 She and her colleagues were studying an aging population in Marin County, California, and they documented a surprising reduction in vision as that population aged. Of particular interest was the reduction of low-contrast visual acuity (particularly in the presence of any glare) and perhaps more relevant for falls in the elderly, a dramatic reduction in stereoscopic three-dimensional vision. Haegerstrom-Portnoy and her colleagues have published a number of related articles on these vision changes.3,4 Most recently, OVS published a study from the same population and noted the quite dramatic increase in the difference in refraction of the two eyes in the older population (more than 10 times that of the younger population).4 Although it could be argued that correction of that refractive error difference could bring more balanced vision between the eyes and minimize stereoscopic deficits, the fact was that the population they studied was wearing their habitual correction and it was often in need of updating. In my own comments in a preview of the article and in an Editorial5 some years before, I brought attention to the fact that, for older patients who simply wear “dime store” reading glasses with equal correction in each eye and who fail to take them off as they navigate around their homes, the problem of unequal refractive error and consequently stereoscopic vision is not being addressed. It may well contribute to some falls. Such speculation on my part really deserves a more rigorous test by well-designed research. In this issue of OVS, we lead with the substantial research of our 2013 Glenn A. Fry Awardee, David Elliott.6 Professor Elliott’s article provides excellent insight into the ways that vision impacts on negotiating steps, where falls are often reported. I urge you to read this interesting report of his research journey. It is accompanied by a brief video clip that quickly alerts you to his experimental approach. Elliott draws compelling connections between vision and postural control and falls, particularly falls going down steps. As he notes, “most epidemiological studies have shown that visual impairment (typically defined as binocular visual acuity worse than 20/40 or 20/60) is a significant and independent risk factor for falls,” and that “Epidemiological studies have also shown that PAL and bifocal wearers are twice as likely to fall as nonmultifocal wearers.” Elliott points out “a randomized controlled trial has shown that an additional pair of distance-vision single-vision glasses for outdoor use can reduce falls rate.” As I noted, this was an award-winning research worthy of being the 2013 Academy of Optometry Glenn A. Fry Award Lecture in Seattle. His article6 reviews the literature on how blurred vision and magnification7 contribute to falls, gait, and postural control, and he discusses how these are influenced by spectacle correction. As he reminds us, vision provides significant input to postural control as well as information about the size and position of hazards and obstacles. It allows us to safely negotiate steps and stairs. In fact, he notes that many studies have shown that reduced vision is a significant risk factor for falls. He reports that “Falls are the major cause of accidental death and nonfatal injuries in elderly US adults.8 About 21,700 older US adults died from fall-related injuries in 2010 and 2.3 million nonfatal injuries among older adults were treated in emergency departments, with more than 660,000 hospitalized, at a direct cost of about $30 billion.” Optometry and Vision Science readers will have yet other reasons to connect the dots on these issues when they read, in our upcoming August Feature Issue (Age-Related Macular Degeneration), of similar related work by Daniel Marigold and his colleagues in Vancouver, Canada. There is little doubt that the changes in vision as we age, although often seemingly subtle if we only look at visual acuity for the high-contrast traditional eye chart, can have important impact on our daily living, well-being, and even safety. Not the least among these important daily living tasks, helping maintain independence among the elderly, is driving. And, with this final comment, I must give a shout-out to the long series of research studies (e.g.,9–11) by our own Joanne Wood in Queensland, Australia. (Joanne serves currently as an Associate Topical Editor of OVS and was a recent term-limited OVS Board member.) A substantial body of literature supports “connecting the dots” on vision and falls among the elderly. Our own Academy fellows have contributed much to that literature. David Elliott’s publication in this June issue reminds us of the issues and consequences for the elderly. Tony Adams Editor in Chief Optometry and Vision Science

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