Falls Prevention Intervention Modified for Older Adults With Low Vision: A Pilot Study

BACKGROUND AND PURPOSE: For older adults, falls often lead to injury, decreased functional independence, long-lasting confusion, depression, and immobilization (World Health Organization, 2007). Older adults with low vision are approximately twice as likely to fall as those without vision loss. Falls prevention interventions designed specifically for people with low vision are limited, with many available strategies relying on the ability to view demonstrations or read printed or electronic handouts (Crews et al., 2016).

Accessible versions of evidence-based falls prevention interventions are needed to ensure that older adults with vision impairment benefit from established interventions. The purpose of this study was to produce and pilot test a visually accessible version of an evidence-based intervention that can be used permanently in the Southeastern Blind Rehabilitation Center (SBRC), part of the Birmingham Department of Veterans Affairs.

METHOD: We piloted a modified version of the Study of Accidental Falls in the Elderly (SAFE) Health Behavior and Exercise intervention (Hornbrook et al., 1994) using a quasi-experimental pretest–posttest intervention design within the SBRC. The SAFE intervention consists of four classes delivered using educational handouts that address the multiple falls risk factors contributing to decreased safety. Inclusion criteria were veterans at SBRC, age 60 or older, remaining vision allowing for reading, sufficient hearing, and <2 wk since admission to the SBRC.

We first used the ADAPT-ITT model to develop a visually accessible version of the SAFE intervention (Wingood & DiClemente, 2008). Using this model, low vision and falls prevention experts suggested changes to increase the readability of the content and reviewed the final modified intervention to ensure the content was visually accessible. During piloting, we used multiple measures to describe the sample, including vision measures (distance acuity, contrast sensitivity, and visual field), Patient-Reported Outcomes Measurement Information System measures (depression, global health, and social participation), and the Short Physical Performance Battery (lower extremity weakness).

Four outcome measures were administered pre- and postintervention to determine whether the content was accessible to veterans. A knowledge assessment comprising multiple choice and verbal questions was used to test participants’ understanding of the intervention content. We used retrospective pre–post ratings (1–10, with 10 = complete knowledge) to assess whether participants believed they knew more about falls prevention strategies after the intervention than before. Finally, we assessed fear of falling (Falls Efficacy Scale) and mobility (University of Alabama at Birmingham Life Space Assessment). All participants also provided verbal feedback regarding the accessibility of the intervention.

RESULTS: Nine veterans (eight men, one woman) completed the intervention. Descriptive measures showed that participants were representative of the typical population receiving services at the SBRC. The mean knowledge posttest score, 81.1% ± 16.2% (out of 100%), was significantly higher than the pretest score, 58.9% ± 9.3% (Z = –2.4, p < .02). All participants reported an increase in learning (range = 1–8 points), with 33% reporting a score of 10 (complete knowledge of intervention material) after class completion. The assessments of fear of falling and mobility showed no significant change after intervention. All participants provided positive feedback regarding the intervention, and none described negative components or suggested changes.

CONCLUSION: Participants who completed the visually accessible handouts significantly increased their knowledge of the intervention content from baseline. Participants also perceived that that they had a better understanding of the content and expressed satisfaction with the intervention. Participants did not experience a significant decrease in fear of falling or increase in mobility, most likely because of the small sample size and short time frame of the intervention. We plan to deliver the intervention in the SBRC using a larger sample and to include a control group. We will also follow participants for a longer period of time and monitor number of falls postintervention.

IMPACT STATEMENT: Feedback from experts during the intervention modification supported the supposition that some evidence-based interventions for older adults are not accessible to people with visual impairment. The use of nonaccessible intervention materials is an important problem that extends into all areas of health education for older adults with low vision. Inaccessible health education materials may needlessly create a preventable and easily remediable barrier to assisting older adults to age in place safely. When considering an intervention, it is important for occupational therapy practitioners to acknowledge the presentation style of the intervention content to ensure that older adults with low vision can access the material.

References

Crews, J. E., Chou, C.-F., Stevens, J. A., & Saaddine, J. B. (2016). Falls among persons aged ≥65 years with and without severe vision impairment—United States, 2014. MMWR, 65(17), 433–437. https://doi.org/10.15585/mmwr.mm6517a2

Hornbrook, M. C, Stevens, V. J., Wingfield, D. J., Hollis, J. F., Greenlick, M. R., & Ory, M. G. (1994). Preventing falls among community-dwelling older persons: Results from a randomized trial. Gerontologist, 34, 16–23. https://doi.org/10.1093/geront/34.1.16

Wingood, G. M., & DiClemente, R. J. (2008). The ADAPT-ITT model: A novel method of adapting evidence-based HIV interventions. Journal of Acquired Immune Deficiency Syndrome, 47(Suppl. 1), S40–S46. https://doi.org/10.1097/QAI.0b013e3181605df1

World Health Organization. (2007). WHO global report on falls prevention in older age. Retrieved from http://www.who.int/ageing/publications/Falls_prevention7March.pdf