Falls Among Persons Aged ≥65 Years With and Without Severe Vision Impairment — United States, 2014

John E. Crews; DPA1; Chiu-Fung Chou, DrPH1; Judy A. Stevens, PhD2; Jinan B. Saaddine, MD1 (View author affiliations)

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Summary

What is already known about this topic?

Vision impairment is associated with falls among persons aged ≥65 years. Limited state-level data exists on the prevalence of falls among older persons with vision impairment.

What is added by this report?

A state-based, cross-sectional, telephone survey of noninstitutionalized U.S. adults aged ≥65 years found that 28.9% of respondents reported at least one fall in the previous year. Among the 6.7% of respondents who reported severe vision impairment, 46.7% reported a fall, ranging from 30.8% in Hawaii to 59.1% in California.

What are the implications for public health practice?

It is important to develop fall prevention interventions intended for persons with severe vision impairment and for each state to identify and implement effective strategies both to reduce falls and improve vision, especially among those with severe vision impairment.


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In 2014, an estimated 2.8 million persons aged ≥65 years in the United States reported severe vision impairment* defined as being blind or having severe difficulty seeing, even with eyeglasses. Good vision is important for maintaining balance as well as for identifying low-contrast hazards, estimating distances, and discerning spatial relationships. Conversely, having poor vision increases the risk for falls (1,2). Falls among older adults are common and can cause serious injuries, disabilities, and premature death (1,3). To date, no state-level investigations have examined the annual prevalence of falls among persons with and without severe vision impairment. CDC analyzed data from the 2014 Behavioral Risk Factor Surveillance System (BRFSS) to estimate the state-specific annual prevalence of falls among persons aged ≥65 years with and without self-reported severe vision impairment. Overall, 46.7% of persons with, and 27.7% of older adults without, self-reported severe vision impairment reported having fallen during the previous year. The state-specific annual prevalence of falls among persons aged ≥65 years with severe vision impairment ranged from 30.8% (Hawaii) to 59.1% (California). In contrast, the prevalence of falls among persons aged ≥65 years without severe vision impairment ranged from 20.4% (Hawaii) to 32.4% (Alaska). Developing fall-prevention interventions intended for persons with severe vision impairment will help states manage the impact of vision impairment and falls on health care resources, and can inform state-specific fall prevention initiatives.

The BRFSS is a state-based, cross-sectional, telephone surveillance system that examines health-related behavioral risk factors among the U.S. civilian population aged ≥18 years. It is administered by states and territories in collaboration with CDC. The median response rate in 2014 was 47.8%; the median completion rate was 47.0%.

The 2014 BRFSS included questions about severe vision impairment§ and about falls. Persons who responded “don’t know” or “refused” to either question were excluded from the analyses. The study sample included 140,762 adults aged ≥65 years from 50 states and the District of Columbia (DC). SUDAAN statistical software version 9.3 was used for the analyses to account for the complex sampling design. Estimates were age-adjusted and weighted to account for individual selection probabilities, nonresponse, and poststratification. State and national populations and prevalences were estimated. Statistically significant differences (p<0.05) were determined by a chi-square test.

Overall, 6.7% of respondents reported severe vision impairment. Among all respondents, 28.9% reported at least one fall in the previous year (Table). Among respondents who reported severe vision impairment, 46.7% reported a fall during the previous year, ranging from 30.8% in Hawaii to 59.1% in California (p<0.001). Among persons who did not report vision impairment, 27.7% reported a fall during the previous year, ranging from 20.4% in Hawaii to 32.4% in Alaska (p<0.001). In 30 states, 40%–49% of persons with vision impairment fell, and in 11 states and DC, approximately half of older adults with severe vision impairment fell. Extrapolating these findings to the U.S. population in 2014, an estimated 1.3 million persons ≥65 years with severe vision impairment fell in the previous year.

Discussion

Approximately 2.8 million older adults have severe vision impairment,** a condition associated with chronic diseases, depression, and social isolation (4). During 2014, vision problems were estimated to cost $145 billion annually (5). Vision impairment is associated with falls, which occur frequently among older adults and often cause long-term disabilities (2). In 2013, the direct medical costs of falls among persons aged ≥65 years were $34 billion (6).

In this assessment, 46.7% of adults aged ≥65 years with severe vision impairment fell, compared with 27.7% of those without severe vision impairment. The differences were statistically significant in all but six U.S. states (Alaska, Delaware, Hawaii, Idaho, Vermont, and Wisconsin). In 11 states and DC, approximately half of older adults with severe vision impairment fell. In 2014, an estimated 1.3 million persons aged ≥65 years with severe vision impairment fell in the previous year.

These findings are consistent with those from previous investigations that found an association between vision impairment and falls (2). Factors associated with falls include contrast sensitivity and poor balance, as well as poor visual acuity (2). Additional reasons include multiple chronic conditions, gait problems, lower extremity muscle weakness, and the use of multiple medications, some of which might exacerbate these problems (7). Addressing these risk factors would require a range of interventions, including education, medical risk management, exercise, and home modifications (7), as well as improved access to and use of eye care. Evidence-based interventions to prevent falls among older persons have been identified (http://www.cdc.gov/homeandrecreationalsafety/falls/community_preventfalls.html.) In the only randomized controlled trial to date that evaluates fall-prevention interventions among older adults with vision impairment, investigators reported that, of the two interventions examined, a home safety intervention (e.g., increasing illumination, removing throw rugs, etc.), but not a strength and balance training program, significantly reduced falls among persons with vision impairment aged ≥75 years in New Zealand (8).

A number of evidence-based fall interventions address environmental hazards using occupational therapists (http://www.cdc.gov/homeandrecreationalsafety/falls/compendium.html), but these interventions are not designed for persons with vision impairment. Given the variety of visual factors associated with falls (visual acuity, visual fields, and contrast sensitivity) as well as visual barriers in educational materials (print size, poor contrast, and visual clutter) (9), randomized controlled trials of fall-prevention interventions intended for persons with severe vision impairment are needed (10).

The findings in this report are subject to at least five limitations. First, BRFSS data are self-reported and the accuracy of responses might be affected by recall, social desirability, or other factors. Second, these data are cross-sectional and do not permit causal inference. Third, although these estimates are age-adjusted, they do not account for differences such as health behaviors or chronic conditions that might be associated with vision impairment and also contribute to falls. Fourth, the median response rate was low (<50%). Finally, all of the excess falls among persons with severe vision impairments might not be caused by vision impairments.

Many state health departments are committed to reducing falls among older adults. The prevalence of falls among adults aged ≥65 years with severe vision impairment varies widely among states. However, the consistently high prevalence of falls among older persons with severe vision impairment suggests the need for all states to implement evidence-based fall reduction interventions specifically targeted to the needs of persons with severe vision impairment as well as to improve methods to prevent vision impairment. This approach might lead to fewer injuries, higher quality of life, and greater independence among older adults, as well as reduced health care costs.

Corresponding author: John E. Crews, JCrews@cdc.gov, 770-488-1116.


1Vision Health Initiative, Division of Diabetes translation, National Center for Chronic Disease Prevention and Health Promotion, CDC; 2National Center for Injury Prevention and Control, CDC.

References

  1. Herndon JG, Helmick CG, Sattin RW, Stevens JA, DeVito C, Wingo PA. Chronic medical conditions and risk of fall injury events at home in older adults. J Am Geriatr Soc 1997;45:739–43. CrossRefExternal PubMedExternal
  2. Lord SR, Smith ST, Menant JC. Vision and falls in older people: risk factors and intervention strategies. Clin Geriatr Med 2010;26:569–81. CrossRefExternal PubMedExternal
  3. Morrison A, Fan T, Sen SS, Weisenfluh L. Epidemiology of falls and osteoporotic fractures: a systematic review. Clinicoecon Outcomes Res 2013;5:9–18. PubMedExternal
  4. Reed-Jones RJ, Solis GR, Lawson KA, Loya AM, Cude-Islas D, Berger CS. Vision and falls: a multidisciplinary review of the contributions of visual impairment to falls among older adults. Maturitas 2013;75:22–8. CrossRefExternal PubMedExternal
  5. Wittenborn J. The future of vision: forecasting the prevalence and cost of vision problems. In: Prevent Blindness 2014. Chicago, IL: NORC at the University of Chicago; 2014.
  6. Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and non-fatal falls among older adults. Inj Prev 2006;12:290–5. CrossRefExternal PubMedExternal
  7. Steinman BA, Nguyen AQ, Pynoos J, Leland NE. Falls-prevention interventions for persons who are blind or visually impaired. Insight: Res Pract Vision Impairment Blindness 2011;4:83–91.
  8. Campbell AJ, Robertson MC, La Grow SJ, et al. Randomised controlled trial of prevention of falls in people aged > or =75 with severe visual impairment: the VIP trial. BMJ 2005;331:817. CrossRefExternal PubMedExternal
  9. Williams AS. Making diabetes education accessible for people with visual impairment. Diabetes Educ 2009;35:612–21. CrossRefExternal PubMedExternal
  10. Tricco AC, Cogo E, Holroyd-Leduc J, et al. Efficacy of falls prevention interventions: protocol for a systematic review and network meta-analysis. Syst Rev 2013;2:38. CrossRefExternal PubMedExternal

* http://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_12_1YR_S1810&prodType=tableExternal.

http://www.cdc.gov/brfss.

§ The BRFSS vision question is, “Are you blind or do you have serious difficulty seeing, even when wearing glasses?” Severe vision impairment was defined as a positive response to this question.

In even-numbered years, the BRFSS core survey contains the question, “In the past 12 months, how many times have you fallen?” and defines a fall as “when a person unintentionally comes to rest on the ground or another lower level.” Respondents were dichotomized into either those in the last year who did or those who did not fall.

** http://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_12_1YR_S1810&prodType=tableExternal.

Return to your place in the textTABLE. Age-adjusted prevalence* of falls among persons aged ≥65 years, by self-reported vision impairment status and state — United States, 2014
State Vision impairment No vision impairment Total
No.§ % (95% CI) No % (95%CI) No.§ % 95% CI
Alabama 24,184 43.4 (36.4–50.7) 178,857 28.7 (26.5–31.1) 203,040 29.8 (27.7–32.1)
Alaska 1,781 45.3 (30.3–61.3) 20,304 32.4 (28.0–37.1) 22,085 33.2 (29.0–37.6)
Arizona 24,352 39.2 (32.3–46.6) 226,772 26.8 (25.2–28.4) 251,124 27.7 (26.1–29.3)
Arkansas 20,301 58.7 (48.7–68.1) 121,766 32.1 (29.4–35.0) 142,068 34.4 (31.7–37.2)
California 169,407 59.1 (47.6–69.8) 983,556 28.4 (25.7–31.3) 1,152,963 30.9 (28.1–33.8)
Colorado 12,119 37.4 (28.8–46.9) 148,836 26.6 (24.8–28.4) 160,955 27.3 (25.6–29.1)
Connecticut 13,647 47.0 (35.4–59.0) 121,889 25.6 (23.2–28.1) 135,536 26.8 (24.4–29.2)
Delaware 2,614 37.3 (23.3–53.8) 36,776 28.1 (25.2–31.2) 39,390 28.4 (25.6–31.4)
District of Columbia 2,829 51.0 (36.0–65.7) 18,464 29.3 (26.0–32.8) 21,293 31.0 (27.8–34.5)
Florida 74,318 35.2 (27.6–43.5) 779,171 24.8 (23.0–26.6) 853,489 25.4 (23.7–27.3)
Georgia 43,124 48.0 (38.1–58.1) 279,281 27.4 (24.9–30.1) 322,406 29.1 (26.6–31.7)
Hawaii 2,530 30.8 (19.1–45.7) 40,476 20.4 (18.0–23.1) 43,005 20.9 (18.5–23.5)
Idaho 5,840 37.5 (25.7–51.1) 57,583 29.4 (26.6–32.4) 63,423 30.0 (27.2–32.9)
Illinois 46,609 54.9 (38.7–70.1) 411,836 26.0 (23.4–28.9) 458,444 27.5 (24.7–30.5)
Indiana 25,963 51.5 (43.7–59.2) 243,856 30.4 (28.5–32.4) 269,819 31.7 (29.8–33.6)
Iowa 9,297 46.8 (35.8–58.2) 132,301 30.8 (28.7–33.0) 141,598 31.5 (29.4–33.7)
Kansas 11,907 46.1 (39.0–53.4) 103,525 29.3 (27.7–31.0) 115,432 30.3 (28.8–31.9)
Kentucky 26,934 46.3 (35.9–57.0) 164,501 30.9 (28.4–33.5) 191,435 32.4 (29.9–35.0)
Louisiana 23,897 40.9 (33.0–49.4) 122,972 23.5 (21.2–25.9) 146,870 25.2 (23.0–27.6)
Maine 4,069 51.3 (40.2–62.3) 63,338 29.6 (27.6–31.7) 67,407 30.3 (28.3–32.4)
Maryland 10,515 35.6 (26.9–45.4) 180,676 25.1 (22.9–27.3) 191,191 25.4 (23.3–27.7)
Massachusetts 30,674 47.7 (38.3–57.3) 232,550 27.3 (25.4–29.2) 263,224 28.6 (26.8–30.6)
Michigan 48,140 53.4 (43.2–63.3) 418,074 31.1 (29.0–33.4) 466,214 32.5 (30.4–34.7)
Minnesota 16,267 43.4 (34.9–52.3) 173,790 25.7 (24.1–27.3) 190,057 26.5 (25.0–28.2)
Mississippi 13,609 42.2 (31.4–53.8) 95,772 26.3 (23.4–29.4) 109,381 27.6 (24.8–30.6)
Missouri 23,583 44.8 (34.5–55.5) 253,825 32.0 (29.4–34.7) 277,408 32.8 (30.2–35.4)
Montana 4,640 44.2 (34.9–54.0) 46,622 31.5 (29.0–34.2) 51,262 32.3 (29.9–34.9)
Nebraska 5,936 42.1 (34.5–50.1) 65,575 27.3 (25.9–28.8) 71,510 28.1 (26.7–29.6)
Nevada 14,246 44.5 (31.7–58.1) 85,860 26.1 (22.6–29.9) 100,106 27.7 (24.3–31.4)
New Hampshire 4,642 45.8 (31.6–60.7) 49,598 27.1 (24.5–29.8) 54,240 28.0 (25.5–30.7)
New Jersey 30,544 41.8 (32.4–51.8) 254,566 22.7 (20.7–24.9) 285,110 23.9 (21.9–26.0)
New Mexico 9,998 50.5 (40.8–60.1) 67,539 26.3 (23.9–28.7) 77,537 28.0 (25.7–30.4)
New York 70,967 39.9 (28.4–52.5) 656,123 26.9 (24.3–29.7) 727,090 27.7 (25.2–30.4)
North Carolina 42,971 40.2 (32.2–48.8) 338,647 27.5 (25.3–29.9) 381,617 28.5 (26.4–30.8)
North Dakota 2,560 44.9 (32.8–57.8) 24,813 26.1 (23.6–28.7) 27,373 27.2 (24.8–29.7)
Ohio 57,032 51.7 (41.4–61.7) 441,646 28.4 (26.2–30.7) 498,678 29.8 (27.7–32.1)
Oklahoma 16,450 44.5 (36.3–53.0) 142,903 29.7 (27.7–31.9) 159,353 30.8 (28.8–32.8)
Oregon 15,716 54.5 (42.9–65.7) 167,689 30.6 (28.1–33.2) 183,406 31.8 (29.4–34.4)
Pennsylvania 46,270 48.4 (39.6–57.3) 518,933 27.7 (25.8–29.8) 565,204 28.8 (26.8–30.8)
Rhode Island 3,664 44.5 (33.7–55.8) 37,037 25.7 (23.3–28.4) 40,701 26.7 (24.3–29.3)
South Carolina 26,792 47.9 (40.7–55.3) 181,227 28.2 (26.3–30.2) 208,020 29.8 (27.9–31.7)
South Dakota 5,302 57.0 (44.8–68.4) 29,074 26.1 (23.2–29.3) 34,376 28.3 (25.4–31.5)
Tennessee 37,676 49.1 (39.4–58.9) 231,815 29.6 (26.8–32.5) 269,491 31.1 (28.4–33.9)
Texas 114,897 49.1 (40.0–58.3) 742,627 30.0 (27.5–32.6) 857,524 31.5 (29.1–34.1)
Utah 8,954 52.6 (43.4–61.6) 72,355 28.4 (26.5–30.4) 81,308 29.9 (28.0–31.9)
Vermont 2,008 43.5 (30.7–57.3) 28,925 31.6 (28.9–34.3) 30,933 32.2 (29.6–34.9)
Virginia 30,020 42.9 (33.2–53.3) 248,024 24.7 (22.6–27.1) 278,044 25.9 (23.7–28.1)
Washington 26,753 46.4 (37.6–55.4) 255,718 29.8 (27.8–31.9) 282,470 30.9 (28.9–32.9)
West Virginia 12,740 34.1 (27.4–41.6) 70,809 25.9 (23.6–28.4) 83,548 26.9 (24.7–29.3)
Wisconsin 8,396 39.4 (25.6–55.2) 181,745 27.5 (24.5–30.7) 190,142 27.7 (24.8–30.9)
Wyoming 2,373 44.0 (35.4–53.0) 21,584 31.3 (28.8–34.0) 23,957 32.3 (29.9–34.9)
Total 1,290,055 46.7 (44.5–49.0) 10,572,200 27.7 (27.2–28.1) 11,864,255 28.9 (28.4–29.4)

Abbreviation: CI = confidence interval.
* Weighted estimates, age adjusted to the 2000 U.S. standard population.
Respondents were asked, “Are you blind or do you have serious difficulty seeing, even when wearing glasses?”; “In the past 12 months, how many times have you fallen?” Respondents who refused to answer, reported “don’t know,” or who had other missing responses were excluded from the analyses.
§ Weighted numbers.
States without significant difference in falls between those with vision impairment and no vision impairment.


Suggested citation for this article: Crews JE, Chou C, Stevens JA, Saaddine JB. Falls Among Persons Aged ≥65 Years With and Without Severe Vision Impairment — United States, 2014. MMWR Morb Mortal Wkly Rep 2016;65:433–437. DOI: http://dx.doi.org/10.15585/mmwr.mm6517a2External.

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