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Vision, Aging, Falls, and Falls Prevention - Part III

Thursday, November 22, 2018

Dr. Lois CalderDr. Tammy Labreche

THIS WEBINAR IS BEING RECORDED.THE SLIDE DECK AND RECORDING WILL BE

EMAILED AFTER THE WEBINAR.

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VISION, AGING, FALLS, AND FALLS PREVENTION

- PART IIILois Calder, O.D. Community Outreach and Low Vision, Vision Institute of Canada, Toronto

Tammy Labreche, BSc., O.D., F.A.A.O. Clinical Associate Professor, School of Optometry and Vision Science, University of Waterloo

Today’s focus:

•Double vision

•Considerations in a long term care (LTC) setting

•Dementia

•Systemic conditions

Double Vision and Falls Risk

Good binocular vision and depth perception require the perfect integration in the brain of two slightly disparate images of approximately equal quality

Common sources for late onset diplopia:

• Cranial nerve palsies• Cranial nerve III – horizontal and vertical

• Cranial nerve IV – mostly vertical and torsional (one tilted image)

• Cranial nerve VI – mostly horizontal, at distance only

• Ocular surgeries such as retinal detachment repair

• Head injuries, concussion

• Decompensating congenital binocular vision disorders

Strong association with falls

“When evaluating risk by the type of disorder of binocular vision, the strongest association with a risk of musculoskeletal injury, fracture, and fall was in patients with a diagnosis of diplopia.” 1

1 Pineles et al (2015) JAMA Ophthalmol 133 Issue 1: 60-65

Quality of life

One study compared QoL scores for strabismic patients age 50+ (most with diplopia) vs. patients with other ocular diseases:

“Strabismic patients performed the same or worse on nearly all vision-related subscales than did patients with diabetic retinopathy, age-related macular degeneration, glaucoma, cataract, and CMV retinitis” 2

2Chang et al (2015) American Journal of Ophthalmology 159(3): 539-544

Options for relief

•Prism

•Occlusion

•Surgery

•Vision therapy

Prism -used to move images in visual space to more closely match the deviating eyes’ lines of sight

Full thickness Fresnel

Prism may be used as a temporary measure, or permanently if necessary

Occlusion

Surgery

Viable option in many cases

One recent study:

63% of strabismic patients (75% having reported diplopia) who underwent surgery reported “complete resolution of their presenting complaint” 3

3Fang et al (2018) Journal of AAPOS 22(3): 170-173

Vision Considerations in a Long Term Care Setting

Reflections from the viewpoint of a vision care provider

age

Vision lossLTC

population

Fall risk

Mobile eye clinic

Spectacles Communication

Surgery Environment

Training

Spectacles

• Lens choice

• Frame choice

• Spectacle care

Lens choice• Single vision vs. bifocal / progressive

• Traditional strategy: single vision distance for ambulation (for active people)

• Advantages: decreased fall incidence compared with full addition bifocal

• Disadvantages: at least two pairs of spectacles needed, switching glasses frequently is inconvenient, may not decrease fall incidence for less active people

• More recently studied strategy: bifocal / progressive with distance and intermediateadd 1

• Advantages: one pair may be acceptable, decreased falls incidence demonstrated (compared with full add), acceptable near vision for many tasks

• Disadvantages: may require one more pair of reading glasses

1 Elliot et al (2016) Ophthalmic Physiol Opt 36: 60-68

Frame choice

• Familiar usually best

• Nose pads vs one piece bridge

• Temples not too wide

Eleanor’s story

Spectacle care

• Cleaning

• Lens coatings

• Lost lenses

• Repairs

Lens coatings

Functional loss

Lost lenses

Now you don’t see it… Now you do

RepairsConsider role of volunteers

Communication

• Resident photos

• Labels

• Eyeglass identifier binder

• Keep front-line caregivers informed

• Falls signage

Resident photos

Blurred, no spectacles Clear, spectacles identifiable

Great idea –resident eyewear identifier photo resource

New eyewear?

Try to keep frontline caregivers informed

Falls risk signage

Surgery

• Evidence strongly suggests cataract extraction reduces falls risk

• Monovision implications

Logistical challenges

Wait times www.hqontario.ca

Family 2

Post surgical eyewear concerns

2 Friedman et al (2005) Arch Ophthalmol 123: 1581-1587

Environment

Lighting often poor 3

Flooring/colours

3 De Lepeleire (2007) Journal of the American Medical Directors Association 8(5): 314-317

Training

• Multimodal exercise (balance training, group exercise, tai chi) may improve aspects of balance in the low vision population 4

4 Chen et al (2012) Age & Aging; 41 Issue 2: 254-259

VISION & DEMENTIA

DEMENTIA

• Term to describe deterioration in cognitive ability that significantly impacts daily living

• Not a normal part of aging – damage to brain cells (depending on type of dementia)

• Progressive

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwjPqNzKt9neAhUI74MKHY_RAGoQjRx6BAgBEAU&url=https%3A%2F%2Fwww.nextavenue.org%2F7-surprising-early-signs-of-alzheimers-disease%2F&psig=AOvVaw1lVutgZr9hc6qrQDEz33Rz&ust=1542475470592506

• Must have significant decline in two of the following functions:• Memory

• Reasoning/judgement

• Communication

• Attention/focus

• Visual perception

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwjB_bqSy9neAhUE9IMKHdZpBewQjRx6BAgBEAU&url=https%3A%2F%2Fwww.scientificamerican.com%2Farticle%2Fthe-role-of-visual-attent%2F&psig=AOvVaw1TRQ2Gef9JgKcJO8TnaQHO&ust=1542480828884729

Types of dementia

• Alzheimer’s

• Vascular dementia

• Dementia with Lewy bodies

• Mixed dementia

• Parkinson’s disease

• Frontotemperal

❖Not an exhaustive list!!https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwiKv9CPt9neAhXD7oMKHU3CCiYQjRx6BAgBEAU&url=https%3A%2F%2Finfobase.phac-aspc.gc.ca%2Fdatalab%2Fdementia-alzheimers-blog-en.html&psig=AOvVaw1yLJt0wQp0vycY91vqcaHy&ust=1542475481474425

Alzheimer’s

• Most common dementia (60-80%)

• Most often affects those 65+

• Tangles and plaques (Twisted strands of tau protein and deposits of beta-amyloidprotein fragment)

• Posterior Cortical Atrophy• “visual dementia”

• Likely caused by Alzheimer’s – degeneration occurs at the back of the brain NOT eye

• Characterized by degeneration of vision!

• Memory often preserved

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwi-iYfjttneAhXi5YMKHTIABhEQjRx6BAgBEAU&url=https%3A%2F%2Fwww.brightfocus.org%2Falzheimers%2Farticle%2Fform-dementia-affects-vision-posterior-cortical-atrophy&psig=AOvVaw0yjqM-w5rOIsBEQ0Epk5Pt&ust=1542475378199970

• PCA…impact on VISION

• Eye movement abnormalities• Difficulty with visual crowding• Diminished useful field of view

• Difficulty with localization/navigation

Crutch, Sebastian J., et al. “Looking but Not Seeing: Recent Perspectives on Posterior Cortical Atrophy.” Current Directions in Psychological Science. 2016. 25 (4): 251–260. doi:10.1177/0963721416655999.

Yong, K. X. X., Holloway, C., Carton, A., Yang, B., Suzuki, T., Serougne, R., .Crutch, S. J.. Effects of cortical visual impairment on navigational ability in posterior cortical atrophy and typical Alzheimer’s disease. 2015. Paper presented at the Alzheimer’s Association International Conference, Washington, DC.

Vascular dementia• Second most common cause of dementia

• Following stroke

• Memory loss not first symptom• More problems with judgement and planning

• BUT…• ~25% of those who have experienced a stroke also have some form of residual vision loss

• Visual field loss, eye movement disorders, reduced visual acuity, diminished perception

Rowe et al. A prospective profile of visual field loss following stroke: prevalence, type, rehabilitation, outcome. Biomed Research International. 2013: http://dx.doi.org/10.1155/2013/719096

Dementia with Lewy bodies

• Lewy bodies = abnormal clumps of alphasynuclein protein that develop in the cortex

• Early memory loss but also early sleep disturbances, visual hallucinations and muscle rigidity• Visually have more difficulty with perception

• visual discrimination, space-motion, and object-form perception impairments

Mosimann UP, Mather G, Wesnes KA et al. Visual perception in Parkinson disease dementia and dementia with Lewy bodies.Neurology. 2004; 63 (11): 2091-2096; DOI: 10.1212/01.WNL.0000145764.70698.4E

Parkinson’s disease

• Dementia similar to that of LBD occurs as disease progresses

• Movement disorder initial symptom• Tremor

• Bradykinesia/stooped posture

• Rigid muscles

• Loss of autonomic movements

• Speech changes

• Visual changes to LBD

Frontotemporal dementia

• Often younger onset ~60 years

• Cell degeneration in the frontal and temporal lobes• planning and judgment; emotions, speaking and understanding speech, some

movement

• 3 broad categories of FTD• Behavioral variant frontotemporal dementia

• Primary progressive aphasia

• semantic dementia, progressive nonfluent aphasia

• FTD movement disorders

• Corticobasal degeneration, Progressive supranuclear palsy (Causes slurring of speech and ‘quiet talkers’ earlier than onset of dementia)

• Eye movement disorders

Visual Acuity

ColourVision

Stereoacuity Visual Field

Contrast Sensitivity

Eye Movements

Visual Hallucinations

Azheimer’s ? Advanced

stages

? √ ? √ Somewhat Somewhat

Vascular X X √ X √ X X

Lewy Body X ? X ? X √ √

Parkinson’s X ? X X X √ √

FTD X X X X X Somewhat Somewhat

Armstrong R, Kergoat H. Oculo‐visual changes and clinical considerations affecting older patients with dementia. Ophthalmic & Physiological Optics. 2015; 35: 352–376.

Does reduced vision cause or further progress dementia???

• Maybe….mixed outcomes on studies

• Final verdict not out

• However…reduced vision will exacerbate symptoms of dementia

Mary A. M. Rogers, Kenneth M. Langa; Untreated Poor Vision: A Contributing Factor to Late-Life Dementia, American Journal of Epidemiology, Volume 171, Issue 6, 15 March 2010, Pages 728–735, https://doi.org/10.1093/aje/kwp453

The Modified Eye Exam

• How is the eye exam conducted for those with dementia?• It is important to obtain as much information as possible.

• IT IS NOT ASSUMED THAT A PATIENT WITH DEMENTIA WILL NOT BE ABLE TO FULLY PARTICIPATE IN THE EYE EXAM

Communication Strategies

• Extra noise in the room minimized.

• Extra time for exam completion provided.

• The individual is included in the conversation.

Communication Strategies

• The practitioner does not stand too close or above the individual.

• Speaks clearly and at a slower pace.

• One idea presented at a time.

• Questions kept simple.• Yes/no questions

• Limited options for decision making.

• Objective results possible

• If testing not successful, attempts on other days made

Review: Visual Risk Factors for Falls

• Reduced visual acuity

• Reduced contrast sensitivity

• Impaired depth perception

• Visual field loss

• Inappropriate spectacle correction

• Light adaptation

• Glare sensitivity

Potential Management Considerations

Spectacle prescription• Prescription revised but changes implemented more gradually

• multifocal wear introduction avoided for those that habitually wear single vision distance correction or no specs

• separate distance correction considered

• frames that limit peripheral vision avoided

• tint for light adaptation, glare sensitivity or decreased contrast sensitivity considered

Early referral for cataract surgery• 34% fall less if surgery is expedited to < 4 wks

• Those that wait > 6mths have poorer quality of life and are more likely to fall

Management of Contrast Sensitivity Loss

• For those with a decrease in contrast sensitivity, counsel appropriately regarding decreased ability to detect low contrast obstacles, minimize low contrast items

• Consider demonstrating specialty filters

www.lasikcomplications.com

• Advise marking stairs with high contrast borders or referral for in-home assessment (OT/CNIB ILS)

– Counsel on importance of good and even lighting

Management of Field Loss

• Counsel patients on importance of uncluttered and consistent habitual environments

• Consider referral for orientation & mobility training

• Use of mobility cane?

IMPACT OF SYSTEMIC CONDITIONS ON

VISUAL FUNCTION

Diabetic Retinopathy

• What is it?• New blood vessel growth on the retina which causes bleeds and fluid build up

• Secondary to systemic diabetes that is not well controlled

• May still occur if long-term insulin-dependent even if well controlled

• May cause glaucoma

• Also associated with premature cataracts

Diabetic Retinopathy

https://www.google.com/url?sa=i&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwjHsqzYs-DeAhXGy4MKHS2CCLkQjRx6BAgBEAU&url=http%3A%2F%2Fwww.reachoutradio.org%2Fpost%2Fdiabetic-retinopathy-its-not-just-about-blood-sugar-levels&psig=AOvVaw2liGEqmAxGTWqK0WRLbz76&ust=1542715080322815

Diabetic Retinopathy

• Effects on vision• Decrease in vision

• decreased contrast sensitivity

• fluctuating refractive error (prescription)

• sudden loss of vision (if bleed into vitreous)

• may have trouble with night vision

• may experience double vision

• ***All risk factors for falls!

Hypertensive Retinopathy

• As a result of uncontrolled or untreated hypertension

• Impact on retinal circulation

• Causes reduction in vision in later stages, double vision

• May lead to others: Retinal Artery or Vein Occlusions

Wong TY, Mitchell M. Hypertensive retinopathy. N Engl J Med. 2004; 351:2310-2317

Wong TY, Mitchell M. The eye and hypertension. Lancet. 2007; 369(9559):425-435.

https://www.google.com/url?sa=i&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwjK0bKds-DeAhWBy4MKHflyAzQQjRx6BAgBEAU&url=https%3A%2F%2Fwww.gponline.com%2Fclinical-picture-hypertensive-retinopathy%2Fcv-blood-pressure%2Fhypertension%2Farticle%2F1363980&psig=AOvVaw0RFXyWJIlD9xnKmHSXC1gr&ust=1542714958181282

Arteritic Anterior Ischemic Optic Neuropathy (AAION)• As a result of temporal or giant cell arteritis

• Inflammation of the blood vessel leads to insufficient oxygen to optic nerve leading to damage

• A condition that affects predominantly those that are 65+

• Causes damage to one eye initially typically followed by the fellow eye within one to two weeks.

AAION

• Visual symptoms include:• Reduction in vision (typically initially noticed in upper or lower visual fields)

• May result in complete loss of vision if untreated

CVA

>400,000 Canadians living with disability as a result of stroke

Statistics Canada.Causes of Death, Canada, 2011.CANSIM data.Released January 28, 2014.

Visual Sequelae of Stroke

• Alignment/movement impairment – 68%

• Visual field impairment – 49%

• Low Vision – 26.5%

• Perceptual impairment – 20.5%

Rowe et al. A prospective profile of visual field loss following stroke: prevalence, type, rehabilitation, outcome. Biomed Research International. 2013: http://dx.doi.org/10.1155/2013/719096

Visual pathways….

http://www.floiminter.net/psychology/brain_and_behaviour/dorsal_ventral.png

Visual Versus Perceptual?

http://ih2.redbubble.net/image.14161792.3742/flat,550x550,075,f.jpg

Attentional/ Perceptual Changes

• Neglect

• Extinction

• Visual Midline Shift Syndrome

Neglect

• aka Unilateral Spatial Inattention

• Unawareness of one side of visual space• Personal

• Peripersonal

• Extrapersonal

Suchoff IB, Ciuffreda KJ. A primer for the optometric management of unilateral spatial inattention. Optometry. 2004:75(5): 305-318.

Extinction

• Different from neglect??

• Selective impairment in awareness/response to a stimulus when presented simultaneously on both sides

http://ichef.bbci.co.uk/naturelibrary/images/ic/credit/640x395/c/cr/cretaceous-tertiary_extinction_event/cretaceous-tertiary_extinction_event_1.jpg

Vossel S et al. Visual Extinction in relation to visuospatial neglect after right-hemispheric stroke: quantitative assessment and statistical lesion-symptom mapping. J Neurol Neurosurg Psychiatry. 2011:82: 862-868.

Visual Midline Shift Syndrome (VMSS)

• aka Abnormal Egocentric Localization (AEL)

• Deviated perception of visual midline• Poor eye/hand coordination

• Postural changes

• Diminished ability to navigate environment

Houston K E. Measuring visual midline shift syndrome & disorders of spatial localization: A literature review & report of a new clinical protocol. J Behav Optom. 2010:21(4): 87-93.

THANK YOULois Calder, O.D. Vision Institute of Canada, Toronto

visioninstitute@rogers.com

Tammy Labreche, BSc., O.D., F.A.A.O. School of Optometry and Vision Science, University of Waterloo

tammy.labreche@uwaterloo.ca

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THIS WEBINAR IS BEING RECORDED.THE SLIDE DECK AND RECORDING WILL BE

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Upcoming webinars

Wednesday, February 13th 2018

A Team Approach to Deprescribing and Preventing Medication Related Falls

Presenter: Pam Howell, Pharmacist, Bruyère Continuing Care

Vision, Aging, Falls, and Falls Prevention - Part III

Thursday, November 22, 2018

Dr. Lois CalderDr. Tammy Labreche

THIS WEBINAR IS BEING RECORDED.THE SLIDE DECK AND RECORDING WILL BE

EMAILED AFTER THE WEBINAR.

Webinar technology managed by:

Questions?

Type your questions into the chat box.

OR

Dial *7 on your telephone to unmute.

Dial *6 when you are finished speaking to re-mute.

THIS WEBINAR IS BEING RECORDED.THE SLIDE DECK AND RECORDING WILL BE

EMAILED AFTER THE WEBINAR.

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