Why this question is important
Low vision that cannot be corrected by standard glasses or any medical treatment is called visual impairment. It is common for people to become visually impaired in later life. Older people with visual impairment tend to avoid physical activity; for example, they might walk fewer steps in a day than people who are not visually impaired. They are also more likely to experience anxiety or depression, or to sustain an injury through falling.
Changes to a person’s environment or behavior can be made to help older, visually impaired people move safely around - inside and outside - their homes. These include adaptations to the home to enable safe movement around it, or improvement to the person’s balance through exercise.
To find out if strategies designed to help people move around safely are effective for older people with visual impairment, a team of Cochrane researchers reviewed the evidence from research studies. Specifically, we wanted to know if these strategies:
• increase physical activity;
• reduce risk of falling;
• decrease fear of falling;
• increase quality of life.
How we identified and assessed the evidence
First, we searched for all relevant studies in the medical literature. We then compared the results, and summarized the evidence from all the studies. Finally, we assessed how certain the evidence was. We considered factors such as the way studies were conducted, study sizes, and consistency of findings across studies. Based on our assessments, we categorized the evidence as being of very low-, low-, moderate- or high-certainty.
What we found
We found six studies in a total of 686 older people with visual impairment who were followed for between two and 12 months. People who took part in the studies were aged 80 years on average, and they lived either at home or in a residential setting.
Five studies compared changes to the home made by occupational therapists versus home visits from research staff or volunteers. The evidence from these studies suggests that six months after they were made, changes to the home may make little to no difference to physical activity, fear of falling or quality of life (low-certainty evidence). Changes to the home may make little to no difference to people’s risk of falling six months after they were made, but may slightly reduce risk of falling after one year (low-certainty evidence).
Six studies compared exercise versus usual activities or home visits. The evidence from these studies suggests that exercise may make little to no difference to physical activity, risk of falling, fear of falling or quality of life after six months (low-certainty evidence).
What this means
Current evidence suggests that strategies designed to help people move around safely may not increase physical activity, reduce fear of falling or improve the quality of life of older people with visual impairment. Changes to a home to improve how safe it is to move around in it may slightly reduce risk of falling after one year, but not after six months.
The certainty of the evidence is low. Further research is likely to change the findings of this review. Future studies that investigate which strategies are acceptable to people and why, and that measure changes in physical activity and falls using robust research methods, will help to reduce uncertainty in this field.
How-up-to date is this review?
The evidence in this Cochrane Review is current to 4 February 2020.
There is no evidence of effect for most of the environmental or behavioral interventions studied for reducing physical activity limitation and preventing falls in visually impaired older people. The certainty of evidence is generally low due to poor methodological quality and heterogeneous outcome measurements.
Researchers should form a consensus to adopt standard ways of measuring physical activity and falls reliably in older people with visual impairments. Fall prevention trials should plan to use objectively measured or self-reported physical activity as outcome measures of reduced activity limitation. Future research should evaluate the acceptability and applicability of interventions, and use validated questionnaires to assess the adherence to rehabilitative strategies and performance during activities of daily living.
Impairment of vision is associated with a decrease in activities of daily living. Avoidance of physical activity in older adults with visual impairment can lead to functional decline and is an important risk factor for falls. The rate of falls and fractures is higher in older people with visual impairment than in age-matched visually normal older people. Possible interventions to reduce activity restriction and prevent falls include environmental and behavioral interventions.
We aimed to assess the effectiveness and safety of environmental and behavioral interventions in reducing physical activity limitation, preventing falls and improving quality of life amongst visually impaired older people.
We searched CENTRAL (including the Cochrane Eyes and Vision Trials Register) (Issue 2, 2020), Ovid MEDLINE, Embase and eight other databases to 4 February 2020, with no language restrictions.
Eligible studies were randomized controlled trials (RCTs) and quasi-randomized controlled trials (Q-RCTs) that compared environmental interventions, behavioral interventions or both, versus control (usual care or no intervention); or that compared different types of environmental or behavioral interventions. Eligible study populations were older people (aged 60 and over) with irreversible visual impairment, living in their own homes or in residential settings. To be eligible for inclusion, studies must have included a measure of physical activity or falls, the two primary outcomes of interest. Secondary outcomes included fear of falling, and quality of life.
We used standard Cochrane methods. We assessed the certainty of the evidence using the GRADE approach.
We included six RCTs (686 participants) conducted in five countries (Australia, Hungary, New Zealand, UK, US) with follow-up periods ranging from two to 12 months. Participants in these trials included older adults (mean age 80 years) and were mostly female (69%), with visual impairments of varying severity and underlying causes. Participants mostly lived in their homes and were physically independent. We classified all trials as having high risk of bias for masking of participants, and three trials as having high or unclear risk of bias for all other domains. The included trials evaluated various intervention strategies (e.g. an exercise program versus home safety modifications). Heterogeneity of study characteristics, including interventions and outcomes, (e.g. different fall measures), precluded any meta-analysis.
Two trials compared the home safety modification by occupational therapists versus social/home visits. One trial (28 participants) reported physical activity at six months and showed no evidence of a difference in mean estimates between groups (step counts: mean difference (MD) = 321, 95% confidence interval (CI) -1981 to 2623; average walking time (minutes): MD 1.70, 95% CI -24.03 to 27.43; telephone questionnaire for self-reported physical activity: MD -3.68 scores, 95% CI -20.6 to 13.24; low-certainty of evidence for each outcome). Two trials reported the proportion of participants who fell at six months (risk ratio (RR) 0.76, 95% CI 0.38 to 1.51; 28 participants) and 12 months (RR 0.59, 95% CI 0.43 to 0.80, 196 participants) with low-certainty of evidence for each outcome. One trial (28 participants) reported fear of falling at six months, using the Short Falls Efficacy Scale-International, and found no evidence of a difference in mean estimates between groups (MD 2.55 scores, 95% CI -0.51 to 5.61; low-certainty of evidence). This trial also reported quality of life at six months using 12-Item Short Form Health Survey, and showed no evidence of a difference in mean estimates between groups (MD -3.14 scores, 95% CI -10.86 to 4.58; low-certainty of evidence).
Five trials compared a behavioral intervention (exercise) versus usual activity or social/home visits. One trial (59 participants) assessed self-reported physical activity at six months and showed no evidence of a difference between groups (MD 9.10 scores, 95% CI -13.85 to 32.5; low-certainty of evidence). Three trials investigated different fall measures at six or 12 months, and found no evidence of a difference in effect estimates (RRs for proportion of fallers ranged from 0.54 (95% CI 0.29 to 1.01; 41 participants); to 0.93 (95% CI 0.61 to 1.39; 120 participants); low-certainty of evidence for each outcome). Three trials assessed the fear of falling using Short Falls Efficacy Scale-International or the Illinois Fear of Falling Measure from two to 12 months, and found no evidence of a difference in mean estimates between groups (the estimates ranged from -0.88 score (95% CI -2.72 to 0.96, 114 participants) to 1.00 score (95% CI -0.13 to 2.13; 59 participants); low-certainty of evidence). One trial (59 participants) assessed the European Quality of Life scale at six months (MD -0.15 score, 95% CI -0.29 to -0.01), and found no evidence of a clinical difference between groups (low-certainty of evidence).