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OT Pract. 2012 June 18; 17(11): 716.

Watching Their Steps:

Integrating Vision Intervention Into Daily Practice to Limit Fall Risk at Skilled Nursing
Facilities

Natalie E. Leland, PhD, OTR/L, BCG [assistant professor],

the Division of Occupational Science and Occupational Therapy at the Herman Ostrow School of
Dentistry & Davis School of Gerontology at the University of Southern California in Los Angeles

Jennifer Kaldenberg, MSA, OTR/L, SCLV, FAOTA [the director], and

occupational therapy services at the New England Eye Institute in Boston, Massachusetts, and
an adjunct assistant professor of vision rehabilitation at the New England College of Optometry in
Boston

Irene Lee [occupational therapy student]

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the Division of Occupational Science and Occupational Therapy at the University of Southern
California

Abstract
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Strategies that address decreased vision are an important part of multifactorial interventions to
prevent falls and facilitate safe participation in valued occupations.

The skilled nursing facility (SNF) is the dominant setting for older adults after acute care
hospitalization.1 However, 21% of patients admitted to a nursing home fall within the first
 Leland et al. Page 2

30 days of admission.2 These fall events are the result of a combination of intrinsic and
extrinsic risk factors, including decreased vision and environmental hazards.3 Visual
impairment, identified as part of a larger group of functional impairments, has been shown
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to approximately double the risk for falls.45 With 27% of nursing home residents having a
visual impairment,6 vision has been an important underlying risk factor for falls and related
injuries.

Because of the multifactorial nature of falls and the knowledge occupational therapy
practitioners have about the factors affecting occupational performance,7 occupational
therapy practitioners can play a pivotal role in addressing decreased vision and minimizing
fall risk among SNF patients. This article uses the case example of Esther to highlight
interventions that address decreased vision as one strategy within a multifactorial effort to
prevent falls and facilitate safe participation in occupations. Although this article does not
provide details on the interventions targeting Esther's other risk factors, it is essential to take
a holistic approach to address the multifactorial nature of falls when working with a
postacute care population in a SNF.

Esther's Occupational Profile

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Esther is a 94-year-old widowed female who retired from teaching 29 years ago. Until the
age of 90, Esther was a dedicated volunteer in the after school program at the local
community center. She was also an avid gardener and ardent traveler, exploring the world
with her sister. At age 91, Esther moved into an assisted living facility, where she was
known for her green thumb and had a reputation for maintaining an impeccably clean and
organized apartment. As the resident gardener, she cared for the five raised mobile garden
boxes that lined the corridor from the elevators to the community dinning room. She also
had a bay window in her apartment where her own potted plants were placed. She had been
independent in mobility with her four-wheeled walker, but in her apartment she would leave
the walker by the door and furniture walk. Esther had been independent in activities of
daily living, but she did require verbal reminders from facility staff to attend meals and
social activities and to see the facility nurse to take daily medications.

Esther was admitted to a SNF for postacute care after falling and fracturing her hip while
adjusting a rug in her apartment. She underwent surgical repair for the hip fracture and was
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hospitalized for 6 days before being transferred to the SNF. She had a history of dementia,
urinary tract infections, glaucoma, and poor balance.

Current Occupational Performance

The occupational therapist at the nursing home conducted the occupational therapy
evaluation with Esther. Sitting at the sink, Esther required minimum assistance with
grooming and hygiene and upper-body bathing and dressing. She had difficulty locating the
white towel, white toothbrush, and white hairbrush on the white sink. She required
maximum assistance with lower-body bathing and dressing. She was able to participate in
functional transfers with minimum assistance by using a two-wheeled rolling walker and
moderate verbal cues to maintain hip precautions. Her daughter, who was present during the
occupational therapy evaluation, reported that Esther had been wearing bifocals for the past

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 Leland et al. Page 3

15 years. Esther had difficulty reading her hip precautions, which were presented in 16-point
Times New Roman font. Further vision screening conducted during the occupational therapy
evaluation found that Esther was unable to detect peripheral obstacles (e.g., medicine cart,
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clean linen cart) within her walking path. Table 1 provides the fall and vision screening and
assessment tools used with Esther as part of the occupational therapy evaluation.

Esther and her family expressed their desire for Esther to return to her apartment in the
assisted living facility. To do so, Esther needed to be independent with toileting and
functional mobility in her apartment. Esther was adamant about wanting to be independent
with self-care again, but she did express a fear of falling in the shower. She also expressed a
desire to get back to her plants. Together with Esther and her daughter, the occupational
therapist developed a holistic plan of care and goals for occupational therapy.

Occupational Therapy Treatment Process

Esther's treatment plan focused on increasing her independence with her desired occupations
(e.g., self-care, gardening, functional mobility) in order to return to her assisted living
apartment. The plan of care identified the client factors and performance skills that were
limiting Esther's occupational engagement. The plan of care highlighted her vision
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limitations (e.g., limited peripheral visual field, decreased contrast sensitivity, difficulty with
low lighting situations) as an area of concern that would benefit from intervention. Without
intervention, Esther's vision limitations and fall risk would be a barrier to her safe
participation in desired occupations and affect her ability to achieve her long-term goal of
returning to assisted living.

Because increasing Esther's independence in desired occupations was her primary goal, the
occupational therapy sessions incorporated strategies to address her vision limitations and
fall risk (see Table 2 on pp. 910). Specifically, Esther's occupational therapy practitioner
incorporated visual skills training (scanning), compensatory strategies (organizational
strategies), environmental modifications (lighting, contrast, glare control), and staff and
family education into treatment (see Table 2 for details of Esther's intervention). Fall
prevention strategies were integrated into self-care retraining through behavior modification
(e.g., activity modification, positioning, safety education), self-efficacy training (e.g.,
shower transfer retraining), and environmental modifications (e.g., hazard removal, adaptive
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equipment training, object placement).

Upon discharge from skilled services, Esther returned to her assisted living facility
apartment. She had achieved independence with her functional mobility using a two-
wheeled walker and was integrating her vision and fall prevention strategies into her
occupational participation. Her family had painted her clay flowerpots to increase the
contrast between the pots and the soil in order to support Esther's continued role as the
resident gardener. Esther was able to independently shower with a shower seat and dress
herself, but she continued to report fear of falling in the shower. Esther reported being more
comfortable taking a shower if someone was in her apartment. She agreed to have a certified
nursing assistant in the apartment when she was going to have her showers; her family was
supportive of paying for this additional service. Esther's family also followed through with

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the recommendations from the home assessment. They replaced her cloth shower curtain
with a clear transparent curtain to increase illumination inside the shower. To provide
contrast to the white shower, the facility's maintenance department painted Esther's silver
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grab bars black and the family painted her white shower seat her favorite color, pink, using
outdoor furniture paint and at the recommendation of the occupational therapist. The
physician had ordered nursing and occupational therapy home health services to support
Esther's transition back to the assisted living facility and provide staff caregiver education to
support Esther in her desired occupations.

Conclusion
As is the case for all clients, addressing the context and environment is pivotal8 for the client
who is aging, particularly among frail older adults who have recently been hospitalized and
are in a new and unfamiliar environment. Esther's interventions incorporated modifications
to the context and environment in the SNF as well as in the assisted living facility (see Table
2 on pp. 910) to address her vision limitations and fall risk.

Her occupational therapy interventions also incorporated her other fall risk factors and
strategies to compensate for her vision limitations. Esther's case example highlights a few
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intervention strategies, including rearranging the bed to allow for wide, clutter-free
walkways; improving the contrast between flooring and furniture or grab bars and walls
(e.g., a high-contrast throw or pillow placed on the furniture, tape applied to the grab bar or
wall); limiting glare (e.g., using blinds or shades); and highlighting a task by positioning
lighting.9 The interventions for Esther are used only as examples to highlight approaches for
integrating fall prevention and vision into practice within a SNF.

The ultimate goal of occupational therapy is to facilitate participation in desired occupations.

Occupational therapy practitioners working in SNFs should utilize the initial evaluation to
identify all potential safety and risk factors, including fall risk and vision limitations, in
order to develop a comprehensive plan of care. Many older adults lack awareness of the
impact of their vision loss and fall risk on occupational performance. Additionally, because
of multiple health issues, lack of social support, and/or misconceptions regarding vision and
aging, older adults may not visit their eye care practitioner as often as needed or may equate
vision loss to normative aging. The occupational therapy practitioner may be the first to
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identify the change in visual function, fall risk, and the need for intervention. It is critical to
integrate evidence-based fall prevention and vision interventions into practice with the older
adult client in the SNF.

References
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of the American Geriatrics Society. 2007; 55:S327S334. PubMed. 10.1111/j.
1532-5415.2007.01339.x [PubMed: 17910554]

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 Leland et al. Page 5

4. Lord SR. Visual risk factors for falls in older people. Age and Ageing. 2006; 35(S2):4245.
[PubMed: 16364933]
5. Lord SR, Dayhew J, Howland A. Multifocal glasses impair edge-contrast sensitivity and depth
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perception and increase the risk of falls in older people. Journal of the American Geriatrics Society.
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6. Gabrel CS. Characteristics of elderly nursing home current residents and discharges: Data from the
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7. Peterson EW, Clemson L. Understanding the role of occupational therapy in fall prevention for
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62.6.625 [PubMed: 19024744]
9. Warren, M.; Barstow, E. Occupational therapy interventions for adults with low vision. Bethesda,
MD: AOTA Press; 2011.
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balance. Journal of Gerontology. 1990; 45:M192. [PubMed: 2229941]
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chronic disabilities. American Journal of Medicine. 1986; 80:429434. [PubMed: 3953620]

13. Feinbloom W. Introduction to the principles and practice of sub-normal vision correction. Journal
of the American Optometric Association. 1935; 6:318.
14. Ferris FL, Kassoff A, Bresnick GH, Bailey I. New visual acuity charts for clinical research.
American Journal of Ophthalmology. 1982; 94:9196. [PubMed: 7091289]
15. Hyvrinen L, Nsnen R, Laurinen P. New visual acuity test for preschool children. Acta
Ophthalmologica. 1980; 58:507511. [PubMed: 7211248]
16. Warren, M. Brain Injury Visual Assessment Battery for Adults. Lenexa, KS: Visabilities Rehab
Services; 1998.
17. Mansfield, JS.; Legge, GE.; Luebker, A.; Cunningham, K. MNRead Acuity Charts: Continuous-
text reading-acuity charts for normal and low vision. Long Island City, NY: Lighthouse Low
Vision Products; 1994.
18. Scheiman, M. Understanding and managing vision deficits: A guide for occupational therapists.
2nd. Upper Thorofare, NJ: Slack; 2002.
19. Dougherty BE, Flom RE, Bullimore MA. An evaluation of the MARS Letter Contrast Sensitivity
Test. Optometry and Vision Science. 2005; 82:970975. [PubMed: 16317373]
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21. Illuminating Engineering Society of North America. RP-28-98: Recommended practice for lighting
and the visual environment for senior living. New York: Author; 1998.

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 Leland et al.
Table 1
Vision and Fall Assessments
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Assessment of Screening Tools
Fall risk Functional Reach10
Time Up and Go (TUG)11
The presence of four or more fall
risk factors=75% fall risk12
Visual acuity: Distance: Feinbloom chart,13
ETDRS chart,14 LEA symbols,15
Distance visual
acuity Warren chart16
Near: Lighthouse card, the
Near visual acuity
Minnesota Low-Vision Reading
Test,17 continuous text card, use
functional task
Visual field: Peripheral: Confrontation Fields
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(CF)
Peripheral field
Central: Amsler grid9,18
Central visual field
Contrast sensitivity: Clinical: Mars Letter Contrast
Sensitivity Test,19 Pelli-Robson
Clinical assessment charts20
tools
Functional: Can the client identify a
Functional white plate on a white table?
assessment
Environmental assessment: Lighting: light meter (minimum
levels should be 300 lux for mobility
Lighting and 5001000 lux for detailed
Contrast tasks21
Glare Contrast: Surface changes clearly
identified? Hazards marked clearly?
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Optical aids (e.g., current What kind of glasses does she use?
glasses or magnifiers) Are they the correct glasses (e.g.,
distance versus reading)? For
bifocals, consider:
Proper fit?
Is the patient looking into
the bifocal segment when
ambulating?
Difficulty judging steps or
distances while using
bifocals?
Note: These are not all possible screening and assessment tools that can be used; this table provides examples of possible screening and assessment
tools that may be used to identify vision limitations and fall risk.
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Page 6
Esther's Screening Results
Score=4 (risk for falling)
Score=0; she was unable to complete the
TUG
Fall risk=4+ (i.e., hip fracture, urinary tract
infection, dementia, fall history, impaired
vision, bifocal wearer, decreased safety
awareness, and being in a new
environment)
Using Feinbloom and Lighthouse near acuity card:13
Distance visual acuity: (with current
glassesbest corrected vision) OD (right
eye): 20/40 and OS (left eye): 20/80
Near acuity: OD: 20/60 and OS: 20/100
(unable to read standard newsprint)
Tests were completed with good adjacent lighting.
CF: General constriction in both eyes (tunnel vision)
Amsler grid was intactno significant distortion or
field impairment in central vision was noted; if Esther
reported distortion or missing portions of the grid, this
could identify macular degeneration or progression of
the glaucoma
Contrast assessed during Esther's activities of daily
living tasks:
Esther struggled to identify clothing on her
colored bed spread.
Esther was unable to distinguish between
her hygiene items (e.g., white tooth brush)
and white sink in the nursing home.
She was able to identify her white
breakfast plate on the brown wooden table.
An environmental assessment was completed based on
Esther's needs in her room in the SNF and her assisted
living facility apartment (prior to discharge).
Esther's bifocal segment seemed to be placed high.
When ambulating with the wheeled walker, Esther was
looking into the bifocal segment. When her glasses
were removed to assess safety with the walker, Esther
said she saw the floor better and it didn't seem like it
was jumping up at her.
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Table 2
Fall and Vision Interventions: Assisting Esther
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Examples of Strategies to Address Fall Prevention and Vision Intervention Into

Esther's Plan of Care
Skilled Nursing Facility
(SNF) Environment and
Strategy Description General Interventions Approaches Self-Care Functional Mobility Home Environment

Fall prevention strategies Provide Teach Educate and train on safely Recommend
behavior walker using and placing the walker adaptive
modification safety for occupational participation equipment
(e.g., modify forself-care (e.g., gardening, self-care). (e.g., reacher,
the tasks (e.g., shower
client'sroutines safe bench, walker
and activities, approaches basket).
provide safety to enter
education). shower). Identify
optimal
Facilitate safe Modify placement of
engagement in positioning frequently
occupations to for used items for
promote components safe access
strength and of self-care (e.g., shower
balance. to items,
maximize gardening
Educate on safety. items,
environmental clothing).
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modification Discuss
and adaptive alternate Remove
equipment. shoe wear hazards from
options that walkways in
may limit SNF room
Esther's fall and home
risk but still environment.
meet her
needs for
style.
Identify
and modify
components
of self-care
that trigger
Esther's
fear of
falling.

Visual skills Teach systematic scanning
of environment to locate
potential hazards.
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Teach scanning to Instruct not to use bifocal Teach scanning to
identify position of segment of glasses during identify potential hazards.
shower chair, grab bar functional mobility.
placement.

Lighting Direct light Use clear Provide consistent lighting Provide

onto task. shower levels to prevent proper
curtain to misinterpretation of shadows as ambient
Place increase changes of surface or glare. lighting to
flashlights at lighting in support safe
bedside for shower. mobility.
nighttime use
and in pocket Have Position
for low- lighting gooseneck
lighting placed to lamp to
situations. highlight illuminate
activity. working
Manage glare space.
using window
shades or Face away
sheers, from glare
nonglare sources.
polish on
floors or

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 Leland et al. Page 8

Examples of Strategies to Address Fall Prevention and Vision Intervention Into

Esther's Plan of Care
Skilled Nursing Facility
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(SNF) Environment and

Strategy Description General Interventions Approaches Self-Care Functional Mobility Home Environment
tabletops, and Set up
shades to planting area
cover light- with adequate
bulbs. ambient and
task lighting.
Manage glare
using sheers
or blinds at
Esther's bay
window to
support
engagement
in Esther's
gardening.

Contrast To improve Use high-contrast tape Mark steps, Provide high-

contrast in the or paint for easy doorways, changes contrast
environment, identification between of surface, etc. to garden pots
use opposing background wall and highlight and watering
colors on the grab bar, shower seat, transitional areas. cans and
color wheel and shower stall. brightly
Consult with eye
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(black/white; colored
blue/yellow). care professional plants.
This will regarding filters to
allow the control glare and Mark table
individual to enhance contrast. corners to
locate and increase ease
distinguish an of mobility
object from its and safety of
background. placing plants
back on
Create tables.
visibility (e.g.,
white plate on
black
placemat, dark
blue towels in
bathroom with
light yellow
walls).
Improve
safety (e.g.,
dark furniture
against light
floor or wall,
warning tape
on stair edges
or cabinet
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corners).
Use filters to
heighten
contrast (e.g.,
yellow and
plum tend to
improve
contrast and
decrease the
effects of
glare).
Use
commercially
available
products (e.g.,
black felt-tip
pens, signature

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 Leland et al. Page 9

Examples of Strategies to Address Fall Prevention and Vision Intervention Into

Esther's Plan of Care
Skilled Nursing Facility
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(SNF) Environment and

Strategy Description General Interventions Approaches Self-Care Functional Mobility Home Environment
guides, writing
guides for
checks and
paper).

Magnification Use large- Install magnifying Use large-print items for Provide large-print
print products mirror in bathroom. reading information after the instructions for plants and
(e.g., occupational therapy session. calendar to track watering
telephones, schedules.
address books,
client
educational
materials).
Use simple
techniques
such as
marking items
with large-
print labels.
If the OD/MD
prescribes
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optical
devices,
ensure they
are used
appropriately
(e.g.,
ergonomics,
focal
distances) and
the
appropriate
environmental
modifications
are used (e.g.,
book stand,
lighting).

Sensory substitution Mark common Provide Consider

settings on liquid level sensory
appliances or indicators substitution
number pads for safely for watering:
(e.g., bump pouring hot Use sense of
dots or puff liquids. touch to
paint). By identify dry
using sensory Provide plants.
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substitution, talking
Esther will not scale. Provide
need to get memory aids
Mark soap, (recorded
closer to
shampoo, instructions)
objects to see
and for watering
them. This
conditioner schedules and
may decrease
to care
her risk of
distinguish instructions.
falls but may
between
also decrease
three Provide
her potential
bottles. tactile
for frustration
markings to
and giving up
identify plant
on
or
occupations
instructions
she previously
(e.g., one
completed.
rubber band
around a pot

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Examples of Strategies to Address Fall Prevention and Vision Intervention Into

Esther's Plan of Care
Skilled Nursing Facility
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(SNF) Environment and

Strategy Description General Interventions Approaches Self-Care Functional Mobility Home Environment
Distinguish means once-
between items per-week
(e.g., safety watering, two
pins, rubber rubber bands
bands). means twice
per week).
Use
commercially
available
products with
voice
activation
(e.g., alarm
clocks, scale),

Compensatory strategies Teach memory and Educate Esther on Create cleaning Teach
organizational skills (e.g., organizational schedule to organizational
have identified location strategies in bathroom eliminate clutter strategies
for placement of watering for easy identification. and keep walkways (e.g.,
can). clear. systematically
water once
Teach per week).
organizational and
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memory strategies Provide staff

to keep commonly and family
used items in a education to
fixed location, assist with
decreasing maintaining
frustration and risk the system.
of falls.
Use different
pots to
identify
plants with
different
needs.
Place plants
and gardening
equipment in
an area where
Esther is able
to navigate
safely and
easily.

The occupational therapy practitioner may be the first to identify the change in visual function, fall risk, and the need for intervention. It is critical
to integrate evidence-based fall prevention and vision interventions into practice with the older adult client in the SNF.
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