A systematic review of the experiences of older people with visual impairment of interventions aiming to prevent falls, with a particular focus on environmental and/or behaviour interventions.

PRIMARY REVIEWER/CONTACT Name: Prof Claire Ballinger Deputy Director, Joanna Briggs Collaborating Centre for Evidence- Based Care of Older People, Glasgow, Scotland Telephone: + 00 44 (0)141 331 8883 Email: [email protected] SECONDARY REVIEWERS Name: Fiona Neil Telephone: +00 44 (0)141 273 1448 Email: [email protected] Name: Dr Dawn Skelton Telephone: +00 44 (0)141 331 3391 Email: [email protected] Name: Prof Tracey Howe Telephone: +00 44 (0)141 273 1433 Email: [email protected] COMMENCEMENT DATE April 2009 EXPECTED COMPLETION DATE September 2009 BACKGROUND Falls are the leading cause of injury in people aged 75 years and over1. Falls in older people have been the subject of several systematic reviews including a Cochrane review 2 that has recently been divided into community and institutional dwelling - older people 3. A recent systematic review has also focused on the effectiveness of environmental interventions alone in preventing falls amongst older people 4. In addition, a systematic review of both qualitative and quantitative studies and reviews was undertaken to explore older people's views and experiences of falls prevention 5. However, to our knowledge, there have been no specific reviews which have focused on older people with visual impairment in terms of either the effectiveness of environmental and/or behavioural interventions to prevent falls, or exploring their views and experiences of such interventions. This is in spite of evidence to suggest that the rate of falls in older people with visual impairment is 1.7 times higher, and hip fractures are 1.3-1.9 times higher than within the general population 6. It seems likely that the mechanisms of fall prevention within this group will be different, particularly with respect to environmental/behavioural components and we consequently also believe that the experience of such interventions will also differ. Recent work has suggested that in order for older people to engage with activities to prevent falls, the benefits of interventions fitting with a positive self identify should be promoted; a variety of forms of social engagement are used; the intervention is designed to meet individual needs and preferences; and self management is promoted 7. Whilst we have evidence to support these recommendations within the context of the general older population 8, 9, the extent to which these recommendations are transferable to older people with visual impairment is unclear. This current review therefore seeks to extend the existing evidence base for engaging older people in falls prevention activities, through exploring the feasibility, appropriateness and meaningfulness of such interventions older people with visual impairment. The team is ideally placed to carry out this work, having experience and expertise in falls prevention research (Skelton, Ballinger), falls prevention services (Neil, Skelton), systematic reviewing (Howe, Ballinger, Neil, Skelton) and qualitative research (Ballinger). We have been funded by the Thomas Pocklington Trust and Help the Aged to carry out a systematic review of environmental and behavioural interventions to prevent falls amongst older people, and this supplementary review will provide additional information to support falls prevention with this group. OBJECTIVES This review seeks to explore the experiences of older people with visual impairment who have participated in falls prevention activities, with a view to investigating how appropriate and meaningful they are. CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW Types of studies The review will consider any qualitative research which describes, explores or analyses the experiences of older people with visual impairment, carers, family, and health and social care providers who have either received or delivered falls prevention programmes. The study types to be considered within the review will include (but are not limited to) grounded theory, phenomenology, IPA, ethnography, (auto)biographical methods, action research, participatory research, conversation analysis, discourse analysis, case study and mixed methods (where at least one of the methods used is qualitative). If we are unable to locate qualitative research papers for inclusion in the review, we will consider conference papers and proceedings and where appropriate, information included in voluntary organisation, management and government reports. Types of participants The review will focus on the experiences of older people (i.e. aged 65 or over) having visual impairment, including (but not limited to) low visual acuity, glaucoma, poor contrast sensitivity, poor depth perception and reduced visual field. It will also include research reporting the perspectives of others such as carers, family members and health and social care providers about delivering falls prevention interventions to this group of older people. Phenomenon of interest This review will examine the experience of falls prevention activities from the perspective of older people with visual impairment, with respect to the appropriateness and meaningfulness of those activities. We suspect that environmental and/or behavioural interventions will have a particular resonance with this group of older people, but are also interested in exploring the experience of falls prevention more broadly to see if our expectations are supported by the evidence. In addition to environmental and behavioural falls prevention activities, this review will therefore also consider: exercise interventions pharmacological review comprehensive geriatric assessment review of footwear Anticipated outcomes The anticipated outcome will be a synthesis of themes and categories deriving from data generated through engagement with older service users with visual impairment, carers, family and health and social care providers. This will therefore enable comparison with the views, perspectives and experiences of older people who fall more generally, and thus determine whether recommendations to enhance uptake and adherence of falls prevention activities 7 can be generalised to this group. Search strategy The search strategy will use a three step process. Step one will be the identification of MeSH terms and keywords within the key databases. An initial limited search of Medline and CINAHL will be carried out followed by an analysis of the text words used in the title and abstract, and index terms to describe the paper. Systematic reviews including elements in common with this proposed review 2, 3, 4, 5 will also be examined, and the search terms of these reviews extracted, reviewed and compared. Help with developing the search strategy will also be sought from an experienced librarian, with the aim of developing a comprehensive search strategy, specific to each of the databases searched. The second step will be the execution of the search strategy within each of the databases identified below. The review will be limited to research published in the English language and will focus on literature from 1990 onwards. We plan to use Endnote, a management software system, within the review. Step three will aim to capture additional studies which have not been included in the databases. In addition to research evidence from peer reviewed journals included within databases, we also aim to identify evidence from non-peer reviewed journals, conference proceedings, dissertations, reports, publications from voluntary organisations and websites. Grey literature will be included where relevant. The network of Joanna Briggs Collaborating Centres and the Joanna Briggs Institute will be interrogated to identify other literature which it is not possible to identify through other routes (e.g. research studies in progress). Additional strategies will include: Contact with key individuals within the field (e.g. those with research roles within voluntary and statutory organisations whose remit includes older people with visual impairment) Contact with Thomas Pocklington Trust, Royal National Institute for the Blind and Visibility, and exploration of web sites and research collections Analysis of relevant UK and Scottish government websites Contact with relevant professional bodies (e.g. RCN, COT, CSP) Exploration of the Kings Fund library and database Liaison with University departments with a record of research within this field Investigation of citations within research papers Initial key words to be used in the first step of the search strategy include: accidental fall, old, older, elder, senior, aged vision, visual disorders, eye disease, visual acuity, macular degeneration, glaucoma, cataract, ophthalmic experience, subjective, perception, meaning qualitative, qualitative findings, qualitative study, qualitative research, focus group, interview, participatory research, case study, mixed methods Databases, search engines and journal aggregators to be explored include: CINAHL Pubmed/Medline Embase AMED Cochrane Library PsychINFO ASSIA Science Direct ISI Web of Knowledge Mednar Conference Proceedings METHODS OF REVIEW Selection of papers Where possible, the abstracts of relevant papers will be reviewed in pairs according to agreed, prespecified criteria to determine if they should be included in the review. Any areas of disagreement will be noted, and subject to review by a third contributor. Reasons for exclusion will also be noted. Critical appraisal Full text copies of papers included in the review will be obtained, and independently reviewed in pairs using the Joanna Briggs QARI (Qualitative Assessment and Review Instrument) Appendix I). The prespecified items in QARI will be objectively assessed using additional criteria identified and agreed by the review team. Areas of disagreement will be resolved through involvement of a third, independent reviewer. Data extraction and synthesis Data will be extracted from included papers using the QARI system. (Appendix II) Meta-synthesis will be completed, also using the QARI tool. This involves a synthesis of the themes and categories reported within relevant publications (reaching an agreed quality level as determined by the two reviewers), together with supporting data. This synthesis will be completed separately both for types of interventions (e.g. exercise, environmental, pharmacological etc) and for data contributions from different stakeholders (i.e. older service users, carers, family, health and social care providers). If appropriate, the findings will be subject to a metasynthesis which will result in a single set of findings which can inform health and social care provision in the area of falls prevention with older people with visual impairment. Conflicts of interests N/A Acknowledgement Following this submission to the Joanna Briggs Institute, our team will also be submitting a systematic review protocol to the Cochrane Eyes and Vision group, to explore the effectiveness of environmental and behavioural interventions in improving mobility and preventing falls with older people with visual impairment. We will also include a request for joint recognition of this review with the Joanna Briggs Institute.