Rate of falls, fear of falling, and avoidance of activities at-risk for falls in older adults with glaucoma

Abstract

Purpose:

To determine the relationship between glaucoma severity and rate of falls, fear of falling, and avoidance of activities at-risk for falls.

Design:

Cross-sectional study.

Methods:

Glaucoma patients (n=138), ages 55–90 years, with mild (n=61), moderate (n=54), and advanced (n=23) glaucoma in the better-eye based on the Glaucoma Staging System, and age-matched controls (n=50) were recruited from the Eye Clinics at Washington University, St. Louis, MO. Participants completed questionnaires regarding falls, fear of falling, and avoidance of activities at-risk for falls.

Results:

Of the glaucoma participants, 36% reported at least one fall in the prior 12 months compared to 20% of controls (adjusted odds ratio [OR], 2.7; 95% CI, 1.18–6.17; p=0.018). Compared to controls, the mild glaucoma group trended towards a higher fall risk (adjusted OR, 2.43; 95% CI, 0.97–6.08; p=0.059) and the advanced group had the highest fall risk (adjusted OR, 7.97; 95% CI, 2.44–26.07; p=0.001). A greater risk of a high fear of falling and high avoidance of at-risk activities occurred at the moderate stage of glaucoma compared to controls (adjusted OR, 4.66; 95% CI, 1.24–17.49; p=0.023 and adjusted OR, 4.49; 95% CI, 1.34–15.05; p=0.015, respectively).

Conclusions and Relevance:

Patient education, interventions, and appropriate referrals to minimize falls should be considered in older adults with early glaucoma and continue with advancing disease. Decreasing a patient’s fall-risk may decrease their fear of falling and avoidance of at-risk activities. Reducing falls, fear of falling, and avoidance of at-risk activities may lower morbidity and mortality and improve emotional and social well-being of glaucoma patients.

Falls Paper Table of contents

This study highlights the relationship between falls, fear of falling, and avoidance of activities in older adults with and without glaucoma. Mild glaucoma patients may have a higher risk of falls than individuals without glaucoma. Moderate and advanced glaucoma patients have a higher fear of falling and avoidance of at-risk activities. Interventions to decrease falls and improve emotional and social well-being should be considered in glaucoma patients at-risk for falls starting early in the disease.

Introduction:

Falls in the older adult population have a significant public health impact on morbidity and mortality, as well as individual and societal cost ¹. Patients with glaucoma have a higher risk of falling ² and being injured from a fall compared to individuals without glaucoma. Moreover, in a large epidemiologic study, glaucoma patients had the greatest risk of a fall compared to patients with other eye diseases including diabetic retinopathy and age-related maculopathy ². While increased visual field loss is a risk factor for falls ³, the stage of glaucoma at which this risk occurs is not clear. This information is critical in order for clinicians to identify and educate patients at-risk for falls and recommend interventions aimed to reduce the risk of having a fall.

An individual’s fear of falling and avoidance of activities that increase the risk of falling have a significant impact on their overall well-being. Fear of falling is associated with decreased physical and social activity, independence, quality of life, and an increased risk of depression ³. Older adults with self-reported visual impairment have a high prevalence of falls, fear of falling, and activity limitation due to fear of falling ⁴. Increasing visual field loss in glaucoma patients has been associated with a fear of falling and avoidance of areas at high-risk for falls ^3,5. To our knowledge, there have been no prior studies evaluating the rate of falls, fear of falling, and avoidance of activities at-risk for falls in the same sample of glaucoma patients. Understanding the relationships between these three factors can be instrumental in improving the safety and quality of life of patients with glaucoma.

This report uses data from a larger pilot study of a well-characterized sample of patients with mild, moderate, advanced glaucoma and age-matched controls ⁶. The purpose of this report is to determine the stage of glaucoma at which patients have an increased rate of falls, a high fear of falling, and a high avoidance of activities that increase their risk of falls compared to controls. In addition, this report analyzes the relationship between glaucoma severity and these three fall-related factors.

Methods:

Data for this analysis was obtained from a pilot study of visual function and quality of life of glaucoma patients, which has been previously described⁶. The study protocol was in accordance with the Declaration of Helsinki and approved by the Human Research Protection Office at Washington University School of Medicine St. Louis, MO. All study participants signed an informed consent prior to study participation.

Patients ages 55–90 with a clinical diagnosis of glaucoma, as well as age-matched controls, were consecutively recruited from their regularly scheduled eye clinic visit at Washington University School of Medicine between December 15, 2005 and July 7, 2009. A clinical diagnosis of glaucoma was based on glaucomatous optic nerve cupping and reproducible visual field defects in one or both eyes. Normal controls had an absence of ocular disease affecting their vision. Patients were excluded if they had neovascular, uveitic, or acute angle closure glaucoma, nonglaucomatous ocular disease, visually significant cataracts, > six diopters of refractive error, current use of miotic glaucoma medications, incisional or laser eye surgery within three months of enrollment, moderate or severe impaired cognition (Short Blessed Test score > 10), self-reported physical disability limiting function (e.g. stroke), unreliable visual field tests, resided in a nursing home, or if English was not their primary language.

Eligible glaucoma participants were categorized based on monocular visual field testing obtained within six months of the study using a Humphrey Visual Field (HVF) Analyzer II (Carl Zeiss Meditec, Dublin, CA, USA) equipped with the Swedish Interactive Thresholding Algorithm (SITA). Each eye was classified into a glaucoma stage (0–5) using the Glaucoma Staging System ⁷ and further classified as mild (stages 0–1), moderate (stages 2–3), or advanced (stages 4–5) glaucoma. Glaucoma stage of the better-seeing eye (i.e. less severe glaucoma) was used for this analysis based on prior reports associating the better-seeing eye with visual disability ^8,9.

Two research coordinators and nineteen graduate students in the Program in Occupational Therapy at Washington University, St. Louis, MO conducted a clinic and home visit for the pilot study. Inter-grader reliability between examiners for vision testing was high (intraclass correlation coefficient range 91–94%) ⁶. All examiners were masked to the participant’s diagnosis and used a scripted interview. The vision measures and questionnaires regarding falls, fear of falling, and avoidance of activities at-risk for falls used in this report were conducted in the clinic environment and on the same day. Demographic information including age, gender, race, marital status, education and co-morbidities were recorded.

Falls Questionnaire:

One hundred percent of participants completed 100% of questions in the Falls Questionnaire and the Fear of Falling Questionnaire (eAppendix1). Fall rate was assessed by verbally asking participants “During the past 12 months, have you fallen and landed on the floor or ground, or fallen and hit an object like a table or stair? If so, how many times have you fallen in the past 12 months?” Participants were also asked, “How fearful are you of falling?” Responses included: not at all, a little, moderate, or very fearful. For purposes of this report, responses of “moderate” or “very” fearful were categorized as a high fear of falling.

Activity Avoidance Questionnaire:

Ninety-four percent of participants completed 100% of questions in the Activity Avoidance Questionnaire (eAppendix1). The Activity Avoidance Questionnaire (unpublished) is a 35 item self-report questionnaire that assesses the participant’s level of worry and avoidance of specific daily activities due to their eyesight. Level of worry and avoidance of each activity is measured on a 5-point Likert scale ranging from never, a little, some, quite a lot, or extremely/always. Fifteen of the thirty-five activities were identified as activities that may potentially increase an individual’s risk for falls and are used in this analysis. Examples of these “at-risk” activities include getting in/out of a bathtub, walking on uneven ground, walking down dimly-lit stairs, and getting on/off a bus. Responses of “quite a lot” or “always” were categorized as a high avoidance.

Vision Assessments:

Vision assessments used in this analysis were administered in the clinic with the patient’s habitual correction. Binocular distance visual acuity was measured using non-illuminated ETDRS charts (Precision Vision, Catalog No. 2110) ¹⁰ at 3.2 meters testing distance and 1.6 meters distance for two participants who were unable to view any letters at 3.2 meters. Binocular near visual acuity was measured using the Sloan Near Visual Acuity card (Precision Vision, Catalog No. C170) at the participant’s preferred reading distance. Distance and near visual acuity were scored as the number of letters correctly identified ¹¹. Binocular contrast sensitivity (CS) was measured using the Pelli-Robson contrast sensitivity chart (Clement Clarke International, Reference No. 7002250) at 1 meter ¹². Binocular CS with glare testing was measured using bilateral Brightness Acuity Test (BAT) (Mentor, Norwell, MA) in conjunction with a Pelli-Robson chart of a different version from that used for CS testing. Measurements obtained using the BAT on the medium setting were analyzed for this report. The number of triplets correctly identified for both the CS and CS with glare testing was converted to log₁₀ contrast for data analysis. Monocular visual field testing was obtained for all participants using the HVF Analyzer II with the SITA standard 24–2. Visual field testing in the eye with the higher (i.e., better) mean deviation is reported in this analysis. Binocular visual field testing using the Esterman test was obtained and recorded using the Esterman Disability Score (range 0–100).

Other clinical assessments:

Self-reported questionnaires were administered by an examiner using large font-size cue cards with response options. Questionnaires pertinent to this report are explained in detail below.

Medical Index:

A modified version of the Duke Medical Index was used to identify co-morbidities potentially affecting daily function and quality of life ¹³. The medical index includes arthritis, asthma, emphysema/bronchitis, high/low blood pressure, cardiac disease, circulatory disease, diabetes, anemia, stroke, neuromuscular disease, back pain, and cancer.

Hollingshead Index of Social Position:

Education and occupation levels were coded using the scales from the Hollingshead Index of Social Position ¹⁴. Education level of the participant was classified on a scale of one (graduate professional training) to seven (less than seven years of school). For this analysis, patients with education levels one through three were subclassified as “some college or more”. The occupation level of the head of the household was classified on a scale of one (e.g. major professional) to seven (e.g. unskilled worker) with levels one through three sub-classified as “major or minor professionals”.

Short Blessed Test:

The Short Blessed Test is a reliable and valid tool used to screen for dementia in community-dwelling and long-term care populations ^15,16. Scores range from zero to 28 with scores > 10 suggestive of cognitive impairment ¹⁶.

All data was entered in a double-data entry fashion with discrepancies manually checked and re-entered.

Data analysis:

Descriptive statistics are reported for demographic data, rate of falls, fear of falling, and avoidance of activities at-risk for falls. For this report, rate of falls refers to proportion of participants who self-report having at least one fall in the prior 12 months. Comparisons between the control and glaucoma groups were made using Kruskal-Wallis tests for continuous outcomes and chi-square tests for categorical outcomes. Odds ratios and univariate, unadjusted logistic regression models were used to describe the relationship between a diagnosis of glaucoma and fall rate, high fear of falling, and high avoidance of activities at-risk for falls compared to controls. An adjusted, logistic regression was also calculated adjusting for age, gender, race, number of systemic co-morbidities and medications. Comparisons of proportions within diagnostic sub-groups were done using the Fisher’s exact test. All data analyses were performed using SAS version 9.3; SAS Inc, Cary, North Carolina.

Results:

There were 356 eligible patients, of which 190 participated in the pilot study ⁶. Of the 190 participants,188 completed the Falls Questionnaire. This included 50 controls and 138 patients with glaucoma (61 mild, 54 moderate, and 23 advanced glaucoma patients). Table 1 describes the baseline characteristics of these 188 participants. There were more African Americans (39.9% vs. 24.0%, p=0.04) and fewer major or minor professionals (53.7% vs. 70.8%, p=0.04) in the glaucoma group than control group. The glaucoma group scored worse than controls for all vision measures including distance (p=0.006) and near visual acuity (p=0.01), contrast sensitivity (p=0.0001), contrast sensitivity with glare testing (p=0.0001), visual field mean deviation (p=0.001), and Esterman disability score (p=0.0001). African Americans had a significantly higher number of co-morbidities than Caucasians (p=0.001). There was no significant difference in pseudophakia status between the glaucoma and control groups (Table 1) or between the control and mild glaucoma groups (40% vs. 36%, p=0.6707). There was a difference in pseudophakia status between the mild and moderate glaucoma groups (36% vs. 54% respectively, p=0.0574) and the moderate and severe glaucoma groups (54% vs. 78% respectively, p=0.0431). The control group was less likely to live alone compared to the glaucoma group (16.3% vs. 28.3%, p=0.10). In addition, glaucoma patients were more likely to report staying at home due to their vision compared to controls (12.3% vs 0%, p=0.009)

Table 1:

Baseline Characteristics

Demographics	Controls (n=50)	Glaucoma (n=138)	P-value
Age, mean years (SD)	70.9 (8.1)	72.7 (7.8)	0.20
Women, %	60.0	57.2	0.74
African American, %	24.0	39.9	0.04
Married, %	60.0	48.6	0.17
Education (partial college or more), %	70.0	67.4	0.73
Major/Minor Professional, %	70.8	53.7	0.04
Lives alone, %	16.3	28.3	0.10
Frequently stays home due to vision, %	0.0	12.3	0.009
Medical
Number of co-morbidities, mean (SD)	2.5 (1.6)	2.5 (1.6)	0.98
Total non-glaucoma medications, mean (SD)	3.2 (2.0)	3.3 (1.9)	0.83
Vision
ETDRSa Binocular Distance Visual Acuity, mean (SD)	58.8 (8.1)	53.4 (13.0)	0.006
Sloan Binocular Near Visual Acuity, mean (SD)	66.1 (9.5)	58.7 (16.1)	0.01
Binocular Contrast Sensitivity, logMAR (SD)	1.78 (0.2)	1.51 (0.4)	0.0001
Binocular Glare, Cd/m2 (SD)	12.2 (1.4)	10.1 (2.8)	0.0001
Visual Field Mean Deviation (better eye), mean (SD)	−2.0 (2.4)	−7.4 (8.2)	0.001
Esterman Disability Score, mean (SD)	94.9 (8.3)	82.4 (20.9)	0.0001
Pseudophakia in eye with better mean deviation (%)	40	50	0.2250
Cognition
Short Blessed Test, mean (SD)	2.7 (4.1)	3.2 (4.0)	0.15

^aEarly Treatment Diabetic Retinopathy Study

Of the 138 glaucoma participants, 50 (36%) reported falling at least once in the prior 12 months compared to 10 of 50 (20%) controls (p=0.013) (Figure 1). The proportion of participants having a fall in each glaucoma subgroup was 20 of 61 (33%) mild, 16 of 54 (30%) moderate, and 14 of 23 (61%) advanced glaucoma participants (Figure 2). Participants with glaucoma had a 2.3x greater risk of having a fall in the prior 12 months than controls (unadjusted OR, 2.27; 95% CI, 1.05–4.93; p=0.038) and a 2.7x greater risk after adjusting for age, gender, race, number of systemic co-morbidities and number of systemic medications (adjusted OR, 2.70; 95% CI, 1.18–6.17; p=0.018) (Table 2). Compared to controls, a significant increase in falls occurred at the advanced glaucoma stage (unadjusted OR, 6.22; 95% CI, 2.10–18.45; p=0.001) (Table 3). After adjusting for the aforementioned factors, there was a trend towards a higher risk of falls compared to controls for the mild glaucoma group (adjusted OR, 2.43; 95% CI, 0.97–6.08; p=0.059) and a significantly higher risk for the advanced glaucoma group (adjusted OR, 7.97; 95% CI, 2.44–26.07; p=0.001).

Figure 1:

Percent of participants with 95% confidence intervals self-reporting ≥ 1 fall in the prior 12 months, high fear of falling, and high avoidance of at least one activity at-risk for falls in the control and glaucoma groups.

Figure 2:

Percent of participants with 95% confidence intervals self-reporting ≥ 1 fall in the prior 12 months, high fear of falling, and high avoidance of at least one activity at-risk for falls in the control group and mild, moderate, and advanced glaucoma subgroups.

Table 2:

Odds ratios for rate of falls, high fear of falling, and high avoidance of activities at-risk for falls between controls and glaucoma participants.

	Unadjusted OR (95% CI)	P-value	Adjusteda OR (95% CI)	P-value
Controls vs Glaucoma
Rate of falls	2.27 (1.05, 4.93)	0.0379	2.70 (1.18, 6.17)	0.0184
High fear of falling	2.61 (0.95, 7.14)	0.0621	3.64 (1.08, 12.31)	0.0377
High avoidance of activities	2.97 (1.24, 7.13)	0.0146	4.25 (1.43, 12.62)	0.0092

CI: Confidence Interval

^aAdjusted for age, gender, race, and number of systemic co-morbidities and medications

Table 3:

Odds ratios for rate of falls, high fear of falling, and high avoidance of activities at-risk for falls by glaucoma severity

	Unadjusted OR (95% CI)	P-value	Adjusteda OR (95% CI)	P-value
Rate of falls
Control vs Mild	1.95 (0.81 – 4.68)	0.134	2.43 (0.97 – 6.08)	0.059
Control vs Moderate	1.68 (0.68 – 4.17)	0.260	2.05 (0.78 – 5.35)	0.144
Control vs Advanced	6.22 (2.10 – 18.45)	0.001	7.97 (2.44 – 26.07)	0.001
High fear of falling
Control vs Mild	1.17 (0.35 – 3.93)	0.804	1.87 (0.46 – 7.57)	0.381
Control vs Moderate	3.46 (1.15 – 10.39)	0.027	4.66 (1.24 – 17.49)	0.023
Control vs Advanced	5.79 (1.66 – 20.13)	0.006	8.12 (1.79 – 36.84)	0.007
High avoidance of activities
Control vs Mild	1.35 (0.48 – 3.79)	0.567	2.18 (0.63 – 7.52)	0.217
Control vs Moderate	3.33 (1.26 – 8.84)	0.015	4.49 (1.34 – 15.05)	0.015
Control vs Advanced	11.52 (3.57 – 37.19)	0.0001	19.35 (4.46 – 84.07)	0.0006

CI: Confidence Interval

^aAdjusted for age, gender, race, and number of systemic co-morbidities and medications

A high fear of falling was reported by 31 of 138 (22.5%) glaucoma participants compared to 5 of 50 (10%) controls (adjusted p=0.038) (Figure 1). The proportion of participants with a high fear of falling increased with increasing glaucoma severity: 7 of 61 (11.5%) mild, 15 of 54 (27.8%) moderate, and 9 of 23 (39.1%) advanced glaucoma participants (Figure 2). Glaucoma participants had a 2.6x greater risk of reporting a high fear of falling compared to controls (unadjusted OR, 2.61; 95% CI, 0.95–7.14; p=0.062) and a 3.6x greater risk after adjusting for aforementioned factors (adjusted OR, 3.64; 95% CI, 1.08–12.31; p=0.038) (Table 2). There was a greater risk of participants with moderate glaucoma reporting a high fear of falling than controls for both the unadjusted (OR, 3.46; 95% CI, 1.15–10.39; p=0.027) and adjusted analyses (OR, 4.66; 95% CI, 1.24–17.49; p=0.023) (Table 3). Advanced glaucoma participants had the greatest risk of reporting a high fear of falling compared to controls in both the unadjusted (OR, 5.79; 95% CI, 1.66–20.13; p=0.006) and adjusted analyses (OR, 8.12; 95% CI,1.79–36.84; p=0.007).

A high avoidance of at least one at-risk activity was reported by 45 of 138 (32.6%) glaucoma participants compared to 7 of 50 (14%) controls (p=0.015) (Figure 1). The proportion of participants with high avoidance of at least one at-risk activity increased with increasing glaucoma severity: 11 of 61(18.0%) of mild, 19 of 54 (35.2%) of moderate, and 15 of 23 (65.2%) of the advanced glaucoma groups (Figure 2). Glaucoma participants had a 3.0x greater risk of high avoidance of an at-risk activity than controls (unadjusted OR, 2.97, 95% CI, 1.24 – 7.13, p=0.015) and a 4.3 greater adjusted risk (adjusted OR, 4.25, 95% CI 1.43 – 12.62, p=0.009) (Table 2). Compared to controls, glaucoma participants had a greater risk of high avoidance at the moderate stage in both the unadjusted and adjusted analyses (unadjusted OR, 3.33; 95% CI, 1.26–8.84; p=0.015; adjusted OR, 4.49; 95% CI, 1.34–15.05; p=0.015) (Table 3). Advanced glaucoma participants had the greatest risk of high avoidance of an at-risk activity compared to controls in both the unadjusted and adjusted analyses (unadjusted OR, 11.52; 95% CI, 3.57–37.19; p=0.0001; adjusted OR, 19.35; 95% CI, 4.46–84.07; p=0.0006).

The proportion of glaucoma participants reporting a high fear of falling was greater in those reporting at least one fall in the prior 12 months (15 of 50, 30%) than those reporting no falls (16 of 88, 18%), however this difference was not statistically significant (p=0.14). The proportion of controls with a high fear of falling was significantly greater in those reporting at least one fall (4 of 10, 40%) compared to those reporting no falls (1 of 40, 2.5%) (p=0.004). The proportion of glaucoma participants with a high avoidance of at least one at-risk activity was greater in those reporting at least one fall (21 of 50, 42%) compared to those reporting no falls (24 of 88, 27%), however this difference was not statistically significant (p=0.09). The proportion of controls with a high avoidance of at least one at-risk activity was significantly greater in those reporting at least one fall (4 of 10, 40%) compared to those reporting no falls (3 of 40, 7.5%) (p=0.023).

Discussion:

Understanding the risk of and relationship between a patient’s rate of falls, fear of falling, and avoidance of activities at-risk for falls is critical to improve overall safety and quality of life for individuals with glaucoma. This study evaluates these three factors together in a well-characterized sample of participants with varying severity of glaucoma as well as controls. Results from this study suggest that even patients with mild glaucoma may have a higher risk of falls than individuals without ocular disease. In addition, a high fear of falling and high avoidance of activities at-risk for falls may be greater in patients with moderate and advanced glaucoma than patients with mild glaucoma or individuals without ocular disease. Patients with advanced glaucoma appear to have the highest rate of falls, fear of falling, and avoidance of at-risk activities. Information regarding these three key factors related to falls is necessary to develop and implement educational and interventional programs to decrease morbidity and mortality related to falls and to improve quality of life for individuals with glaucoma.

The results of this analysis support the literature that individuals with glaucoma have an increased risk of falls compared to those without glaucoma ¹⁷. The risk of falls in the glaucoma group was 2.7x higher than the controls after adjusting for covariates, including race. The proportion of glaucoma patients reporting a fall within a one-year period in prior studies ranges from 15% to 45% ^18–20. The 36% of glaucoma participants reporting a fall in our sample lies within and on the higher side of this range. The wide range of reported fall rates in glaucoma patients may be due to many factors including differences in study design, sample size, glaucoma severity, patient demographics and characteristics including cognition, co-morbidities, and other fall risk factors. An increasing rate of falls has been associated with increasing glaucoma severity by five dB decrements of visual field mean deviation ¹⁹. In our study, the largest proportion of participants reporting a fall were indeed those with advanced glaucoma with almost an 8x adjusted relative risk of reporting a fall compared to controls. Interestingly, compared to individuals without glaucoma, we found a trend suggesting that an increased risk of falls may occur in glaucoma patients with even mild severity. Our results support the growing body of literature that glaucoma patients have an increased risk of falls and further suggests that this risk may begin in patients with early disease. It should be noted that our study categorizes severity of glaucoma based on the Glaucoma Staging System which was developed for research purposes and uses a widely used classification system with well-defined criteria. Our results, therefore, may not apply to other glaucoma staging systems, such as the ICD10 coding system.

A patient’s fear of falling may result in anxiety, depression, and social isolation potentially leading to decreased independence and quality of life ²¹. Thus, it is critical to evaluate fear of falling to broaden our understanding of the impact that a fall may have on a person’s well-being. Overall, glaucoma participants in our study had a greater risk of having a high fear of falling compared to controls. This risk increased significantly in the moderate and advanced glaucoma groups. Previously described, an increased fear of falling has been associated with increasing glaucoma severity in a linear relationship (five dB decrement in visual field deviation) ³. Our results suggest that the relationship may not be truly linear given that fear of falling was similar in the control and mild glaucoma groups yet did not increase until the moderate stage of glaucoma. Further studies are needed to clarify these relationships.

This study introduces the “Activity Avoidance Questionnaire”, a novel assessment that analyzes the level of avoidance of activities including those that put an individual at-risk for a fall. Avoiding at-risk activities may reduce an individual’s risk for a fall, but also limits their activities affecting their overall quality of life. While fear of falling provides information regarding a person’s emotional well-being, avoidance of activities provides insight about a person’s direct behavior to reduce their risk of a fall. For example, a person may have a fear of falling in large social gatherings, but choose to attend such events despite their fear. If, however, they choose to avoid social gatherings, they avoid the risk of falling and anxiety associated with falling at such an event, however, may suffer from the negative sequela of social isolation and possibly depression. We report a greater proportion of glaucoma participants with a high avoidance of activities due to their vision as compared to individuals without glaucoma (32.6% vs.14%). This rate increases with worsening glaucoma severity although a significant increase from controls was only noted at the moderate and advanced stages of glaucoma. Similar to a high fear of falling, participants with advanced glaucoma were more likely to avoid an activity that may lead to a fall compared to participants with moderate glaucoma. Common areas for falls inside the home for glaucoma patients reportedly include stairs, bedrooms, and living rooms⁵. Our questionnaire assesses activities that are avoided due to their vision both inside and outside of the home. Increased awareness of areas or activities at-risk for a fall can guide patient education and environmental modifications. These interventions may enable patients to increase their activities thus promoting increased independence and quality of life.

This study analyzes the relationship between rate of falls, fear of falling and avoidance of at-risk activities in glaucoma patients compared to individuals without ocular disease. Mild glaucoma participants had a potentially greater risk of falls than controls, but their fear of falling and avoidance of at-risk activities were similar to the controls. A higher fear of falling and avoidance of at-risk activities increased in patients with moderate glaucoma and increased even further with advanced disease. Our results also suggest that if an individual, with or without glaucoma, has had at least one fall in the prior year, they are more likely to have a fear of falling and avoid at-risk activities than if they didn’t fall. While this cross-sectional study cannot confirm causality, it is plausible that patients with mild glaucoma are at-risk for a fall and develop a fear of falling and avoidance of activities at the later stages of disease. If so, educational efforts and interventions directed to decrease fall risk at the early stages of glaucoma may mitigate the adverse effects related to a fear of falling and avoidance of at-risk activities that may occur later in the disease.

There is little known regarding the effectiveness of interventions to reduce falls in older adults with glaucoma. However, in a large meta-analysis of fall-intervention studies for older adults, the most effective intervention was a multifactorial falls risk assessment and management program ²². Recent studies have further supported multifactorial interventions including home evaluations, home modifications, and exercise programs to reduce the rate and risk of falls in older adults ^23–25. Orientation and mobility specialists, physical therapists, and occupational therapists may help reduce fall-risk in glaucoma patients with interventions including mobility devices, strengthening exercises, and visual scanning strategies. Further studies are needed to address fall risk factors to help with prevention and mitigation. A comprehensive analysis of risk factors associated with fall-risk, such as body mass index, gait, and strength were not included in this descriptive analysis, however, is currently under investigation.

A key strength of this study is the assessment of rate of falls, high fear of falling, and high avoidance of at-risk activities measured in the same sample of glaucoma patients. This sample was relatively large and stratified across disease severity. In addition, controls were recruited from clinics in the same location as the glaucoma patients, reducing possible recruitment bias. Each participant underwent a comprehensive assessment of visual function using standardized tests. Due to the self-reported questionnaires, this study has inherent recall bias which may lead to measurement error. As stated, the cross-sectional nature of this study precludes conclusions regarding causal relationships between falls, fear of falling and avoidance of at-risk activities. Participants in this study were recruited from a tertiary care center and were mainly Caucasian or African American, English speaking older adults who were cognitively intact with no major ocular co-morbidities. Therefore, these results may not be generalizable to the broader population of glaucoma patients with differing characteristics. Lastly, patients in this study were recruited from a busy urban tertiary care center that may attract patients that are more functional and independent and detract patients with increased risk of falls, fear of falling, or avoidance of activities that make an individual prone to falls. This potential recruitment bias may underestimate the overall degree of falls, fear of falling, and avoidance of at-risk activities in patients with glaucoma.

Older adults with glaucoma are impacted by falls in many ways including physically, emotionally, and socially. Patients with as early as mild glaucoma may have a greater risk of having a fall than individuals without glaucoma and patients with advanced glaucoma have the greatest risk of having a fall, fear of falling, and avoiding at-risk activities. If a patient has a fall, they may develop a fear of falling and avoidance of at-risk activities. Interventions to decrease the risk of falls should be considered for patients even with early glaucoma, particularly if they have other risk factors for falling. Interventions may include referrals to orientation and mobility specialists, physical therapists, and occupational therapists as well as patient education and home environment modifications. Proper education and timely referrals are needed to prevent the potential downward spiral of physical, emotional, and social effects that can ensue after a patient has a fall.