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
Patients with glaucoma (n = 138) 55 to 90 years of age with mild (n = 61), moderate (n = 54), or advanced (n = 23) glaucoma in the better eye based on the Glaucoma Staging System and age-matched control subjects (n = 50) were recruited from the Eye Clinics at Washington University, St. Louis, MO. Participants completed questionnaires regarding falls, the fear of falling, and the avoidance of activities at-risk for falls.
Results
Of the glaucoma participants, 36% reported ≥1 fall in the previous 12 months compared with 20% of control subjects (adjusted odds ratio [OR] 2.7 [95% confidence interval {CI} 1.18-6.17]; P = .018). Compared with control subjects, the mild glaucoma group trended toward a higher fall risk (adjusted OR 2.43 [95% CI 0.97-6.08]; P = .059) and the advanced group had the highest fall risk (adjusted OR 7.97 [95% CI 2.44-26.07]; P = .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 with control subjects (adjusted OR 4.66 [95% CI 1.24-17.49]; P = .023 and adjusted OR 4.49 [95% CI 1.34-15.05]; P = .015, respectively).
Conclusions
Patient education, interventions, and appropriate referrals to minimize falls should be considered in older adults with early glaucoma and continue with advancing disease. Minimizing a patient’s fall risk may decrease their fear of falling and avoidance of at-risk activities. Reducing falls, the fear of falling, and the avoidance of at-risk activities may lower morbidity and mortality and improve emotional and social well-being of patients with glaucoma. Am J Ophthalmol 2021;221:•••–•••. © 2021 Elsevier Inc. All rights reserved.
Falls in the older adult population have a significant public health impact on morbidity and mortality, as well as individual and societal costs. Patients with glaucoma have a higher risk of falling and being injured from a fall compared with individuals without glaucoma. Moreover, in a large epidemiologic study, patients with glaucoma had the greatest risk of a fall compared with patients with other eye diseases, including diabetic retinopathy and age-related maculopathy. While increased visual field loss is a risk factor for falls, the stage of glaucoma at which this risk occurs is not clear. This information is critical to enable 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. Older adults with self-reported visual impairment have a high prevalence of falls, fear of falling, and activity limitation because of the fear of falling. Increasing visual field loss in patients with glaucoma has been associated with a fear of falling and the avoidance of areas that are at high risk for falls. , To our knowledge, there have been no studies evaluating the rate of falls, fear of falling, and avoidance of activities at-risk for falls in the same sample of patients with glaucoma. Understanding the relationships between these 3 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, or advanced glaucoma and age-matched control subjects. 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 with control subjects. In addition, this report analyzes the relationship between glaucoma severity and these 3 fall-related factors.
Methods
Data for this analysis were obtained from a pilot study of visual function and quality of life of patients with glaucoma, which has been previously described. 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 provided informed consent before study participation.
Patients 55 to 90 years of age with a clinical diagnosis of glaucoma, as well as age-matched control subjects, 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 control subjects 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, >6 diopters of refractive error, current use of miotic glaucoma medications, incisional or laser eye surgery within 3 months of enrollment, moderate or severe impaired cognition (Short Blessed Test score >10), self-reported physical disability limiting function (eg, stroke), unreliable visual field tests, resided in a nursing home, or if English was not their primary language.
Eligible participants with glaucoma were categorized based on monocular visual field testing obtained within 6 months of the study using a Humphrey Visual Field Analyzer II (Carl Zeiss Meditec, Dublin, California, USA) equipped with the Swedish Interactive Thresholding Algorithm. Each eye was classified into a glaucoma stage (0-5) using the Glaucoma Staging System 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 (ie, less severe glaucoma) was used for this analysis based on previous reports associating the better-seeing eye with visual disability. ,
Two research coordinators and 19 graduate students in the Program in Occupational Therapy at Washington University conducted a clinic and home visit for the pilot study. Intergrader reliability between examiners for vision testing was high (intraclass correlation coefficient range 91%-94%). 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 comorbidities were recorded.
Falls Questionnaire
All participants completed 100% of questions in the falls questionnaire and the fear of falling questionnaire (Supplemental Appendix 1). The 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 high fears of falling.
Activity Avoidance Questionnaire
Ninety-four percent of participants completed 100% of questions in the activity avoidance questionnaire (Supplemental Appendix 2). The activity avoidance questionnaire is a 35-item self-report questionnaire that assesses the participant’s level of worry and avoidance of specific daily activities because of 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 35 activities were identified as activities that may potentially increase an individual’s risk for falls and were 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 nonilluminated Early Treatment Diabetic Retinopathy Study charts (Precision Vision, catalog no. 2110) at 3.2 meters testing distance and 1.6 meters distance for 2 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. Binocular contrast sensitivity (CS) was measured using the Pelli-Robson CS chart (Clement Clarke International, reference no. 7002250) at 1 meter. Binocular CS with glare testing was measured using bilateral Brightness Acuity Test (Mentor, Norwell, Massachusetts, USA) in conjunction with a Pelli-Robson chart of a different version from that used for CS testing. Measurements obtained using the Brightness Acuity Test 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 log 10 contrast for data analysis. Monocular visual field testing was obtained for all participants using the Humphrey Visual Field Analyzer II with the Swedish Interactive Thresholding Algorithm standard 24-2. Visual field testing in the eye with the higher (ie, 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 comorbidities potentially affecting daily function and quality of life. 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. Education level of the participant was classified on a scale of 1 (graduate professional training) to 7 (<7 years of school). For this analysis, patients with education levels 1 through 3 were subclassified as “some college or more.” The occupation level of the head of the household was classified on a scale of 1 (eg, major professional) to 7 (eg, unskilled worker) with levels 1 through 3 subclassified 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. , Scores range from 0 to 28 with scores >10 suggestive of cognitive impairment.
All data were 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 ≥1 fall in the previous 12 months. Comparisons between the control and glaucoma groups were made using Kruskal-Wallis tests for continuous outcomes and χ 2 tests for categorical outcomes. Odds ratios (ORs) 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 with control subjects. An adjusted logistic regression was also calculated adjusting for age, gender, race, number of systemic comorbidities, and medications. Comparisons of proportions within diagnostic subgroups were done using the Fisher’s exact test. All data analyses were performed using SAS software (version 9.3; SAS Inc, Cary, North Carolina, USA).
Results
There were 356 eligible patients of whom 190 participated in the pilot study. Of the 190 participants,188 completed the falls questionnaire. This included 50 control subjects and 138 patients with glaucoma (61 cases of mild, 54 cases of moderate, and 23 cases of advanced glaucoma). Table 1 describes the baseline characteristics of these 188 participants. There were more African-Americans (39.9% vs 24.0%, P = .04) and fewer major or minor professionals (53.7% vs 70.8%, P = .04) in the glaucoma group than in the control group. The glaucoma group scored worse than control subjects for all vision measures including distance ( P = .006) and near visual acuity ( P = .01), contrast sensitivity ( P = .0001), contrast sensitivity with glare testing ( P = .0001), visual field mean deviation ( P = .001), and Esterman disability score ( P = .0001). African-Americans had a significantly higher number of comorbidities than whites ( P = .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 = .6707). There was a near significant difference in pseudophakia status between the mild and moderate glaucoma groups (36% vs 54%, respectively, P = .0574) and the moderate and severe glaucoma groups (54% vs 78% respectively, P = .0431). The control group was less likely to live alone compared with the glaucoma group (16.3% vs 28.3%, P = .10). In addition, patients with glaucoma were more likely to report staying at home because of their vision compared with control subjects (12.3% vs 0%, P = .009).
| Demographics | Control Subjects (n = 50) | Patients With Glaucoma (n = 138) | P Value |
|---|---|---|---|
| Age (y), mean (SD) | 70.9 (8.1) | 72.7 (7.8) | .20 |
| Women (%) | 60.0 | 57.2 | .74 |
| African American (%) | 24.0 | 39.9 | .04 |
| Married (%) | 60.0 | 48.6 | .17 |
| Education (partial college or more) (%) | 70.0 | 67.4 | .73 |
| Major/minor professional (%) | 70.8 | 53.7 | .04 |
| Lives alone (%) | 16.3 | 28.3 | .10 |
| Frequently stays home because of vision (%) | 0.0 | 12.3 | .009 |
| Medical | |||
| Comorbidities (n), mean (SD) | 2.5 (1.6) | 2.5 (1.6) | .98 |
| Total nonglaucoma medications, mean (SD) | 3.2 (2.0) | 3.3 (1.9) | .83 |
| Vision | |||
| ETDRS binocular distance visual acuity, mean (SD) | 58.8 (8.1) | 53.4 (13.0) | .006 |
| Sloan binocular near visual acuity, mean (SD) | 66.1 (9.5) | 58.7 (16.1) | .01 |
| Binocular contrast sensitivity (logMAR) (SD) | 1.78 (0.2) | 1.51 (0.4) | .0001 |
| Binocular glare (cd/m 2 ) (SD) | 12.2 (1.4) | 10.1 (2.8) | .0001 |
| Visual field mean deviation (better eye), mean (SD) | −2.0 (2.4) | −7.4 (8.2) | .001 |
| Esterman disability score, mean (SD) | 94.9 (8.3) | 82.4 (20.9) | .0001 |
| Pseudophakia in eye with better mean deviation (%) | 40 | 50 | .2250 |
| Cognition | |||
| Short Blessed Test, mean (SD) | 2.7 (4.1) | 3.2 (4.0) | .15 |
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