September 2018

GLAUCOMA

Risk for falls common among those with glaucoma


by Vanessa Caceres EyeWorld Contributing Writer

Heightened awareness important to lower risk, researchers say

Falls can be a real danger to those age 65 and over. Among Americans age 65 or older, one in four has a fall each year, according to the Centers for Disease Control and Prevention. Falls are the leading cause of fatal injury among older adults and the most common cause of nonfatal trauma-related hospital admissions, the National Council on Aging (NCOA) reported.
Even just the risk of falling can make a difference in the life of an older adult, causing fear and the limiting of social activities, in turn leading to physical decline, social isolation, and depression, the NCOA reported.
With the aging of the U.S. population, ophthalmologists are in a position to help patients with glaucoma who are older stay vigilant about their fall risk and help them prevent falls.
Here’s what some recent studies have found about the risk of falls in glaucoma patients.

History of falls, systemic disease increase risk

In a group of 294 patients with primary open angle glaucoma (POAG), the risk of falls was higher dependent upon visual acuity in the worse eye, history of falls, fear of falling, having diabetes, and systemic hypertension, reported Adachi et al.1 Among the participants, 69 had experienced a fall during a 3-year follow-up.
“Ophthalmologists should advise patients about the risk of falls when visual acuity in the worse eye is decreased, there is a history of falls, and there is fear of falling,” said Ryo Asaoka, MD, assistant professor, Department of Ophthalmology, University of Tokyo Graduate School of Medicine, Tokyo, Japan. Dr. Asaoka was the corresponding author for the study.
Dr. Asaoka and fellow authors also examined falls in a study that focused on the fear of falling among those with POAG.2 Among the 392 subjects, 87.2% reported that they had a fear of falling at least once during a 3-year period. Older age, being female, and having visual field damage in the inferior peripheral area all were related to the fear of falling. Careful consideration about the fear of falling is important for both ophthalmologists and patients who have visual damage in this area, Dr. Asaoka said.

Tracking where falls happen

A group of researchers from Johns Hopkins University, Baltimore, have focused research on falls locations and falls hazards among those with glaucoma. They did their research as part of the Falls in Glaucoma Study (FIGS).
In one study they published last year in Ophthalmology,3 the researchers focused on characterizing falls-related hazards in the homes of those with glaucoma or those suspected of having glaucoma. Using a Home Environment Assessment for the Visually Impaired, an evaluator assessed the homes of 174 participants for 127 potential falls hazards in eight home regions. Researchers also performed clinical exams.
The study found no significant difference in the number of home hazards among those with visual field damage compared with those who had less damage; in other words, homes were not necessarily made safer just because someone had more glaucoma damage.
Researchers found that the bathroom had the largest number of hazards of any room in the home; ambient lighting was the most common hazard overall (less than 300 lux and exposed light bulbs). Only 27.9% of graded rooms had enough lighting, the researchers reported.
In a study published this year from the Johns Hopkins researchers,4 it was found that falls among 142 patients with glaucoma occurred in or around the home 71% of the time. The likelihood of where falls would occur did not change significantly with more visual field damage. Tripping (43.6%), slipping (31.3%), uneven flooring (23.5%), and poor vision (15.9%) were the most commonly cited fall circumstances. Among the 330 falls total that occurred, 43% had some sort of injury; the factors associated with likelihood of injury included floor type and number of comorbidities.
Those with severe glaucoma were more likely to have a fall resulting in a fracture (9.4%) or the need for an ER visit (18.8%).
Apart from vision loss, it is not completely clear why falls are higher among those with glaucoma, said Pradeep Ramulu, MD, chief of the glaucoma division, Wilmer Eye Institute, Johns Hopkins School of Medicine, one of the study authors.
“Poor balance, slower gait speed, and greater variability in gait are all associated with increased risk of falling, though it remains to be determined if this is why persons with glaucoma fall more often,” Dr. Ramulu said. It may be that persons with glaucoma have difficulty with hazard perception, but this would be hard to test, he said.
The interest in falls led Dr. Ramulu and others to conduct FIGS, a 3-year prospective cohort of patients with glaucoma or suspected glaucoma who were recruited at their institution between 2013 and 2015. Vision, gait, and balance tests were repeated every year, and respondents completed questionnaires about falling, driving, and quality of life.
Although some of the work is still under review for publication, Dr. Ramulu revealed that there does not appear to be any clear circumstance to explain why those with glaucoma fall more.

Tips to help prevent falls

Knowing that patients with glaucoma may fall more, even if it is not clear why, what can ophthalmologists do to better educate about the risk? Below are a few suggestions.
1. Provide verbal and written guidance. When a patient has glaucoma, particularly if he or she is older and has more visual field damage, talk about the risk for falls. Have handouts available at the office that address falls. One resource that Dr. Ramulu and colleagues like is the National Falls Prevention Resource Center (www.ncoa.org/center-for-healthy-aging/falls-resource-center) from the NCOA.
2. Encourage patients to have a home visit for a review of falls prevention and falls risk. This kind of visit can be done by occupational therapists, said Scott Trudeau, PhD, OTR/L, productive aging and interprofessional collaborative practice program manager, American Occupational Therapy Association, Bethesda, Maryland. Although there are general factors that can decrease the risk for falls, each person will have individualized needs, Dr. Trudeau said. For example, installing a grab bar in the shower may be helpful, but its optimal placement will vary individually.
3. Think better lighting and contrast. This may be something that an occupational therapist would address in more detail with a home visit, but it’s something to keep in mind if patients ask about falls risk or if physicians plan to update their office to cut down on the risk for falls. Better lighting and better contrast are two areas often discussed during home visits about falls, Dr. Trudeau said. He gave the example of a pristine white bathroom that may look great, but the lack of contrast can raise the risk for falls. Contrasting the color of the walls and floors—in addition to better lighting in the bathroom and other home areas—can be helpful, he said.
Patients who have home visits are often pleasantly surprised to learn that switching to brighter LED bulbs can also save on their electric bill, Dr. Trudeau said.
4. Let patients know that falls are not inevitable. “Falls are not a natural part of aging,” Dr. Trudeau said. That knowledge would hopefully prompt clients to seek help if they experience one or more falls, instead of accepting it as a reality because they have vision loss or are getting older.
5. Find out about area programs that focus on falls prevention, medication review, and strength/balance training. “These programs are likely to be useful even if they are not specifically tailored to the visually impaired,” Dr. Ramulu said.

References

1. Adachi S, et al. Factors associated with the occurrence of a fall in subjects with primary open-angle glaucoma. BMC Ophthalmol. 2017;17:213.
2. Adachi S, et al. Factors associated with developing a fear of falling in subjects with primary open-angle glaucoma. BMC Ophthalmol. 2018;18:39.
3. Yonge AV, et al. Quantifying fall-related hazards in the homes of persons with glaucoma. Ophthalmology. 2017;124:562–571.
4. Sotimehin AE, et al. Locations, circumstances, and outcomes of falls in patients with glaucoma. Am J Ophthalmol. 2018;192:131–141.

Editors’ note: The sources have no financial interests related to their comments.

Contact information

Asaoka
: ryoasa0120@mac.com
Ramulu: pramulu@jhmi.edu
Trudeau: strudeau@aota.org

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