Simple steps to preventing falls in glaucoma patients

Patients with glaucoma have a three to four times greater risk of falling, which exceeds the risks associated with age-related macular degeneration, cataract, or diabetes. Here are some steps clinicians can share with their patients to help reduce falls

It is well recognized that falling is a leading cause of injury-related death in the United States. Importantly, a high percentage of older patients fall at least once during a year’s time, and as a result from 10% to 20% sustain a severe physical injury such as a hip fracture or head trauma.

In addition to physical consequences, falls can result in decreased quality of life, with consequent restricted activities, social isolation, dependence on caregivers, and depression.

Increased risk of falls by older patients is not limited to those with physical disabilities, i.e., those with impaired visual fields (VFs) are at increased risk of falling, said Anjali M. Bhorade, MD, MSCI, associate professor of Ophthalmology, Washington University School of Medicine, St. Louis, MO.

Patients with glaucoma have a three to four times greater risk of falling, which exceeds the risks associated with age-related macular degeneration, cataract, or diabetes.

A number of steps can be implemented to decrease falls in patients with glaucoma, according to Dr. Bhorade, that include identification of the at-risk patients, the locations and circumstances surrounding the falls, and the modifiable risk factors, and development and implementation of programs to prevent falls.

The risk factors for falls in patients with glaucoma include decreased VF sensitivity, particularly in the inferior hemifield, and possibly the velocity of progression of the VF deterioration. In addition, female gender, older age, body mass index, and poor balance, posture, and strength, have all been associated with increased risk or fear of falling.

However, Dr. Bhorade pointed out, studies of the risk factors associated with falling disagree regarding the thresholds of VF sensitivity, visual acuity, contrast sensitivity, medications, and gender possibly because the studies that calculate the risk of falls over a year’s time may not be accurately assessing the risks. She suggested that the rates of falls may be predicted more accurately based on specific activities.

Dr. Bhorade recounted the recent findings of the prospective Falls in Glaucoma Study (Am J Ophthalmol. 2019;200:169-78) that included 225 subjects with glaucoma or glaucoma suspects who recorded falls using calendars. Patients received a follow-up phone call after a fall to determine the injuries sustained and the location and circumstances of the fall.  All patients wore an accelerometer for 1 week during the year of the study and a GPS was used to estimate the steps taken by the patients both at home and while outside the home.

“The investigators found that the risk factors for falls were associated with less physical activity, i.e., worse VF sensitivity, older age, female gender, black race, and use of multiple medications,” Dr. Bhorade noted.

The study also evaluated more falls per step compared with falls per year. They found that  only factors associated with falls per step were associated significantly with worse overall VF sensitivity especially in the inferior quadrant, older age, female gender, and increased co-morbidities, she pointed out.

“The results suggested that older women with worse VF sensitivity may be engaging in less physical activity and are at risk for more falls based on their activity level,” she commented.

Evaluation of the locations of the falls indicated that while subjects walked more while away from home, more falls, i.e., 57%, occurred while they were at home. Patients walking at home were twice as likely to have a fall there than while away from home (P<0.001).

The places in the home where most falls occurred in descending order were on stairs (24.8%) and in the bedroom (18.8%) and bathroom (14.5%). Falls that occurred on stairs  and in the bedroom and kitchen resulted in injurious falls, with respective percentages of 19.5%, 19.5%, and 17.1% resulting in injuries, Dr. Bhorade noted.

Falls with and without subsequent injuries occurred most on floors made of cement, stone, or brick. Falls on carpets resulted in injuries less often. The patients reported that the falls occurred as the result of tripping, slipping, uneven floor surfaces, and poor vision, with most resulting from the first two.

The greatest hazards in the home that were identified in eight home areas with found most often in the bathroom (54.1%), stairs (40.7%), and entryway (28.4%) as a result of poor lighting, exposed lightbulbs, no grab bars by toilets, a door threshold height exceeding 0.5 inch, and no armrests on seats, she enumerated.

Modifying the risk factors

“The potentially modifiable risk factors that can result in decreased numbers of falls are VF progression; poor balance, posture, and strength; flooring; lighting; and home hazards,” Dr. Bhorade said.

“Using this information, we can develop and implement programs to prevent falls using a team of experts that include glaucoma specialists and occupational therapist to reduce VF progression and improve balance, posture, and strength," she said.

Occupational therapists can assess patients’ home and recommend replacing hard surfaces with carpeting, ensure that flooring is even and not slippery, optimize lighting and decrease hazards with use of guard rails and armrests. In many cases, these are simple solutions that can achieve success in reducing the risk of falls in patients with glaucoma and results by decreasing morbidity and mortality and improving quality of life, Dr. Bhorade concluded.

Disclosures:

Anjali M. Bhorade, MD, MSCI

This article was adapted from Dr. Bhorade's presentation at the American Academy of Ophthalmology 2019 meeting. Dr. Bhorade has no financial interest in the subject of this report.