Frequent falls in glaucoma patients loosely associated with balance, gait measures
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While associated with fall rates, balance and gait measures do not explain why people with greater visual field damage fall more frequently, according to findings in a recent study.
“Although previous work suggests that balance and gait deficits both contribute to a higher risk of falls, it is less understood how balance and gait relate to falls in populations with concomitant vision loss,” Aleksandra Mihailovic, Wilmer Eye Institute at The Johns Hopkins University, and colleagues wrote. “We hypothesized that the balance and gait features predisposing individuals to a higher rate of falls over time would differ from the features predisposing individuals to a higher rate of falls per step, and that balance and gait features would mediate the association between visual field damage and higher fall rates.”
In a prospective longitudinal cohort, investigators included 239 participants with glaucoma or suspected glaucoma for analysis. They collected data on falls, balance, gait and vision at baseline and follow-up over 24-months. Multivariable negative binomial models compared balance and gait associations with average daily steps and rates of falls per time or step. Researchers also compared integrated visual field sensitivity as it is associated with falls.
Study results showed the cumulative probability of falling one or more times over the first 12 months of follow-up was 44.8%, with the cumulative probability of falling two or more times calculated at 17.7%. Gait deficits carried higher association with fewer daily steps than balance parameters (P < .03 vs. P > .019), and worse balance carried a higher association with fall rates per year and per step when compared to gait measures (P < .03 vs. P > .17). Integrated visual field remained an independent predictor of falls per step (1.36 – 1.48; P < .001 – P < .005) and neither gait nor balance mediated the association between visual field damage and fall rates.
“Balance and gait were clearly important predictors of falls in the current study ... they did not contribute to fall risk more in persons with more advanced visual field damage, nor did they explain the association between visual field damage and the risk of falling,” Mihailovic and colleagues concluded. “Future research should specifically address other potential causes of falls that, in conjunction with changes in balance and gait, could more fully explain the relationship between visual field damage and falls among glaucoma patients.”
Perspective
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Kelly Malloy, OD, FAAO
It is already well established that an increased risk for falling occurs because of each of these three circumstances individually: balance problems, gait deficits and visual impairment. The authors here set out to determine if visual field loss may, in turn, lead to changes in gait and balance, which would also contribute to the increased risk for falls in glaucoma patients.
This hypothesis was disproven in the study. It was determined that while gait and balance problems are independent risk factors for falling, the fall risk related to gait or balance was not disproportionately greater in patients with worse visual fields. Therefore, the visual field damage itself, or a related consequence such as poor hazard perception, may be the main reason for increased falls in glaucoma patients.
There were several acknowledged limitations of this study, such as the fact that balance and gait were tested in controlled conditions and may be misrepresentative of typical conditions encountered by glaucoma patients on a daily basis. Nevertheless, this study does bring to light the importance of asking older patients about recent falls, performing cursory assessments of gait and balance, as well as interdisciplinary referrals and communication about fall risk and assessment. Eye care providers should be considering and addressing fall risk in all patients with visual impairment.
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