Characterizing the Impact of Fear of Falling on Activity and Falls in Older Adults with Glaucoma

Association of fear of falling with performance-based physical function and low back pain in older adults: a cross-sectional study in Iran

OBJECTIVES

This study investigated the association of fear of falling with performance-based physical function and low back pain (LBP) among older adults.

DESIGN

Cross-sectional study.

SETTING

Participants were selected via convenient sampling from Iran University orthopaedic and/or physiotherapy outpatient clinics, between March 2022 and April 2023.

PARTICIPANTS

140 subjects with and without LBP, aged over 60 years, were included.

OUTCOME MEASURES

The Falls Efficacy Scale International was used to measure fear of falling. A baseline questionnaire inquired about LBP. Participants performed the Timed Up and Go, 30 s Sit-To-Stand (30s-STS), single leg stance with open and closed eyes and gait speed tests to assess performance-based physical function. Demographic variables including age, gender and body mass index were considered as potential covariates. Bivariate and multivariable linear regression analyses were used to investigate the associations.

RESULTS

A significant association between fear of falling and the 30s-STS test score (β=-0.30, 95% CI -1.27 to -0.28; p=0.00) and the sex (β=0.31, 95% CI 1.53 to 4.83; p=0.00) was confirmed in multivariable analyses. LBP and other performance-based physical function tests were not associated with a fear of falling.

CONCLUSION

Fear of falling was significantly associated with lower extremity muscle function, measured by the 30s-STS test and female gender. Older adults with a fear of falling could benefit from interventions that improve lower extremity muscle function. Also, the observed association between the fear of falling and the female sex confirms the need for effective interventions to reduce the fear of falling among older women.

The Quantitative Impact of Visual Function on Accelerometer-measured Physical Activity in Older United States Adults: A Nationwide Cross-sectional Analysis

Purpose

To explore the impact of objective vision measures on novel metrics of objectively-measured physical activity (PA) in a nationally representative sample of United States (US) older adults.

Design

Cross-sectional analysis using data from the National Health and Aging Trends Study.

Participants

Adults had their distance and near visual acuity (VA) and contrast sensitivity (CS) tested. Any objective vision impairment (VI), defined as any VI in distance VA, near VA, or CS, was the primary exposure. Physical activity data were collected using the Actigraph CentrePoint Insight Watch worn for 7 days.

Methods

Multivariable regression models were used to investigate the association between vision and PA measures. All analyses accounted for the survey design and models were adjusted for age, sex, race, living arrangement, education, and comorbidities.

Main Outcome Measures

Physical activity metrics included (1) total daily activity (active minutes per day, number of active bouts, and mean length of active bouts), (2) activity fragmentation, and (3) time until 75% activity. An active bout was defined as ≥ 1 consecutive active minute. Activity fragmentation was defined as the probability of an active minute being followed by a sedentary minute, with higher values indicating more fragmented activity. Time until 75% activity was defined as the time taken to complete 75% of daily PA starting from their first active bout.

Results

Among 723 participants, sampled from 10 443 338 older adults in the US, 30% had any objective VI. Any objective VI was significantly associated with lower number of active minutes per day (7.8% fewer [95% confidence interval {CI}: -13.6% to -1.7%]), shorter active bouts (7.0% shorter [95% CI: -12.3% to -1.4%]), and greater activity fragmentation (2.5% [95% CI: 0.8% to 4.2%]), while no associations were found with number of active bouts. Time until 75% activity did not significantly differ between adults with any objective VI and those without (P = 0.34).

Conclusions

Older US adults with any objective VI displayed lower total daily activity, as well as more fragmented, shorter periods of PA, despite having a similar number of active bouts compared to their normally sighted counterparts. Implementing interventions that increase bout duration may help promote PA in adults with VI.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

A Multidimensional Approach for Nurse Practitioners to Screen Fall Risk and Fear of Falling in Community-Dwelling Older Adults

Nurse practitioners are essential in the care of the older adult population. Older adults are at high risk for falls; therefore, nursing assessment should include psychological and physiological measures. Fear of falling is a primary psychological contributor to fall risk. The Falls Efficacy Scale International short; Centers for Disease Control and Prevention Stopping Elderly Accidents, Deaths, and Injuries fall risk scale; and Balance Tracking System (BTrackS) balance test are reliable, efficient tools for assessment. Data obtained from these multifactoral tools may inform mobility interventions and education for the patient, further meeting a national safety goal of reducing falls in the older adult population.

Evaluation of away-from-home excursion patterns after falling among individuals with glaucoma: a longitudinal study

Background

Unintentional falls among older adults are associated with an ensuing decline in physical activity. Our objective is to evaluate the associations between fall status and changes in excursions after a fall.

Methods

Prospective cohort study of older adults with glaucoma or suspected glaucoma who reported falls for 1 year and wore a GPS device for 1-week at the baseline and 1 year later. GPS data were quantified into average: daily excursions, daily time away from home, and time per excursion. Fall status was categorized as fallers, injurious fallers, recurrent fallers, and recurrent injurious fallers. Multivariable negative binomial regression and generalized estimating equations models were employed to evaluate relationship between excursion parameters and fall status.

Results

A total of 192 eligible participants were included in the analyses. Approximately half were males (50.5%) with a mean age of 70.1 years and one-fourth were Black (28.1%). There were no significant associations between fall status and end-of-study excursion parameters (p > 0.06 for all), and visual field damage did not modify these relationships (p > 0.07 for all). For instance, patients with multiple falls during a one-year study period did not demonstrate more daily excursions (incident rate ratio [IRR] = 1.16, 95% confidence interval [CI] = 0.85 to 1.57), longer time per excursion (IRR = 0.79, 95% CI =0.59 to 1.06), or more average daily time away (IRR = 1.05, 95% CI = 0.84 to 1.30) conducted at the end-of-the study. Excursion parameters at the final assessment were not significantly different from those at baseline (p > 0.09 for all) and the changes did not vary by fall status (p > 0.23 for all).

Conclusions

Older adults with glaucoma did not modify their travel away from home after experiencing a fall. Additional research is necessary to understand how often maintenance of travel outside the home after a fall reflects proper compensation for greater fall risk or continued activity despite the risk of falling.

Importance and Severity Dependence of Physical Activity by GPS-Tracked Location in Glaucoma Patients

PURPOSE

To quantify the association of visual field (VF) damage on physical activity away-from-home, per away-from-home excursion, and at-home.

DESIGN

Prospective cohort study.

METHODS

Among 229 participants with glaucoma or suspected glaucoma, the severity of VF damage was defined as average sensitivity within the integrated VF (IVF). Participants wore accelerometers and global positioning system trackers for 7 days to measure physical activity and characterize activity location. Multivariable negative binomial regressions were used to test whether away-from-home activity per day, physical activity per away-from-home excursion, and at-home activity per day varied by the severity of VF damage.

RESULTS

Each 5-dB decrement in IVF sensitivity was associated with a lower number of away-from-home activities per day (18% less moderate and vigorous physical activity [MVPA] minutes/d, 95% confidence interval, 0.69-0.97) and physical activities per away-from-home excursion (20% less MVPA minutes/excursion, 95% confidence interval, 0.65-0.98). Similar findings were noted for other away-from-home activity measures (including active minutes/steps per day, or active minutes/steps per excursion). However, worse IVF sensitivity was not associated with measures of at-home activities (MVPA minutes/d, active minutes/d, and steps/d), time spent at or away from home, or excursions/wk (P > .1 for all).

CONCLUSIONS

Restriction of physical activity in more patients with severe glaucoma results mostly from activity restriction outside the home environment. These findings highlight the importance of maintaining a safe home environment (where activity is less restricted) and increasing confidence to perform activity, particular high-intensity activity, when leaving the home amongst patients with glaucoma.

Associations of objectively measured physical activity and sedentary behaviour with fall-related outcomes in older adults: a systematic review

BACKGROUND

Higher physical activity (PA) and lower sedentary behaviour (SB) are associated with better muscle strength, balance, and functional ability, which are imperative for avoiding falls. This systematic review aimed to describe the association between objectively measured PA and SB with falls, fear of falling, and fractures.

METHODS

Six databases were searched from inception to July 21, 2020 for articles reporting the association of objectively measured PA/SB with falls, fear of falling, and/or fractures in community-dwelling older adults ≥60 years old. Results were synthesized in effect-direction heat maps and albatross plots expressed as Pearson's correlation coefficients (R).

RESULTS

A total of 43 articles were included, representing 27,629 (range 26 to 5,545) community-dwelling older adults (mean [SD] age 76.6 [8.4] years, 47% female). Longitudinal associations were reported in 13 articles and cross-sectional associations in 30. Falls were reported in 11 articles, fear of falling in 18 and fractures in 2. Higher PA and lower SB were associated with less fear of falling (median [interquartile range] Rs = steps: -0.214 [0.249; -0.148], total PA: -0.240 [0.267; -0.144], and moderate-to-vigorous PA: -0.180 [0.382; -0.121]), but these associations did not extend to falls or fractures, which showed inconsistent effect directions.

CONCLUSION

Fear of falling is associated with less engagement in PA and more SB, thus indicating that it is a psychological barrier to an active lifestyle. Varying effect directions for associations between PA and SB with falls and fractures may provide evidence for non-linear associations and require further research considering details of the fall or fracture incident.

PROSPERO REGISTRATION NUMBER

CRD42018103910.

Visual Impairment and Objectively Measured Physical Activity in Middle-Aged and Older Adults

BACKGROUND

Vision loss is associated with increased falls risk and restricted physical activity, yet the relationship between multiple vision measures and objectively measured physical activity, especially activity patterns, in mid-to-late life is not well understood.

METHODS

This study included 603 participants aged ≥ 50 years (mean age=73.5) in the Baltimore Longitudinal Study of Aging who had the following assessments: presenting and best-corrected visual acuity, contrast sensitivity, visual fields, stereo acuity, and free-living physical activity using a wrist-worn ActiGraph accelerometer for 7 days. Linear regression models were used to examine the association between vision measures and daily activity counts, active minutes, and activity fragmentation (defined as an active-to-sedentary transition probability), adjusting for potential confounders. Mixed-effects models estimated differences in activity by time of day comparing those with and without each visual impairment.

RESULTS

In the fully adjusted model, worse presenting visual acuity, contrast sensitivity, and visual fields were associated with fewer activity counts, less active time, and more fragmented activity patterns (p<0.05 for all). Participants with presenting or best-corrected visual acuity impairment had 19.2 and 29.3 fewer active minutes (p=0.05, p=0.03, respectively) per day. Visual field impairment was associated with 268,636 fewer activity counts (p=0.02), 46.2 fewer active minutes (p=0.02) per day, and 3% greater activity fragmentation (p=0.009). Differences in activity levels tended to be greatest from 6am-6pm (p<0.05).

CONCLUSIONS

Older adults with visual impairment have restricted and more fragmented patterns of daily activity. Longitudinal studies to quantify the long-term impacts of visual impairments on activity decline are warranted.

Characterizing Longitudinal Changes in Physical Activity and Fear of Falling after Falls in Glaucoma

BACKGROUND

Older adults with visual impairments experience a higher risk of falling, and are more vulnerable to adverse health consequences associated with falls than those with normal vision. This study characterizes longitudinal changes in objectively measured physical activity and fear of falling (FoF) occurring after various types of falls in visually impaired older adults.

DESIGN

Prospective cohort study.

SETTING

Hospital-based enrollment.

PARTICIPANTS

People with glaucoma or suspected glaucoma.

MEASUREMENTS

Falls were defined as unintentionally coming to rest on the ground or a lower level, and injurious falls were determined though follow-up calls. Study participants were categorized into three groups-fallers with injurious consequences, fallers without injurious consequences, and non-fallers based on fall status in the first year. Physical activity was assessed by waist-bound accelerometer. FoF was evaluated by questionnaire, with Rasch modeling generating FoF scores where higher scores reflected worse FoF. The 3-year longitudinal changes of physical activity and FoF were modeled using mixed-effects models.

RESULTS

In linear models fully adjusted for visual field damage and other covariates, physical activity among injurious fallers showed greater annual (per year) declines in daily steps (-425 steps/d, 95% confidence interval (CI) = -793, -57), daily active minutes (-13 min/d, 95% CI = -21, -6), and daily moderate and vigorous physical activity (MVPA) minutes (-3 MVPA minutes/d, 95% CI = -5, 0) over the 3-year period as compared to non-fallers; however, physical activity did not significantly decline among non-injurious fallers. No longitudinal increases in FoF scores were observed in injurious or non-injurious fallers when compared to non-fallers.

CONCLUSION

Among visually impaired older adults, injurious falls identified prospectively over 12 months contributed to a significant decline in physical activity over a 3-year period, while minimal changes were observed in FoF.

Physical activity level, fear of falling and quality of life: a comparison between community-dwelling and assisted-living older adults

Background

Physical activity (PA), fear of falling (FOF) and quality of life (QOL) are very important constructs in geriatrics. The interplay among these constructs may vary between community-dwelling and assisted-living older adults. However, studies comparing the wellbeing of community-dwelling older adults with those residing in the assisted-living facilities (ALFs) are rather rare especially from developing countries. This study was aimed at comparing PA, FOF and QOL between assisted-living and community-dwelling older adults and also determining the correlations amongst the constructs for each group.

Methods

This cross-sectional survey involved consecutively sampled 114 older adults (≥65 years, ambulant and well-oriented in time, place and person) residing in conveniently selected ALFs (11.3% males) and adjoining communities (54.1% males). PA, FOF and QOL were evaluated using the Physical Activity Scale for the Elderly, the Modified Fall Efficacy Scale and the Short-form Health Survey (SF-36) questionnaire respectively. Data was analysed using descriptive statistics, analysis of covariance and Spearman rank-order correlation test at 0.05 level of significance.

Results

Participants from the ALFs had significantly lower domain and overall PA (F=5.6–103.34; p< 0.05) and QOL (F=11.12–118.05; p< 0,05) scores than community-dwelling groups. FOF was significantly more prevalent in assisted-living group (p< 0.05). There were significant positive correlations (p< 0.05) between each pair of PA, FOF and QOL for both assisted-living and community-dwelling groups.

Conclusions

Older adults in the ALFs had lower PA and QOL scores with higher prevalence of FOF than their community-dwelling counterparts. Significant relationships existed between PA, FOF and QOL for participants in either group. Present results may be suggesting that ageing in place ensures better health outcomes than institutionalised ageing. Whenever possible, older adults should therefore be encouraged to age in place rather than moving into ALFs.

Environmental and behavioural interventions for reducing physical activity limitation and preventing falls in older people with visual impairment

BACKGROUND

Impairment of vision is associated with a decrease in activities of daily living. Avoidance of physical activity in older adults with visual impairment can lead to functional decline and is an important risk factor for falls. The rate of falls and fractures is higher in older people with visual impairment than in age-matched visually normal older people. Possible interventions to reduce activity restriction and prevent falls include environmental and behavioral interventions.

OBJECTIVES

We aimed to assess the effectiveness and safety of environmental and behavioral interventions in reducing physical activity limitation, preventing falls and improving quality of life amongst visually impaired older people.

SEARCH METHODS

We searched CENTRAL (including the Cochrane Eyes and Vision Trials Register) (Issue 2, 2020), Ovid MEDLINE, Embase and eight other databases to 4 February 2020, with no language restrictions.

SELECTION CRITERIA

Eligible studies were randomized controlled trials (RCTs) and quasi-randomized controlled trials (Q-RCTs) that compared environmental interventions, behavioral interventions or both, versus control (usual care or no intervention); or that compared different types of environmental or behavioral interventions. Eligible study populations were older people (aged 60 and over) with irreversible visual impairment, living in their own homes or in residential settings. To be eligible for inclusion, studies must have included a measure of physical activity or falls, the two primary outcomes of interest. Secondary outcomes included fear of falling, and quality of life.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included six RCTs (686 participants) conducted in five countries (Australia, Hungary, New Zealand, UK, US) with follow-up periods ranging from two to 12 months. Participants in these trials included older adults (mean age 80 years) and were mostly female (69%), with visual impairments of varying severity and underlying causes. Participants mostly lived in their homes and were physically independent. We classified all trials as having high risk of bias for masking of participants, and three trials as having high or unclear risk of bias for all other domains. The included trials evaluated various intervention strategies (e.g. an exercise program versus home safety modifications). Heterogeneity of study characteristics, including interventions and outcomes, (e.g. different fall measures), precluded any meta-analysis. Two trials compared the home safety modification by occupational therapists versus social/home visits. One trial (28 participants) reported physical activity at six months and showed no evidence of a difference in mean estimates between groups (step counts: mean difference (MD) = 321, 95% confidence interval (CI) -1981 to 2623; average walking time (minutes): MD 1.70, 95% CI -24.03 to 27.43; telephone questionnaire for self-reported physical activity: MD -3.68 scores, 95% CI -20.6 to 13.24; low-certainty of evidence for each outcome). Two trials reported the proportion of participants who fell at six months (risk ratio (RR) 0.76, 95% CI 0.38 to 1.51; 28 participants) and 12 months (RR 0.59, 95% CI 0.43 to 0.80, 196 participants) with low-certainty of evidence for each outcome. One trial (28 participants) reported fear of falling at six months, using the Short Falls Efficacy Scale-International, and found no evidence of a difference in mean estimates between groups (MD 2.55 scores, 95% CI -0.51 to 5.61; low-certainty of evidence). This trial also reported quality of life at six months using 12-Item Short Form Health Survey, and showed no evidence of a difference in mean estimates between groups (MD -3.14 scores, 95% CI -10.86 to 4.58; low-certainty of evidence). Five trials compared a behavioral intervention (exercise) versus usual activity or social/home visits. One trial (59 participants) assessed self-reported physical activity at six months and showed no evidence of a difference between groups (MD 9.10 scores, 95% CI -13.85 to 32.5; low-certainty of evidence). Three trials investigated different fall measures at six or 12 months, and found no evidence of a difference in effect estimates (RRs for proportion of fallers ranged from 0.54 (95% CI 0.29 to 1.01; 41 participants); to 0.93 (95% CI 0.61 to 1.39; 120 participants); low-certainty of evidence for each outcome). Three trials assessed the fear of falling using Short Falls Efficacy Scale-International or the Illinois Fear of Falling Measure from two to 12 months, and found no evidence of a difference in mean estimates between groups (the estimates ranged from -0.88 score (95% CI -2.72 to 0.96, 114 participants) to 1.00 score (95% CI -0.13 to 2.13; 59 participants); low-certainty of evidence). One trial (59 participants) assessed the European Quality of Life scale at six months (MD -0.15 score, 95% CI -0.29 to -0.01), and found no evidence of a clinical difference between groups (low-certainty of evidence).

AUTHORS' CONCLUSIONS

There is no evidence of effect for most of the environmental or behavioral interventions studied for reducing physical activity limitation and preventing falls in visually impaired older people. The certainty of evidence is generally low due to poor methodological quality and heterogeneous outcome measurements. Researchers should form a consensus to adopt standard ways of measuring physical activity and falls reliably in older people with visual impairments. Fall prevention trials should plan to use objectively measured or self-reported physical activity as outcome measures of reduced activity limitation. Future research should evaluate the acceptability and applicability of interventions, and use validated questionnaires to assess the adherence to rehabilitative strategies and performance during activities of daily living.

Diurnal patterns of sedentary behavior and changes in physical function over time among older women: a prospective cohort study

BACKGROUND

Sedentary behavior (SB) is linked to negative health outcomes in older adults. Most studies use summary values, e.g., total sedentary minutes/day. Diurnal timing of SB accumulation may further elucidate SB-health associations.

METHODS

Six thousand two hundred four US women (mean age = 79 ± 7; 50% White, 34% African-American) wore accelerometers for 7-days at baseline, yielding 41,356 person-days with > 600 min/day of data. Annual follow-up assessments of health, including physical functioning, were collected from participants for 6 years. A novel two-phase clustering procedure discriminated participants' diurnal SB patterns: phase I grouped day-level SB trajectories using longitudinal k-means; phase II determined diurnal SB patterns based on proportion of phase I trajectories using hierarchical clustering. Mixed models tested associations between SB patterns and longitudinal physical functioning, adjusted for covariates including total sedentary time. Effect modification by moderate-vigorous-physical activity (MVPA) was tested.

RESULTS

Four diurnal SB patterns were identified: p1 = high-SB-throughout-the-day; p2 = moderate-SB-with-lower-morning-SB; p3 = moderate-SB-with-higher-morning-SB; p4 = low-SB-throughout-the-day. High MVPA mitigated physical functioning decline and correlated with better baseline and 6-year trajectory of physical functioning across patterns. In low MVPA, p2 had worse 6-year physical functioning decline compared to p1 and p4. In high MVPA, p2 had similar 6-year physical functioning decline compared to p1, p3, and p4.

CONCLUSIONS

In a large cohort of older women, diurnal SB patterns were associated with rates of physical functioning decline, independent of total sedentary time. In particular, we identified a specific diurnal SB subtype defined by less SB earlier and more SB later in the day, which had the steepest decline in physical functioning among participants with low baseline MVPA. Thus, diurnal timing of SB, complementary to total sedentary time and MVPA, may offer additional insights into associations between SB and physical health, and provide physicians with early warning of patients at high-risk of physical function decline.