Falls

Falls are a leading cause of injury and death in older Americans. The incidence and severity of falls rises with increasing age. Approximately one-third of US adults older than 65 years fall each year, yet less than half talk to their physicians about it. In 2010, about 21,700 older adults in the United States died as a result of unintentional fall injuries. In 2014 alone, older Americans experienced 29 million falls, resulting in 7 million injuries and incurring about $31 billion in annual Medicare costs. Falls are responsible for more than 60% of all traumatic brain injuries (TBIs) in people over 65 years old. In the United States, fall-related TBIs are responsible for 14,347 deaths per year. Men are more likely to die from a fall. Older white individuals are 2.4 times more likely to die from falls than are older black individuals. Also, there are differences in fatal fall rates among ethnic groups; older non-Hispanic persons have higher fatal fall rates than do older Hispanic persons. Fear of falling may cause elderly persons to limit activities, leading to reduced physical fitness, which, in turn, increases the actual risk of falling.

Prevention of falls is key. Older adults may reduce their chances of falling by

• exercising regularly

• increasing leg strength and balance

• asking their physician or pharmacist to review any of their medications that might cause dizziness or drowsiness

• having their eyes checked annually to update glasses or evaluate for eye diseases that limit vision

• getting assistance to make their living areas safer by

  • removing tripping hazards

  • installing grab bars in the bathroom and railings on the side of stairways (such as the entry to the home)

  • improving lighting

Visual disorders are a frequent cause of falls. Recent studies in the United States and the United Kingdom suggest that elderly individuals are almost twice as likely to fall if they are visually impaired. An ophthalmologist may help patients reduce the risk of falls by

• asking patients appropriate questions about the activities listed above that might reduce fall risk

• recognizing and treating visual disorders, including refractive errors, to identify and minimize ocular reasons for falls

Patients with reduced vision from eye disease, most often macular degeneration, are at the highest risk of falling. Once a history of falls is obtained, it is incumbent upon the ophthalmologist to notify the patient’s primary care physician about this finding or refer the patient to a multidisciplinary medical facility with resources for managing falls in the elderly.

• Centers for Disease Control and Prevention (CDC). Stopping elderly accidents, deaths   injuries (STEADI): Older adult fall prevention. www.cdc.gov/steadi. Updated March 23, 2017. Accessed February 21, 2019.

• Stevens JA, Ballesteros MF, Mack KA, Rudd RA, DeCaro E, Adler G. Gender differences in seeking care for falls in the aged Medicare population. Am J Prev Med. 2012;43(1):59–62.

Ophthalmic considerations Many activities of daily living require adequate functioning of different visual components such as near, intermediate, and distance vision, as well as peripheral vision, binocular vision, depth perception, contrast sensitivity, and color vision. Cataract surgery improves functional visual status, resulting in overall improved health-related quality of life, mental health, and emotional well-being. Visual function plays an important role in physical performance, especially in terms of mobility. The rate of falls in the elderly is diminished after cataract removal, with a lower incidence of hip fracture 1 year after the procedure when compared with patients with cataract who did not have cataract surgery.

• American Academy of Ophthalmology Cataract/Anterior Segment Panel, Hoskins Center for Quality Eye Care. Preferred Practice Pattern^® Guidelines. Cataract in the Adult Eye. San Francisco: American Academy of Ophthalmology; 2016. www.aao.org/ppp.

• American Academy of Ophthalmology Committee, Hoskins Center for Quality Eye Care. Preferred Practice Pattern^® Guidelines. Comprehensive Adult Medical Eye Evaluation. San Francisco: American Academy of Ophthalmology; 2015. www.aao.org/ppp.

• American Academy of Ophthalmology Retina/Vitreous Panel, Hoskins Center for Quality Eye Care. Preferred Practice Pattern^® Guidelines. Age-Related Macular Degeneration. San Francisco: American Academy of Ophthalmology; 2015. www.aao.org/ppp.

• American Academy of Ophthalmology Retina/Vitreous Panel, Hoskins Center for Quality Eye Care. Preferred Practice Pattern^® Guidelines. Diabetic Retinopathy. San Francisco: American Academy of Ophthalmology; 2017. www.aao.org/ppp.

• Tseng VL, Yu F, Lum F, Coleman AL. Risks of fractures following cataract surgery in Medicare beneficiaries. JAMA. 2012;308(5):493–501.

• US Census Bureau website; www.census.gov.

• United Nations Statistics Division Demographics and Social Statistics: Population Censuses’ Datasets (1995–Present). New York, NY. https://unstats.un.org/unsd/demographic-social/products/dyb/dybcensusdata.cshtml. Accessed February 21, 2019.

Excerpted from BCSC 2020-2021 series: Section 1 - Update on General Medicine. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.