Trio of Eye Diseases Linked to Falls, Fractures in Older Adults

Older adults with cataracts, age-related macular degeneration (AMD), and glaucoma are all more likely to have falls or fractures compared with those without these eye diseases, a population-based cohort study suggested.

While the findings don’t definitively prove that vision problems cause these accidents, an analysis of health records in England revealed higher risks of falls compared with control patients for those with cataracts (adjusted HR 1.36, 95% CI 1.35-1.38), AMD (aHR 1.25, 95% CI 1.23-1.27), and glaucoma (aHR 1.38, 95% CI 1.35-1.41), reported Jung Yin Tsang, MRes, of the University of Manchester, and colleagues.

Risks were also higher for fractures in those with cataracts (aHR 1.28, 95% CI 1.27-1.30), AMD (aHR 1.18, 95% CI 1.15-1.21), and glaucoma (aHR 1.31, 95% CI 1.27-1.35) compared with controls, although it’s not clear how many were caused by falls, the authors noted in JAMA Ophthalmology.

The findings suggest that clinicians who treat eye diseases can help patients by counseling them about fall risks and referring them to fall prevention programs, Tsang said in an interview with MedPage Today. “What is important is the recognition and awareness. All that may be needed is that at-risk patients can be given some extra advice or pointed in the right direction, so we avoid missed opportunities to prevent falls.”

How does vision loss affect fall risk? “Our study is observational, so we don’t know the exact connection,” Tsang said. “Based on previous research, it’s likely a mixture of vision, balance, poorer hazard perception, and unmeasured factors. Even mild eye disease appears to increase your fall risk.”

A 2014 CDC survey of adults ages 65 and up found that 46.7% of those with severe vision loss reported a fall within the last year versus 27.7% of those without severe vision loss. The report estimated that 1.3 million people in the U.S. 65 and older with severe vision loss fell that year.

In 2005, a study of 537 older patients with hip fractures in Scotland found that 46% had significant visual impairment, in almost half of cases due to untreated cataracts.

In an invited commentary, Shrinivas Pundlik, PhD, and Gang Luo, PhD, of Schepens Eye Research Institute of Massachusetts Eye and Ear at Harvard Medical School in Boston, pointed out that the study “is one of the largest studies of falls and fractures among people with eye diseases.”

“Interestingly, patients at the highest level of comorbidity index had lower risk of falls in all 3 diseases compared with those at slightly lower levels of comorbidity index,” they wrote. “Those with higher comorbidities may have self-limiting behavior, thereby decreasing the risk relative to those who have fewer comorbidities.”

They also noted that “curiously,” non-white patients had a lower risk of falls: “Whether this is associated with lower access to medical care, lower socioeconomic living conditions, worse comorbidity indices, or higher mortality rates among non-white race and ethnicity groups needs further investigation.”

For this study, Tsang and colleagues used electronic medical record data from England for adults from 2007-2020 and compared 410,476 patients with cataracts (mean age 73.8, 57.1% women, 88.3% white) to 2,034,194 controls; 75,622 patients with AMD (mean age 79.4, 62.1% women, 93.9% white) to 375,548 controls; and 90,177 with glaucoma (mean age 69.8, 51.8% women, 83.4% white) to 448,179 controls. Patients and controls were followed for a median of 4 years.

Those with eye disease were more likely to also have heart disease, hypertension, type 2 diabetes, heavy alcohol use, and osteoporosis, but less likely to have asthma/chronic obstructive pulmonary disease, neurological conditions, and kidney disease.

Tsang and team made adjustments for more than 50 potential confounders, such as demographics, long-term conditions, and medications that may boost fall risk.

Of the patients, 29.7% of those with cataracts experienced a fall compared with 13.9% of controls, 37.1% of those with AMD had a fall versus 20.7% of controls, and 25% of those with glaucoma fell versus 12.8% of controls. These rates for fractures were 14.4% versus 8.2%, 17.8% versus 11.6%, and 12.2% versus 7.3%, respectively.

As for limitations, “we used routinely collected electronic health records, so it is retrospective data with irregular follow-up,” Tsang said. “As our focus was eye disease as a marker of increased risk, we did not look at visual function or treatments during follow-up.”

However, he added that “other studies have shown that cataract surgery has an impact on lowering fall risk. The evidence base for AMD and glaucoma is still developing, particularly as newer treatments for these conditions are still evolving.”

The researchers also noted that they didn’t have information about whether the conditions affected one or both eyes in patients. Those with vision loss in both eyes would presumably be at higher risk.

Another potential limitation was that unreported falls may not have been included.

Moving forward, Tsang said “we are planning to investigate whether conversations about fall prevention happen across a range of patients and professionals. We aim to enhance existing care to make sure the correct advice is given at the right time to optimize fall prevention and patient care.”

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