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Falls in older people with cataract: a longitudinal evaluation of impact and risk

The George Institute for Global Health, UNSW Australia
Project Added:
23 June 2017
Last updated:
30 June 2017

Falls in older people with cataract: a longitudinal evaluation of impact and risk

Summary

This project identified factors associated with an increased falls risk in older people with cataract during their wait for cataract surgery.

View a poster of this project, presented at the ACI Ophthalmology Network Eyes on the Future Forum, 2017 and a summary fact sheet.

Aim

To explore the burden of falls in older Australians with cataract during their wait for cataract surgery and identify the factors associated with an increased falls risk.

Benefits

  • Identifies risk factors associated with falls in older people waiting for cataract surgery.
  • Provides evidence of the high rate of falls in older people with cataract, to support initiatives that reduce wait time for cataract surgery.

Background

Cataract is a leading cause of vision impairment globally. Around 1.2 million Australians over the age of 65 have clinically significant cataract1, which places them at a risk of falling that’s three times higher than normal2. In Australia, falls cost over $1 billion in treatment, disability, lost output and mortality each year3.

While cataract surgery is highly effective at restoring sight4, long waiting times for public cataract surgery are common in Australia5. Patients can wait up to three years for their first eye surgery: an initial two years wait for an outpatient ophthalmology assessment6 and a further 12 months on the surgical waiting list5.

There is evidence that reducing wait times for cataract surgery can reduce the rate of falls among people over 65 years of age. A study in the United Kingdom found a 34% reduction in falls of patients waiting for cataract surgery, by reducing surgery wait time from 12 months to one month7.

Implementation

  • 329 participants were recruited from eye clinic referral records and surgical waiting lists at eight public hospitals in Sydney, Melbourne and Perth. The following eligibility criteria applied to all participants in the study:
    • aged 65 years or older
    • bilateral cataract, presenting for their first eye cataract surgery (no combined surgery)
    • no diagnosis of dementia, Parkinson’s disease or stroke
    • living in the community or a self-care unit of a retirement village
    • no other significant ocular comorbidities
    • able to walk (not wheelchair bound).
  • Pre-surgical data of participants was analysed, with the following baseline measurements recorded:
    • measures of visual function (visual acuity, contrast sensitivity, stereopsis, refractive error, spectacle correction, ocular dominance)
    • visual disability (Catquest-9SF)
    • medications and comorbidities
    • fear of falling (Short Falls Efficacy Scale-International)
    • depressive symptoms (5-item Geriatric Depression Scale) and quality of life (QoL; EQ-5D-5L)
    • exercise frequency (Incidental and Planned Exercise Questionnaire) and physical function (Short Physical Performance Battery).
  • Participants recalled falls in the 12 months prior to baseline and self-reported falls during their surgical wait using a monthly calendar. The context and outcomes of any falls were determined by phone interview.
  • Fall rate during the cataract surgery waiting period was the primary outcome measure and was calculated using the formula: total prospectively reported falls ÷ total time (in years) in study pre-surgery.
  • Factors predicting an increased risk of falls were assessed using statistical analysis (negative binomial regression). Additional analysis was conducted to assess factors predicting falls in those who fell twice or more during their surgical wait (‘multiple fallers’).

Project status

Sustained – The project has been implemented and is sustained in standard business.

Key dates

Participants were recruited between October 2013 and August 2015. They were monitored for up to two years, or until their first eye surgery.

Implementation sites

Sydney Eye, Westmead, Bankstown, Royal North Shore, Royal Victorian Eye and Ear, Royal Perth, Sir Charles Gairdner and Freemantle Hospitals.

Partnerships

  • Curtin Monash Accident Research Centre, Curtin University
  • Eye and Vision Epidemiology Research Group, University of Western Australia
  • National Health and Medical Research Council
  • NSW Agency for Clinical Innovation
  • Save Sight Institute, University of Sydney
  • The George Institute for Global Health, UNSW Australia
  • Westmead Institute for Medical Research, Westmead Hospital

Results

  • In a group of 329 patients aged over 65 years with bilateral cataract, one in three experienced a fall during their wait for their first cataract surgery.
  • There were a total of 267 falls reported by 101 (31%) of participants while waiting for their first eye surgery, or 1.2 falls per person per year.
  • Greater walking activity, poorer quality of life and a fall in the prior 12 months were associated with an increased falls rate during the waiting period.
  • Multiple falls were experienced by 49 (15%) participants while waiting for surgery, ranging from two falls to 31. Poorer quality of life was the sole predictor of multiple falls in this group.
  • Over one half of falls (52%) caused injury, including 14 head injuries and two fractures. 22 (8%) falls resulted in a visit to the general practitioner and 10 (4%) resulted in a presentation to the hospital emergency department.
  • The median observation time prior to first eye surgery was 176 days or 5.7 months, with a range of 2-730 days.
  • It was estimated that 91 falls could potentially be prevented, if participants received cataract surgery within one month of referral, compared to their actual wait time7.
  • The findings are being used to support policy development and resourcing for cataract surgical services.
  • Ongoing work with participants is currently underway, to evaluate the impact of a second eye surgery on falls risk.

Lessons learnt

These findings demonstrate a high rate of falls and fall-induced injuries in older adults with cataract waiting for surgery in Australia. Within this relatively homogenous group of participants, measures of visual function did not adequately predict falls risk. Walking activity proved more valuable in assessing falls risk during their wait for surgery. Further research on the impact of expedited surgery on falls risk is planned.

References

  1. Australian Institute of Health and Welfare (AIHW). Vision problems among older Australians. Canberra: AIHW; 2005.
  2. McCarty CA, Fu CL, Taylor HR. Predictors of falls in the Melbourne visual impairment project. Australian and New Zealand Journal of Public Health 2002; 26(2): 116-119.
  3. Moller J. Cost of injury. National estimates based on the cost model reported by Watson and Ozanne-Smith. Canberra: AIHW; 1998.
  4. Lansingh VC, Carter MJ, Martens M. Global cost-effectiveness of cataract surgery. Ophthalmology 2007; 114(9): 1670-1678.
  5. AIHW. Australian hospital statistics 2013-14: elective surgery waiting times. Canberra: AIHW; 2014.
  6. Victorian Government Department of Human Services. Victorian ophthalmology services planning framework. Melbourne: State Government Victoria; 2005.
  7. Harwood RH, Foss AJ, Osborn F et al. Falls and health status in elderly women following first eye cataract surgery: a randomised controlled trial. British Journal of Ophthalmology 2005; 89(1): 53-59.

Further reading

  • Palagyi A, McCluskey P, White A et al. While we waited: incidence and predictors of falls in older adults with cataract. Investigative Ophthalmology & Visual Science 2016; 57: 6003-6010. DOI: 10.1167/iovs.16-20582

Contact

Lisa Keay
Deputy Director, Injury Division
The George Institute for Global Health, UNSW Australia
Phone: 02 8052 4335
lkeay@georgeinstitute.org.au

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