Fear of falling and associated factors in community elderly with cataracts

Objective: To investigate prevalence of the fear of falling of elderly with cataracts living in the community and the associated factors with high concern with falling occurrences. Methods: A cross-sectional, analytical and observational study. It was composed by 86 elderly diagnosed with bilateral cataracts. To quantify the fear of falling among elderly, the scale Falls Efficacy Scale-InternationalBrasil (FES-I-BRASIL) was used. Other variables were obtained through application of a structured questionnaire. Results: Between participants, 41.9% reported low concern of falling, while 58.1% reported high concern. From those last ones, 52% fell at least once on the past 12 months and, 30% of them are recurrent fallers. The activities “to walk in slippery surfaces”, “to walk in irregular surfaces” and, “to walk up and down the stairs” represented higher concern for elderly. Conclusion: Cataracts or any other visual issue predispose falls due to difficulty in overcoming obstacles present in the environment. Fear of falling is especially associated with factors acquired after the first fall episode.


INTRODUCTION
T he falls represent one of the main problems in populations older than 65 years, considering about 30% of the elderly Brazilian population fall each year (1) .Concern or fear triggers a vicious cycle which includes the risk of new falls, balance and mobility deficit and consequently, functional decline resulting in fear of new falls (2) .
The referred fear is characterized by anxiety to walk or excessive concern to fall.Such condition is associated with the factors: advanced age, female gender, education level lower or equal to four years, depression, urinary incontinence, chronic pain, difficulties in activities of daily living (ADLs), lesions caused by falls, decrease of socializing, sedentary lifestyle, rare conviviality with friends, to have fallen five or more times, limitation of activities after falling and, worse health perception (3) .
Besides these factors, decrease in vision, hearing, postural control, muscle power and, changes in joints can facilitate the risk of accidents and falls by the reduction of defensive reactions (4) .Decrease in visual acuity is a contributing factor for fall occurrence and fear of falling in elderly.
Cataracts is one of the ophthalmologic diseases that most affect individuals older than 65, and it is defined as any opacity in the lens that refracts light, causing negative effects in vision (5) .Although it is a pathology with simple diagnosis, it still is the main cause of age-related visual impairment, but this risk decreases when treated early and with the necessary ophthalmologic accompaniment (6) .
Considering elderly with low visual acuity tend to decrease their routine activities, increasing social isolation and likelihood for falls and/or fear of falling, it becomes relevant for more studies about the theme to be conducted.Besides, associated factors with risk of falling have not been well investigated yet in cataracts patients.Thus, this study aimed to investigate the fear of falling prevalence in elderly with cataracts living in the community, and the associated factors to high concern with fall occurrence.

METHODS
This was a cross-sectional, analytical and observational study conducted at the Federal District (Distrito Federal -DF), Brazil, and it is part of a larger project entitled "Impact of cataract surgery on the occurrence of falls and on multidimensional health aspects: a longitudinal study of elderly in the Federal District".
Initially, 144 elderly were recruited by scheduling ophthalmology ambulatory services from two public hospitals in the Federal District (DF) and, in health centers from Ceilândia and Sobradinho, which are DF regions.After applying the selection criteria, the final sample was composed by 86 elderly with bilateral cataracts diagnosis.
The adopted inclusion criteria were: elderly aged 60 years or more, of both genders and, with bilateral cataract diagnosis.Diagnosis was confirmed through an exam conducted by an ophthalmologist (7) .The following exclusion criteria were adopted: neurological diseases, visual impairment not corrected by use of lens or glasses, previous cataract surgery, cognitive impairment assessed by scoring on the Mini-Mental State Examination (8) (17 points cutoff), palsies or orthopedic changes (as amputations and fractures), incapability to self-keep orthostatic and to move without assistance.Falls as well as the fear of falling are common syndromes with potentially harmful results for elderly.The fear of falling is characterized by anxiety while walking or excessive concern of falling.To quantify the fear of falling between elderly, the Falls Efficacy Scale-International Brasil (FES-I-BRASIL) ( 1) was used.It assesses the level of concern about falling when the individual executes some daily activities, including outdoor activities and social interaction.It is a self-report questionnaire composed by 16 items.The answer in each item varies from 1 (without concern) to 4 (very concerned), and the total score varies from 16 to 64 points (9) .For better data fitting, obtained scores were classified as "low concern with fall occurrence" (< 22 points) and "high concern with fall occurrence" (> 22 points), according to the cut point proposed by Delbaere et al. (10) .
Elderly were enquired about occurrence of falls on the past year by the following question: "Have you fallen on the past year?"If yes, how many times?Other variables were obtained through the application of a structured questionnaire containing questions as: age, gender, marital status, literacy and education level, health-related information (presence or not of cataracts diagnosis, cataract surgery, presence of comorbidities, depression, number of medications, and use of psychotropic drugs), and lifestyle (tobacco, physical activity and alcohol drinking).
Data were descriptively analyzed through the statistical package SPSS 13.0.To assess association of fear of falling and the variables of interest for elderly with cataracts, the following tests were used: Chi-Squared and Fisher's Exact test.For all analyses, the level of significance adopted was p<0.05.

RESULTS
The present study was composed by 86 elderly with cataracts, 53 females and 33 males.Mean ages were 69.3 ± 5.3 years for women and 72.1 ± 5.8 years for men.Between men and women, the mean age was 70.3 ± 5.6 years.Between participants, 36 (41.9%) reported low concern of falling (d" 22 points), while 50 (58.1%)reported high concern (> 22 points).The investigated factors regarding high concern are presented on Tables 1, 2 and 3.
We can observe that sociodemographic characteristics (Table 1) did not negatively interfered on the fear of falling.
Clinical characteristics and their associations with the concern of falling occurrence are described on table 2.
When analyzing the report of previous falls with the actual concern in having new falls, it is observed that 52% (n=26) of the population with high concern of falling suffered at least one fall on the past 12 months, while only 22.2 (n=8) of elderly with low concern of falling fell on the past year.From the elderly with high concern of falling (n=26), 30% (n=15) are recurrent fallers.These reported falls occurred at night time and outside the house.
The FES-I-BRASIL instrument presents different activities that can be characterized as ADLs, physical, and social activities.In the investigated population, it is noted that physical activities present higher scores, that is, they arise more concern with falls.
The activities "to walk in slippery surfaces", "to walk in irregular surfaces", and "to walk up and down the stairs" were the ones which presented more concern of falling for elderly.

Table 3 Concern of falling during ADL, physical and social activities, proposed by the FES-I-BRASIL instrument, in community elderly with cataract
Footnotes: (*) Significance on the Chi-Square test; NA: did not answer; DK: does not know; ND: not determined When analyzing the report of previous falls with the actual concern in having new falls, it is observed that 52% (n=26) of the population with high concern of falling suffered at least one fall on the past 12 months, while only 22.2 (n=8) of elderly with low concern of falling fell on the past year.From the elderly with high concern of falling (n=26), 30% (n=15) are recurrent fallers.These reported falls occurred at night time and outside the house.
The FES-I-BRASIL instrument presents different activities that can be characterized as ADLs, physical, and social activities.In the investigated population, it is noted that physical activities present higher scores, that is, they arise more concern with falls.
The activities "to walk in slippery surfaces", "to walk in irregular surfaces", and "to walk up and down the stairs" were the ones which presented more concern of falling for elderly.

DISCUSSION
The prevalence of fear of falling in elderly with cataracts is associated to extrinsic factors, as the presence of slippery, irregular floors or stairs.
Elderly with hypertension and low hearing ability present higher concern of falling.The presence of factors as hypertension (that is a great contributor for the maintenance of erectile posture), and low hearing acuity (which can be associated to vestibular issues), are common in elderly who had falling episodes (11) .Although the obtained results in this study does not present an association between visual issues and concern with fear of falling, studies shows visual deficit negatively interfering in the functional capacity of elderly, making activities of daily living difficult, and potentially increasing the fear of falls (12) .There is an important association between the presence of cataracts and the fear of falling (5) .In addition, the visual acuity deficit, the increase in light susceptibility and the lack of stability when fixing sight, are leading factors for loss of balance, once the visual sensorial function helps the postural control mechanism and, compromising this mechanism decreases the elderly everyday performance (13,14) .

Activities Frequency (%) I am not
Smokers also demonstrated less fear or concern about falling.Tobacco is assumed to be considered a scape valve and it helps with anxiety and depression control for those who consume it.
The fear of falling in this population is also influenced by psychological and cognitive factors that negatively affect balance (15) .The decrease of motor skills, difficulty to adapt to the environment, low self-confidence, functionality decrease, fragility increase, depression, anxiety, loss of social contact, negatively affects balance and, they are predispose factors for falls in elderly (16) .
Elderly who fell have more fear of falling than those who fell only once.Decrease in self-confidence, low self-esteem, and fear triggered after falls are feelings guiding the elderly postaccident (12) .Besides, in the present study, the concern with fear of falling was not strong in those who reported falling on the previous year, contrary to expectations.This absence can be related to how the FES-I assesses, emphasizing falls on the past year (17) .Elderly who are fearful of falling reported falling more than once, relating fear with the number of falls, and not with time.
The majority of elderly who fell reported to be outside the house and during night time.Factors as adequate light, nonslippery floors, adequate disposition of objects and, absence of carpets help with the prevention of possible incidents (18) .The predominance of elderly falls happen at the house (internal or external areas), especially in the living room, following by the bathroom and kitchen (19) .
The risk of falling in elderly includes not only the falling result itself, but also the high likelihood of lesions caused by the episode (20) .Falls can be responsible for fractures and injuries needing sutures (21) .Not only the first falling event needs to be avoided, substantially decreasing the chance of new episodes, but only to monitor elderly who already fell and, to establish which factors increase risk of severe lesion (22) .
With the increase of age, fear of falling increases.For people older than 75 years, it is one of the most cited barriers for adoption of physical activity (23) Fear of falling can result in a sequence of events leading to social isolation and to loss of function (24) .Physical weakness, social isolation, functional decline and polypharmacy have been largely associated to increase of recurrent falling incidence (25) .
The fear of falling is not only an acute result from a fall, but an acknowledgement of a risk probability.Once developed, it is very likely for this fear to persist, independently from fall occurrence (26) .The low self-perception of efficacy can reduce the gait speed and to create a more careful behavior in daily movement that is not immediately detected (27) .The lack or decrease of muscle strength, the low cardiovascular fitness level, and the agility decrease are highly associated to fear of falling (20) .
The referred fear can be associated not only to a balance decrease, but also a reduction in mobility, physical activity, and the increase of falls.Thus, the importance to invest in programs aimed to incentivize regular physical activity and educational practices for general population, but especially for elderly individuals, can be re-affirmed (28) .

CONCLUSION
Visual impairment, being cataracts or any other visual issue, predisposes falls due to the difficulty created in perceiving the environment and for independent and safe mobility to perform activities and face obstacles.The majority of problems related to vision can be corrected and, if they are corrected, other problems can be avoided.The fear of falling is especially associated with factors acquired after the first falling episode.Psycho-emotional factors, as self-confidence decrease, depression, and social isolation are responsible for the functional decrease and fragility appearance.
It is suggested for other studies related to fear of falling to be conducted between people with cataracts, and for new studies to investigate the relationship between the use of tobacco and concern of falling.

Table 1 Sociodemographic characteristics and concern with occurrence of falls of community elderly with cataract
NA: did not answer; DK: does not know; ND: not determined