Beruflich Dokumente
Kultur Dokumente
12355
Abstract
Correspondence Background Sight impairment increases with age and, compared
Heather A. Waterman PhD, BSc (Hons)
RN
with the general older population, older people with sight impair-
Professor ment are more likely to fall. There is a growing body of evidence
School of Nursing, Midwifery and on the views and perceptions of older people about falls, but little
Social Work
is published on the views of older people with sight impairment.
University of Manchester
Jean McFarlane Building
Objective To explore what older people with sight impairment
Oxford Road
Manchester M13 9PL believe to be the causes of falls.
UK
E-mail: heather.waterman@ Design A qualitative design was used, incorporating focus groups
manchester.ac.uk and interviews in which participants discussed falls and falls pre-
Accepted for publication vention. Framework analysis was employed to identify themes
28 January 2015 arising from participants discussions of the causes of falls.
Keywords: causes of falls, focus
groups, interviews, qualitative
Setting and participants Fifty-four community dwelling men and
research, risk factors of falls, severe women with sight impairment, aged 65 and over, were recruited
sight impairment from across Greater Manchester, UK.
Results Five types of factors were identied that were believed to
cause falls: (i) health issues and changes in balance caused by age-
ing; (ii) cognitive and behavioural factors; (iii) the impact of sight
impairment on getting around the home; (iv) the impact of sight
impairment on negotiating the environment away from home; and
(v) unexplained falls.
Discussion and conclusions Older people with sight impairment
reported many researched risk factors previously identied by
older people without sight impairment but also described many
perceived risks unique to people with sight impairment. There are
few interventions to prevent falls aimed at older people with sight
impairment, and the results of this study allow further tailoring of
such interventions based on views of older people with sight
impairment.
2015 The Authors Health Expectations Published by John Wiley & Sons Ltd., 18, pp.20212031 2021
This is an open access article under the terms of the Creative Commons Attribution License,
which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
2022 Causes of falls in older people, C Brundle et al.
2015 The Authors Health Expectations Published by John Wiley & Sons Ltd
Health Expectations, 18, pp.20212031
Causes of falls in older people, C Brundle et al. 2023
In Phase 1, focus groups took place with requirements. Older people were excluded if they
older people with sight impairment and their were receiving a home safety or exercise inter-
carers. Those not able to participate in groups vention or were cognitively impaired.
were invited to contribute their perspectives People meeting the eligibility criteria who
through semi-structured interviews. Every eort were interested in taking part in the research
was made to encourage older people with sight were given a participant information sheet
impairment to attend focus groups, including (PIS) to take away and consider. The PIS was
oering practical support such as booking appropriately designed for people with sight
transport. However, for some potential partici- impairment, with columns of large print on a
pants, their vision, health conditions and other yellow background. A follow-up telephone call
diculties made them reluctant to attend. By was made a few days later to answer questions
oering interviews in the home as an alternative, and conrm participation.
we were able to capture the views of a broader Phase 1 took place between September and
range of older people than if focus groups alone December 2011. Four focus groups were car-
were used. ried out. Group size varied between three and
In Phase 2, semi-structured interviews were eight participants to facilitate discussion and
used. Focus groups were not practical for this turn taking, which can be dicult when visual
phase because the interviews were conducted as conversation cues cannot be relied upon. Six
each individual completed their participation in people participated in semi-structured inter-
the RCT. views, three with a carer present.
Thirty-three people participated in semi-
structured interviews in Phase 2, two with a
Participants
carer. These interviews took place between
Participants were recruited to the study in two October 2012 and May 2013.
ways.16 (i) Patients attending Manchester
Royal Eye Hospitals low vision clinic were
Data collection
informed about the research by optometrists.
(ii) Participants of social and support group All participants provided written informed con-
meetings of vision-related charities in Greater sent. Focus groups took place at a clinical
Manchester, UK, were invited to participate by research facility which was accessible for those
one member of the research team (CBr) after with impaired mobility. The groups were facili-
giving a presentation about the study. tated by experienced qualitative researchers
The RCT eligibility criteria16 were applied to (CB, PS, HW). Four other members of the
recruitment for both phases of the study: moder- research team were present in order to meet
ately or severely vision impaired, dened as participants as they arrived, to provide assis-
visual acuity less than 0.6 logMAR and/or mod- tance in navigating around the room, help with
erate visual eld loss, dened as aecting more turn taking during the discussions and arrange
than 20% of the test location used in a binocular transport home.
Esterman test; aged 75 and over (Phase 1), sub- We drew on expertise from within the project
sequently reduced to 65 and over for Phase 2 management team, took advice from the
due to recruitment diculties; independently Thomas Pocklington Trust and iteratively built
community dwelling; able to walk around their on our early experiences of the groups to
own residence; cognitively able to participate in develop eective strategies for eliciting and pro-
the study; and able to understand the study moting discussion. For example, wearing of
brightly coloured clothes by researchers, each in
a dierent colour, to help participants to distin-
Esterman binocular test: an eyesight test on both eyes
together where the person wears their usual distance guish between them, and making available a
glasses. hearing loop system for hearing aid users.
2015 The Authors Health Expectations Published by John Wiley & Sons Ltd
Health Expectations, 18, pp.20212031
2024 Causes of falls in older people, C Brundle et al.
Semi-structured interviews were carried out characteristics of the research participants are
by experienced individual researchers (CB and shown in Table 1.
NO). The topic guides used were developed by Five themes capturing older peoples views
the project management team. Questions about on the causes of falls were identied in the
the causes of falls were asked as part of wider analysis and are described in this section.
discussions around sight impairment and falls 1. Health issues and changes in balance caused
prevention. by ageing.
2. Cognitive and behavioural factors, including
risk taking.
Data analysis
3. The impact of sight impairment on getting
Focus group and interview data were audio- around the home.
recorded, transcribed and anonymized. Frame- 4. The impact of sight impairment on negotiat-
work analysis was used, selected for its explicit ing the environment away from home.
and systematic process of sorting and ordering 5. Unexplained falls.
data, thus making the resultant ndings acces-
The descriptions of the themes are elabo-
sible. The framework approach comprises ve
rated with extracts from the interview and
interconnected phases:20
focus group transcripts (annotated as Int and
1. Familiarization with the data to gain an
FG respectively below).
overview of the data coverage.
2. Identifying a thematic framework, drawing
upon recurrent themes and issues introduced Health issues and changes in balance caused
through the topic guide. Themes are grouped by ageing
under a smaller number of higher order main
Older people with sight impairment suggested
themes.
several health issues that they believed were
3. Indexing data into the framework, deciding
responsible for causing them and other older
which themes apply to each phrase or para-
people to have falls. Some of the suggestions
graph in the data.
were specic conditions and related symptoms
4. Developing charts from categories identied
such as Parkinsons Disease, arthritis, vertigo
in the framework so that each main theme
and a lack of sensation in the feet caused by
and its subtopics are plotted in separate
diabetes. Older people also described more
charts.
vague health-related factors they linked with
5. Mapping and interpretation, in which key
falling, such as knees giving out, poor circula-
points of each piece of data are summarized
tion, heart problems, blacking out and ear
into the thematic matrix, retaining the con-
problems that cause dizziness. Some suggested
text and language in which it was expressed.
that medication taken to control health prob-
The use of the NVivo 9 software package lems, rather than the health conditions them-
facilitated the analysis. selves, could be responsible for causing people
Analysis of the two phases of qualitative to fall.
research produced similar themes so the nd-
Sometimes my knee, this knee like, you know,
ings are presented in the results section without on my right leg like, thats a little bit dodgy now
dierentiation. and again, and sometimes a factor. (Phase 2 Int
P001)
Results
When you sit down or lie down your circulation
Fifty-four older people with sight impairment goes a little bit. . .you must make sure you shake
took part in the study, 38 women and 16 men. yourself around to get that circulation going.
(Phase 1 FG1)
The mean age was 83 (range 6596). The
2015 The Authors Health Expectations Published by John Wiley & Sons Ltd
Health Expectations, 18, pp.20212031
Causes of falls in older people, C Brundle et al. 2025
FG, focus group; Ints, interviews; OPVI, older people with visual impairment; NoK, next of kin or carer; M, male; F, female; WB, White British;
N/A, not applicable.
Balance problems caused diculties for I found that Id gone to sleep and the television
many participants, and some of them talked was still on. I jumped up. It was very bad to do
that because I got to about there [pointing to
about other older people being more likely to
wall]. Id turned the television o, but I dont
fall as a result of being wobbly and unsteady remember much after. I remember being near the
on their feet. Turning around too quickly wall, and sliding down the wall, but I blacked
caused some participants to fall. out. (Phase 1 Int P04)
2015 The Authors Health Expectations Published by John Wiley & Sons Ltd
Health Expectations, 18, pp.20212031
2026 Causes of falls in older people, C Brundle et al.
They dont slow down; they try to carry on the It was in the bedroom and you know the open
same pace as they used to do. (Phase 2 Int P027) end of a duvet, I got my foot caught in the end
and I went ying and I hurt my shoulder and I
I think its just carelessness really. (Phase 2 Int had physio for about six months on that
P035) shoulder. (Phase 2 Int P034)
Several participants believed that using some Well, of course, rugs in the house, tripping over
general common sense, taking care and slowing rugs and things like that, or in the house, the
down, they were less likely to fall than those carpet, when youve got a divider, going from
others who rushed around. However, risk- one room to the other, if they come a bit loose
and you stub your toe against them, things like
taking behaviour was practiced by others, such
that. (Phase 1 FG2)
as climbing onto chairs to reach items on high
shelves, even though they acknowledged they Slipping on spillages, recently mopped oors
knew they really should not be doing such and washing machine leaks that the older peo-
things. ple were unable to see had caused falls in the
home.
Youve just got to think what youre doing all
the time, havent you? (Phase 1 FG 4) If you spill anything, which I do, because Im
always independent, I can do it [clear up the
Sometimes I climb up and I shouldnt. I know spillage]. And of course you cant always do it,
that. Thats my fault. (Phase 1 Int P05) so you spill something then you dont know
where youve spilt it, you dont know where its
landed. And by the time youve found it youve
I actually fell over in the garden, missed my step,
slipped in it. (Phase 1 FG2)
and broke my wrist. . .I was stood on a wall
and. . . doing. . . cutting some nettles down or ivy, Stairs were seen as a particular problem.
thats right, and I stepped back and missed my Many participants recalled times that they had
step and woof, o I went, and I went back like
stumbled or fallen when they thought they had
that. (Phase 2 Int P09)
reached the top or bottom of a ight of stairs,
Both lack of exercise and exercising were but in fact they still had one step to go. Poor
implicated in causing falls. A small number of lighting was thought to be a contributory fac-
participants recognized that exercising less in tor in some of these cases. There was not
older age as could lead to frailty and falling. agreement on whether going up or going down
. . .exercise and going out and about and what
stairs was more risky for older people with
not, if you dont do that then. . .theyre more sight impairment; both directions were men-
likely to fall. (Phase 2 Int P034) tioned as hazardous.
Some older people with sight impairment Going down the stairs and its the last step. . .the
were concerned that exercise programmes stair carpet was the same colour as the hall car-
pet, you see, so it all just merged in, and it disap-
designed to reduce the risk of falls could actu-
peared completely. It was a horrible feeling.
ally be counterproductive. (Phase 1 FG 3)
You might fall while youre doing your exercises.
(Phase 2 Int P029) But its notable particularly when Im going
upstairs, and I have to be very careful that I
dont fall backwards. (Phase 2 Int P039)
The impact of sight impairment on getting Changes to a previously familiar home envi-
around the home ronment were thought to be particularly haz-
Many older people with sight impairment ardous. For example, if visitors moved
talked about falls in the home as a result of furniture or left objects on the oor, an older
tripping on unseen hazards. person with sight impairment would be very
2015 The Authors Health Expectations Published by John Wiley & Sons Ltd
Health Expectations, 18, pp.20212031
Causes of falls in older people, C Brundle et al. 2027
likely to trip and fall over them because they I think its, you know, that where the pavements
would not expect them to be there and often are breaking up, and sometimes Im really afraid
of it. (Phase 2 Int P002)
navigate around their own home by relying on
familiarity rather than sight. In addition to the conditions underfoot,
Another reason why we fall is objects in the way,
dustbins left out, shops signs and products,
things in the middle of the room, if children have and hedges that have not been trimmed back
been and left toys. (Phase 2 Int P038) are all extra obstacles for an older person to
deal with when walking on pavements. Some
Some participants reported falling after their participants were concerned that and if they
home had been altered with the aim of improv- cannot be seen properly, collisions with these
ing safety and reducing the risk of falls. For items would cause them to fall.
example, a rug was removed for safety because
it was a trip hazard; however, the older person Some of the shops insist they put all their wares
outside all over the pavements. . . oh theyre a
used it as a way of knowing her position in the
pain. . .and it is coming further out and further
room and after it was removed fell getting to out. (Phase 1 FG2)
her bed.
I was amazed on a night how I couldnt nd I never saw, well, I should have been looking,
the. . . Its like its a bed, its big enough to see, but I never saw the thing, and I tripped over one
isnt it? And I couldnt see it, because Id shifted of them signs on the pavement. But there was
the mats (Phase 2 Int P005) two people that came along and lifted me up.
(Phase 2 Int P001)
2015 The Authors Health Expectations Published by John Wiley & Sons Ltd
Health Expectations, 18, pp.20212031
2028 Causes of falls in older people, C Brundle et al.
could be more of a hazard than steps. Slopes or mats, unfamiliar objects on the oor, slip-
can be harder to dierentiate, for people with pery surfaces, and stairs/steps inside and out-
poor vision, than steps. Changes to well-known side the home, also previously found in
places have resulted in accidents when familiar- research.8 The evidence on falls suggests that a
ity has caused an older person to be less hazardous environment is not a risk factor for
vigilant. falls per se; that is if a persons home or out-
side environment is unsafe, it does not neces-
My biggest advantage is knowledge of a place,
cognitive mapping, thats my biggest advantage.
sarily mean they will fall.8 What appears to be
But it can also mean that you lead to making signicant is the persons ability to cope with
mistakes because youre anticipating something an unsafe environment, that is the interaction
and its changed. (Phase 2 Int P022) between the person themselves and the envi-
ronment.8 Thus, older people with sight
impairment may be less likely to be able to
Unexplained falls manage an unsafe environment as they may be
A couple of participants were at a loss to unaware of hazards until it is too late. For
explain why they had fallen. example, as some of the respondents reported,
they found it dicult to locate or were una-
I dont know why I keep falling. Half the time I ware of spillages and fell because of them. If
dont remember falling. I mean when all these the person does not interact with the environ-
falls started, I knew when I was going to go and
couldnt stop myself. But now it seems as if I just
ment much because they are not very mobile,
go, as if I blackout or something like that. Thats the fact that the environment is hazardous is
whats worrying me now. . . (Phase 2 Int P004) not a huge problem as they would not be plac-
ing themselves in danger often. In contrast, a
Some older people accepted falling as an
mobile individual with sight impairment who
inevitable consequence of ageing.
interacts with the environment a great deal is
I dont think you can predict it. (Phase 2 Int more likely to place themselves in a hazardous
P017) situation which could lead to a fall.8 Partici-
pants indicate that falls were caused by unfa-
I dont think theres anything you could do. miliar changing environments especially outside
(Phase 2 Int P049) the home. The ndings add weight to the
hypothesis that falls prevention interventions
that promote a familiar and safe environment
Discussion
may be successful in preventing falls in those
This study has generated new knowledge in a with sight impairment.
previously unexplored area on the causes of The strength of asking patients with sight
falls from a group of community dwelling older impairment for their views on the causes of
people with sight impairment about two-thirds falls is that it provides personal explanations
of who reported having had at least one fall. for falls and the context to falling. The meta-
Participants conrmed many of the risk factors narrative (or big story) in the interviews was
identied by quantitative prospective studies as that there is a varying, complex, interplay of
having strongest association with falling includ- many factors which may determine whether
ing sight impairment, gait problems, medical someone falls and whether they are amenable
conditions and vertigo.21 Many of these risks to preventative interventions. The qualitative
were incorrectly seen, by them, as inevitable data add the human nature or behavioural
aspects of ageing. aspect of falling which the epidemiological
Participants also discussed the impact of studies on risk factors for falls cannot. By nd-
sight impairment and hazards in the environ- ing out from patients their experiences of fall-
ment which led to falls including loose carpets ing, health-care professionals understand in
2015 The Authors Health Expectations Published by John Wiley & Sons Ltd
Health Expectations, 18, pp.20212031
Causes of falls in older people, C Brundle et al. 2029
what circumstances patients fall and whether conrm those of another study in which partic-
they take risks, tend to be careless and/or rush ipants who had sustained a fractured hip from
and this information becomes a point of refer- falling and who described how they had no
ence in planning and evaluating personalized choice but to carry out essential household jobs
falls prevention interventions. However, tools as they had no one to help even though they
for assessing the safety of peoples homes tend knew they may be placing themselves in danger
to focus on the material aspects of the persons of a fall.25 This information could help the
home, for example whether there any physical health-care professional to discuss with the
trip hazards and do not explicitly interrogate older person with sight impairment whether
the human context of promoting safety.22 Fur- there are any ways in which they could make
ther research is required to develop and test themselves safer, for example by installing a
these tools to take into account in what cir- visitor microphone/speaker system at the door
cumstances people fall including behavioural so they can let the caller know it will take a
aspects related to falling. while to get there. Other research suggests that
Participants often describe the causes of falls this needs to be carried out in an empathetic
as inevitable and largely beyond their control, manner such that it is not patronizing nor feels
for example from blackouts or uneven pave- distressing to the person concerned.2628 Fur-
ments. Of note, was the omission of lack of ther research is required to investigate from the
exercise as a contributory factor in falls despite perspective of older people with sight impair-
some of the sample having participated in an ment their own personal understandings of
exercise intervention in the RCT to prevent how they prevent falls.
falls. This is further evidence that reinforces
the view that many patients think they cannot
Limitations
do much about falling. Espoused beliefs about
falls need to be checked against the circum- The sample were drawn from urban areas and
stances of falls and evidence as there might be did not represent the experiences of people liv-
possible interventions to prevent falls in the ing in rural areas who might have dierent
future. For example, help with medication experiences outside of the home, for example
adherence may reduce the likelihood of falls with lack of public transport and lack of pave-
from poorly controlled medical conditions. If ments. We included people who had not fallen
lack of exercise is not seen as a cause of falls, and participants had received either (i) a home
then this may contribute to poor adherence safety assessment and modication or (ii) home
with exercise programmes.23 Further research safety assessment and modication, and home-
is required to learn whether exercise pro- based exercise programme as part of the RCT.
grammes have any eect in preventing falls in These could be construed as limitations of the
older people with sight impairment. study, but it means the sample is inclusive of a
Alternately, there were circumstances in broad group of older people with sight impair-
which patients in our study report frankly that ment making the ndings relevant to a bigger
they were responsible for falling from, for section of the older population with sight
example rushing to answer the door or climb- impairment. Another limitation of our sample
ing walls to prune hedges. Hurrying has been was the absence of participants from ethnic
identied previously as a risk factor for falls in minorities. They were not actively excluded,
those with multiple sclerosis24 and also in the but it transpired that they did not attend low
context of pedestrian road crossings.8 Thus, a vision clinics nor were members of the vision-
detailed health-care assessment of the circum- related charities, and hence, they were not
stances of the fall is necessary to understand recruited. Novel methods to access this group
whether an individual accepts they may fall of older people with sight impairment are
and/or whether they lack help. Our ndings needed in future research.
2015 The Authors Health Expectations Published by John Wiley & Sons Ltd
Health Expectations, 18, pp.20212031
2030 Causes of falls in older people, C Brundle et al.
2015 The Authors Health Expectations Published by John Wiley & Sons Ltd
Health Expectations, 18, pp.20212031
Causes of falls in older people, C Brundle et al. 2031
during stepping down by the elderly. Gait & Posture, 20 Ritchie J, Spencer L, OConnor W. Carrying out
2005; 21: 6571. qualitative analysis. In: Ritchie J, Lewis J (eds)
9 Buckley JG, Heasley K, Scally A, Elliott DB. The Qualitative Research Practice. London: Sage
eects of blurring vision on medio-lateral balance Publications, 2005: 219262.
during stepping up or down to a new level in the 21 Deandrea S, Lucenteforte E, Bravi F, Foschi R,
elderly. Gait & Posture, 2005; 22: 146153. La Vecchia C, Negri E. Risk factors for falls in
10 Buckley JG, Panesar GK, MacLellan MJ, Pacey IE, community-dwelling older people: a systematic
Barrett BT. Changes to control of adaptive gait in review and meta-analysis. Epidemiology, 2010; 21:
individuals with long-standing reduced stereoacuity. 658668.
Investigative Ophthalmology & Visual Science, 2010; 22 Clemson L. Home Fall Hazards: A Guide to
51: 24872495. Identifying Fall Hazards in the Homes of Elderly
11 Wang MY, Rousseau J, Boisjoly H et al. Activity People and an Accompaniment to the Assessment
limitation due to a fear of falling in older adults Tool, the Westmead Home Safety Assessment. West
with eye disease. Investigative Ophthalmology & Brunswick, Vic.: Coordinates, 1997.
Visual Science, 2012; 53: 79677972. 23 Campbell AJ, Robertson MC, Grow SJL et al.
12 Lamoureux E, Gadgil S, Pesudovs K et al. The Randomised controlled trial of prevention of falls in
relationship between visual function, duration and people aged > or =75 with severe visual impairment:
main causes of vision loss and falls in older people the VIP trial. British Medical Journal, 2005; 331:
with low vision. Graefes Archive for Clinical and 817.
Experimental Ophthalmology, 2010; 248: 527533. 24 Nilsagard Y, Denison E, Gunnarsson LG,
13 Yardley L, Donovan-Hall M, Francis K, Todd C. Bostrum K. Factors perceived as being related to
Older peoples views of advice about falls accidental falls by persons with multiple sclerosis.
prevention: a qualitative study. Health Education Disability and Rehabilitation, 2009; 31916:
Research, 2006; 21: 508517. 13011310.
14 Yardley L, Bishop FL, Beyer N et al. Older peoples 25 Mahler M, Sarvimaki A. Fear of falling from a
views of falls-prevention interventions in six European daily life perspective; narratives from later life.
countries. The Gerontologist, 2006; 46: 650660. Scandanavian Journal of Caring Sciences, 2000; 26:
15 Martin M. Falls in Older People With Sight Loss: A 3844.
Review of Emerging Research and key Action Points. 26 Ballinger C, Payne S. Falling from grace or into
London: Thomas Pocklington Trust, 2013. expert hands? Alternative accounts about falling in
16 Waterman H, Ballinger C, Brundle C et al. older people. British Journal of Occupational
Adapting a home safety programme and an exercise Therapy, 2000; 63: 573579.
programme to prevent falls in a feasibility study. 27 Health Foundation. Available at: http://
Presentation at Royal National Institute for the patientsafety.health.org.uk/sites/default/les/
Blind, London, 21st October, 2014. resources/an_overview_of_best_
17 Mason J. Qualitative Researching, 2nd edn. London: practice_for_falls_prevention_
Sage Publications, 2002. from_an_occupational_therapy_perspective_0.pdf,
18 Morgan DL. Focus Groups as Qualitative Research, accessed 20 December 2014.
2nd edn. Thousand Oaks, CA: Sage Publications, 1997. 28 Age UK. Available at: http://www.ageuk.org.uk/
19 Arthur S, Nazroo J. Designing eldwork strategies Documents/EN-GB/For-professionals/Research/
and materials. In: Ritchie J, Lewis J (eds) Services-what_works_spreads.pdf?dtrk=true,
Qualitative Research Practice. London: Sage accessed 20 December 2014.
Publications, 2005: 109137.
2015 The Authors Health Expectations Published by John Wiley & Sons Ltd
Health Expectations, 18, pp.20212031