Falls and quality of life of people with cataracts

Objective: To investigate the association between falls and quality of life in elderly individuals with cataract. Methods: This was an observational and cross-sectional study carried out in the Federal District, Brazil, with a sample of 38 community-dwelling elderly individuals, who were divided into two groups: falling elderly (n=18) and non-falling elderly (n=20). The NEI-VFQ-25 was used as a tool to assess the patient overall health and the quality of life related to visual health. Sample characterization was performed by descriptive analysis and the nonparametric Mann-Whitney test (p<0.05) was used to evaluate the association between falls and the other variables. Results: Elders within the age group ≥ 70 years old were the majority in this study. 36 participants (94.74%) of this study claimed to have some vision problems. Falling elderly presented lower scores when compared to the non-falling elderly (p=0.0159) and they also showed worse mental health (p=0.0001), higher level of dependence (p=0.0008) and greater difficulty to perform up close vision tasks (p=0.0299) and far vision tasks (p=0.0104). Conclusion: Falls have a negative impact on the quality of life of elderly individuals with cataract, which makes preventive actions and the treatment and/or correction of visual impairments important in order to avoid future harms.


C
ataract is the leading cause of blindness and reversible visual impairment in the world (1)(2)(3) , and is defined as any opacity in the crystalline reducing the visual acuity.It affects about 75% of the elderly over 70 years of age (3)(4)(5) , and impacts various aspects of vision interfering negatively in the quality of life (QOL) (4,6) .According to Lee et al., decreased visual acuity is the second symptom of greater impact in the QOL, second only to breathing difficulties (4) .
Consequent to cataract, there is a decrease of visual communication, thus increasing the risk for falls in this population (7,8) , because in parallel comes decreased stability, balance, perception of distance and depth, and adaptation to dark, which results in difficulties for the recognition of impending dangers (3,9,10) .Elderly in this condition, struggling to remain stable facing complex environments and tasks, have two times more chances to fall (9,11) .
The fall is defined as the unintentional displacement of the body to a level lower than the starting position without correction in a timely manner, being determined by multifactorial conditions which compromise the stability, i.e. mechanisms involved with the maintenance of posture (12) .It is considered to be an important cause of morbidity and mortality in the elderly population, and one of the leading clinical and public health problems due to the high incidence, the complications and the high healthcare costs (9,13) .This event can result in physical, functional and psychosocial limiting consequences, also resulting in reduced QOL (4,(12)(13)(14) .
Considering the limiting effect of cataracts and falls imposed on the elderly population, the aim of this study is to assess the association between falls and the quality of life in elderly with cataract.

METHODS
It is an observational study with cross-sectional design conducted in Distrito Federal (DF), Brazil.We assessed 55 elderly patients from the ophthalmology departments of two public hospitals in DF enabled for cataract treatment and surgery.
The inclusion criteria used in the present study were: community elderly (e" 60 years) of both sexes with diagnosis of bilateral cataract confirmed by ophthalmic and diagnostic exams.The exclusion criteria were: clinical diagnosis or severe cognitive impairment suggestive of dementia (MMSE < 17) (n = 0), positive self-report to other uncorrected vision problems (n = 17) and surgical correction of cataract in one eye (n = 0).These criteria were adopted to prevent interfering in the interviews and acting as disturbers for the outcome analyzed.
This study was conducted during the period from December 2011 to December 2012.
The research project was approved by the Ethics Committee of the College of Education and Research in Health Sciences (FEPECS), and duly registered with the National Research Ethics Committee (opinion No. 0153/11).
A total of 38 elderly from the 55 previously selected were included in the study and divided into two groups: faller elderly (n = 18) and non-faller elderly (n = 20).It is understood by fallers elderly who have experienced one or more falls in the 12 months preceding the interview.
The questionnaire National Eye Institute -Visual Function Questionnaire 25 (NEI VFQ-25) was applied to assess the overall health of the patient as well as the quality of life related to visual health.This instrument is statistically proven for validity and reliability (15) .
The NEI-VFQ 25 consists of three parts, the first with four questions related to general health and vision, the second part with twelve questions about the difficulties with daily activities, and the third part with nine questions related to visual problems and how they can interfere with the activities (15) .
The 25 questions contained in the instrument can be grouped into five domains (physical, psychological, level of dependence, social relationships and overall health) and 12 subdomains (general health, vision, eye pain, nearsight activities, farsight activities, social aspects, mental health, activities of daily life, dependence, ability to drive cars, color vision and peripheral vision).For each question, there are 5 or 6 answer alternatives, and for such answers the score ranges from 0 to 100 points (0, 25, 50, 75, 100).For the questions with 6 possible answers, if the respondent chooses the last option, number 6, this question will not be scored and will not be part of the score as it does not refer to visual impairment.The total score will have a minimum value of zero and a maximum value of 100.The higher the score achieved, the better the quality of life and the visual function of the respondant (15) .
We collected the following sociodemographic data by semistructured interview: sex, age (years), race (white, black or mulatto / mestizo / brown), education (literacy), marital status (married / living together, single, divorced / separated or widow), socioeconomic activity (with the question: "do you currently work?), economic situation (retirement) and family support (with the questions: 'do you live aline?' and if not 'who lives with you, family or friends?).
On general health data, the elderly were asked and answered a self-report with the number of diagnosed diseases, the number of medications in use, physical activity and self awareness of the ability to see even with the use of glasses or contact lenses (without difficulty, with a little or a lot of difficulty).
The fall was questioned by the question: "have you fallen in the last year?"and if so, "how many times did you fall?"All patients were told about the objectives and the methodology employed by signing, after said guidance, the term of free consent.
The Mini Mental State Examination was used in the study to exclude the elderly with severe cognitive impairment suggestive of dementia (cutoff < 17 points) (16) .The instrument was developed by Folstein et al. (17) , and comprised 30 questions grouped into seven categories: time orientation (5 points), spatial orientation (5 points), recording three words (3 points), attention and calculation (5 points), recall of three words (3 points), language (8 points) and visual constructive capacity (1 point).For each question 0 (wrong) and 1 (right) is scored, accounting a total score varying from a minimum of 0 points and a maximum of 30 points (18) .
After tabulation and use of the data obtained in this study, we chose to characterize the sample and general health data through descriptive analysis and assess the association between falls and other variables using the nonparametric Mann-Whitney test.The statistical program used was BioEstat version 5.3, installed in a Windows environment and with a α=0.05 established.

RESULTS
The sample included 38 elderly of both sexes, with an average age of 71.66 years (± 5.80).Table 1 presents the general characterization of the sample (n = 38) according to the variables studied.
According to the perception of the elderly participanting in this study, 2 (5.26%) reported having no problem to see, 16 Table 1 General characteristics (42.11%) had little problems and 20 (52.63%) with many problems.For the ability to hear, 17 (44.74%)reported having no problems, 15 (39.47%) had little problems and 6 (15.79%) with many problems.
The quality of life related to visual health (NEI-VFQ 25) is described by means of general average scores per group, detailed in table 2.
When we compare the group of fallers to the non-fallers, 10 subdomains showed lower scores among the fallers.Of these, besides the general score, four more subdomains assessed by the NEI-VFQ 25 showed statistical significance: nearsight activities (p = 0.0299), farsight activities (p = 0.0104), mental health (p = 0.0001) and dependence (p = 0.0008).
Only 3 (7.89%)participants in the study answered questions relating to the subdomain ability to drive; the others reported not performing this activity.Therefore, these data were not statistically significant for this study, and thus were not presented in the table 2.

Table 2 Comparative analysis of the general average score and subdomains of NEI-VFQ 25 between faller and non-faller elderly Fallers Non fallers P value General score (n=18) (n=20) and subdomains Average Average (Standard deviation) (Standard deviation)
The subdomain "Ability to Drive" was not presented in this table for not presenting statistical significance for this study.(*p < 0.05 Mann-Whitney test)