Abstract

The aim of the present study was to evaluate factors associated with falls in community-dwelling older adults diagnosed with cataracts. An analytical, cross-sectional study was conducted with a sample of community-dwelling older adults residing in the Federal District of Brazil. Interviews and assessment tools were administered, such as the Timed Up and Go test, Short Physical Performance Battery (SPPB), Biodex Balance System, Katz Index, Lawton Scale, Minnesota Leisure Time Physical Activity Questionnaire and Mini Mental State Examination. Statistical analysis involved binary logistic regression. One hundred forty-two older adults (85 with cataracts) participated in the study (mean age: 69.39 ± 5.67 years). Falls were associated with the female sex (OR: 4.45) and sub-maximum score on the SPPB (OR: 3.53) among patients with cataracts, whereas multimorbidity (OR: 5.10) was the risk factor risk for older adults without cataracts. The data suggest different risk factors for falls among older adults diagnosed with cataracts.

Accidental falls; Cataract; Aged; Postural balance; Physical fitness

Introduction

Cataract is the most common cause of blindness and one of the most prevalent degenerative diseases among older adults¹1. Thompson J, Lakhani N. Cataracts. Prim Care Clin Off Pract 2015; 42(3):409-423.. It is estimated that among the 20 million people affected by severe visual impairment throughout the world, one third of the cases is the result of cataract²2. Brian G, Taylor H. Cataract blindness--challenges for the 21st century. Bull World Health Organ 2001; 79(3):249-256.. According to data from the 2013 Brazilian National Health Survey, cataract affects 28.7% of the older population in the country³3. Instituto Brasileiro de Geografia e Estatística (IBGE), Barbosa N, Menezes AP, Carlos A, Nardi F. Pesquisa Nacional De Saude 2013 - Ciclos De Vida. Rio de Janeiro: IBGE; 2013..

Cataract can exert a negative impact on postural balance, mobility and functional capacity and is related to the fear of falls, a greater number of morbidities, depressed mood and cognitive decline⁴4. Aartolahti E, Häkkinen A, Lönnroos E, Kautiainen H, Sulkava R, Hartikainen S. Relationship between functional vision and balance and mobility performance in community-dwelling older adults. Aging Clin Exp Res 2013; 25(5):545-552.,⁵5. Borges LDL, Santos FPV, Pagotto V, Menezes RL. Functional disability in community-dwelling elderly: the role of cataracts and contextual factors. Fisioter em Mov 2014; 27(2):189-200.. As postural balance depends on the proper integration of vestibular, proprioceptive and visual information, any impairment in one of these sensory systems can lead to deficiencies in the postural adjustments needed to maintain one’s balance⁶6. Pasma JH, Engelhart D, Maier AB, Schouten AC, van der Kooij H, Meskers CGM. Changes in sensory reweighting of proprioceptive information during standing balance with age and disease. J Neurophysiol 2015; 114(6):3220-3233.,⁷7. Horak FB. Postural orientation and equilibrium: What do we need to know about neural control of balance to prevent falls? Age Ageing 2006; 35(Supl. 2):7-11..

Older adults with cataracts have blurred vision, which results in a reduction in visual acuity as well as reduced sensitivity to contrast and the perception of colors¹1. Thompson J, Lakhani N. Cataracts. Prim Care Clin Off Pract 2015; 42(3):409-423.. When combined with poor lighting, cataracts favor the occurrence of tripping and slips on irregular surfaces on the ground of the environment (e.g., puddles, carpet edges, doorjambs, etc.)⁸8. Reed-Jones RJ, Solis GR, Lawson K, Loya AM, Cude-Islas D, Berger CS. Vision and falls: A multidisciplinary review of the contributions of visual impairment to falls among older adults. Maturitas 2013; 75(1):22-28.. Indeed, studies report an association between visual impairment and falls in older adults⁸8. Reed-Jones RJ, Solis GR, Lawson K, Loya AM, Cude-Islas D, Berger CS. Vision and falls: A multidisciplinary review of the contributions of visual impairment to falls among older adults. Maturitas 2013; 75(1):22-28.,⁹9. Lord SR, Smith ST, Menant JC. Vision and falls in older people: Risk factors and intervention strategies. Clin Geriatr Med 2010; 26(4):569-581..

There is a consensus in the literature regarding the significant improvement in visual acuity following cataract surgery¹⁰10. Desapriya E, Subzwari S, Scime-Beltrano G, Samayawardhena L, Pike I. Vision improvement and reduction in falls after expedited cataract surgery. Systematic review and metaanalysis. J Cataract Refract Surg 2010; 36(1):13-19.,¹¹11. Meuleners LB, Lee AH, Ng JQ, Morlet N, Fraser ML. First Eye Cataract Surgery and Hospitalization from Injuries Due to a Fall: A Population-Based Study. J Am Geriatr Soc 2012; 60(9):1730-1733.. However, the effect of surgery on the risk of falls is inconclusive¹⁰10. Desapriya E, Subzwari S, Scime-Beltrano G, Samayawardhena L, Pike I. Vision improvement and reduction in falls after expedited cataract surgery. Systematic review and metaanalysis. J Cataract Refract Surg 2010; 36(1):13-19.; there are reports of both a reduction¹²12. Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2012; (9):CD007146. and an increase in such risk¹¹11. Meuleners LB, Lee AH, Ng JQ, Morlet N, Fraser ML. First Eye Cataract Surgery and Hospitalization from Injuries Due to a Fall: A Population-Based Study. J Am Geriatr Soc 2012; 60(9):1730-1733.. Other factors, such as lifestyle, the use of medication, multimorbidity and level of physical activity, can affect the risk of falls among older adults with cataracts, even after recovering their vision¹¹11. Meuleners LB, Lee AH, Ng JQ, Morlet N, Fraser ML. First Eye Cataract Surgery and Hospitalization from Injuries Due to a Fall: A Population-Based Study. J Am Geriatr Soc 2012; 60(9):1730-1733..

Besides visual impairment, other intrinsic and extrinsic factors may be related to the risk of falls among community-dwelling older adults, such as urinary incontinence, depression, fear of falls, balance abnormalities, cognitive deficiency, polypharmacy and functional limitations¹³13. Frith J, Davison J. Falls. Rev Clin Gerontol 2013; 23(02):101-117.. The literature offers numerous studies addressing the multidimensional aspects of the risk of falls in older adults living in the community¹⁴14. Rodrigues IG, Fraga GP, Barros MBDA. Falls among the elderly: risk factors in a population-based study. Rev Bras Epidemiol 2014; 17(3):705-718.,¹⁵15. Deandrea S, Bravi F, Turati F, Lucenteforte E, La Vecchia C, Negri E. Risk factors for falls in older people in nursing homes and hospitals. A systematic review and meta-analysis. Arch Gerontol Geriatr 2013; 56(3):407-415. and those in nursing homes¹⁶16. Menezes RL, Bachion MM. Estudo da presença de fatores de riscos intrínsecos para quedas, em idosos institucionalizados. Cien Saude Colet 2008; 13(4):1209-1218.,¹⁷17. Menezes RL, Bachion MM, Souza JT, Nakatani AYK. Estudo longitudinal dos aspectos multidimensionais da saúde de idosos institucionalizados. Rev Bras Geriatr Gerontol 2011; 14(3):485-496.. However, few researchers have addressed groups with specific problems, such as older adults with cataracts. Therefore, investigations are needed to examine the relationship between visual impairment and falls, as many studies do not take into consideration the influence of multiple confounding factors that may be associated with this outcome¹⁸18. Salonen L, Kivel SL. Eye diseases and impaired vision as possible risk factors for recurrent falls in the aged: A systematic review. Curr Gerontol Geriatr Res 2012; 2012:1-10..

This investigation was based on the hypothesis that older adults with cataracts have different risk factors for falls than those without cataracts. Thus, the aim of the present study was to evaluate factors associated with falls in community-dwelling older adults with cataracts.

Methods

An observational, analytical, cross-sectional study was conducted in the Federal District of Brazil. Community-dwelling older adults were recruited through active searches at healthy ageing programs in the city of Ceilândia and ophthalmology services at two public hospitals in the Federal District.

Male and female older adults aged 60 years or older with a medical diagnosis of bilateral cataract confirmed using standardized methods¹1. Thompson J, Lakhani N. Cataracts. Prim Care Clin Off Pract 2015; 42(3):409-423. were included in the study. The exclusion criteria were a clinical diagnosis of neurological disease or uncorrected visual impairment and a score on the Mini Mental Health Examination suggestive of cognitive impairment (cutoff point adjusted for schooling)¹⁹19. Brucki SMD, Nitrin R, Caramelli P, Bertolucci PHF, Okamoto IH. Sugestões para o uso do mini-exame do estado mental no Brasil. Arq Neuropsiquiatr 2003; 61(3 B):777-781.. Older adults with paralysis or orthopedic abnormalities or the inability of remain in a standing position and walk without assistance were also excluded.

This study was conducted between December 2011 and December 2012 in compliance with recommendations for research involving human beings and received approval from the Ethics Committee of the School of Education and Research in Health Sciences, Brasília, DF, Brazil (certificate number: 0153/11). The present study is part of a larger investigation denominated: “Impact of cataract surgery on the occurrence of falls and multidimensional aspects of health: A longitudinal study involving older adults in the Federal District of Brazil”.

The outcome variable (falls) was defined as an unexpected event in which an individual falls to the ground or a lower level²⁰20. Lamb SE, Jørstad-Stein EC, Hauer K, Becker C. Development of a common outcome data set for fall injury prevention trials: The Prevention of Falls Network Europe consensus. J Am Geriatr Soc 2005; 53(9):1618-1622.. This outcome was based on self-reports from the participants using the previous 12 months as the reference.

The other variables and respective assessment methods are listed below:

- Socio-demographic variables: age, sex, marital status, reading skill, schooling, health conditions (diagnosis of cataract, having undergone cataract surgery, comorbidities, depression, number of medications and use of psychotropic agents) and lifestyle (smoking, physical activity and alcohol intake). Multimorbidity was defined as the occurrence of five or more chronic-degenerative diseases (diabetes, arterial hypertension, kidney disease, cardiovascular disease, depression, osteoporosis, etc.). These data were collected with the aid of a structured questionnaire;

- Level of physical activity was determined using the Brazilian version of the Minnesota Leisure Time Physical Activity Questionnaire²¹21. Lustosa LP, Pereira DS, Dias RC, Britto R, Parentoni A, Pereira L. Tradução e adaptação transcultural do Minnesota Leisure Time Activities Questionnaire em idosos. Geriatr Gerontol 2011; 5(2):57-65.. The classification as active or inactive was based on the criteria recommended by the American College of Sports Medicine: at least 150 minutes per week of moderate physical activity (3 METs) or 75 minutes of vigorous or sports activity (6 METs)²²22. Costa TB, Neri AL. Medidas de atividade física e fragilidade em idosos: dados do FIBRA Campinas, São Paulo, Brasil. Cad Saude Publica 2011; 27(8):1537-1550.,²³23. Nelson ME, Rejeski WJ, Blair SN, Duncan PW, Judge JO, King AC, Macera CA, Castaneda-Sceppa C; American College of Sports Medicine; American Heart Association. Physical activity and public health in older adults: Recommendation from the American College of Sports Medicine and the American Heart Association. Circulation 2007; 116(9):1094-1105.;

- Physical-functional performance was evaluated at the Movement Analysis Lab of the university using the Brazilian version of the Short Physical Performance Battery (SPPB)²⁴24. Nakano MM. Versão brasileira da short physical performance battery – sppb: adaptação cultural e estudo da confiabilidade [dissertação]. Campinas: Unicamp; 2007. to evaluate lower limb strength, balance, gait speed and the risk of falls and the Timed Up and Go (TUG) test²⁵25. Podsiladlo SR. Timed Get Up and Go Test. J Am Geriactrics Soc 1991; 29(2):2006. for the evaluation of balance, functional gait capacity and the risk of falls. Cutoff points were determined using ROC analysis (not presented in this study) for the risk of falls based on the SPPB (ordinal) and TUG (numeric), which were considered binary variables. The risk of falls was also evaluated using a force plate: Biodex Balance System (BBS)²⁶26. Parraca J, Olivares PR, Carbonell-Baeza A, Aparicio V, Adsuar JC, Gusi N. Test-retest reliability of biodex balance SD on physically active old people. J Hum Sport Exerc 2011; 6(2):444-451.;

- Functional independence was measured using the Brazilian version of the Katz Index of Independence in Activities of Daily Living and the Lawton Instrumental Activities of Daily Living Scale²⁷27. Lino VTS, Pereira SRM, Camacho LAB, Ribeiro Filho ST, Buksman S. Cross-cultural adaptation of the Independence in Activities of Daily Living Index (Katz Index). Cad Saude Publica 2008; 24(1):103-112.,²⁸28. Santos RL, Virtuoso Júnior JS. Confiabilidade da versão brasileira da Escala de Atividades Instrumentais da Vida Diária. Rev Bras Promoção da Saúde 2008; 21(1):290-296., which have been validated for the Portuguese language.

To evaluate associations between the outcome (falls) and the variables of interest in the older adults with and without cataract, binary logistic regression analysis was conducted using the SPSS program, version 20, to determine odds ratios (OR). The variables determined to be possible risk or protection factors regarding the occurrence of falls were incorporated in the model one by one (univariate regression analysis with “insert” method). Variables with a p-value < 0.20 were incorporated in blocks of variables grouped based on socio-demographic characteristics, health conditions, physical-functional performance and lifestyle to obtain a more representative model. Multivariate analysis was then performed based on the division of the sample into individuals with and without a diagnosis of cataract (models A and B, respectively). All models were adjusted for age. The “at least ten events” rule (successes or failures) was obeyed for each independent variable in the model. Differences between groups were evaluated using the Mann-Whitney test and chi-squared test (categorical variables).

Results

One hundred seventy-six older adults were invited to participate in the study, 144 of whom appeared for the evaluations. Two were excluded (one for not being able to see the target on the screen of the BBS and another was unable to report whether or not a fall had occurred in the previous year). Thus, 142 older adults participated in the study. Table 1 displays the characteristics of the sample stratified for the presence/absence of cataract. No statistically significant differences were found between the two groups regarding the variables investigated, except visual acuity and the risk of falls determined using the TUG test with a cutoff point of 7.67 seconds.

The prevalence of falls in the previous 12 months was 40%. The prevalence of the practice of physical activity at the recommended level was high in the overall sample. Sub-maximum scores were found regarding the evaluations of physical-functional performance and independence on basic and instrumental activities of daily living. A tendency toward a greater prevalence rate of falls among the individuals without a diagnosis of cataract was found, but the difference between groups did not achieve statistical significance.

Table 2 displays the results of the univariate analysis considering the groups with and without cataract and the results of the analysis of differences between groups regarding the separate variables. Variables individually associated with falls are highlighted with one (p < 0.05) or two (p < 0.20) asterisks in each group. The cutoff points for the TUG test and SBBP were 7.67 seconds and 11 points, respectively. Multivariate regression models A and B represent the risk of falls in the groups with and without cataract, respectively, and were adjusted for both age (75 years or older) and sex. The female sex had fourfold greater odds of having suffered a fall than the male sex. Individuals with cataracts who had a score lower than 11 points on the SPPB had 3.5-fold greater odds of having suffered a fall than those with a higher score. Multimorbidity was associated with falls in the group without a diagnosis of cataract (Table 3).

Discussion

In this study, factors associated with falls in community-dwelling older adults with a diagnosis of cataract were investigated and compared to factors found for older adults without cataracts. The female sex and a score of less than 11 points on the SPPB were associated with falls in the group with cataract, whereas having five or more chronic diseases was associated with a greater chance of falls in the group without cataract.

Few analytical studies involving older adults with cataract have been conducted in Brazil. Previous investigations report associations between cataract and postural balance, fear of falls and quality of life²⁹29. Macedo BG, Pereira LSM, Rocha FL, Castro ANBV. Association between funcional vision, balance and fear of falling in older adults with cataracts. Rev Bras Geriatr e Gerontol 2012; 15(2):265-274.,³⁰30. Macedo BG, Pereira LSM, Rocha FL, Castro ANBV. Medo de cair e qualidade de vida em idosos com catarata. Rev Bras Geriatr e Gerontol 2013; 16(3):569-577.. However, the studies cited did not address other dimensions of the phenomenon (falls) in the population and were limited to the description of socio-demographic characteristics³¹31. Carlos GA, Schellini SA, Espindola RF, Lana FP, Rodrigues AC, Padovani CR. Cataract prevalence in Central-West region of Sao Paulo State, Brazil. Arq Bras Oftalmol 2009; 72(3):375-379.,³²32. Silva LMP, Muccioli C, Belfort Júnior R. Perfil socioeconômico e satisfação dos pacientes atendidos no mutirão de catarata do Instituto da Visão - UNIFESP. Arq Bras Oftalmol 2004; 67(5):737-744.. Likewise, few multidimensional studies are found in the international literature addressing the relationship between visual impairment and falls¹⁸18. Salonen L, Kivel SL. Eye diseases and impaired vision as possible risk factors for recurrent falls in the aged: A systematic review. Curr Gerontol Geriatr Res 2012; 2012:1-10..

Visual impairment can cause difficulties in detecting obstacles with little contrast, judging distances, perceiving spatial relationships and processing all visual information necessary to perform adjustments in order to maintain postural control and adequate mobility, thereby hindering the adaptation to the environmental demands required for the execution of activities of daily living⁹9. Lord SR, Smith ST, Menant JC. Vision and falls in older people: Risk factors and intervention strategies. Clin Geriatr Med 2010; 26(4):569-581.,⁷7. Horak FB. Postural orientation and equilibrium: What do we need to know about neural control of balance to prevent falls? Age Ageing 2006; 35(Supl. 2):7-11.. The impact of visual impairment on falls may be greater when accompanied by other sensory and balance deficiencies³³33. Kulmala J, Viljanen A, Sipilä S, Pajala S, Pärssinen O, Kauppinen M, Koskenvuo M, Kaprio J, Rantanen T. Poor vision accompanied with other sensory impairments as a predictor of falls in older women. Age Ageing 2009; 38(2):162-167..

An impaired performance on visual tests is related to a worse performance on physical-functional tests.³⁴34. West CG, Gildengorin G, Haegerstrom-Portnoy G, Schneck ME, Lott L, Brabyn J. Is vision function related to physical functional ability in older adults? J Am Geriatr Soc 2002; 50(1):136-145. Older adults with cataracts and a self-reported fear of falls are less confident regarding their ability to maintain their balance and avoid falls and may therefore limit their functional activities due to the fear of falling³⁰30. Macedo BG, Pereira LSM, Rocha FL, Castro ANBV. Medo de cair e qualidade de vida em idosos com catarata. Rev Bras Geriatr e Gerontol 2013; 16(3):569-577.. There is a gap in knowledge regarding the effects of visual impairment on the level of physical activity among older adults. Cataract surgery is known to improve visual acuity¹⁰10. Desapriya E, Subzwari S, Scime-Beltrano G, Samayawardhena L, Pike I. Vision improvement and reduction in falls after expedited cataract surgery. Systematic review and metaanalysis. J Cataract Refract Surg 2010; 36(1):13-19., but there is no certainty regarding a subsequent reduction in the risk of falls¹⁰10. Desapriya E, Subzwari S, Scime-Beltrano G, Samayawardhena L, Pike I. Vision improvement and reduction in falls after expedited cataract surgery. Systematic review and metaanalysis. J Cataract Refract Surg 2010; 36(1):13-19.

11. Meuleners LB, Lee AH, Ng JQ, Morlet N, Fraser ML. First Eye Cataract Surgery and Hospitalization from Injuries Due to a Fall: A Population-Based Study. J Am Geriatr Soc 2012; 60(9):1730-1733.-¹²12. Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2012; (9):CD007146..

Cataract is considered an independent risk factor for falls⁹9. Lord SR, Smith ST, Menant JC. Vision and falls in older people: Risk factors and intervention strategies. Clin Geriatr Med 2010; 26(4):569-581.and can determine more accentuated impairment with regard to balance and mobility in comparison to older adults without cataract⁵5. Borges LDL, Santos FPV, Pagotto V, Menezes RL. Functional disability in community-dwelling elderly: the role of cataracts and contextual factors. Fisioter em Mov 2014; 27(2):189-200.. Thus, one would expect a poorer performance on balance tests and, consequently, a greater prevalence rate of falls in individuals with cataract. However, this did not occur in the present study, as no statistically significant difference was found between groups regarding the prevalence of falls. In fact, there was a tendency toward a greater prevalence rate of falls in the group without cataract, whereas those with cataract had a worse performance on the physical-functional tests. The prevalence of falls among older adults without cataract may be associated with the occurrence of multimorbidity, as having five or more comorbidities increased the odds of falling fivefold in this group. Multimorbidity may be associated with falls³⁵35. Deandrea S, Lucenteforte E, Bravi F, Foschi R, La Vecchia C, Negri E. Risk Factors for Falls in Community-dwelling Older People. Epidemiology 2010; 21(5):658-668. and frailty, which can increase the risk of unfavorable outcomes over time, such as falls, hospitalizations and fractures³⁶36. Bauer JM, Sieber CC. Sarcopenia and frailty: A clinician’s controversial point of view. Exp Gerontol 2008; 43(7):674-678..

Despite this apparent difference in the prevalence of falls between the groups studied, no significant differences were found between the individuals with and without cataract for any of the variables investigated, except visual acuity and performance on the TUG test. A previous case-control study conducted in Malaysia involving older adults who had suffered hip fracture found no differences between the cases with cataract and those without cataract (controls) with regard to the pre-morbid state, degree of independence for mobility, the use of gait-assistance devices or living alone³⁷37. Chew FLM, Yong CK, Mas Ayu S, Tajunisah I. The association between various visual function tests and low fragility hip fractures among the elderly: A Malaysian experience. Age Ageing 2010; 39(2):239-245.. On the other hand, older adults in Scotland with visual impairment at primary care services exhibited more comorbidities in comparison to those without this type of impairment³⁸38. Court H, McLean G, Guthrie B, Mercer SW, Smith DJ. Visual impairment is associated with physical and mental comorbidities in older adults: a cross-sectional study. BMC Med 2014; 12(1):181.. The differences between studies may be related to the recruitment setting, as the sample was recruited from a hospital setting in the first study and primary care in the second.

An interesting finding of the present investigation was the high prevalence of falls in community-dwelling older adults with high levels of functioning, as demonstrated by the high levels of physical activity and sub-maximum scores for physical-functional performance and independence in terms of basic and instrumental activities of daily living.

A poor performance on a balance test, such as the TUG test, is associated with a history of falls³⁹39. Beauchet O, Fantino B, Allali G, Muir SW, Montero-Odasso M, Annweiler C. Timed up and go test and risk of falls in older adults : a systematic review. J Nutr Heal Aging 2011; 15(10):6-11.. Therefore, this test has been used to screen for older adults at risk of suffering a fall, although there is no consensus on the ideal cutoff point for the identification of this population⁴⁰40. Schoene D, Wu SM, Mikolaizak AS, Menant JC, Smith ST, Delbaere K, Lord SR. Discriminative ability and predictive validity of the timed up and go test in identifying older people who fall: Systematic review and meta-analysis. J Am Geriatr Soc 2013; 61(2):202-208.. Indeed, the use of the TUG test has been questioned with regard to its predictive capacity for falls among older adults⁴¹41. Barry E, Galvin R, Keogh C, Horgan F, Fahey T. Is the Timed Up and Go test a useful predictor of risk of falls in community dwelling older adults: a systematic review and meta- analysis. BMC Geriatrics 2014; 14(1):14.. Since older adults with higher levels of physical activity obtain better scores on postural balance tests⁴²42. Pau M, Leban B, Collu G, Migliaccio GM. Effect of light and vigorous physical activity on balance and gait of older adults. Arch Gerontol Geriatr 2014; 59(3):568-573., there may be a ceiling effect for scores on balance tests⁴⁰40. Schoene D, Wu SM, Mikolaizak AS, Menant JC, Smith ST, Delbaere K, Lord SR. Discriminative ability and predictive validity of the timed up and go test in identifying older people who fall: Systematic review and meta-analysis. J Am Geriatr Soc 2013; 61(2):202-208.,⁴³43. Hernandez D, Rose DJ. Predicting Which Older Adults Will or Will Not Fall Using the Fullerton Advanced Balance Scale. Arch Phys Med Rehabil 2008; 89(12):2309-2315..

The participants in the present investigation had high scores on the physical-functional performance tests (TUG, SPPB and BBS). It should be stressed that the adequacy of cutoff points on balance tests for the profile of the population studied is fundamental. However, even with the establishment of adequate cutoff points on the physical-functional tests to improve sensitivity and specificity⁴²42. Pau M, Leban B, Collu G, Migliaccio GM. Effect of light and vigorous physical activity on balance and gait of older adults. Arch Gerontol Geriatr 2014; 59(3):568-573., the measures for the evaluation of postural balance (TUG and BBS) were not associated with falls in the groups investigated in the present study. Moreover, the physical-functional tests employed do not include an evaluation of the sensory components of postural balance⁴³43. Hernandez D, Rose DJ. Predicting Which Older Adults Will or Will Not Fall Using the Fullerton Advanced Balance Scale. Arch Phys Med Rehabil 2008; 89(12):2309-2315..

Taken together, the present findings and those described in the literature suggest that a higher score on physical-functional tests does not necessarily imply an absence of a risk of falls. Individuals with high levels of functioning and no postural balance deficiencies continue to perform their habitual activities and could expose themselves to situations of risk⁴⁴44. Muir SW, Berg K, Chesworth B, Klar N, Speechley M. Balance impairment as a risk factor for falls in community-dwelling older adults who are high functioning: a prospective study. Phys Ther 2010; 90(3):338-347.. Therefore, the high prevalence of physical activity among the individuals may explain the high prevalence of falls in the present sample, as 41% reported practicing physical activity at the recommended levels¹⁹19. Brucki SMD, Nitrin R, Caramelli P, Bertolucci PHF, Okamoto IH. Sugestões para o uso do mini-exame do estado mental no Brasil. Arq Neuropsiquiatr 2003; 61(3 B):777-781. and this percentage was even higher (52%) among the individuals with cataract. These figures are higher than the rate described in the 2013 National Health Survey, in which the proportion of older adults who practiced physical activity at the recommended level in Brazil was 13.6%⁴⁵45. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde - 2013: percepção do estado de saude, estilos de vida e doenças crônicas - Brasil, Grandes Regiões e Unidades da Federação. Rio de Janeiro: IBGE; 2014..

Although practicing physical activity can reduce the risk of falls⁴⁶46. Thibaud M, Bloch F, Tournoux-Facon C, Brèque C, Rigaud AS, Dugué B, Kemoun G. Impact of physical activity and sedentary behaviour on fall risks in older people: A systematic review and meta-analysis of observational studies. Eur Rev Aging Phys Act 2012; 9(1):5-15., practicing such activity in an outdoor environment may expose older adults to environmental barriers⁴⁷47. Oliveira AS, Trevizan PF, Bestetti MLT, Melo RC. Fatores ambientais e risco de quedas em idosos: revisão sistemática. Rev Bras Geriatr e Gerontol 2014; 17(3):637-645.. Moreover, Okubo et al. (2015) found that the habit of walking did not increase the risk of falls among older adults with a low risk of falls, but was strongly associated with this outcome among those with two or more risk factors for falls⁴⁸48. Okubo Y, Seino S, Yabushita N, Osuka Y, Jung S, Nemoto M, et al. Longitudinal association between habitual walking and fall occurrences among community-dwelling older adults: Analyzing the different risks of falling. Arch Gerontol Geriatr 2015; 60(1):45-51..

In the present study, the regression models revealed different risk factors for falls between older adults with and without cataract. In the group with cataract, the female sex and a poorer physical performance remained in the final model as factors associated with falls.

Women with cataracts were fivefold more likely to fall than men with cataracts. This may have occurred because women undergo sensory, motor and cognitive decline earlier than men⁴⁹49. Chang VC, Do MT. Risk Factors for Falls Among Seniors: Implications of Gender. Am J Epidemiol 2015; 181(7):521-531. and are closer to the limit at which reduced muscle power could compromise their functional status⁵⁰50. Foldvari M, Clark M, Laviolette LC, Bernstein MA, Kaliton D, Castaneda C, Pu CT, Hausdorff JM, Fielding RA, Singh MA. Association of Muscle Power With Functional Status in Community-Dwelling Elderly Women. J Gerontol A Biol Sci Med Sci 2000; 55(4):M192-M199.. Another factor to consider is the greater use of healthcare services by older women, including medical appointments, which increases the chances of a greater number of diagnoses of cataracts⁵¹51. Destro JR, Boing AF, D’Orsi E. Factors associated to medical consultations by elderly adults in southern Brazil: a population based study. Rev Bras Epidemiol 2014; 17(3):692-704.. Women also have greater longevity and a consequent accumulation of age-related disease and also seek cataract surgery more⁵²52. Olofsson P, Lundstrom M, Stenevi U. Gender and referral to cataract surgery in Sweden. Acta OphthalmolScand 2001; 79(1395-3907):350-353.. Similar differences between women and men regarding the functional impact of cataract have been reported⁵³53. Tobacman JK, Zimmerman B, Lee P, Hilborne L, Kolder H, Brook RH. Visual function impairments in relation to gender, age, and visual acuity in patients who undergo cataract surgery. Ophthalmology 1998; 105(9):1745-1750.. In general, women have more fear of falling than men and this fear is believed to play a protective role against falls⁵⁴54. Pohl P, Ahlgren C, Nordin E, Lundquist A, Lundin-Olsson L. Gender perspective on fear of falling using the classification of functioning as the model. Disabil Rehabil 2015; 37(3):214-222.. The divergence between men and women may be linked to cultural factors, as women (even those who have suffered falls) continue playing their social roles, exercising activities in the home environment⁵²52. Olofsson P, Lundstrom M, Stenevi U. Gender and referral to cataract surgery in Sweden. Acta OphthalmolScand 2001; 79(1395-3907):350-353..

In the group with cataract, a score of less than 11 points on the SPPB was considered a risk factor for falls. Balance is affected more when visual impairment is greater. Therefore, these factors tend to result in a greater incidence of falls, as reported in two previous studies involving the use of the Berg balance scale⁴4. Aartolahti E, Häkkinen A, Lönnroos E, Kautiainen H, Sulkava R, Hartikainen S. Relationship between functional vision and balance and mobility performance in community-dwelling older adults. Aging Clin Exp Res 2013; 25(5):545-552.,⁵⁵55. Lee HKM, Scudds RJ. Comparison of balance in older people with and without visual impairment. Age Ageing 2003; 32(6):643-649.. In the present investigation, the SPPB was the only measure of physical-functional performance associated with falls in individuals with cataract, perhaps because of its broader scope, as this battery involves muscle strength, balance and gait speed tests. Therefore, among the measures employed, the SPPB is suggested to be the most adequate for the evaluation of older adults with different levels of functioning, as it can differentiate active individuals from sedentary individuals⁵⁶56. Morie M, Reid KF, Miciek R, Lajevardi N, Choong K, Krasnoff JB, Storer TW, Fielding RA, Bhasin S, Lebrasseur NK. Habitual physical activity levels are associated with performance in measures of physical function and mobility in older men. J Am Geriatr Soc 2010; 58(9):1727-1733. and detect differences in performance between frail and non-frail individuals⁵⁷57. Chang SF, Yang R Sen, Lin TC, Chiu SC, Chen ML, Lee HC. The Discrimination of using the short physical performance battery to screen frailty for Community-Dwelling elderly people. J Nurs Scholarsh 2014; 46(3):207-215.. In a population-based study, a statistically significant difference on the SPPB was found between recurring fallers and non-recurring fallers⁵⁸58. Ferriolli E, Perracini MR. Factors associated with falls and recurrent falls in elderly: a population-based study. Rev Bras Geriatr e Gerontol 2007; 1(2):49-60..

The present findings and the lack of evidence favoring cataract correction surgery as the only strategy for reducing the risk of falls⁵⁹59. Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls in older people living in the community. Cochrane database Syst Rev 2012; 9(9):CD007146.,⁶⁰60. Meuleners LB, Fraser ML, Ng J, Morlet N. The impact of first-and second-eye cataract surgery on injurious falls that require hospitalisation: A whole-population study. Age Ageing 2014; 43(3):341-346. underscore the importance of multidisciplinary follow up of older adults with a diagnosis of cataract to orientate these individuals and implement interventions directed at modifiable risk factors, as multidimensional strategies are effective at reducing the risk and occurrence of falls⁵⁹59. Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls in older people living in the community. Cochrane database Syst Rev 2012; 9(9):CD007146.. Indeed, a multidisciplinary evaluation of falls is fundamental. Certain adverse health conditions can affect one’s postural control, such as those that impair the vision (e.g., cataract) or cause sensory deficiencies, as occurs in diabetes mellitus⁶¹61. Close JCT, Lord SR. Fall assessment in older people. BMJ 2011; 343:d5153., thereby increasing the risk of falls. In the context of a multidimensional evaluation, it is also important to note that variables related to the use of medications were factors associated with falls in both groups in the present sample, although not achieving statistical significance.

The limitations of the present study regard the cross-sectional design and the impossibility of performing probabilistic sampling. The strengths of this study reside in the stratified analyses to determine the existence of confounding factors and the choice of regression models based on adherence statistics of the models to the data.

The present results suggest that older adults with high levels of functioning may achieve sub-maximum scores on balance tests and still have a high prevalence rate of falls. These findings can contribute to the develop of new ideas regarding the evaluation of active community-dwelling older adults, including the use of multidimensional measures for screening in primary care services⁶²62. Tiedemann A, Lord SR, Sherrington C. The development and validation of a brief performance-based fall risk assessment tool for use in primary care. J Gerontol A Biol Sci Med Sci 2010; 65(8):896-903.. Simple measures in primary care, such as the distribution of glasses and screening with visual acuity tests in the community, could assist in the management of individuals with cataracts⁶³63. Araújo Filho A, Salomão SR, Berezovsky A, Cinoto RW, Morales PHA, Santos FR, Belfort Júnior R. Prevalence of visual impairment, blindness, ocular disorders and cataract surgery outcomes in low-income elderly from a metropolitan region of São Paulo--Brazil. Arq Bras Oftalmol 2008; 71(2):246-253.. It is also necessary to provide education and training for health professionals that include the promotion of functional health for older adults in their integrality, breaking away from the fragmentation of work by professionals in the field⁶⁴64. Brasil. Ministério da Saúde (BR). Envelhecimento e saúde da pessoa idosa. Brasília: MS; 2007..

Conclusion

The present data suggest that sex and physical performance exert an influence on the risk of falls among community-dwelling older adults with cataract, whereas multimorbidity was associated with falls among those without cataract.

Physical performance tests, including tests addressing postural balance, should not be used as the only means for the identification of older adults at risk for falls, even when the cutoff points are adjusted.

Longitudinal studies are needed to confirm these findings and contribute to the development of multidisciplinary strategies for the evaluation of the risk of falls among community-dwelling older adults with a diagnosis of cataract.

Acknowledgments

To CNPq for the financing.

References

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