Falls are experienced every year in approximately 20–33% of community-dwelling older adults (Peel 2011). The population in the UK is ageing; currently, there are 12 million people in the UK aged 65 and above, and by 2066 this could increase to over 20 million (ONS 2018). With this increase in demographic ageing, the prevalence of sight loss and blindness may increase from 3.0% to 5.4% by 2050 (Pezzullo et al. 2018). Furthermore, as the evidence shows that the risk of falls increases with age (Klein et al. 2003), we need to address the association of both vision and falls as a matter of public health concern. The annual hospital cost for all incident hip fractures in individuals aged 60 years in the UK is estimated to be £1.1 billion (Leal et al. 2016) and does not include onward social care. A briefing paper published by the RNIB estimated that the cost of falls associated with sight loss to the NHS is £25.1 million per year (Boyce 2011). Along with the financial implications of falls to the NHS, the consequences to the individual’s quality of life are more far-reaching, including loss of independence, increased depression and reduced mobility (Salkeld et al. 2000).
Physiologically, to maintain balance and stay upright we need appropriate inputs from the visual, proprioceptive and somatosensory systems; therefore, any deficient input from one of these systems could potentially lead to postural instability and subsequently a fall (Black & Wood 2005). Therefore, the impact of impaired vision in falls is crucial, and research has shown the association between reduced visual functions and falls in older adults (de Boer et al. 2004; Freeman et al. 2007; Ivers et al. 2003; Klein et al. 2003; Lord, Clark & Webster 1991; Lord & Dayhew 2001; Nevitt et al. 1989; Tinetti, Speechley & Ginter 1988). Several studies have also examined the association between age-related ophthalmological conditions and falls.
Increased risk of falls has been reported in individuals with age-related macular degeneration (Chung et al. 2017; Radvay et al. 2007; Szabo et al. 2010), glaucoma (Black, Wood & Lovie-Kitchin 2011; Haymes et al. 2007; Tanabe et al. 2012) and cataracts (Ivers et al. 1998; Palagyi et al. 2016). Studies have reported a reduction in falls risk following first eye surgery (Harwood et al. 2005; Palagyi et al. 2017a; To et al. 2014). In contrast, an increase in falls has been reported between first and second eye surgery (Meuleners et al. 2014), which may cause a deficit in stereovision. A further modifiable visual risk factor that has been linked to an increased risk of falls, and in particular trips, is the use of varifocal glasses (Davies et al. 2001; Lord, Dayhew & Howland 2002) when compared to wearing distance single-vision spectacles (Johnson et al. 2007). Haran et al. (2010) also found that older adults who took part in regular outdoor activity experienced fewer falls when wearing single-vision glasses.
Whilst we have highlighted several cohort studies that have identified specific visual risk factors for falls and falls risk in older adults with ophthalmological conditions, there is no study to identify the prevalence of falls in patients presenting to an ophthalmology outpatient department. We also understand that a history of falling is a strong risk factor for a further fall (Deandrea et al. 2010; Gale et al. 2018; Pohl et al. 2014). Therefore, prior to designing a case-control study to measure clinical visual functions to determine the risk of falls, we conducted a surveillance audit to determine the prevalence of falls in patients attending an ophthalmology outpatient department. In addition, the audit would highlight the need for ophthalmic health professionals to identify patients at risk of further falls as per the new quality statement in the NICE guidance (NICE 2017): ‘’Older people are asked about falls when they have routine assessments and reviews with health and social care practitioners, and if they present at a hospital’.
A public health surveillance initiative to identify the prevalence of falls in adult patients (>18 years) attending the ophthalmology unit led to the development of a short questionnaire in collaboration with the falls multi-disciplinary team at Southport and Ormskirk NHS Trust. The questionnaire was purposefully kept brief to not make it too onerous for the patient. The aim was for patients to self-report any falls that they had in the previous 12 months, fractures that may have occurred as a result of the fall, the type of glasses they wore and their eye condition.
The questionnaire was completed at two NHS hospital trusts: Southport and Ormskirk Hospital Trust and Warrington and Halton Hospitals Trust. The ophthalmology reception staff for each trust administered the forms to patients attending the ophthalmology outpatients. The data was collected for one month over two time points for each site. This data was then anonymised, collated across both sites and analysed using descriptive statistics, ANOVA and chi-square analysis. Local trust approval was obtained at both Southport and Ormskirk Hospital Trust and Warrington and Halton Hospitals Trust. Ethical approval and informed consent were not required for this audit.
A total of 585 patients with a mean age of 69 years (range 20–102 years, SD 13.8) reported their falls history from the previous 12 months from both trusts. There was no significant difference in the age of the respondents across the sites and time periods they were surveyed (Figure 1, p > 0.05, one-way ANOVA). A significant proportion of responders were older adults (aged 60 years and over) (N = 463 (79%) vs N = 122 (21%), p < 0.0002, one-sample binomial test).
A total of 96 respondents (16.4%) had experienced at least one fall in the previous year. Figure 2 illustrates the proportion of patients within each age group of the entire sample who experienced a fall. A significant proportion of the falls respondents were older adults (N = 79, 82%, p < 0.0001, one-sample binomial test), and of these, 44% (N = 35) were aged 80 years and over. Thirty-nine patients (41%) had experienced multiple (two or more) falls, and a significant proportion of these individuals were seen in Southport and Ormskirk (69%) compared to Warrington and Halton (31%) (p = 0.0009, chi-square). Twelve respondents experienced a fracture (mean age: 72 years, SD: 13.5, range 39–84).
Patients were asked to self-report their eye condition, and over half of the respondents (N = 297, 50.7%) did not record this information. Glaucoma was the most commonly self-reported condition (N = 116), which was reported either as an isolated condition or with cataracts, AMD or Sjorgren’s syndrome. This was followed by cataracts (N = 55), which also featured alongside other ophthalmological conditions. Data was cross-referenced against the patient records to determine the presence of key age-related ophthalmic conditions: cataracts, AMD and glaucoma (Table 1). No data were obtained for six respondents, and the remaining had other conditions (N = 160).
|Age-related ophthalmic condition||N (%)|
|Missing data||6 (1)|
Two thirds of respondents aged 60 and over presented with at least one key age-related ophthalmic condition (N = 306, 66%), and the remaining one third had other conditions or were under review for suspect age-related ophthalmic conditions. Amongst the older adults who had experienced a fall, 68% (N = 54) had at least one of the key ophthalmic conditions compared to 32% (N = 25) who had other conditions (p = 0.002, one-sample binomial test).
Many of the older adults had co-existing age-related ophthalmic conditions. The most prevalent condition was glaucoma, followed by cataracts in the older adults who had experienced a fall in the previous 12 months (Figure 3).
Varifocals (30.6%) and single-vision glasses (35.7%) were commonly worn by all respondents (Table 2). On further analysis of the sample who had experienced a fall, a significant proportion wore single-vision glasses compared to bifocals, varifocals and no glasses (p < 0.0001, one-sample chi-square test, Table 2).
|TYPES OF GLASSES WORN||N (%) ALL RESPONDENTS||N (%) RESPONDENTS REPORTING A FALL|
|No glasses||99 (16.9)||14 (15.1)|
|Single-vision glasses||209 (35.7)||40 (43.0)|
|Varifocals||179 (30.6)||23 (24.7)|
|Bifocals||77 (13.2)||16 (17.2)|
|Not reported||21 (3.6)||3 (3)|
The results of our cross-sectional surveillance audit demonstrate that 17% of all the older adult patients (60 years and over) attending an ophthalmology outpatient department at two North West Trusts reported having had a fall in the previous 12 months. The proportion of falls in the older adult sample is contrary to the commonly reported statistic of one third of older adults aged 65 and over experiencing at least one fall per year and rising to 50% of people older than 80 years (NICE 2013). This low prevalence seen in our surveillance audit may be explained by the reluctance of older adults to ‘go public’ about their fall due to fear of added pressure to change their lifestyle and threat to their independence (Kingston 2000; Yardley et al. 2006). Also, the under-reporting of falls may be due to the cross-section nature of our data and lack of cognitive function measure contributing to recall bias (Freiberger & de Vreede 2011).
A further limitation when capturing the data was that the fall was not defined. Therefore, participants may not have recognized and reported a fall that was a slip, trip, near miss or non-injurious (Freiberger & de Vreede 2011). Hence, in future studies to improve the reporting of falls, a diary or calendar should be used to collect prospective data using the Prevention of Falls Network Europe (ProFaNE) definition of a fall as ‘an unexpected event in which the participant comes to rest on the ground, floor, or lower-level’ (Lamb et al. 2005).
Furthermore, in a survey-based study of 33,104 adults over 18 years of age, self-reported moderate rather than severe visual impairment was reported to be associated with injurious falls (OR 1.58, 95%CI: 1.15–2.17) (French et al. 2016). There were fewer individuals with severe visual impairment who experienced an injurious fall possibly due to them adopting a more cautious approach to ambulation. This was confirmed in a qualitative study exploring the fear of falling in older adults with age-related ophthalmic conditions where the participants reported taking more care and being cautious (Mehta 2020) and could further account for the fewer number of falls reported in this study. Future studies could examine the prevalence of falls in older adults in other outpatient departments and conduct case-control studies to establish whether individuals with objectively assessed mild, moderate and severe visual impairment and/or deficit visual functions are at greater risk of falls.
The respondents’ lack of awareness of their ophthalmic condition was evident in over half of the patients. This finding points to the need to improve the ability of individuals to access and understand their condition as low levels of health literacy have been reported to be associated with poor health outcomes and increased healthcare costs (Easton, Entwistle & Williams 2010). A qualitative piece of work exploring the fear of falling in older adults with age-related ophthalmic conditions reported the importance of knowledge as cultural capital in managing risk or fear of falling (Mehta 2020). Hence, further work should aim to evaluate the effect of health literacy and information on managing the risk of falls. Falls risk in older adults can also be explored in those who are aware of their condition to determine if they take extra precautions by altering gait and gaze when navigating their environment. Falls and fear of falling have been reported to be predictors of each other and have common shared risk factors, for example being female, history of stroke, visual impairment and a sedentary lifestyle (Friedman et al. 2002; Murphy, Dubin & Gill 2003). A few studies have reported the association of increased fear of falling with specific ophthalmic conditions, for example, glaucoma, AMD, cataracts and diabetic retinopathy (Adachi et al. 2018; Hewston & Deshpande 2018; Palagyi et al. 2017b).
The prevalence of age-related ophthalmic conditions, namely cataracts, glaucoma and AMD, increases with age. Older adults aged 80 years have one third of all cases of cataract, glaucoma and AMD (Klein & Klein 2013). In our study, glaucoma was the most common presenting condition in older adults (aged 60 years and over) followed by cataracts. Both glaucoma and cataracts can potentially be associated with reduced visual fields and stereopsis, respectively. In our study, of those who had a fall, twice as many of the patients aged 60 and over had at least one of the key age-related ophthalmic conditions, yet there was no significant association between a fall in the previous 12 months and the presence of an age-related ophthalmic condition. A limitation of this study is the lack of clinical data on measured visual function to determine the association between falls and impaired visual function.
Unlike previously reported evidence on the association between varifocals and the increased risk of falls (Davies et al. 2001; Lord, Dayhew & Howland 2002), our data did not demonstrate an association between the use of varifocals and falls, and instead, a greater proportion of those who had fallen wore single-vision glasses. It is conceivable that respondents did not always wear their single-vision glasses at all times, and this postulation would require further study.
The prevalence of falls in older adult patients attending an ophthalmology outpatient department in our audit was less than that reported in the general older adult population. Impaired vision is a recognised risk factor for falls, but this is potentially the case in those who have undetected visual defects and are not under any ophthalmic care. Future work could explore whether ophthalmic patients adopt a more cautious modified approach to ambulation due to their vision and therefore experience fewer falls. However, falls remain to be an issue in older age groups. Irrespective of the prevalence, ophthalmic health professionals are in an ideal position for falls case/risk identification and onward referral specialist assessment to prevent further falls. Furthermore, this surveillance study highlights that people have poor health awareness. As healthcare professionals, we need to consider health literacy in communicating to patients their ophthalmic diagnosis and potential effects on their vision to increase their understanding of their condition.
The authors have no competing interests to declare.
Adachi, S, Yuki, K, Awano-Tanabe, S, Ono, T, Shiba, D, Murata, H, Asaoka, R and Tsubota, K. 2018. Factors associated with developing a fear of falling in subjects with primary open-angle glaucoma. BMC Ophthalmology, 17: 7. DOI: https://doi.org/10.1186/s12886-018-0706-5
Black, A and Wood, J. 2005. Vision and falls. Clin Exp Optom, 88(4): 212–222. DOI: https://doi.org/10.1111/j.1444-0938.2005.tb06699.x
Black, AA, Wood, JM and Lovie-Kitchin, JE. 2011. Inferior field loss increases rate of falls in older adults with glaucoma. Optometry and Vision Science, 88(11): 1275–1282. DOI: https://doi.org/10.1097/OPX.0b013e31822f4d6a
Chung, S-D, Hu, C-C, Lin, H-C, Kao, L-T and Huang, C-C. 2017. Increased fall risk in patients with neovascular age-related macular degeneration: A three-year follow-up study. Acta Ophthalmologica, 8: 800. DOI: https://doi.org/10.1111/aos.13281
Davies, JC, Kemp, GJ, Stevens, G, Frostick, SP and Manning, DP. 2001. Bifocal/varifocal spectacles, lighting and missed-step accidents. Safety Science, 38(3): 211. DOI: https://doi.org/10.1016/S0925-7535(01)00002-9
de Boer, MR, Pluijm, SM, Lips, P, Moll, AC, Volker-Dieben, HJ, Deeg, DJ and van Rens, GH. 2004. Different aspects of visual impairment as risk factors for falls and fractures in older men and women. Journal of Bone and Mineral Research, 19(9): 1539–1547. DOI: https://doi.org/10.1359/JBMR.040504
Deandrea, S, Lucenteforte, E, Bravi, F, Foschi, R, La Vecchia, C and Negri, E. 2010. Risk factors for falls in community-dwelling older people: A systematic review and meta-analysis. Epidemiology, 21(5): 658–668. DOI: https://doi.org/10.1097/EDE.0b013e3181e89905
Easton, P, Entwistle, VA and Williams, B. 2010. Health in the ‘hidden population’ of people with low literacy. A systematic review of the literature. BMC Public Health, 10. DOI: https://doi.org/10.1186/1471-2458-10-459
Freeman, EE, Munoz, B, Rubin, G and West, SK. 2007. Visual field loss increases the risk of falls in older adults: The Salisbury eye evaluation. Investigative Ophthalmology & Visual Science, 48(10): 4445–4450. DOI: https://doi.org/10.1167/iovs.07-0326
Freiberger, E and de Vreede, P. 2011. Falls recall—limitations of the most used inclusion criteria. European Review of Aging and Physical Activity, 8(2): 105–108. DOI: https://doi.org/10.1007/s11556-011-0078-9
French, DD, Margo, CE, Tanna, AP, Volpe, NJ and Rubenstein, LZ. 2016. Associations of Injurious Falls and Self-Reported Incapacities: Analysis of the National Health Interview Survey. Journal of Patient Safety, 12(3): 148–151. DOI: https://doi.org/10.1097/PTS.0000000000000084
Friedman, SM, Munoz, B, West, SK, Rubin, GS and Fried, LP. 2002. Falls and fear of falling: Which comes first? A longitudinal prediction model suggests strategies for primary and secondary prevention. Journal of American Geriatrics Society, 50. DOI: https://doi.org/10.1046/j.1532-5415.2002.50352.x
Gale, CR, Westbury, LD, Cooper, C and Dennison, EM. 2018. Risk factors for incident falls in older men and women: The English longitudinal study of ageing. BMC Geriatrics, 18(1): 117–117. DOI: https://doi.org/10.1186/s12877-018-0806-3
Haran, MJ, Cameron, ID, Ivers, RQ, Simpson, JM, Lee, BB, Tanzer, M, Porwal, M, Kwan, MM, Severino, C and Lord, SR. 2010. Effect on falls of providing single lens distance vision glasses to multifocal glasses wearers: VISIBLE randomised controlled trial. British Medical Journal (Clinical Research ed), 340. DOI: https://doi.org/10.1136/bmj.c2265
Harwood, RH, Foss, AJ, Osborn, F, Gregson, RM, Zaman, A and Masud, T. 2005. Falls and health status in elderly women following first eye cataract surgery: A randomised controlled trial. Br J Ophthalmol, 89(1): 53–59. DOI: https://doi.org/10.1136/bjo.2004.049478
Haymes, SA, Leblanc, RP, Nicolela, MT, Chiasson, LA and Chauhan, BC. 2007. Risk of falls and motor vehicle collisions in glaucoma. Invest Ophthalmol Vis Sci, 48(3): 1149–1155. DOI: https://doi.org/10.1167/iovs.06-0886
Hewston, P and Deshpande, N. 2018. Fear of Falling and Balance Confidence in Older Adults With Type 2 Diabetes Mellitus: A Scoping Review. Canadian Journal of Diabetes, 42(6): 664–670. DOI: https://doi.org/10.1016/j.jcjd.2018.02.009
Ivers, RQ, Cumming, RG, Mitchell, P and Attebo, K. 1998. Visual impairment and falls in older adults: The Blue Mountains Eye Study. Journal of American Geriatrics Society, 46(1): 58–64. DOI: https://doi.org/10.1111/j.1532-5415.1998.tb01014.x
Ivers, RQ, Cumming, RG, Mitchell, P, Simpson, JM and Peduto, AJ. 2003. Visual risk factors for hip fracture in older people. J Am Geriatr Soc, 51(3): 356–363. DOI: https://doi.org/10.1046/j.1532-5415.2003.51109.x
Johnson, L, Buckley, JG, Scally, AJ and Elliott, DB. 2007. Multifocal spectacles increase variability in toe clearance and risk of tripping in the elderly. Investigative Ophthalmology & Visual Science, 48(4): 1466–1471. DOI: https://doi.org/10.1167/iovs.06-0586
Kingston, P. 2000. Falls in later life: Status passage and preferred identities as a new orientation. p. 216. DOI: https://doi.org/10.1177/136345930000400205
Klein, BEK, Moss, SE, Klein, R, Lee, KE and Cruickshanks, KJ. 2003. Associations of visual function with physical outcomes and limitations 5 years later in an older population: The Beaver Dam eye study. Ophthalmology, 110(4): 644. DOI: https://doi.org/10.1016/S0161-6420(02)01935-8
Klein, R and Klein, BEK. 2013. The prevalence of age-related eye diseases and visual impairment in aging: Current estimates. Investigative Ophthalmology & Visual Science, 54(14): ORSF5–ORSF13. DOI: https://doi.org/10.1167/iovs.13-12789
Lamb, SE, Jørstad-Stein, EC, Hauer, K, Becker, C, Europe, o.b.o.t.P.o.F.N. and Group, OC. 2005. Development of a Common Outcome Data Set for Fall Injury Prevention Trials: The Prevention of Falls Network Europe Consensus. Journal of the American Geriatrics Society, 53(9): 1618–1622. DOI: https://doi.org/10.1111/j.1532-5415.2005.53455.x
Leal, J, Gray, AM, Prieto-Alhambra, D, Arden, NK, Cooper, C, Javaid, MK, Judge, A and Group, R.E.s. 2016. Impact of hip fracture on hospital care costs: A population-based study. Osteoporosis Int, 27(2): 549–558. DOI: https://doi.org/10.1007/s00198-015-3277-9
Lord, SR, Clark, RD and Webster, IW. 1991. Visual acuity and contrast sensitivity in relation to falls in an elderly population. Age and Ageing, 20(3): 175–181. DOI: https://doi.org/10.1093/ageing/20.3.175
Lord, SR and Dayhew, J. 2001. Visual risk factors for falls in older people. Journal of American Geriatrics Society, 49(5): 508–515. DOI: https://doi.org/10.1046/j.1532-5415.2001.49107.x
Lord, SR, Dayhew, J and Howland, A. 2002. Multifocal glasses impair edge-contrast sensitivity and depth perception and increase the risk of falls in older people. Journal of American Geriatrics Society, 50(11): 1760–1766. DOI: https://doi.org/10.1046/j.1532-5415.2002.50502.x
Meuleners, LB, Fraser, ML, Ng, J and Morlet, N. 2014. The impact of first- and second-eye cataract surgery on injurious falls that require hospitalisation: A whole-population study. Age & Ageing, 43(3): 341–346. DOI: https://doi.org/10.1093/ageing/aft177
Murphy, SL, Dubin, JA and Gill, TM. 2003. The development of fear of falling among community-living older women: Predisposing factors and subsequent fall events. Journal of Gerontologly Series A Biological Scences and Medical Sciences, 58(10): M943–947. DOI: https://doi.org/10.1093/gerona/58.10.M943
Nevitt, MC, Cummings, SR, Kidd, S and Black, D. 1989. Risk factors for recurrent nonsyncopal falls. A prospective study. JAMA, 261(18): 2663–2668. DOI: https://doi.org/10.1001/jama.261.18.2663
NICE. 2013. Falls in older people: Assessing risk and prevention Available at https://www.nice.org.uk/guidance/cg161 [Last accessed 31 October 2019].
NICE. 2017. Falls in older people. Available at https://www.nice.org.uk/guidance/qs86 [Last accessed 31 October 2019].
ONS. 2018. Overview of the UK population: November 2018. Available at https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/articles/overviewoftheukpopulation/november2018 [Last accessed: 31 October 2019].
Palagyi, A, McCluskey, P, White, A, Rogers, K, Meuleners, L, Ng, JQ, Morlet, N and Keay, L. 2016. While We Waited: Incidence and Predictors of Falls in Older Adults With Cataract. Investigative Ophthalmology & Visual Science, 57(14): 6003–6010. DOI: https://doi.org/10.1167/iovs.16-20582
Palagyi, A, Morlet, N, McCluskey, P, White, A, Meuleners, L, Ng, JQ, Lamoureux, E, Pesudovs, K, Stapleton, F, Ivers, RQ, Rogers, K and Keay, L. 2017a. Visual and refractive associations with falls after first-eye cataract surgery. Journal of Cataract & Refractive Surgery, 43: 1313–1321. DOI: https://doi.org/10.1016/j.jcrs.2017.07.029
Palagyi, A, Ng, JQ, Rogers, K, Meuleners, L, McCluskey, P, White, A, Morlet, N and Keay, L. 2017b. Fear of falling and physical function in older adults with cataract: Exploring the role of vision as a moderator. Geriatrics & Gerontology International, 17(10): 1551–1558. DOI: https://doi.org/10.1111/ggi.12930
Peel, NM. 2011. Epidemiology of Falls in Older Age. Canadian Journal on Aging/La Revue canadienne du vieillissement, 30(1): 7–19. DOI: https://doi.org/10.1017/S071498081000070X
Pezzullo, L, Streatfeild, J, Simkiss, P and Shickle, D. 2018. The economic impact of sight loss and blindness in the UK adult population. BMC Health Services Research, 18. DOI: https://doi.org/10.1186/s12913-018-2836-0
Pohl, P, Nordin, E, Lundquist, A, Bergström, U and Lundin-Olsson, L. 2014. Community-dwelling older people with an injurious fall are likely to sustain new injurious falls within 5 years – A prospective long-term follow-up study. BMC Geriatrics, 14(1): 120. DOI: https://doi.org/10.1186/1471-2318-14-120
Salkeld, G, Cameron, ID, Cumming, RG, Easter, S, Seymour, J, Kurrle, SE and Quine, S. 2000. Quality of life related to fear of falling and hip fracture in older women: A time trade off study. British Medical Journal, 320(7231): 341–346. DOI: https://doi.org/10.1136/bmj.320.7231.341
Szabo, SM, Janssen, PA, Khan, K, Lord, SR and Potter, MJ. 2010. Neovascular AMD: An overlooked risk factor for injurious falls. Osteoporosis Int. 21(5): 855–862. DOI: https://doi.org/10.1007/s00198-009-1025-8
Tanabe, S, Yuki, K, Ozeki, N, Shiba, D and Tsubota, K. 2012. The association between primary open-angle glaucoma and fall: An observational study. Clinical Ophthalmology (Auckland, N.Z.), 6: 327–331. DOI: https://doi.org/10.2147/OPTH.S28281
Tinetti, ME, Speechley, M and Ginter, SF. 1988. Risk factors for falls among elderly persons living in the community. New England Journal of Medicine, 319(26): 1701–1707. DOI: https://doi.org/10.1056/NEJM198812293192604
To, KG, Meuleners, L, Bulsara, M, Fraser, ML, Duong, DV, Do, DV, Huynh, V-AN, Phi, TD, Tran, HH and Nguyen, ND. 2014. A longitudinal cohort study of the impact of first- and both-eye cataract surgery on falls and other injuries in Vietnam. Clinical Interventions In Aging, 9: 743–751. DOI: https://doi.org/10.2147/CIA.S61224
Yardley, L, Donovan-Hall, M, Francis, K and Todd, C. 2006. Older people’s views of advice about falls prevention: A qualitative study. Health Education Research, 21(4): 508–517. DOI: https://doi.org/10.1093/her/cyh077