Written By: Dr. Sarah Mireles Jacobs
At 84 years old, Helen* was especially proud of two things: living independently, and taking a 2 mile walk every afternoon. There are 255 cloudy days a year in Seattle, Washington, but it was brilliantly sunny that day as she headed out on her usual route one afternoon in July. She remembers the gravel crunching under her strong, confident steps. She remembers looking up at the sky, feeling thirsty, thinking about the heat and the blinding glare from the sun. After that, she remembers regaining consciousness laying on the sidewalk—knees scraped, face covered in blood, no vision in her right eye—and realizing that she must have fainted. She had hit her face against a roadside guardrail when she fell, causing the right eyeball to rupture. The eye could not be salvaged despite world-class ophthalmologic care, so it had to be surgically removed. Over the next 5 years, Helen steadily realized that the injury had started a cascade of losses beyond simply losing the vision in one eye.
“I’m afraid to go walking anymore. What if I fall again?”
When she came home from the hospital, she fully intended to resume her activities of daily living as soon as she was allowed to do so by her doctor. However, when she tried to find her old confidence, she mainly found fear instead. She gave up driving, then gave up her daily walk, then ultimately gave up living independently and moved in with relatives. In one study, patients who lost an eye after 65 years old showed a trend toward higher dependency scores on the National Eye Institute’s Visual Function Questionnaire, and were likely to stop driving despite good vision in the remaining eye. In another study, decreased daily activities among the elderly was associated with higher risk of hospitalization. In contrast, the Lifestyle Interventions and Independence for Elders (LIFE) study found that increasing geriatric patients’ daily physical activity resulted in lower risk for onset of major disability. Several examples of this also exist in the orthopedic literature after hip fractures. In other words, a vicious cycle exists in which fear of falling again leads to activity restriction and dependency, which leads to a higher chance of hospitalization and disability, which leads to further activity restriction and dependency. Helen descended straight into that cycle.
“I feel like a burden asking for help with things I used to do on my own.”
When she stopped driving, Helen had to ask for rides to the grocery store. Reluctant to impose, she would go shopping as infrequently as possible, and rush through her purchases so that her driver would not have to wait as long. She stopped going to hair appointments. She struggled to get to doctor’s appointments. Her health and self-care deteriorated. Unfortunately, this pattern is common worldwide after trauma. In a study done in Tunisia, the psychosocial consequences after a fall were more frequent among elderly women.5 A large study in Australia found that after trauma, deterioration in physical health was tied to older age and how severe the patient perceived the injury to be (e.g. monocular blindness in Helen’s case, but mobility limitation is also a common predictor in cases of fractured femur, hip, or vertebrae). Higher risk of deterioration in mental health was predicted by female gender and the patient’s perceived lack of control over their environment.
“Why don’t people tell me when something is wrong? It’s like I’m less of a person now.”
Helen eventually moved into a nursing home. She’d leave her room to play Bingo with a friend once a week in the activity room. Without vision in one eye, her lack of depth perception made her clumsy enough to drop things or spill food, and her limited visual field meant she often would not notice the spills. She did notice a repeated pattern of people trying to discretely tell her friend that something had dropped, though, instead of telling her. “I’m still here,” she would think. “Talk to me. Tell me.”
Finding the Way Back
After significant trauma, the combination of fear, dependence on others, and less-than-equal treatment in social interactions can be progressively debilitating. While there are no absolute remedies, there are strategies that can help. Physical therapy and Occupational therapy can rebuild skills, which in turn can increase strength, confidence, activity level, and independence. Counseling with a licensed therapist can help process the fear and other emotions that may manifest after an injury. Relaxation techniques such as meditation, guided imagery, deep breathing, massage, or yoga can also alleviate those feelings.
Practicing phrases in advance to use in social situations can help remind peers when unequal treatment creeps in. With practice, when people directed their comments toward her friend rather than her, Helen found that she could say “I’m missing an eye, but I’m still just as sharp as ever. What do you need to tell me?”
While some level of dependence may be unavoidable, outlining what can still be done for oneself and then tapping into community/family/social/hired resources for the remainder may decrease the sense of burden. Another technique involves deliberately finding ways to say “Thank you,” rather than “Sorry,” in situations where help has been needed, as illustrated in an excellent guide by artist Yao Xiao. For example, “Thank you for making this delicious meal,” rather than “Sorry you have to cook for me because my blind eye makes me clumsy.”
With steady physical therapy, Helen got back to talking a daily walk again, but only if she could get a friend to come along for support. Refocusing her mind toward feeling grateful rather than burdensome helped make it a pleasant stroll. At the end of each walk, rather than “Sorry I’m not confident enough to walk alone,” she would say “Thank you for coming out for a walk with me. What a beautiful day to be outside.”
Meet the Author Dr. Sarah Mireles Jacobs
Dr. Sarah Mireles Jacobs is an Oculoplastic Reconstructive Surgeon who graduated from Mayo Clinic School of Medicine, completed Ophthalmology residency at Washington University in St Louis, then Oculoplastic Surgery fellowship at the University of Washington in Seattle. She is on faculty at the University of Alabama Birmingham Callahan Eye Hospital. Learn More About the Author.
References:
- Mangione CM, Lee PP, Gutierrez PR, et al. Development of the 25-item National Eye Institute Visual Function Questionnaire. Arch Ophthalmol. 2001;119:1050-8.
- Na L, Pan Q, Xie D, et al. Activity limitation stages are associated with risk of hospitalization among Medicare beneficiaries. PM R, 2017;9(5):433-43.
- Fielding RA, Guralnik JM, King AC, et al. Dose of physical activity, physical functioning and disability risk in mobility-limited older adults: Results from the LIFE study randomized trial. PLoS One. 2017;12(8):e0182155.
- Amata O, Panella L, Incorvaia C, et al. Role of frailty in functional recovery after hip fracture, the variable impact in restoring autonomy. Acta Biomed. 2022;92(6):e2021387.
- Kechaou I, Cherif E, Sana BS, et al. Traumatic and psychosocial complications of falls in the elderly in Tunisia. Pan Afr Med J. 2019;32:92.
- Aitken LM, Chaboyer W, Kendall E, Brumeister E. Health status after traumatic injury. J Trauma Acute Care Surg. 2012;72(6):1702-8.
- http://www.yao.nyc/shortcomics/2020/3/30/if-you-want-to-say-thank-you-dont-say-sorry
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