Avoid Missing Those First and Last Steps

Ladies and Gentlemen, There have been times when I have been descending down a set of steps, holding onto a rail, and have stepped onto what I thought was the last step. You know what? It was not. There was one more step. I misplaced my footing that almost resulted in falls. Yes, I have been lucky. I have not fallen yet going down a set of stairs! But, I have learned to be very cautious, especially because of my bifocal eyeglasses.

One of my neighbors was not so lucky. She was visiting a friend, entered a staircase to go down to the basement and outside to a backyard garden. While going down the stairs, she missed that there was still one more step as her right leg and foot was in motion to touch what she though was the floor. Instead, her right foot slipped off the edge of that last step, her ankle twisted, her right knee collapsed, and down she went to the floor. My neighbor fractured her ankle as a result of this fall, appreciating that the extent of her injuries could be much worse.

Falls Associated with Stairs

Ladies and gentlemen, descending down a set of steps, missing that last step has happened to many people, but occurs more often with older adults. I imagine that you too have experienced similar experiences.

Did you know that older adults are more likely, three times more likely, to experience fall-related accidents while descending the steps, rather than climbing up the stairs? This is indeed the case according to Elliott, et al. (2015). Falls among older adults that occur while navigating stairs also are associated with injuries (Blanchet & Edwards, 2018). Extensive research has been conducted that asserts the importance of caution when navigating stairs. To be cautious, one of the most important safety practices is to rely on your vision. Vision is particularly important for this preparation phase, but also to begin taking the first steps down.

Visual Accuracy

Elliott, et al., (2015) recommend an initial visual scan of the stairs to look for hazards and plan for navigating down the steps. Their literature review suggests a visual inspection before going down the stairs, and this inspection should include scanning for objects on the stair, looking at the size, edges, and height of the steps.

The accidents that happen on steps occur more often on the top three or bottom three stairs, when vision is increasingly relied on. We must rely on clear, not blurred vision, and ability to discern depth. These requirements are compromised when wearing bifocal and multi-focal eye glasses. Multifocal glasses have three different lens strengths – to read, use the computer and interact with people – whether lined or progressive lenses. Multifocal glasses impair depth perception and edge-contrast awareness and critical distances to detect environmental obstacles. Recommendations have even suggested that we use non-multifocal glasses with negotiating stairs or unfamiliar environment outside the home (Lord, Dayhew & Howland, 2002). We are also more vulnerable when we our vision changes required updated eyeglass prescriptions – we have transition time of increased fall risk while adjusting to new transition glasses. Clearance over steps and surface-height changes become even more variable with wearing bifocal or multi-focal eyeglasses, which are common types of eyeglasses worn by older adults. Additional research studies have reported that multifocal lenses double the risk of falls in older adults, particularly on stairs and steps (Elliot, et al, 2015).

Accurate vision helps us compensate for sensory neuropathy, another fall risk factor that requires wearing proper shoes. Our vision gives us a point of reference to maintain our safety mobility and balance, used to adapt gait to enable safety travel through environments, avoid obstacles and negotiating steps and stairs. Many of the studies about fall among older adults fall, fail to document if patients were wearing their glasses. However, we know how important visual acuity is to our safety. I have written you previously about the importance of eye health and current eye glass prescriptions to reduce our fall risks..

Foot Placement

Other factors that increase our risk of missing the last steps during our descent, according to Elliott, et al. (2015), is related to mobility – reduced heel clearance, where the heel strikes the edge of a step and impedes proper foot placement on the next step. Balance may be lost resulting in a fall. Heel clearance can also be misjudged because of sensory neuropathy, due to trouble with sensation in our feet, foot placement on the steps and floor, impairing steppage and balance. Again, fall risks are increased navigating steps.

These findings emphasize the importance of exercising much caution when negotiating stairs, taking extra time to “feel” your way to the floor, ensuring the accuracy of each footstep. The most dangerous period of the gait cycle is when the body is only supported by one leg (referred to as “single leg support time”)is increased, and the other leg is in transition to a step. This increased time of single leg support can lead to decreases our center of gravity needed to maintain balance. Loss of balance can result in sideways falls on stairs, unfortunately common among older adults (Elliott, et al.). Assuring extra time for accurate foot placement compensates for unreliable or incomplete sensory information, visual and somatosensory. Again, we must exercise caution when descending stairs. Our foot placement must be precise.

Step Safely on the Global Stage

While I have focused on safe navigation of steps for older adults, just last year the World Health Organization addressed the importance of stepping safely for all persons, all age groups. For all age groups, safer “people interventions” include raising awareness about the risks of reduced vision, as well as loss of muscle strength with age. All persons should be aware and correct unsafe steps, stairs, and footpaths. They address workers and the workplace, emphasizing that falls can occur in any workplace, emphasizing going down stairs (WHO, 2021). Stairs are included in their risk factor model for falls in older age (WHO, p. 34), highlighting the bottom 3 steps of a staircase, as I have shared. Of course, railings for stairs are essential to increase staircase safety features when both ascending and descending stairs.

Last month I invited you into my home and discussed the importance of environmental assessments. I shared with you samples of environmental assessments, hoping that one may have been of interest to you so that you and your family and/or friends could complete such an assessment, with the goal of reducing your fall risks in your home. Blanchett and Edwards, (2018) reviewed 42 environmental checklists, which rarely included objective features of stairs and steps that indicated they were safe. Their in-depth analysis of step and stair assessments revealed that the characteristics of the steps and stairs were reviewed by an evaluator of various levels of training. So, there is much work to be done in this area.

Nonetheless, we know individualized risk factors that, when combined, help us to realize how important it is for heightened safety awareness when navigating stairs, especially going down the steps. Let’s commit to follow these safety strategies: visual clarity and inspection; deliberate and cautious foot placement; vigilance to task going down the stairs, with special attention for first and last steps; hold onto a rail if one is present (if not, get a rail installed); and wear proper, safe footwear, such as non-skid shoes (not socks). One last tip, avoid carrying items in your arms as you go down the stairs, because you block your visual field.

Ladies and gentleman, I hope this information is helpful to you. Your safety is so importance to your Harmony Team. Falls involving steps lead to injury. We don’t want you to experience an injury like my neighbor did.

Your Harmony Team is committed to reducing your fall risks, to help you prevent falls, and promote your function and independence.

Your Harmony Team is here to help you!

Thank you for reading this message.

Dr. Pat Quigley

References :

Blanchet R, & Edwards N. (2018). A need to improve the assessment of environmental hazards for falls on stairs and in bathrooms: Results of a scoping review. BMC Geriatr. 18(1):272.

Elliott, DB., Foster, RJ, Whitaker, D, et al. (2015). Analysis of lower limb movement to determine the effect of manipulating the appearance of stairs to improve safety: a linked series of laboratory-based, repeated measures studies. Public Health Res. 3(8).

Lord, S.R., Dayhew, J., & Howland, A. (2002). Multifocal glasses impair edge-contrast sensitivity and depth perception and increase the risk of fall in older people. J Am Geriatric Soc, 50(11): 1760-6. Available here

Step safely: Strategies for preventing and managing fall across the life-course. Geneva: World Health Organization; 2021. Licence: CCBY-NC-SA 3.0.IGO.

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