In this clinical sample of older adults with varying degrees of visual impairment, we found that physical activity in those who had multiple falls over a year became more transient and fragmented over the subsequent three-year period. Overall activity levels also declined, with most pronounced declines occurring during the evening hours. However, changes in fragmentation and patterns of daily activity were not observed in those with only one fall or no fall over a 12 month period. Collectively, our results suggest that, in a group largely consisting of persons with visual impairment from glaucoma, multiple fallers experience a more decline in physical capacity and endurance over time (as suggested by changes in fragmentation and evening activity) as compared to non-fallers. Our study provides important information on quantifying the longitudinal changes in patterns of free-living physical activity as a consequence of fall frequency in a population of older adults with visual impairment. The strengths of this study include: (1) use of objective measurement of physical activity to capture a variety of metrics e.g., number of steps, minutes of activity, and bouts of activity, (2) quantification of daily activity patterns in a sample at higher risk of falling because of their visual impairments, (3) assessment of three-year activity changes as the effect of fall occurrences e.g., effects are enduring and dramatic at least for multiple fallers. The results of our study indicate that, more resources and practice guidelines should be directed to multiple fallers, such as investigation on falling at least twice in the past 12 months should be a screening step in identifying multiple fallers who are in need of early treatment; further, given single fallers may fall again in subsequent years attention to them should be noted as well. Our findings add to the literature suggesting that older adults experience functional declines and reduced daily activity after falling, and this extends out to three years from falling. A previous cross-sectional study in a well-functioning population of older adults found that people who reported falling in the past year exhibited a similar amount of accelerometer-measured physical activity compared to their comparators who did not fall. However, fall measurement through a health interview questionnaire is subject to substantial recall bias, and the consequence of prospectively collected and continuously monitored falls on long-term changes in physical activity was not described. Another study with a large sample of independently mobile and community-dwelling older men reported that recurrent falls were cross-sectionally associated with fewer daily steps, less moderate and vigorous activity, and more sedentary behavior; however, daily patterns of physical activity, such as fragmentation, which reflects a metric of overall health and physiologic decline, were not evaluated. Prior evidence has demonstrated that greater activity fragmentation (i.e., shorter episodes of activity) is associated with older age, slower gait speed, higher fatigability, poor functionality, and shorter lifespan - all independent of total activity. Our prospective three-year study provides novel insights as to the long-term consequences of falls on changing physical activity patterns, demonstrating that multiple falls over 12 months appear to be associated with more transient and fragmented activity over a three-year period compared to individuals experiencing only one or no falls. However, it remained unclear that if falls were the cause of changes in activity or simply a marker of physical activity changes that were happening as a result of other systemic issues, and might have taken place even if the fall did not occur. Further, these results suggest that multiple falls should be targeted for intervention to prevent the possibility of greater functional challenges with daily activities and/or lower endurance capacity through fatigue as a result of these multiple falls, or in combination with risk factors that both increase the risk of falls and alter physical activity patterns. Previous research has noted that older people who have a higher risk of falling (e.g., balance problems) and perceived fatigability display altered and downshifting diurnal patterns of physical activity (e.g. lower activity levels). Consistent with prior research based on accelerometer measurement of physical activity, the distribution of daily activity in our study showed a similar pattern at each of four annual visits for our first-year multiple fallers. Furthermore, our study examined changes in activity levels across fall categories and demonstrated that long-term declines of activity after multiple falls occurred over all waking periods of the day, with activity declines most pronounced during evening hours (5:00 PM to 8:00 PM). Such declines in late-day activity over time suggest multiple fallers with glaucoma may have more difficulties in performing activity and optimizing functionality after sunset when it is darker; alternately, it may indicate greater late-day fatigue in this group. Further research is warranted to study whether declines in late-day activity is associated with fatigability in glaucoma patients. Our study has several limitations. First, although our study population was mostly representative of patients seeking eye care at Johns Hopkins, where participants were recruited, it is unclear if our findings are generalizable to other older adults in general or even to others with visual impairment. Second, our ability to assess other potential confounders (home hazards, lighting conditions) was limited, and it is unclear if environmental conditions differed across the three fall categories. Additionally, although the longitudinal cohort study traditionally allowed stronger inferences than cross-sectional studies, our study design was unable to account for reverse causality. For instance, declining physical function may result in less activity and promote falls, such that falls only serve as a marker for declining functionality and do not necessarily cause it. Third, our prior research has described the circumstances and location of falls in this cohort; however, given that not all falls could be explained by participants, we did not collect the information as to whether falls could be explained or unexplained and the exact timing of the falls. Moreover, although prior research demonstrated that falls per activity exposure (e.g., falls per hours walked) complemented falls per person time, we did not incorporate this measurement in present study as it was our hypothesis that it was the fall itself, not the rate of falling per unit of activity, that would result in changes in activity. Fourth, we did not obtain individual comorbid condition that may impact daily physical activity, such as severity and duration of each comorbidity and the interaction between these comorbidities. Fifth, although the dropout rate over three years did not differ by fall frequency categories, we did not perform complex analysis using joint models for longitudinal and censoring data approach. Sixth, it was possible that vision loss varied over time; however, as this was a treated cohort, changes in vision loss were infrequent, making it difficult to judge changes in vision measures and changes in physical activity. Seventh, the original objective of our grant was to determine the impact of falling in the first year on the long-term (three-year) mobility in a glaucoma cohort; a limitation of this pre-planned design is that it does not incorporate information regarding falls during follow-up years and thus it is not clear if falls in subsequent years contributed to observed activity patterns over the three years. It is possible that in real-world settings participants who were initial fallers might not fall in follow-up years and those who were non-fallers might transition to become fallers. However, the cumulative incidence of falls for each year was similar over the three-year study period, and risk of staying multiple fallers was higher for multiple fallers as opposed to non-fallers in the first year, suggesting that first-year fall data may be a good surrogate for events occurring in later years. Of note, multiple faller group started out with less fragmentation of activity than the other groups and ended with only slightly more fragmentation. However, this lower fragmentation at baseline was likely true as it persisted for two years of measurement. This might reflect that multiple fallers did enough activity to have these falls and thus made them more susceptible to greater fragmentation over time. In conclusion, our study found that in an older population enriched for visual impairment, multiple fallers identified prospectively over 12 months developed more transient and fragmented activity over a subsequent three-year period, with activity declines occurring throughout the day but most pronounced during evening hours. However, longitudinal changes in fragmentation and patterns of daily activity were not observed in those identified in the first 12 study months as single or non-fallers. Future research is warranted to focus on interventions to prevent recurrent falls and reductions in activity in high risk older individuals, i.e. those with visual impairment with multiple falls.