Current guidance on fall prevention and diabetes
Posted September 22, 2017
It is well established that falls are a major cause of disability and preventable cause of death in older adults. This is especially true for older adults with diabetes mellitus (DM) who make up close to 50% of the DM population (1, 3).
These older adults have a significantly higher incidence of falls at an estimated annual rate of 39% and are more likely to suffer severe consequences such as fractures and institutionalization as a result compared to older adults without DM (6).
When we think of falls and diabetes, we often first consider balance impairment due to diabetic peripheral neuropathy (DPN) as the likely cause of increased falls risk. While it is established that DPN is a significant risk factor in fall risk in older adults with DM, studies have identified that even persons without overt DPN have an elevated fall risk (7).
In the following article, we will explore the emerging evidence to support a broader examination of falls risk in older adults with DM and recommend strategies aimed at reducing the fall risk and severity in this population.
Decreased Sensorimotor Function
Almost one third of all persons with DM have neuropathy (3). The most common symptoms of DPN are pain, numbness, and tingling in the hands and feet. Persons with DPN with diminished plantar sensation on their feet and exhibit increased postural sway along with significant loss of postural control, reduced walking speed, cadence, and step length, particularly when walking on irregular surfaced and they may have impaired peripheral sensation, reaction time and balance (1, 3).
DPN remains the most significant contributor to falls in this population (1,3).
Current guidance: Current guidance focuses on identifying vulnerable feet, screening for impaired sensation or vibration, diminished foot pulses, foot deformity and provision of foot care education, podiatry, footwear and symptomatic relief of neuropathic pain (3).
Watch how to perform the 60 second diabetic foot screen.
View the 60 second diabetic foot screening tool.
Musculoskeletal/Neuromuscular
Following DPN, lower levels of physical activity, muscle strength and poor postural control are among the next most significant risk factors that influence increased falls risk in DM (1).
Declines in leg muscle mass and strength have been reported to decline at an accelerated rate in older adults with type 2 diabetes compared to those without DM (6).
Current guidance: All persons who fall should have their gait assessment using a simple screening tool, such as the “timed up and go” test (3). Closed-toe shoes with rubber shoes should be worn. Gait aids such as grab bars, canes and walkers should be encouraged if required. Balance training with or without strength and/or gait training has been shown to reduce fall risk in persons in this population (1).
View the “Timed Up and Go Test”.
Reduced Vision
Vision loss is not surprisingly associated with frequent falls, accounting for approximately 47% of reported falls in one study (2). About 60% of persons with type 2 diabetes, and nearly all persons with type 1 diabetes will develop retinopathy (3). Additionally, other forms of visual loss due are common to diabetes including cataracts, macular degeneration and glaucoma (6). They are associated with an increased risk of falls due to impaired visual acuity, depth perception and contrast sensitivity particularly in low light conditions and in the presence of low contrast tripping hazards (3, 6).
Current guidance: Rooms within the home should be well-lit with floors free of clutter and tripping hazards such as scatter mats and electrical cords. A major eye examination is recommended every 1-2 for all persons with DM (5).
Medication
Persons with diabetes that suffer with neuropathic pain are frequently managed with psychotropic and other central nervous system mediated medications. Amitriptyline, pregabalin, gabapentin, opioid agonists and duloxetine, for example are commonly used to treat the painful symptoms.
Psychotropic medications are frequently attributed to falls and nearly double an older adults’ risk for experiencing a fall and having recurrent falls (1). Older adults living with DM are also more likely to be taking a greater number of prescription medications and may be more sensitive to the effects of polypharmacy (1).
It has been suggested that regimens involving just 4 or more prescription medications increases the risk of falling in persons with DM (1). Another study observed that each medication added to the DM treatment increased the risk of falling by 7% (2).
View the 2017 Beer’s Criteria for Potentially Inappropriate Medications in the Elderly.
Hypoglycemia
One of the challenges of managing DM is the increased risk for symptomatic hypoglycemia in older adults.
Hypoglycemia episodes can occur with oral hypoglycemic, injectable and/or or insulin use and frequently result in a state of dizziness, confusion, and postural instability which increases one’s risk for falls (1). In one study of persons using insulin, an A1c less than 6% was associated with falling compared with an A1c >8% (4).
Current guidance: Current guidelines recommend an A1c goal of less than or equal to 7% for most adults and a higher goal for those who are frail (5). Sulphonylureas should be used with caution because the risk of severe or fatal hypoglycemia increases exponentially with age (5). Insulin regimens in older adults should be individualized and selected to promote patient safety (5). Premixed insulins are recommended as an alternative to mixing insulins and prefilled pens as an alternative to conventional syringes to minimize dose errors (5).
Fall Severity and Fractures
Diabetes increases not only the risk of falls but also the risk of fractures (1).
Altered body composition and microvascular complications, including retinopathy, peripheral and autonomic neuropathy, hypoglycemic and use of medications, particularly thiazolidinediones (TZDs), are all related to increased risk of fractures in older adults with DM (1).
In addition to predisposition to fractures with falls, the falls that this population suffers from have the potential to be more severe in terms of injuries sustained as well as the recovery process (1). Hip fractures are 1.5 to 12 times more likely in persons with DM (3).
Key Messages
Falls prevention is an often overlooked aspect of diabetes management with potentially significant impacts on physical function, quality of life and independence of older adults with DM.
Falls prevention interventions may halve fracture rates in the general population of older adults and should be targeted to this vulnerable group (3). Systematic monitoring of the many underlying factors that may contribute to falls risk in this population is recommended.
Consider the following additions to routine care:
- Screen for DPN regularly
- Eliminate or reduce potentially harmful medication
- Individualize A1c target to prevent hypoglycemia
- Consider cognitive function and frailty when selecting medication
- Encourage physical activity
- Recommend major eye examination every 1-2 years
View the complete Diabetes in the Elderly Clinical Practice Guideline.
For more information or to refer a patient please call, email, or visit our website:
Diabetes Grey Bruce
1800 8th Street East
Owen Sound, ON N4K 6M9
519-376-2121 Ext. 2876
Fax: 519-371-7695
A program of
The Grey Bruce Health Network
Contact us:
info@diabetesgreybruce.ca
www.diabetesgreybruce.ca
References
Author, T. (2010). Diabetes, falls and fractures. Age and Ageing, (39) 522-525.
Crews, T. e. (2013). A growing troubling triad: diabetes, aging, and falls. Journal of Aging Research, 1-6.
Graydon, S. e. (2013). Diabetes in the elderly. Canadian Journal fo Diabetes, 27: S184-S190.
Hewston, P. a. (2016). Falls and balance impairments in older adults with type 2 diabetes: thinking beyond diabetic peripheral neuropathy. Canadian Journal of Diabetes, 40: 6-9.
Schwartz, A. e. (2008). Diabetes-related complications, glycemic control, and falls in older adults. Diabetes Care, 31(3):391-396 .