Whilst browsing the Oxford journal Age and Ageing last week, I came across a paper focusing on diabetes in the elderly. Interestingly, it noted that men and women with diabetes aged 65 or over are one and half times more likely to have recurrent falls than people in the same age bracket without diabetes. Having two sets of grandparents in their seventies, one pair with diabetes and one without, I wanted to know about this correlation between diabetes and falling, and how it might apply to them. Here, I speak with Ms. Evelien Pijpers (EP), author of this paper, to learn more. – Nicola (NB)
NB: Your recent paper says that in a three-year study of 1145 Dutch participants aged 65 and over, you discovered an increased risk of recurrent falls associated with diabetes. Can you explain why those with diabetes are more likely to have a fall?
EP: We examined a number of possible contributing factors which led to this increased likelihood of recurrent falls, yet we can only explain about half of the increased risk faced by older patients with diabetes.
The factors which we did link with the increased risk of recurrent falling in patients with diabetes included the use of four or more medications; higher levels of chronic pain, mostly experienced in the muscles and bones; poorer self-perceived health; lower physical activity, grip strength and sense of balance, combined with greater limitations in the performance of daily activities such as bathing and dressing; and more significant problems with cognitive impairment.
Fortunately for the patients, we didn’t record enough major injuries or fractures over the three-year study period to be able to track any correlation between diabetes and fracture risk in older people.
NB: What are the consequences of recurrent falling?
EP: As a geriatrician, I see a lot of mobility problems in older patients. They are present in older people in the accident and emergency department, the hospital wards, and the care and nursing homes. When I visit my older patients at home, it is both the mobility difficulties and the fear of falling which stop them from walking to the shops or strolling through the cobblestone streets of Maastricht.
My older patients with diabetes seem to be especially prone to fall and injure themselves. Even if they avoid lasting injury, I find that afterwards they try and avoid situations in which they could fall again. This unfortunately limits their social contact and the number of physical activities they are willing to undertake, and as such their physical condition declines, sometimes to the point where disability and loss of independence are inevitable. For those with diabetes who are more likely to fall, it is more likely that they will face this quandary.
NB: So what could be done to prevent the increased fall risk in older persons with diabetes?
EP: To improve the quality of life of this growing group of older patients with diabetes, it is important to keep them physically and mentally active, mobile, and able to avoid falls and injuries. Therefore even though we cannot yet account for the entirety of the increased risk of falling, it is possible to address fall risk factors we now know about. A medication review can help, as can muscle training and activities to improve balance – which in turn may even improve pain induced by osteoarthritis. Improving mobility helps individuals to perform everyday activities, and it is easier to feel positive about your health if you are able to maintain independence. It is important that we teach older patients how to fall with the least risk of injury, and how to pick yourself up (both physically and mentally) when you have fallen without losing confidence. As such, physicians should be in the practice of counselling all elderly diabetic patients about active lifestyles and the importance of mobility training.
NB: Finally, what’s next in this field of research?
EP: We need new studies looking into additional risk factors for diabetic patients, such as the loss of muscle strength and the loss of muscular mass called sarcopenia that comes with age. We need to know more about the role of neuropathy and chronic pain. We also need intervention studies examining the results of training older diabetic patients in balance, gait and strength, so that we can know better how to reduce the risk of falling. A possibility would be to introduce such training with younger diabetic patients, in order to teach them about the importance of physical activity and how to fall without injury before the increased risk of falling becomes apparent.
Ms. Evelien Pijpers is a specialist in Internal Medicine and Clinical Gerontology at the department of Internal Medicine at the Maastricht University Medical Center and School for Mental Health and Neuroscience. After her specialisation in Internal Medicine she subsequently trained in Clinical Gerontology at the Radcliffe Infirmary in Oxford. Her interests include frailty, multimorbidity, and functional limitations in older patients. Ms Evelien Pijpers’ paper has been made publicly available by the journal Age and Ageing. You can read it in full and for free here.