DIABETIC SENIORS AT GREATER FALL RISK

The “baby boomers” are aging and, consequently, America is getting old. The percentage of US residents that are senior citizens has increased significantly. The elderly population has grown by 15 percent over the course of a decade. By 2050, seniors will make up 20 percent of the United States, a significant number in any discussion of healthcare. A significant health hazard for these individuals are falls. The direct costs of these accidents by seniors totaled over 20 billion dollars in one year. In 2000, ten thousand fatal falls occurred to seniors,  a number that jumped to 41,000 in 2022.

Although typically the result of numerous factors, diabetes has proven itself to be an important one when it comes to falls. The relationship between aging, diabetes mellitus, and falls, has been under study for some time. According to one paper, 40% of senior citizens with diabetes experience a fall annually. Although often dismissed as inconsequential by the individual who had the fall, these untoward events are a major health concern and tend to result in damage, disability, even death.

Diabetes alone increases one’s risk factors for a fall, with a number of mechanisms at play. In addition, people with diabetes tend to experience greater disability from falls. The research shows that roughly one out of 5 falls results in a broken bone or serious injury and approximately a million seniors per year must be hospitalized due to injury. And though most falls are not fatal, disabling consequences are too common.

As to an explanation of why this population experiences these dangerous accidents, some reasons are obvious and not specific to diabetes, like decreasing muscle strength and thinning bones. But a well-recognized effect of diabetes are the nerve changes, termed neuropathy, a condition that increases in prevalence with age. The latest research reveals a complex picture of the nerves affected, and the impairment resulting, which serve to increase fall risk.

Large and small nerve fibers become damaged in diabetic neuropathy, a condition a majority of diabetics get within five to seven years. The process is referred to as a “dying back”  phenomenon of nerves. When large nerve fibers become damaged through diabetes, sensation to the bottom of the feet is altered. This impairment, whether the afflicted individual is aware of the change or not, has been proven to decrease stability when standing. This is summarized in the term ‘postural sway’ referring to movement of the body side to side when attempting to stand up straight. The greater the postural sway, the more unstable someone is and the greater the risk for a fall.

Nerves going to the joints of the foot and ankle can become diseased, reducing feedback to the brain about position sense. Again, a result is increased postural sway, decreasing stability in stance and gait, all leading to an increased risk of falls. A recent discovery, even the nerves going to the balance center in the inner ear can be affected.

Thinning of muscles (aka atrophy) always accompanies aging. Plus, we become less active, reducing our skeletal muscle fitness.  Pain when walking will alter your gait and greatly increases one’s risk for a fall. A different phenomenon is at play when someone says their leg “gave out.” When discomfort is predictable with weight bearing, the subconscious mind may choose not to bear the weight of the body, thus avoiding pain.  The brain may opt not stimulate the appropriate leg muscles required for stance, preventing the limb from supporting the body.

The medications typically prescribed for neuropathy pain are central nervous system agents and have the unwanted side effect of interfering with balance, functioning to increase these risks. Many older adults experience polypharmacy, whereby they are prescribed multiple medications for various signs and symptoms by various providers. This dramatically increases the likelihood of harmful drug-to-drug interactions, increasing the risk of a fall.

A thorough discussion of prevention and treatment of falls would require many pages. Suffice it to say that there has been some success, but this is not a simple prescription, a wave of the pen. Studies have demonstrated the greatest improvements noted when multiple approaches to care are used.

Exercise has clear benefits to fall risk reduction (as well as multiple other components of health and wellness). Treating your neuropathy is being recommended by the American Academy of Neurology through the use of precision nutraceuticals. Working with a physical therapist on improving the strength of the muscles of stance and gait is a commonly used method. And creating a more stable foundation through the use of better shoes, ankle braces, arch supports, or similar means, have all demonstrated benefits to reducing the risk of a fall.

Reducing the incidence of diabetes doesn’t seem to be on the horizon, with more people being diagnosed than ever before. Likewise, the statistics on our aging can’t be refuted. And we can’t prevent all falls. Nor is the answer to better treat the consequences of these damaging events, perhaps a new fracture fixation plate to treat the broken bone.

Many experts believe this issue is best addressed with prevention, which has the capability of significantly limiting the number of these accidents. That requires recognition of the factors which increase a person’s susceptibility to a fall. These are facets of healthcare evaluated by few practitioners. Performing a gait evaluation, or different tests for stability and postural sway, even muscle strength testing, these and others provide critical information on someone’s risk for a fall.

Diabetes causes many complications, including peripheral neuropathy. These and other aspects of aging, diabetes, and neuropathy, are well understood as contributing to gait instability and falls. If you have any of these risk factors, get evaluated for gait instability. Perhaps you have unrecognized neuropathy, or one of your medications is affecting balance. Something as innocuous as a thick callus can be the proverbial “straw” which leads to a debilitating fall. It starts with an evaluation since your next fall is likely preventable.