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Falls in Older People with
Diabetes Mellitus: a study from Kurdistan of
Iraq
Asso Amin (1)
Zana A Mohammed (1)
Osama Shukir Muhammed Amin (2)
Raed Thanoon (1)
Saman H Shareef (3)
Thomas James Oakley (4)
Teshk Shawis (4)
(1) Department of Medicine, College of Medicine,
Ministry of Higher Education, Kurdistan Regional
Government, Iraq
(2) Shorsh Military General Teaching Hospital,
70th Forces, General Command, Ministry of Defense
(Peshmerga), Kurdistan, Iraq
(3) Sulaimany Teaching Hospital, Department
of Orthopaedic, Ministry of Health, Kurdistan
Regional Government.
(4) Department of Care of the Elderly, Colchester
General Hospital, East Suffolk and North Essex
Foundation Trust, Colchester, United Kingdom
Correspondence:
Dr Teshk Shawis
Department of Care of the Elderly,
Colchester Hospital University Foundation Trust,
Colchester, UK
Email: Teshk.Shawis@colchesterhospital.nhs.uk
Dr Asso Amin
Email: delanamin@hotmail.com
Received: March 2019; Accepted: April 2019;
Published: May 1, 2019
Citation: Asso Amin et al. Falls in Older People
with Diabetes Mellitus: a study from Kurdistan
of Iraq. World Family Medicine. 2019; 17(5):
16-21. DOI: 10.5742MEWFM.2019.93641
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Abstract
Falls
are a major cause of disability and a
preventable cause of death in older people.
Diabetes mellitus prevalence increases
with age. The prevalence of falls is higher
in diabetic elderly patients. This cross-sectional
study analyzed factors associated with
higher incidence of falls among 150 older
people with diabetes mellitus in Kurdistan.
Results demonstrated
that incidence of falls were positively
associated with increased age, longer
duration of diabetes, treatment with insulin
therapy and sulfonylureas, poor diabetic
control, polypharmacy, decreased mobility,
peripheral neuropathy, osteoarthritis,
retinopathy, living alone, living in a
care home, smoking and excess alcohol
consumption.
Key words: Falls,
Elderly, Diabetes mellitus, insulin therapy,
oral hypoglycemic drugs, Kurdistan
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The global size of the elderly population is
drastically increasing and the burden of non-communicable
disease is rising concordantly (1). Although
falls can occur at any age, the frequency and
severity of fall-related injuries increases
with age (2). People over 65 are more prone
to falls; the annual incidence of falls increases
from 25% at 70 years to 35% at 75 years(3).
Falls in the elderly are a major cause for
attending General Practitioners (GPs), and emergency
departments. Mechanical falls (i.e. accidental
falls) are uncommon among the elderly population
(4). Approximately 1 in 10 falls results in
a serious soft tissue injury, traumatic brain
injury or fracture. Even non-traumatic falls
can have serious consequences including decrease
in social and physical activities, disability,
loss of independence and institutionalization
(5).
Diabetes Mellitus (DM) is common in older people;
it is estimated that approximately 50% of the
patients with diabetes are over 65 years of
age(6). The significance of the association
between aging, DM and falls has been highlighted
by previous studies that found the annual incidence
of falls in elderly individuals is 39% (7).
The incidence of falls, particularly recurrent
falls, is significantly higher particularly
among women who were treated with insulin (8).
Furthermore, in addition to the well-known cardiovascular
complications, diabetes is associated with several
‘geriatric-syndromes’ such as cognitive
decline, dementia, depression, functional limitations,
physical disabilities, visual and hearing impairments,
urinary incontinence and chronic pain (9). All
of these are causative factors for falls among
community-dwelling older people and are therefore
likely to explain the excess risk of falls in
individuals with diabetes (10).
There are several pathophysiological mechanisms
by which DM may predispose to falls; Decreased
sensory-motor function, musculoskeletal/neuromuscular
deficits, foot and body pain and pharmacological
complications (11). Diabetic peripheral neuropathy
(DPN) is common among diabetic patients and
its incidence increases with age and duration
of diabetes.(11) DPN patients with diminished
plantar sensation have been observed to reveal
increased postural swing associated with significant
loss of postural control (12). Apart from DPN,
lower physical activity, muscle strength, and
poor postural control were also found to be
among the significant risk factors that impacted
gait patterns and raised risk of falls among
the DM population (12).
Those who experience neuropathic pain are frequently
managed with psychotropic and other central
nervous system mediated medications. Amitriptyline
and duloxetine hydrochloride, for example, are
commonly used to manage the aching symptoms
of diabetic neuropathy. Psychotropic medications
are frequently implicated in falls and nearly
double an elderly adult’s risk for experiencing
a fall (23) and having recurrent falls (12,2).Older
adults suffering with diabetes are also more
likely to be taking a larger number of medications
(12) and seem to be more sensitive to the effects
of polypharmacy than similar people without
diabetes (13). Patients with diabetes start
to experience an increased risk of falling with
regimens involving 4 or more prescribed medications.
One of the risks managing diabetes is the risk
of hypoglycaemia. This can occur with insulin
secretagogues and/or insulin use and frequently
result in a state of dizziness, and postural
instability which increases ones’ risk
for a fall accident (14).In summary, there are
plenty of opportunities for older adults with
DM to experience a fall. Numerous steps to improve
balance, strength, and gait in order, have found
to reduce risk of falls (15). The majority of
published studies on falls are from Western
societies and as a consequence the preven¬tion
strategies are based on these populations.
Sulaimany is a town within Kurdistan; an autonomous
region from the Iraqi central government since
1991. The aim of this paper is to explore the
risk factors for falls in diabetic elderly patients
within this population. In obtaining a more
detailed apprehension of the causes of falls
in this group in a developing population a more
relevant prevention strategy can be established
instead of relying upon Western guidance.
This study is a descriptive cross-sectional
study to describe the prevalence of falls among
elderly diabetic patients and to compare the
prevalence between patients on insulin therapy
and patients on oral hypoglycaemic agents.
The data were collected by direct interview
between the researcher and patients (person
to person questionnaire) in the diabetic centre
and emergency department of teaching hospital,
Shar-hospital in Sulaimani city, Iraqi Kurdistan
in the period from 1st of July 2014 to 31st
of June 2015; 150 patients equal to or above
the age of 65 years were collected.
They were asked questions relating to the duration
of diabetes, monitoring, their perception of
occurrence of hypoglycaemic episodes, symptoms
and signs of postural hypotension, type of treatments
they take for diabetes, history of falls and
occurrence of falls within the past 12 months
(how many times, if at all, have they had a
fall in the last year?). They were also asked
about consequences of falls, whether non-traumatic,
soft tissue injury and bruises, fractures or
head injury; they were asked about their perception
of visual impairment and peripheral neuropathy,
past medical history and medications, poly pharmacy,
social history whether living in institution
or living alone or with family; mobility, whether
they are walking independently or they use walking
aids such as sticks or frames, questions about
smoking and alcohol drinking.
A fall was defined as ‘an event, which
results in a person coming to rest inadvertently
on the ground or other lower level’; this
was explained to the patient. Information was
sought regarding contact with other medical
specialties. We collected data about other risk
factors for falls in diabetic elderly.
One hundred and fifty elderly diabetic patients
with history of fall were included in this study;
88 (59%) were females and 62 (41%) were males.
Their ages ranged between 65 – 90 years,
mean age was 77.7 ± 7.11 year, and the
mean duration of diabetes mellitus was 15.12±7.36
years.
Results
are
summarised
in
the
table
commencing
opposite
page,
there
was
an
association
of
increased
incidence
of
falls
with
increasing
age.
Mean
age
of
the
study
population
was
77.7±7.11
(95%
Confidence
Interval
(CI)
was
63.7-91.6).
In
this
study
we
found
an
increased
risk
in
the
older
diabetic
patients
(25.3
%)
above
85
compared
to
(14.7
%)
of
the
studied
population
who
were
in
the
age
group
(65-69).
Furthermore,
the
current
study
demonstrated
higher
incidence
of
falls
in
females
compared
to
males.
These
findings
were
consistent
with
many
previous
studies.
(16,17)
Moreover,
the
existing
study
showed
that
the
frequency
of
falls
increased
with
the
duration
of
DM,
(13%)
compared
to
(26%)
for
duration
(up
to
5
years)
and
(above
20
years)
respectively,
which
is
believed
to
be
due
to
diabetic
micro-vascular
and
macro-vascular
complications.
A
similar
finding
was
illustrated
in
a
study
conducted
in
Homerton
University
Hospital
in
the
UK
(18).
It
is
likely
however
that
if
a
patient
has
had
diabetes
for
many
years
they
are
likely
also
generally
older,
so
ideally
modelling
would
need
to
be
done
to
further
determine
the
effect
of
duration
of
diabetes
independent
of
age.
Most
patients
(70%)
had
a
HbA1c
level
7%,
indicating
uncontrolled
diabetes.
It
is
apparent
that
patients
on
insulin
and
sulfonylurea
agents
had
the
highest
rates
of
falls,
while
the
biggest
risk
factor
identified
within
the
fallers
was
the
presence
of
diabetic
neuropathy.
There
were
significantly
higher
rates
of
injury
than
the
reported
1
in
10
rates
of
injury
noted
in
previous
literature,
with
almost
2
in
3
falls
resulting
in
injury:
it
is
possible
that
this
is
the
result
of
the
selection
methods
used,
as
injuries
are
more
likely
to
present
at
the
emergency
department
which
was
one
method
of
recruiting
subjects.
Click
here
for
Table
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