With Aaron Vinik, MD, PhD, and Kalpana Narayan Shankar, MD
Despite clinical awareness that falls represents major health risks for people over the age of 65,1 challenges remain. Falls represent the leading cause of fatal and non-fatal injuries among older Americans, according to the Centers for Disease Control and Prevention with 2.5 million older adults admitted to emergency room and more than 734,000 of those patients having to be hospitalized for a fall in 2015.2
In a study published in Injury Epidemiology, 3 Kalpana Narayan Shankar, MD, an assistant professor of emergency medicine at Boston Medical Center in Massachusetts and her research team, followed 87 community-dwelling older adults (age 64 to 90 years), to discern what follow-up strategies might be feasible from the emergency department (ED), to lessen risk of future falls.
“The first fall should be viewed as a marker of morbidity, and these patients should be viewed as sicker than they may appear,” Dr. Shankar told EndocrineWeb. Adding to the problem, these patients view the fall as an accident so they will typically be in denial that they are at risk for suffering another fall. Instead, they tend to cut back on other activities in their lives for fear of falling, initiating a vicious cycle that leaves them debilitated and more prone to falls.
“After discharge, we found that patients ended up talking to a variety of people, but no one made changes in their lifestyle aimed at reducing their risk of another fall, during the 60 days we followed the patients,”3 she said.
“We noticed that the time period between discharge and any intervention occurring lessened dramatically as time went on,” said Dr. Shankar. In fact, there was a precipitous drop after just 2 weeks in the chance patients would seek out an intervention and stick with it.3
“Not surprisingly, we observed a recall bias so unless these patients are followed and encourage to make the kind of changes needed to reduce their risk, life will take over and any concern for fall risk fades,” she said.
"For older adults that fall, the first emergency department visit is an important one, but it is an underutilized opportunity to mobilize healthcare resources for people at a high risk for subsequent falls," said Dr. Shankar.
Many of the patients discussed their fall with others, including 71% who spoke to their health care provider, of which 37% talked about ways to reduce future falls, while 46% talked to family and 37% to friends.3
"The amount of dialogue patients reported having about their falls is encouraging, but their fall should trigger a more significant health system response to lessen their risk of future falls. This is difficult to accomplish solely in the emergency department due to time and resource constraints," Dr. Shankar said.
Our study3 identified the dual challenges in reaching patients with effective strategies that will translate to lessening future fall risk, and educating clinicians to be more assertive in promoting these programs in community settings, she said.
“A group plan is needed for these patients because they will be more receptive to making the necessary changes, committing to PT, a fall prevention class, or Tai Chi, if they have more than one healthcare provider reinforcing the same message, so they realize there is a need to lessen any risk for future falls,” said Dr. Shankar, “and, it underscores the need for a more concerted effort from endocrinologists to be involved in developing and implementing a fall risk reduction action plan.”
“Identifying factors that contribute to falls, ways to assess whether an individual is at risk for a fall, and methods to prevent falls will provide major benefit to older patients with diabetes,"1 said Aaron Vinik, MD, PhD, who led development of these clinical recommendations intended to improve the rate of diagnosis and prompt more aggressive care of aging patients with diabetes who are risk for falls.1 These guidelines were published in Endocrine Practice.
The endocrinology of aging has escaped the attention of our medical institutions. We wanted to see if we could change or enhance the lives of older people with diabetes,” by improving clinical responsiveness to fall risk, said Dr. Vinik, director of neuroendocrine research, and the Murray Waitzer Endowed Chair for Diabetes Research at Eastern Virginia Medical School in Norfolk, Virginia, told EndocrineWeb.
“One-third of people over the age of 65 will fall every year. Forty percent of people who fall will experience a brain injury,” said Dr. Vinik, “and in patients over 65 with diabetes, there is a 17-fold increased likelihood of falling compared to their younger counterparts.”
Identifying persons at risk of falling and implementing an effective intervention is the key to decreasing the incidence of falls, he said. Compounding the problem, over 400 factors are linked with falls in adult populations.4
Beyond Diabetes, Multiple Factors Behind Fall Risk
In older patients with endocrinopathy,4 major domains play a role in falls; the Medical Domain, Functional Domain, Social Domain, and Mental Domain.1 Neuropathy, decline in cognitive function, and polypharmacy are major factors in the increased risk of falls for older patients with diabetes.1,5
Up to 50% of people with type 2 diabetes may have diabetic neuropathies, which contribute to increased mortality and decreased quality of life.6 These neuropathies are a major contributing factor to the increased risk of falls.7 Diabetic polyneuropathy affects the peripheral sensory and motor function and impairs balance and walking function.8 This impairment can increase the risk of falls and requires a diagnosis to provide proper treatment and management options.
Changes in cognitive function also play a major role in the risk of falls. Approximately 60% of older persons with cognitive impairment report falling each year, according to the American Geriatrics Society.9 Changes in executive control and the ability to plan the steps required for gait and stride time greatly impact coordination and increase the risk of falling.10
“Take away some of these drugs so patients can think straight, so they’re not living in a fog and in confusion,” Dr. Vinik told EndocrineWeb. Many older patients have diabetes, but often have other comorbidities as well, such as hypertension and pain, and all of these conditions are often treated leading to polypharmacy.
“We’ve provided an extensive list of medications that pose the highest risk in the appendix [of the study], as well as a quick reference in the body of the manuscript,”1 Dr. Vinik said, “These resources make it easy for the clinician who is pressed for time to quickly evaluate medications that could have contributed to a fall.”
The authors designed a falls risk questionnaire to better identify patients at risk for falls.1 At-risk patients can be directed to the intervention designed specifically for their risk factor and monitored by both the endocrinologist and the primary care provider.
“Sometimes with just a few simple questions or a bedside test, the clinician can tell whether the patient is predisposed to a fall and use our appendix that has pictures and diagrams detailing what to do. You don't want to make a diagnosis if you can’t identify a means for managing the patient, especially those who have diabetes” Dr. Vinik said.
“We need to recognize that our patients have competing priorities, and in the age of precision (patient-centered) medicine, even though there are community-based interventions, a one-size-fits all program may not meet the needs of most patients,” Dr. Shankar said, of utmost importance for endocrinologists is to refer patients to programs that most closely matches their needs and fits into their lifestyle, and to follow up with the patients so they feel the need to participate in and continue with whatever plan was developed.
1. Vinik AI, Camacho P, Reddy S, Valencia W, Trence D, Matsumoto A, Morley J. Aging, Diabetes and Falls. Endocr Pract. 2017. [Ahead of Print]
2. Centers for Disease Control and Prevention. Falls are leading cause of injury and death in older Americans. Available at: www.cdc.gov/media/releases/2016/p0922-older-adult-falls.html. Accessed August 4, 2017.
3. Shankar KN. Treadway NJ, Taylor AA, Breaud AH, Peterson EW, Howland J. Older adult falls prevention behaviors 60 days post-discharge from an urban emergency department after treatment for a fall. Injury Epidemiol. 2017;4:18.
4. Close JC, Lord SL, Menz HB, Sherrington C. What is the role of falls? Best Pract Res Clin Rheumatol. 2005; 19(6):913-935.
5. Schwartz AV, Vittinghoff E, Sellmeyer DE, et al. Diabetes-related complications, glycemic control, and falls in older adults. Diabetes Care. 2008; 31(3):391-396.
6. Herriott MT, Colberg SR, Parson HK, Nunnold T, Vinik AI. Effects of 8 weeks of flexibility and resistance training in older adults with type 2 diabetes. Diabetes Care. 2004; 27(12):2988-2989.
7. Richardson JK, Hurvitz EA. Peripheral neuropathy: a true risk factor for falls. J Gerontol A Biol Sci Med Sci. 1995;50(4):M211-M215.
8. Resnick HE, Stansberry KB, Harris TB, et al. Diabetes, peripheral neuropathy, and old age disability. Muscle Nerve. 2002;25(1):43-50.
9. van Dijk PT, Meulenberg OG, van de Sande HJ, Habbema JD. Falls in dementia patients. Gerontologist. 1993; 33(2):200-204.
10. Hausdorff JM, Yogev G, Springer S, Simon ES, Giladi N. Walking is more like catching than tapping: gait in the elderly as a complex cognitive task. Exp Brain Re. 2005;164(4):541-548.