prevention of falls in older people with diabetes · • ensure no pushing or pressure causing...

Prevention

Of Falls In

Older

People With

Diabetes

Ng Jia Lin, Podiatrist

Toylyn Lee, Snr Physiotherapist

Content

• Assessments

- Foot assessment

- Physical mobility

• Management

- Footwear/callus

- Exercise

• Conclusion

Introduction of falls

Falls risk factors

Behavioural

Biological

Socio-economical

Environmental

Diabetes and falls

Risk factors:

- Pharmacological complications

- Visual impairment

- Cognitive dysfunction

- Previous complications affecting function e.g. stroke

- Pain

- Neuropathy: Sensory, motor and autonomic

Diabetes and falls

Neuropathy in DM

- Poorly controlled DM tends to affect the long nerves in the body

- Sensory neuropathy: afferent nerves

- Motor neuropathy: efferent nerves

- Autonomic neuropathy: autonomic nerves controlling involuntary processes in the body

Diabetes and falls

Sensory neuropathy – symptoms

- Numbness

- “Pins & needles” / Parasthesia

- “Ants all over foot” / itchy

- Reduced sensitivity

- Burning sensation

- Allodynia

Diabetes and falls

Risk factors:

Decreased sensorimotor function

- Peripheral neuropathy

- Loss of proprioceptive feedback with postural instability

Musculoskeletal/neuromuscular deficits

- Poor postural control

- Muscle strength

Assessment

What can you do to assess an elderly’s fall risk?

Assessment

Things to check with the patient

- Falls history

- Lifestyle, functional decline

Assessment

Physical assessment

Lower extremity

- Sensation

- At risk pressure areas

Ipswhich Touch Test

- Patients keep their eye closed at all times during this examination

- Using your index finger to touch on the indicated sites lightly

• Hold it there for 1-2 seconds each sites

• Ensure no pushing or pressure causing indentations

- Patient is to say yes when he/she feels that light touch

• Do not repeat the same site if it was not felt the first time

- Total of 8 sites on bilateral feet to be tested

• 4 sites each foot

- ≥2 out of 8 sites = insensate & positive for neuropathy

The 10 sites

Callus/Corns

Calluses:

- Due to increased pressure

Corns:

- Usually long-standing

- Sharp pain

Usually due to poor choice of footwear & foot

deformity

Callus/Corns

- Usually due to poor choice of footwear & foot

deformity

- Caused by prolonged repetitive pressure

- Does not go away with use of corn plasters or one-off

treatment (improper use can lead to more problems)

- Can lead to disastrous outcomes if not treated in time

Assessment – Mobility

Physical assessment

- Various physical parameters that affects daily mobility e.g. endurance, flexibility,

power etc

- For elderly, important parameters to focus on are: fall risk, balance, strength

Assessment – Mobility

Components Assessment tools

Fall risk Timed up and Go test

Balance Functional reach test

Romberg test

Sharpened romberg test

Strength Sit to stand test

Components Functional Assessment tools

Predictor of

Falls risk

Timed up and Go test

- Assesses: basic mobility skills and risk of falls

- Good interrater reliability, showed 87% specificity and sensitivity

- Should not be used as a single measure to determine fall risk

- Normative values:

• >13.5s: predictive of falls for community dwellers (Shumway-Cook et al 2000)

• >30s corresponds with functional dependence in persons with pathology (Bohannon

2006)

• Mean scores for >60 years old: 9.4s (Bohannon RW 2006)

Components Assessment tools

Balance

Functional reach test

- Assesses: dynamic standing balance and limits of stability

- Showed 76% sensitivity and 34% specificity (Duncan et al 1990)

- Normative values

• <7inches: limited functional balance (Duncan et al 1990)

• <15 inches: increased risk of frailty and fall (Thomas et al 2005)

Components Assessment tools

Balance

Romberg & Sharpened Romberg test

- Assesses: static balance with a narrowed base of support

- Appropriate for: those with loss of vestibular function, sensory neuropathy etc.

Romberg test

- Feet together, eyes open

- Feet together, eyes closed

- 60s each

Sharpened Romberg test

- Feet heel to toe (dominant foot behind),

eyes open

- Feet heel to toe (dominant foot behind),

eyes closed

- 60s each

Components Assessment tools

Strength

(Lower limb)

Sit to stand test

- Assesses: strength, balance, functional mobility

- Normative values:

• <8 scores (unassisted) were associated with lower levels of functional ability

(Rikli & Jones 1999)

Assessment – Practical

Spilt into 2 groups and will practice the various assessment tool

Management

How can we help our elderly patient with diabetes, prevent falls? ☺

Callus/Corn Treatments

1. Good footwear for proper pressure relief & cushioning

2. Frequent debridement or filing to reduce pain

3. Emollient use to soften callus

4. Must educate that shoes & deformities are causative

• Consider surgical options to correct deformities for pressure relieve

• Paddings for shock absorption or alleviate pressure

Do Not Encourage Self Treatment with Sharp Objects

Management

Before After

Management

Footwear to improve balance:

• Good heel support

• Should have restraining property

• As low-heel as possible

• Good gripping outsole

Footwear

Footwear to reduce pain:

• Good cushioning property at the heel and ball of the foot

• Should be made of breathable materials

Eg. Leather

• Should have wide and deep toe box

Footwear

Tips on buying shoes:

- Have both feet measured

- Try on shoes at the end of the day

- Bring socks along when buying shoes

Footwear

Tips on buying shoes:

- Try on both shoes and tie the laces

- There should be a finger-width

between longest toe and the end of

the shoe

- Test for comfort by walking around

Management – Exercise

Aim: Improve musculoskeletal deficits

- Strength of LL

- Postural control (balance)

- Functional mobility retraining

Aim: Prevent future and/or further deterioration

- Physical activity in general

- Other benefits e.g. better glycemic control, reduced cardiovascular mortality

Management – Exercise (Balance)

*For safety, hold on to

wall/railing of needed

Management – Exercise (Strengthening)

Management

Education

- Falls prevention – environmental, behavioural

- Falls recovery

Conclusion

Having an appreciation of falls and diabetes

Early detection of falls risk is essential