diabetes and mobility explained: disease, falls and fractures

$: Diabetes and Mobility Explained: Disease, falls and fractures$
Diabetes and Mobility Explained: Disease, falls and fractures

Alistair McInnes Independent Podiatry Consultant

Estimated educational content: 1 hour

Brought to you by

2 Diabetes and Mobility Explained: Disease, falls and fractures

Contents 3 Introduction

3 Learning outcomes

4 Clinical learning

16 Consultation considerations

16 Criteria for referral

17 Summary of learning

17 Further reading

18 References

Alistair McInnes is an independent podiatry consultant who has a background in higher education and the NHS. He was a senior lecturer in the School of Health Professions at the University of Brighton and recently the clinical lead for diabetes foot services for the South East Clinical Network. He also has advised a Multi-disciplinary Foot Team (MDFT) project for the Sussex Community Foundation Trust and provided consultancy for East Sussex NHS Healthcare Trust to improve diabetes foot care and reduce lower leg amputations.

He has been involved with Diabetes foot care for over thirty years, and has published in peer reviewed journals, book chapters and expert consensus documents. He has presented at both National and International Diabetes and Podiatry conferences throughout the world. He was also vice chairman of the multi-disciplinary FDUK interest group and represented the profession at Westminster, Diabetes UK and NHS Diabetes Foot care networks. He is a Fellow of the Society of Chiropodists and College of Podiatry and was awarded with a diamond award from the professional body at the House of Lords for outstanding contribution to the profession in 2010. He is also a Patron of the Leg Club Foundation.

About the author

3

IntroductionAn estimated 4.7 million people live with diabetes in the UK of which 3.8 million are diagnosed. A further 12.3 million thought to be at risk of developing the disease1. In addition, 20% of the UK population over 60 has lower limb arterial disease2 and between them, diabetes and severe peripheral arterial disease account for most of the chronic, complex foot ulcers and the 8,760 non-traumatic lower limb amputations occurring per year in the UK.3 People with diabetes can face many challenges throughout their lifetime including problems with mobility and a high risk of falls with subsequent fractures.

Diabetes and MobilityMobility has been defined as ‘the ability to move or be moved freely and easily’4. Many people with diabetes can move around easily, however, there are many complications of diabetes that can seriously impair mobility which may lead to psychosocial and physical problems. Diabetes has been associated with a greater risk of decline in function and increased prospect of severe disability.5, 6

The module is intended for podiatrists, podiatry assistants and healthcare professionals who support the prevention and management of patients who may present with issues of mobility.

Learning outcomes:By the end of the module the healthcare professional will be able to:• Identify the major effects that neuropathy has on the mobility of people with diabetes.• Identify the major effects that cardiovascular disease has on the mobility of people with

diabetes.• Identify the major effects that polypharmacy has on people with diabetes.• Appreciate the treatment and management available to improve or reduce deterioration of

mobility in people with diabetes.

This module contains an estimated 1 hour of educational content, which can be included as part of your personal development plan.

Continuing Professional Development

CPD

When you’ve finished this module, visit skintelligence.flexitol.co.uk to complete the learning evaluation so we can send your certificate to you!


Clinical learningOverviewIn this module, the effects of diabetes and its complications on mobility will be explored.

Mobility Mobility has been defined as the ability to move oneself within community environments that expand from home to the neighbourhood and to regions beyond.7

The concept of mobility is viewed through five fundamental categories of determinants.7

Determinant Example

Cognitive Mental status, memory, speed of processing, cognitive impairment and dementia

Psychosocial Self –efficacy, coping behaviours, fear of falling, depression, motivation and relationship with others that affect motivation to be mobile

Physical Musculoskeletal disease: fractures and bone disease, cardiovascular and neurological problems, ageing, visual impairment

Environmental Stairs, outdoor terrain, hazards in home, dimly lit streets

Financial Location of home, accessible means of transport, access to fitness class

What is diabetes?Diabetes mellitus, commonly called diabetes, is a metabolic disease characterised by high blood glucose levels (hyperglycaemia), which is the result of either defects in insulin secretion or insulin action, or both. Chronic hyperglycaemia in diabetes is associated with long term damage, dysfunction and failure of organs especially the eyes, kidneys, nerves, heart and blood vessels.1

Type 1 diabetes:• Results from autoimmune destruction of the

pancreatic beta cells, the cells which produce insulin.

• Requires insulin for survival.

• Can appear at any age, although usually before 40 years.

Type 2 diabetes:• Is characterised by resistance to insulin’s

action and impaired insulin production by the pancreas, either of which may predominate.

• Has a strong genetic (familial) propensity which is unmasked by lifestyle factors such as obesity and lack of exercise.

• Is of unknown molecular or metabolic causation in most instances.1

5

Diabetes and MobilityThere are many other factors that add to the complexity as the mobility environment expands further from home. Loss of mobility among older people with diabetes has significant consequences of illness, quality of life and psychological problems. Key practice point: Holistic assessment of all older people with diabetes should include an enquiry of falls history.

PhysicalThe ageing process affects mobility in several ways including loss of muscle mass, reduction in bone density, abdominal obesity and impaired balance. Furthermore, there is an increased susceptibility to the chronic diseases of diabetes and arthritis8 with the majority of people with Type 2 diabetes diagnosed between the ages of 45-64 underlining the relationship between ageing, diabetes and impaired mobility.

Neuropathy and mobilityDiabetic neuropathy is one of the most widely reported complications of diabetes with a lifetime prevalence of 50% and can affect mobility by several different mechanisms including sensory, motor and autonomic nerve damage and loss, with ataxia a common finding.

Falls in the general population Falls are defined by the World Health Organisation (WHO) as “an event which results in a person coming to rest inadvertently on the ground or floor or other lower level”.9

The impact of falling includes distress, pain, injury, loss of confidence, loss of independence and mortality. Falls have been estimated to cost the NHS more than £2.3 billion per year10.

The number of people aged 65 and older is estimated to rise by over 40% in the next 17 years to more than 16 million. 30% of older people (over 65) will fall at least once a year. Up to 5% of falls leads to fracture and hospitalisation11 In 2017/18 there were 220,160 falls-related emergency hospital admissions among patients aged 65 and older.

Diabetes, Mobility and FallsPrevalenceFalls are a major concern for elderly people with Diabetes. Within the UK diabetic population who have reported a fall, 50% are aged over 65 and 25% are over 75.12 Decline in sensory function caused by neuropathy leads to increased falls in people with Diabetes.13 Over 30% of older individuals with diabetes and 19% of individuals without diabetes experienced recurrent falls in the Longitudinal Ageing Study.14

Loss of balance also increases the risk of falls and this loss may be due to:


Visual LossThere are multiple eye pathologies that can impair vision including diabetic retinopathy, which is the most common cause of vision loss for people with diabetes. This causes the retinal blood vessels to bleed or leak fluid which distorts vision and is a leading cause of blindness. Visual loss in diabetes can also occur from cataracts, macular degeneration and glaucoma. There is greater prevalence in elderly people with diabetes and visual impairment which may impede walking and contribute to risk of falls, as sight provides information on the body’s position and spatial location relative to objects. High or low blood glucose can temporarily blur vision.15

Diabetic dermopathies, callus, foot ulcer and mobilityDiabetic peripheral neuropathy can lead to dry, cracked foot skin as a result of autonomic neuropathy. The autonomic nervous system controls a number of everyday body functions including sweating. This is frequently absent in patients with diabetes and leads to dry, cracked skin with subsequent lesions of fissures and callus. Excessive plantar pressure which may result from sensory and motor neuropathy, leads to the build-up of callus, rupture of underlying blood vessels and a pre-ulcerative state.

Treatment for dry skin and plantar callus may include the application of a 10% urea based cream. Advice on the application of the cream should be sought from a suitably qualified healthcare professional.

For dry, cracked fissures of the heels, a 25% urea heel balm is advised as increasingly thickened skin is frequently found in the heel area.

Without treatment for plantar callus, mobility may be affected and combined with other risk factors of peripheral neuropathy and polypharmacy, people with diabetes are more likely to suffer from falls as a consequence.

Diabetic NeuropathyThere is a greater prevalence of neuropathy in older people with diabetes and proprioceptive loss resulting in impaired feedback from skin (touch) and joints (pressure and vibration sense). Impairment of light touch and lower limb position sense, together with altered pressure sensation, can affect safe walking. In combination with motor dysfunction, an abnormal gait can develop with the increased risk of injury.16

Patients with diabetic neuropathy have a fivefold increased risk of falling.17

Motor dysfunctionMuscle weakness as a loss of motor function is commonly found in older people with diabetes and increases the risks for falls. Motor neuropathy can cause significant muscle loss in cases of proximal motor neuropathy known as Amyotrophy. This condition may present with the patient complaining of severe pain which is felt in the thigh and may extend below the knee. There is profound wasting of the quadriceps with accompanying muscle weakness. The weakness can lead to difficulty getting out of a chair or climbing stairs. The motor nerve damage to the common peroneal nerve can result in ‘foot drop’ with subsequent gait and foot problems.18

7

Autonomic dysfunction and postural hypotensionPostural hypotension can cause dizziness, weakness, tiredness, blurred vision and loss of consciousness. All the symptoms can increase the risk for falls. The pathological mechanisms include autonomic neuropathy, reduced baroreflex sensitivity or hypotensive medication.19 Autonomic neuropathy can manifest in the foot with arterio-venous (AV) shunting, distended veins in the dorsal aspect of the foot, oedema and impaired sweating resulting in anhidrotic (dry) skin. Dryness of the skin may lead to cracks and fissures which can act as a portal for both fungal and bacterial invasion.

Charcot FootOne of the most challenging foot complications in patients with diabetes is the development of the Charcot Foot. Diabetic neuropathy is an essential pre-requisite for a diabetic Charcot Foot. By definition, Charcot neuropathic osteoarthropathy (CN), commonly referred to as the Charcot foot, is a condition which affects the bones, joints, and soft tissues of the foot and ankle, characterised by inflammation in the early stages.20

It is vital that this relatively rare condition is diagnosed correctly in the early stages of the disease process to protect and prevent deformity and loss of function. The prevalence for Charcot Foot has been reported in a wide range of figures, however most authorities agree that the prevalence is around 0.1% of the adult diabetes population. There is a possibility that the condition may be under-reported due to misdiagnosis. It is often misdiagnosed as cellulitis, deep vein thrombosis or gout. Charcot Foot typically presents as a swollen, red, warm foot with relatively little pain or discomfort.21

Without early intervention, Charcot Foot can lead to significant deformity (rocker bottom foot) with an increased risk for ulceration, infection and the risk for amputation. Mobility is impaired as the affected foot has to adopt an altered gait as the affected ankle and/or subtalar joint is unable to function leading to high pressures on the collapsed mid-foot.

Offloading and mobilityCurrently, the most effective treatment for the Charcot Foot is the use of total contact casts (TCC).22 The principal aim is to immobilise the foot and avoid deformity. Patients may be advised to use crutches or a wheelchair to avoid weight-bearing. The use of the total contact cast and crutches may have a profound negative psychological effect on patients as the duration for cast wearing may be many weeks with unknown outcome. Activities of daily living may be curtailed and patients may benefit from psychological intervention and support from the multidisciplinary foot care team, and other social services agencies.23

Unfortunately, there may be consequences from the use of TCC on the non-Charcot limb with altered pressures and stresses resulting in ulceration and possible fracture. The risk for falls in this cohort of patients is even greater as the co-existing presence of peripheral neuropathy may increase the risk. Prolonged immobility can lead to loss of bone density, muscle weakness and loss of fitness.24

Patients with diabetes should be offered psychological support for their foot condition and management that includes casting and mobility aids.

Quick fact


Limited joint mobility syndromeLimited joint mobility syndrome (LJMS) or diabetic cheiroarthropathy is a long term complication of diabetes which is caused by the effect of advanced glycation products on collagen and micro and macrovascular complications. The diagnosis is based on clinical features including progression of painless stiffening of hands and fingers, fixed flexion contractures of the small hand and foot joints, and diminution of grip strength in the hand.25 The prevalence in diabetes varies between 8%-58% depending on patient cohorts and different definition of LJMS.

The clinical tests for a positive “prayer sign” and the tabletop sign” help to support the diagnosis. LJMS may increase the risk of falling.25 LJMS in combination with neuropathy may increase loading on the plantar aspects of the foot increasing the risk for ulceration, infection and the potential for amputation. It is important to look for the presence of LJMS in patients with diabetes as it may indicate the presence of other microvascular complications. Older patients with a long duration of diabetes, and history of poor glycaemic control are at increased risk to develop this complication.

Vestibular dysfunctionThere is a greater prevalence in older people with diabetes and vestibular dysfunction. This system, in the inner ear provides information on direction, motion, equilibrium and spatial orientation26 and when present vestibular dysfunction may result in an increased number of falls.

Cardiovascular disease and mobilityThe ageing process leads to increased fatigue, muscle wasting of weakness and a reduction in endurance. Inevitably older people become less physically active with the increased risk for developing Type 2 diabetes, hypertension and dyslipidemia. These co-morbidities together with obesity are ‘red flags’ for cardiovascular disease (CVD). CVD may lead to stroke, intermittent claudication, ischaemic heart disease and amputation. All of which can impact on walking and general mobility. Those individuals affected by CVD will frequently be prescribed many different drugs and polypharmacy may contribute towards falls and fractures.27

The risk factors for the development of Type 2 Diabetes include physical inactivity, obesity, genetic factors, and family history of diabetes. These factors may lead to insulin resistance which is a metabolic state when cells fail to respond normally to the hormone, insulin. Insulin resistance is associated with increased blood pressure and dyslipidemia which may lead to Type 2 diabetes and increased risk of cardiovascular disease in the form of atherosclerosis. The ‘accelerated’ atherosclerosis can also lead to peripheral arterial disease, critical limb ischaemia, arterial thrombosis, coronary thrombosis and cerebral thrombosis.

9

Cerebral Vascular Accident (CVA or stroke)A stroke or CVA may result in partial or complete loss of function affecting the face, leg or arm, most likely on one side of the body. This may impede walking and increase the likelihood for falls. In addition there may be associated dizziness and loss of balance and coordination and blurred vision. All these factors may increase the risk for falls.

Prompt early intervention can reduce the impact of a stroke and the national campaign for ‘FAST’28 has been very successful.

Cardiovascular disease and peripheral arterial diseaseArterial thrombosis in the heart (coronary) and leg (anterior tibial and posterior tibial) arteries can affect mobility in different ways. If heart muscle is damaged and heart function reduced, the resultant decrease in oxygen availability will impair gait and lead to muscle atrophy.

Acute arterial thrombosis in the leg arteries of diabetes patients can be a limb and life-threatening condition. More commonly the chronic condition of peripheral arterial disease (PAD) in the lower limbs can lead to painful cramping in one or both hips, thighs or calf muscles, especially after walking or climbing stairs (intermittent claudication). Vascular assessment to evaluate the extent of the disease is vital in this vulnerable group of patients. The disease as a result of dyslipidemia, hypertension, hyperglycaemia and hypercholesterolemia can lead to excessive calcification of the leg arteries and without medical intervention can lead to the most advanced form of PAD which is a state of critical limb ischaemia with resultant necrosis, gangrene and potential for major amputation.

The definition of critical limb ischaemia (CLI): ischaemic rest pain (ischaemic neuritis), tissue loss or gangrene in the presence of peripheral arterial disease.

Assessment for CLI includes history taking for rest pain (differential diagnosis for neuropathic pain), evidence of tissue loss (necrosis) and an ABPI (ankle/brachial pressure index) of less than 0.5

Clinical features for chronic limb ischaemia Description

Intermittent claudicationCramp like pain in calf, thigh, buttock and hip felt on walking and relieved by rest then reproduced by resuming walking

Critical limb ischaemia rest painRest pain is felt predominantly in the dorsal aspect of the foot and is relentless, burning and unbearable

Dependent rubor Red or purple colour of the foot when dependent and early pallor on elevation

Absent foot pulses Non palpable pulses and may be skin changes of ischaemic ulcers and gangrene


Ankle Brachial Pressure Index (ABPI)The use of a hand held Doppler unit is required to measure the arm and ankle systolic pressures of both sides of the body. The ankle pressure is divided by the arm pressure to establish the ABPI.

Nice Clincal Guidelines for PAD.

ABPI Indication

<0.9 Indicative of peripheral arterial disease

0.5-0.9 Indicative of intermittent claudication

<0.5 Indicative of critical limb ischaemia

>0.9-1.3 May indicate the presence of calcified arteries or renal disease

Ultrasound deviceamplifies the sound ofarterial blood flow

A

C

Systolic pressuresequentially recorded inthe arteries of the ankleaster each arterial flowis located

Sound of arterial bloodflow located in ankle

Systolic pressurerecorded in the brachialof the arm

Brachial Artery

Ultrasound Device

Dorsalis Pedis Artery

Blood pressure cuff

B

D

11

Amputation and mobilityPAD combined with infection in the diabetic foot can result in minor (toes) and major (above ankle) amputations. Following major amputation, the priorities for the patient, family, health and social care teams may prioritise outcomes differently, e.g. mortality, hospitalisations, mobility, self-care, social integration and quality of life.

Successful outcome has been defined by Taylor29 based on a combination of survival, amputation, wound healing and mobility. Mobility is the functional outcome most commonly examined post amputation and is defined as daily ambulation with a prosthesis for 1 year or until death. However, more recently, a more holistic approach to defining mobility success has been adopted. This includes reference to the mobility status prior to amputation and then post amputation following rehabilitation which may be a greater indicator of success.30

Polypharmacy and risk of fallsA definition of polypharmacy is the concurrent use of multiple medications by a patient.31

Patients with diabetes frequently have several chronic co-morbidities such as hypertension, dyslipidemia, coronary artery disease, chronic kidney disease and depression which necessitate the use of multiple medications.32 There is an estimated prevalence of 57%-84% of diabetes patients using five or more medications.33 Studies have demonstrated that the use of four or more medications is an established risk factor for falls in older people with diabetes.34

There are several studies that highlight polypharmacy is a significant problem which can lead to adverse drug events, drug to drug interactions, duplication of therapy, errors with compliance and sub-optimal glycaemic control.35 Additional adverse health outcomes may include risk of hospitalisation, poor function, poor quality of life and increased risks of falls.35

The influence of polypharmacy on falls in older people with diabetes is complex. In addition to the risks from hypoglycaemic drug induced hypoglycaemia causing a fall, other medications that are commonly prescribed to people with diabetes include:

Beta-blockers, diuretics, anti-arrhythmics, digoxin, benzodiazepines, neuroleptics, antidepressants and anti-seizure medications. All are known to be associated with risk of falls with the occurrence of drowsiness, dizziness, muscle weakness, balance change, vertigo and hypertension.36

A full vascular assessment is vital for all older people with diabetes to enable prompt referral to vascular services if required, especially for critical limb ischaemia.

Quick fact


Table for drug and risk for falls

Apart from the hypoglycaemic effects of diabetes medication, metformin, a frequently used drug for diabetes control, can cause vitamin B12 deficiency which can lead to postural instability.

To compound the risk of falls, many older people with diabetes have osteoporosis which may lead to associated fractures occurring with a fall leading to adverse health outcomes.

Older people (aged 65 or older) with diabetes are at increased risk for falls and fractures and the identified risks include ageing, neuropathy, polypharmacy, co-morbidities of cardiovascular disease and peripheral arterial disease. It is important in any falls assessment that the factors above are carefully evaluated. Falls can lead to physical and psychological damage and social isolation.

Drug Potential side effect that can affect mobility and falls

Oral hypogycaemic agents Hypoglycaemic state with blurred vision and cognitive dysfunction

Beta-blockers Lightheadedness and fatigue

Statins Myositis (inflammation and swelling of the muscles) affecting gait

Diuretics Falls may be due to urgency to toilet

Anti-arrhythmics Dizziness and lightheadedness

Neuroleptics Unsteadiness and loss of balance

Antidepressants Orthostatic hypotension causing dizziness

Antiseizures Loss of balance. Effects on gait and equilibrium

Common causes of trips and falls• Poorly organised and cluttered walkways• Inadequate or unsuitable lighting• Moving or handling a load incorrectly• Rushing around• Tiredness• Physical ability, lack of mobility or lack of

balance• Poor eyesight, inappropriate glasses

• Medication that can lead to dizziness (polypharmacy a risk factor)

• Small rugs or rugs on top of carpets• Slippery surfaces• Outdoor kerbs and steps• Low and soft chairs• Slippers, high heeled shoes, non-gripping

soles and barefoot walking• Heavily patterned carpets

AssessmentPreventing falls in older people with diabetes should be considered by all healthcare professionals especially when older people present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance. This cohort of patients should be offered a multifactorial falls risk assessment.37

Careful drug and falls history for older patients with diabetes is very important for risk assessment for slips, trips and falls.

Quick fact

13

Multifactorial Assessment

• Identification of falls history• Assessment of gait, balance and mobility

and muscle weakness• Assessment of osteoporosis risk• Assessment of the older person’s perceived

functional ability and fear relating to falling• Assessment of visual impairment

• Assessment of cognitive impairment and neurological examination

• Assessment of urinary incontinence• Assessment of home hazards• Cardiovascular examination and medication

review

Footwear and falls preventionFootwear influences balance and the subsequent risk of slips, trips and falls by altering sensory feedback to the foot and ankle. Walking barefoot or in socks indoors, and walking outdoors in high heel shoes, have been shown to increase the risk of falls in older people.

Older people should wear shoes with:• Low heels and firm slip-resistant soles both inside and outside the house.38 • The International Working Group on the Diabetic Foot39 state:

“In properly fitting footwear, the shoe should not be either too tight or too loose. The inside of the shoe should be 1–2 cm longer than the foot. The internal width should equal the width of the foot at the metatarsal-phalangeal joints (or the widest part of the foot), and the height should allow enough room for all the toes.”

Case studyFalls managementMr Smith aged 69 has Type 2 diabetes (25 year duration) and a history: of cardiovascular disease, atrial fibrillation, hypertensive disease, dyslipidemia, chronic kidney disease, depression, peripheral arterial disease and peripheral neuropathy. He has a history of foot ulceration and multiple episodes of hospitalisation. He has an extensive list of medications which include Lisinopril 10 mg daily, metformin 1,000 mg twice daily, warfarin (per INR), simvastatin 80 mg, atenolol 25mg daily, furosemide 40mg daily and digoxin 0.25mg once daily.

He has a history of smoking, moderate alcohol intake, lives alone and wears slippers in the home. His home has several rugs in his sitting room.

He has a history of falls and he reports another episode of a fall to the Podiatrist he is attending for treatment for a recurrence of foot ulcer.

Identified Risk factors (red flags) for falls:

Polypharmacy History of recent fall

Rugs in home Peripheral neuropathy

Slippers Age

Diabetes Alcohol consumption

Refer to the Falls Prevention Service and liaise with GP and Diabetes Specialist Service.

Action to be taken


Older people who come into contact with all professionals who have health and social care as part of their remit should be asked routinely about falls. They should be observed for balance and gait deficits and considered for risk assessment and risk reduction interventions.40

‘Red flag’ risk factors (Public Health England 2017)

Risk reduction and managementThere is a need for increased public awareness of the impact that falls and fractures have on the frail, vulnerable and older person with diabetes. A focus should be on promoting a healthy lifestyle to prevent or delay the onset of ill health on the older person with diabetes.

The two key health behaviours:

• Maintaining adequate nutrition• Physical activity: aerobic, strength and balance

Recommendations (Chief Medical Officer) are that adults aged 65> should aim for 150 minutes of moderate activity per week in bouts of 10 minutes or more and activities that improve strength, balance and coordination on at least 2 days a week.

In addition, alcohol consumption should be moderate and non-smoking should be encouraged.

A structured falls assessment for those diabetes patients who have been identified at risk (Mr Smith above) should be carried out by a suitably trained health care professional. Following comprehensive assessment, a tailored exercise programme which includes strength and balance should be offered, and a home hazard assessment and intervention accordingly. (E.g. Mr Smith has several rugs).

In addition, visual assessment and medicines review (polypharmacy of Mr Smith) should be carried out.

History of falls Psychotrophic and anti-arrhythmic medicines

Muscle weakness Environmental hazards

Poor balance Arthritis

Visual impairment Cognitive impairment

Polypharmacy Depression

High alcohol incontinence Diabetes

Parkinson’s disease Stroke

Frailty Syncope

For older patients with diabetes - Refer history of recent falls and polypharmacy to the Falls Prevention Clinic.

Quick fact

15

Evidence has shown that group exercise can reduce the rate of falls by 29% and the risk of falling by 15%. However home based exercise has shown to reduce the rate of falls by 32% and the risk of falling by 22%.

NICE (2017)42 recommends that people who have been hospitalised due to a fall should be offered a home hazard assessment by a suitably trained health professional, i.e. occupational therapist followed by appropriate intervention and /or home modification.

Patients who suffer a fragility fracture need to be further assessed for osteoporosis and sarcopenia (a condition characterised by loss of skeletal muscle mass and function). 43

The five main risk factors you will be looking for during a foot screen:• Peripheral neuropathy.• Peripheral arterial disease (PAD).• Foot deformity.• History of foot ulceration/amputation.• Presence of callus.

The presence of callus when combined with peripheral neuropathy is a significant risk factor for the development of a foot ulcer.

Summary of action for falls• Prompt appropriate action: following a report of a fall• Falls prevention service options: refer to falls prevention/frailty services• Embedding prevention: use of motivational interviewing and other interventions for lifestyle

changes i.e. cessation of smoking, nutrition improvements, exercise, strength and balance exercises, alcohol reduction and bone health. This includes assessment for osteoporosis and sarcopenia, a progressive muscle disorder.

Exercise programme

Programme should be at least 50 hours and for at least 2 hours a week

Should include balance and strength training

At the end of the programme, older people should be offered follow on classes to suit their individual needs. Focus on strength and balance E.g. Tai-Chi has been shown to decrease the risk for falls41


Consultation considerations

Falls history

Any history of recent falls. (Previous 12 months).

Red flags

Dizziness, light-headedness, low blood sugar, peripheral neuropathy with heavy callus and dry fissured skin.

Observe gait & balance

Observe any balance problem while walking or turning. Observe gait for shuffling or postural sway.

Postural hypotension

Can result in dizziness or light-headedness.

Polypharmacy

Review meds and liaise with GP or Diabetes specialist team.

Criteria for referralThere are Falls Prevention Services available in most parts of the country. The majority of the services are multidisciplinary teams which offer tailored assessment, treatment and advice on how to reduce the risks of falls. Additionally they promote improvement in physical wellbeing which will include nutritional advice. They promote independence and improvement in psychological functioning.

The Falls Prevention services may offer training for health and social care professionals and volunteers working with older people in the community, residential and care homes. Criteria may vary across the country.

17

Hospitalised patients• All people aged 65 or older and are admitted to hospital should be considered for a

multifactorial assessment for their risk of falling during their hospital stay. They should also be offered a multifactorial assessment of their community-based falls risk.37

• Patients aged 50-64 who are perceived by a clinician to be at higher risk of falling in hospital because of an underlying condition.

Community patients• Older people in contact with healthcare professionals should be asked routinely if they have

fallen during the year and asked about frequency, context and characteristics of the fall(s).• Older people who present for medical attention because of a fall or history of falls, or

demonstrate abnormalities of balance/gait should be offered a referral to a specialist falls service.

Summary of learning• Falls are a major risk for older people with diabetes and co-morbidities.• All health and social care professionals should ask all patients at risk if they have

experienced a fall recently.• Patients who have had a recent fall should be referred to a falls protection service.• Patients with diabetes should be assessed for their risk-factors for foot disease and falls.• A neurological and vascular assessment ought to include tests for proprioception and

balance and pulse palpation, pain history and ABPI where critical limb ischaemia is suspected.

• Where patients are seen in their own home and have a history of falls, a home hazards assessment should be carried out.

• Polypharmacy is a known risk factor for falls. Commonly prescribed drugs can predispose patients to falls. Consider referral for medicines reviews in at risk patients.

Further readingThe IWGDF Guidelines on the prevention and management of diabetic foot disease 2019

Short-life Working Group. Capability Framework for Integrated Diabetic Lower Limb Care: A user’s guide. London: OmniaMed Communications Ltd. 2019 Available to download from: www.diabetesonthenet.com

NICE Quality Standard (QS86) Falls in older people. Updated in January 2017.

NHS PREVENTION Falls 2018

Strength and Balance Quality Markers: supporting improvement through audit. PHE publications gateway number: GW-531

18 Diabetes and Mobility Explained: Disease, falls and fractures18 Diabetes and Mobility Explained: Disease, falls and fractures

References1. Diabetes UK, 2018. Facts and Figures. www.diabetes.org.uk/

professionals/position-statements-reports/statistics

2. National Institute for Health and Care Excellence, 2018. Peripheral arterial disease: diagnosis and management. www.nice.org.uk/guidance/cg147

3. North West Coast Strategic Clinic Network, 2017. Diabetes foot care pathway blueprint. www.england.nhs.uk/north/wp-content/uploads/sites/5/2018/05/NWCSN_Diabetes_Footcare_Final_Report_2017-1

4. Oxford Living Dictionaries. https://en.oxforddictionaries.com/definition/mobility [accessed 2nd July 2019].

5. Volpato S, Blaum C, Resnick H, Ferruci L, Fried LP, Guralnik JM: Comorbidities and impairments explaining the association between diabetes and lower extremity disability: the Woman’s Health and Aging Study. Diabetes Care 25: 678-683,2002

6. Volpato S, Ferruci L, Blaum C, Ostir G, Cappola A, Fried LP, Fellin R, Guralnik JM: Progression of lower-extremity in older woman with diabetes: the Woman’s Health and Aging Study: Diabetes Care 26:70-75, 2003

7. Webber SC, Porter MM, Menec VH: Mobility in Older Adults: A Comprehensive Framework: The Gerontologist 50: 443-450,2010

8. Piva SR, Susko PT, Toledo GS: Links between Osteoarthritis and Diabetes: Implications for Management from a Physical Activity Perspective: Clin Geriatr Med 31: 67-87, 2015

9. World Health Organisation. Falls: January 2018

10. The Importance of Vision in Preventing Falls. The College of Optomitrists 2011

11. Public Health England. Falls and fracture consensus statement: Supporting commissioning for prevention. January 2017

12. Diabetes UK. Diabetes in the UK. London: Diabetes UK, 2004

13. Hewston P, Deshpande N. Fall and balance impairments in older adults with type 2 diabetes:thinking beyond diabetic peripheral neuropathy: Can J Diabet: 40: 6-9 2016

14. Pipers E, Ferreira I, Jongh RT et al. older individuals with diabetes have an increased risk of recurrent falls: analysis of potential mediating factors: the Longitudinal Ageing Study Amsterdam. Age Ageing: 3: 358-65, 2012

15. Hillson R. ‘I cried for my lost sight.’ Vision and Diabetes. Pract Diabetes: 33: 270-272,2016

16. Brown SJ, Handsaker JC, Bowling FL, Boulton AJ, Reeves ND. Diabetic peripheral neuropathy compromises balance during daily activities. Diabetes Care: 38:1116-22,2015

17. Timar B, Timar R, Lungeanu D. The Impact of Diabetic Neuropathy on Balance and on the Risk of Falls in Patients with Type 2 Diabetes Mellitus: A Cross-Sectional Study: PLoS ONE :11:e)154654,2016

18. Mayne D, Stout NR, Aspray TJ. Diabetes, falls and fractures: Age and Ageing: 39: 522-525 2010

19. Purewal TS, Watkins PJ. Postural hypotension in diabetic autonomic neuropathy: a review:Diab Med: 3: 192-200, 1995

20. Rogers LC, Frykberg RG, Uccioli L. The Charcot Foot in Diabetes: Diabetes Care: 34:2123-2129,2011

21. J effcoate WJ. Charcot foot syndrome:Diabet Med: 32:760-770,2015

22. NICE guideline Diabetic foot problems: prevention and management: 2016

23. Srivastava S, Younis N, Kurdy N. Investigating quality of life in people with Charcot neuroarthropathy. The Diabetic Foot Journal:19:70-74,2016

24. Rogers L, Frykberg RG, Armstrong DG et al. The Charcot Foot in Diabetes. Diabetes Care: 34:2123-2129,2011

25. Gerrits EG, Landman GW, Bilo HJ. Limited joint mobility syndrome in diabetes mellitus: A mini review. World Journal of Diabetes:10:1108-1112, 2015

26. D’Silva L, lin J, Kluding PM. Impact of Diabetic Complications on Balance and Falls: Contribution of the Vestibular System. Phys Ther : 96:400-409,2018

27. Huang ES, Karter AJ , Danielson KK , et al . The association between the number of prescription medications and incident falls in a multi-ethnic population of adult type-2 diabetes patients: the diabetes and aging study. J Gen Intern Med;25:141–6, 2010

28. NHS : Stroke: 2019

29. Taylor SM et al, Preoperative clinical factors predict postoperative functional outcomes after major lower limb amputation : an analysis of 553 consecutive patients: J Vasc Surg: 2: 227-35 2005

30. Norvell DC et al, Defining successful mobility after lower extremity amputation for compliccations of peripheral vascular disease and diabetes: J Vasc Surg: 2: 412-9, 2011

31. Polypharmacy in Elderly Patients (PDF). Vumc.nl. Retrieved 16 January 2015

32. Gadsby R, Galloway M, Barker P, et al Prescribed medicines for elderly frail people with diabetes resident in nursing homes-issues of polypharmacy and medication costs. Diabetes Med ;29:136–9, 2012

33. Dhalwani NN, Fahami R, Sathanpally H et al. Association between polypharmacy and falls in older adults: a longitudinal study from England: BMJ :7: 1-8, 2017

34. Peron EP, Ogbonna KC, Donohoe K L. Diabetic Medications and Polypharmacy: Clin Geriatr Med: 31: 1-26, 2015

35. Noale M, Veronese N, Cavallo Perin A et al. Polypharmacy in elderly patients with type 2 patients receiving oral antidiabetic treatment: Acta Diabetol: 53: 323-30, 2015

36. Berlie HD, Garwood CL. Diabetes Medications Related to an Increased Risk of Falls and Fall-Related Morbidity in the Elderly: The Annals of Pharmacotherapy: 44: 712-717, 2010

37. NICE guidance: Falls in older people: assessing risk and prevention: June 2013

38. Menant JC, Steele JR, Menz HB et al. Optimizing footwear for older people at risk of falls: J Rehabl Res Dev: 45: 1167-81, 2008

39. Schaper NC, Van Netten JJ, ApelQvist J, Bus SC et al. IWGDF Guidelines on the prevention and management of diabetic foot disease 2019

40. Public Health England. Falls and fracture consensus statement: Supporting commissioning for prevention. January 2017

41. Watson GH. The effectiveness of Tai Chi as a fall prevention intervention for older adults: a systematic review: Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews:1-6,2009

42. NICE Quality Standard (QS86) Falls in older people. Updated in January 2017.

43. Beaudart C, McCloskey E, Cooper C. Sarcopenia in daily practice: assessment and management :BMC Geriatr: 16: 1-43: 2016

Protect diabetic feet, prescribe FlexitolThe UK’s No.1 prescribed urea brand1

Thornton & Ross Limited, Linthwaite, Huddersfield HD7 5QH t | +44 (0) 1484 842217 f | +44 (0) 1484 847301 e | [email protected] w | www.thorntonandross.co.uk

REFERENCES: 1. HSCIC, July 2019. 2. Flexitol Listing, Drug Tari�. 3. Thornton & Ross, data on file.

For more information please visit www.flexitol.co.uk/professional or email [email protected]

ADVERSE INCIDENTS SHOULD BE REPORTED. ADVERSE INCIDENTS CAN BE REPORTED TO MEDICAL INFORMATION at [email protected] or Tel. 01484 848164. REPORTING FORMS AND INFORMATION CAN ALSO BE FOUND AT WWW.MHRA.GOV.UK/YELLOWCARD.

Apply once a day, every dayApply to allpre-calluseddiabetic feet

Apply to allcallused

diabetic feet

skintelligence.flexitol.co.uk

[email protected]

Brought to you by

diabetes and mobility explained: disease, falls and fractures

Documents