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