Falls and Fractures in Older Diabetic Patients

Diabetes mellitus us a common disease in elderly; the majority of people with diabetes are aged over 65 years. The risk of hip fractures is 1.5 to 12 times higher in patients with diabetes compared to non-diabetic patients. Furthermore, patients with diabetes are at heightened risk for atypical fractures. Below is a summary of an article (Mayne D, Stout nr, Aspray TJ. Diabetes, falls and fractures. Age and Ageing. 2010;39(5):522-525.) that reviews the pathophysiological mechanisms of falls and fractures in diabetic patients.  

Autonomic dysfunction and postural hypotension:

• Orthostatic hypotension is a risk factor for falls in the elderly. 

• Some causes of orthostatic hypotension are secondary to: automatic neuropathy, reduced baroreceptor reflex sensitivity or hypotensive medication.

• Non-pharmacological treatment of postural hypotension can include: physical counter-maneuvers, use of compression stockings, appropriate hydration and the avoidance of precipitating agents such as alcohol. 

• Common precipitating medicines to be discontinued or curtailed include: alpha blockers, anticholinergic agents, tricyclic antidepressants and tranquilizers.

• In the event of refractor orthostatic hypotension, fludrocortisones can be considered as a first line treatment agent. Midodrine (Pro-Amatine) has been used in the past but is pending immediate removal from the US market.

• Gait abnormalities in older people with diabetes may cause changes in blood pressure while walking, which can cause falls by impairing cerebral perfusion.

Gait disorder:

• All patients who fall should have their gait assessed using “timed up and go” test, which can assist clinicians with categorizing the severity of disorder.

• Classification of gait abnormalities:

* Low-level gait disorder: Consists of peripheral neuropathy; ataxia is a common complication. Diabetic myopathy and statin-induced myositis are common causes for low level gait disorder.

* Middle-level gait disorders: Caused by ischemic lesions in the posterior cerebral circulation or basal ganglia affecting the integration of sensory information.

* High-level gait disorder: includes cortical and subcortical structures. Gait apraxia. Gait apraxia is commonly associated with Alzheimer’s disease. Additionally, elders with dementia and history if falls are a refractory to specialized training. In this case a drug regimen review or targeted coaching of caregivers is warranted.

• Special training to improve gait speed, balance, muscle strength and joint mobility is necessary in diabetic patients with gait disorders.

Diabetes-specific mechanisms: hypoglycemia, diabetic polyneuropathy (DPN) and retinopathy:

• Risk factors for falls in elders with diabetes:

* Metformin can cause vitamin B12 deficiency resulting with postural instability.

* Hypoglycemia, low HbA 1c, frailty and peripheral neuropathy.

• 33% of all patients with diabetes have DPN.

• Important guidance points to consider with respect to appropriate foot care in diabetes with DPN include:

* Screening for foot deformity

* Impaired sensation or vibration and diminished foot pulses

*Update the patient on foot care education, footwear and symptomatic relief of neuropathic pain.

• DPN can be treated with duloxetine, amitripteline, pregabalin and opioid analgesics which can also contribute to increase fall risks.

• Almost all patients with type 1 diabetes and about 60% of those with type 2 will develop retinopathy, which can cause complete visual loss and increase the risk of falls.  

Bone Health:

• Absence of insulin in type 1 diabetes and the low availability of it in type 2 have a negative effect on bone growth, possibility though insulin-like growth factor. This negative effect can eventually lead to osteoporosis.

• Low bone mineral density increases the risk of fractures by 12 times in type 1 diabetes and 2.8 times in type 2 diabetes. Potential reasons for such differences include higher adiponectin levels and visceral fat accumulation.

• Poor glycemic control also increases the risk of fracture via:

* Interfering with collagen metabolism in the bone.

* Causing alterations in bone turnover.

* A calculi effect in patients with type 2 diabetes.

Vitamin D:

• Vitamin D deficiency is associated with increased cardiometabolic risk, hypertension, impaired endothelial function, cardiovascular disease and insulin resistance.

• Vitamin D deficiency promotes an inflamed state which can precipitate bone toxicity.

• Increasing vitamin D intake is beneficial in reducing bone toxicity in type 1 diabetes; however, there are conflicting data as for the benefit of vitamin D intervention in type 2 diabetic patients. 

Thiazolidinediones:

• The ADOPT study investigated and reported an increased risk of peripheral bone fractures in female patients exposed to rosiglitazone. Subsequent investigations present a similar effect wtih pioglitazone, suggesting a class effect.       

• Discontinuation of thiazolidinediones in people with higher risk of fractures is recommended by NICE guidelines.

• Other risks associated with the use of thiazolidine in older people include history of cardiovascular events, fluid retention, heart failure and anemia. 

Conclusion:

• Older diabetic patients have higher risks of falls due to impaired autonomic dysfunction, orthostatic Hypotension, gait disorder, peripheral neuropathy and visual impairment.

• Fractures may be more common in type 1 diabetes and patients who are treated with thiazolidinedione therapy thiazolidinediones in type 2 diabetes along with other factors.               

• Vitamin-D deficiency increases the risk of falls and fractures; however, there us a lack of evidence demonstrating the benefit of vitamin-D supplementation in diabetic patients (especially with type 2).

• Older persons who are diagnosed with diabetes should be targeted for comprehensive evaluation and screening for fall risk reduction. 

Falls and fractures in older diabetic patients. CLIPs-Current Literature and Information for Pharmacists. Oct. 2010;14(37):1-2. 

Prepared by: Claud Khater, Pharm.D. Candidate

Reviewed by: Peter J. Hughes, Pharm.D.

Comments

[marcofisher74]

Diabetes is basically your body not being able to handle the sugar it has in the system. Usually, insulin would take the sugar and place it safely inside the cells who need it. Diabetes develops when either insulin is not produced OR the body develops resistance to insulin, and so the insulin cannot do its job! diabetes destroyed review