Recurrent falls in an older woman with diabetes Professor Isabelle Bourdel-Marchasson

Key points from Case History 87y old woman, treated for diabetes for 14 years She presents with an obliterating arteriopathy of the lower limbs and a distal neuropathy with no muscle atrophy For several weeks she has restricted her activities and she is now dependent on help with activities of daily living, including shopping and meal preparation. Her son has concerns about her medication self management ability. She has been treated for 30 years for hypertension with thiazide diuretics, calcium channel blockers, Angiotensin-converting-enzyme(ACE) inhibitor and received aspirin 75 mg, metformin 850mg twice a day and long-acting insulin analog in the morning of 20 units

Key points from Case History She has fallen four times over the last four months, twice when seated She has lost 5 kg in 4 months (initial weight 70kg) She sustained no injuries and she was not referred to the hospital Blood pressure in the recumbent position was 130/60 mmHg, heart rate 80/min; she was not dehydrated After the last fall episode , her blood glucose was checked at 5.6mmol/l, HbA1c 48.6mmol/mol(6.6%), creatinine 75µmol/l

Main issues raised Recent onset of a geriatric syndrome Falls Loss of autonomy Probable cognitive disorders Malnutrition or malnutrition risk Over treatment with glucose lowering and antihypertensive drugs A Comprehensive Gerontological Assessment is required

Management plan to address key issues The causes of the falls are likely to be multifactorial with interactions between predisposing factors and precipitating factors Consider a diet review (quality and quantity), a review of oral health, bowel transit and vitamin D supplementation Revise treatment Revise anti-hypertensive treatment, assess patient for potential orthostatic hypotension, adapt targets of antihypertensive treatment to less stringent objectives (150/80 mmHg), compressive stockings are contra-indicated (lower limbs ischemic risk) Decrease doses of insulin and measure glucose levels throughout the day, revise glucose targets HbA1c>53mmol/mol(7.0%), range 53mmol/mol(7.0%)-64mmol/mol(8.0%) Medications preparation and intake supervision

Management plan to address key issues Physiotherapy assessment: Gait profile Balance Strength Exercises for prevention of post fall syndrome Physical activity encouragement: Resistance and endurance training Cognitive assessment At the moment: attention and delirium screening In the future: memory clinic, when glucose control has reached the targets

Result of management decision The CGA (Comprehensive Gerontological Assessment) has found Recurrent hypoglycaemia during the afternoon and evening Orthostatic hypotension Severe Vitamin D deficiency Poor oral health and decrease in meal intake Cognitive: MMSE 18/30, improving to 23/30 Poor strength and attention deficit during gait assessment After 6 months She had one more fall, but not as a result of hypoglycaemia She prepares meals and participates in shopping with her son She has gained 2 kg and her diet has improved in quality

Key points for clinical practice Falls are more frequent in older people with diabetes than in older people of the same age A Comprehensive Gerontological Assessment is a good approach to propose a management plan including non-drug treatment (nutrition, exercise, social) and to set targets for both glucose lowering and anti-hypertensive treatment Hypoglycaemia is a risk factor for falls and must be strictly avoided in frail older people with diabetes