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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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