Journal of Diabetes and Its Complications 20 (2006) 158 162

Falls as a complication of diabetes mellitus in older peopleB

Lindsey M. TillingT, Khaled Darawil, Mary Britton
Department of Elderly Care Medicine, Homerton University Hospital, Hackney, London E9 6SR, United Kingdom
Received 29 March 2005; received in revised form 27 May 2005; accepted 1 June 2005

Abstract
Objectives: The aims of this study were to determine the incidence of falls in a group of elderly patients with diabetes and to assess for
the prevalence of risk factors for falls in this population. Design: This is a population-based study with questionnaire-based interviews.
Setting: The setting for this study was the London District General Hospital outpatient department. Participants: Seventy-seven patients
with diabetes, aged over 65 years, randomly selected whilst attending for general diabetic annual review. Patients with dementia, blindness,
and immobility and those who were unable to give informed consent were excluded from this study. Measurements: The incidence of falls in
the last 12 months was used. Information was collected on the incidence of hypoglycaemic episodes, the presence of other medical
conditions, visual impairment, and peripheral neuropathy, the use of medications and walking aids, and HbA1C and blood pressure control.
Results: The incidence of falls was 39%. Falls occurred more frequently in female patients and patients of increasing age. Falls occurred
more frequently in patients with poor diabetic control [risk ratio (RR)=7.83 (2.94820.799), v 2 value = 6.422]; patients requiring assistance
with mobility: for those mobile with a stick [RR=1.839 (1.0483.227), v 2= 4.619]; and those who had previously suffered a stroke
[RR=1.929 (1.1433.257), v 2 = 4.615]. Conclusion: We provide evidence that poorly controlled diabetes and conditions associated with
complications of diabetes are associated with an increased risk of falling in older people. We recommend early recognition of the multiple
causes of falls in the older diabetic patient and prompt referral of this group of patients to a specialist falls clinic.
D 2006 Elsevier Inc. All rights reserved.
Keywords: Older people; Falls; Diabetes

1. Introduction
Falls are a major cause of disability and a preventable
cause of death in older people. About 30% of people over
65 years of age fall each year; the incidence of falls in those
over 75 years of age is 3242% (Tinetti & Speechley,
1989). Diabetes mellitus is also common in older people. It
has been estimated that approximately 50% of the patients
with diabetes are over 65 years of age (Morley, 1998). The
prevalence of diabetes in elderly individuals in the UK was
estimated at between 11% and 14% (Croxson, 2002);
prevalence will vary depending on the date of study,
population, and method of determining diabetes. Diabetic
patients over 65 years old are nearly three times more likely
B

No funding was sought for this study.

T Corresponding author. Department of Cardiology, John Radcliffe
Hospital, Headley Way, Headington, Oxford OX3 9DU, United Kingdom.
E-mail address: [email protected] (L.M. Tilling).
1056-8727/06/$ see front matter D 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.jdiacomp.2005.06.004

than nondiabetic participants to be hospitalised in a given

year (Zaida & Alexander, 2001). The prevention of falls is
therefore important to reduce morbidity and mortality in
this age group. The importance of identifying specific risk
factors and the value of a multidisciplinary assessment of
patients who fall are increasingly being recognised (Chang
et al., 2004; Palmer, 2001). In the National Service Framework for Older People, the importance of assessment and
management of falls is strongly emphasised (National
Service Framework Older People, 2001). The most efficient
fall-prevention programmes target high-risk groups (Close
et al., 2003). Diabetic complications lead to impairments,
which would constitute recognised risk factors for falls
(Bueno-Cavanillas et al., 2000). It would therefore appear
that older diabetic patients would be a suitable target group
for a strategy aimed at preventing falls.
We hypothesised that complications of diabetes may lead
to an increased risk of falls in older diabetic patients,
making falls an indirect complication of diabetes. The aim

L.M. Tilling et al. / Journal of Diabetes and Its Complications 20 (2006) 158 162

159

explained to the patient. Information was sought regarding

contact with other medical specialties.
We subsequently obtained information about glycaemic
control, blood pressure, and the presence of clinically
determined complications of diabetes from the hospital
records by looking at the documentation of the annual
review. Visual impairment was defined by decreased vision
on a Snellen Chart, retinopathy by findings on dilated
fundoscopy, and neuropathy by abnormal monofilament
score. We defined the presence of sensory impairment as
either self-report on the questionnaire or by documented
clinical evidence in the medical records, or both.

of this study was to establish the incidence of falls and to

define risk factors associated with falls.

2. Methods
Seventy-seven patients aged 65 years and over with Type
I or II diabetes were recruited by random selection, whilst
attending for general diabetic annual review at Homerton
University Hospital, a district general hospital in the east of
London, between February and June 2002. Approval for the
project was given by the research ethics committee of East
London and The City Health Authority. Patients with
dementia (documented after consultation with a psychogeriatrician), blindness, and immobility and those who were
unable to give informed consent were excluded from this
study. Although it is recognised that the first three
conditions may contribute to falling, demented patients
were unable to respond appropriately to the questionnaire,
and blindness and immobility would confound the data.
An information sheet was provided to explain the purpose
of the study, and written informed consent was obtained.
Each patient participated in a structured questionnaire-based
interview. They were asked questions relating to the duration
of diabetes, monitoring, their perception of occurrence of
hypoglycaemic episodes, symptoms and signs of postural
hypotension, other illnesses, and medications. Patients were
asked questions regarding the use of walking aids and their
perception of visual impairment and peripheral neuropathy.
They were also asked about the occurrence of falls within
the past 12 months (bHow many times, if at all, have you
had a fall in the last year?Q). A fall was defined as an
unintentional change in body position resulting in contact
with the ground or lower level, not as a result of a major
intrinsic event (e.g., stroke) or overwhelming hazard (e.g.,
car accident; Tinetti, Speechley, Ginter, 1988); this was

2.1. Statistical methods

Analysis of each category was undertaken to obtain a
relative risk ratio (RR) for falling, with 95% confidence
intervals. Chi-squared tests were used to determine the
significance of each potential risk factor comparing participants who had fallen with those who had not. A P value of
less than .05 indicates statistical significance.

3. Results
Table 1 shows the demographics and data regarding
diabetes control. The average age of our cohort was 73 years
(6585 years). Twenty-seven patients (35%) were aged
75 years or older, 50 (65%) were between 65 and 74 years.
There were 32 males and 45 females.
Thirty patients (39%) had suffered at least one fall in the
last year. Females were at greater risk of falling, as were
patients in the older group. Of the patients who had falls,
none of the fallers were managed by diet alone. Poor diabetic
control (HbA1C N7%) was associated with falling, with a
significant v 2 value of 6.422. There was a high prevalence of

Table 1
Demographics and diabetic control

Female
Male
Age N75
Lives alone
Lives with one other
Lives in an institution
Frame to mobilize
Stick to mobilize
Mobilize independently
Smoker
N14 Units alcohol/week
Tablets only
Diet only
Insulin only
Insulin and tablets
HBA1C N7%
Incidence of hypoglycaemic episode

Falls (%)
[n=30]

No falls
(%) [n=47]

Total (%)
[n=77]

Falls/no falls ratio

(95% confidence interval)

23
7
14
13
16
1
2
17
11
5
3
11
0
13
6
26
15

22
25
13
16
28
3
0
15
33
5
0
21
4
14
6
28
14

45
32
27
29
44
4
2
32
44
10
3
32
4
27
12
54
29

2.336
0.428
1.62
1.265
0.857
0.633
2.679
1.839
0.434
1.34
0.670
0.814
0
1.699
1.354
7.83
1.655

(77)
(23)
(47)
(43)
(53)
(3)
(7)
(57)
(37)
(17)
(10)
(37)
(0)
(43)
(20)
(87)
(50)

(47)
(53)
(27)
(34)
(60)
(6)
(0)
(32)
(70)
(11)
(0)
(45)
(9)
(30)
(13)
(60)
(30)

(58)
(42)
(35)
(38)
(57)
(5)
(3)
(42)
(57)
(13)
(4)
(42)
(5)
(35)
(16)
(70)
(38)

(1.144 to 4.766)
(0.21 to 0.73)
(1.014 to 2.586)
(0.729 to 2.196)
(0.491 to 1.495)
(0.112 to 3.521)
(1.998 to 3.593)
(1.048 to 3.227)
(0.241 to 0.783)
(0.670 to 2.682)
(0.497 to 0.904)
(0.452 to 1.466)
(0.969
(0.708
(2.948
(0.957

to
to
to
to

2.980)
2.591)
20.799)
2.862)

160

L.M. Tilling et al. / Journal of Diabetes and Its Complications 20 (2006) 158 162

Table 2
Sensory deficit, coexistent morbidities, and polypharmacy

Visual impairment
Peripheral neuropathy
SBP N135 mm Hg
DBP N85 mm Hg
Ischaemic heart disease
Osteoarthritis
Stroke
Pacemaker
N4 Medications

Falls (%)
[n=30]

No falls (%)
[n=47]

Total (%)
[n=77]

Falls/no falls ratio

(95% confidence interval)

26
15
21
17
9
13
9
1
21

32
15
36
22
14
19
5
2
23

58
30
57
39
23
32
14
3
44

2.129
1.567
0.819
1.275
1.006
1.075
1.929
0.851
1.75

(87)
(50)
(70)
(57)
(30)
(43)
(30)
(3)
(70)

(68)
(32)
(77)
(47)
(30)
(40)
(11)
(4)
(49)

(75)
(39)
(74)
(51)
(30)
(42)
(18)
(4)
(57)

(0.852
(0.904
(0.453
(0.723
(0.547
(0.613
(1.143
(0.167
(0.925

to
to
to
to
to
to
to
to
to

5.317)
2.716)
1.480)
2.249)
1.851)
1.886)
3.257)
4.323)
3.300)

SBPsystolic blood pressure; DBPdiastolic blood pressure.

reported symptoms considered by the patients to be caused

by hypoglycaemic episodes within the group as a whole;
this was not a significant risk factor for falls (v 2 value of
3.187). Dependency on a walking aid was another significant
risk factor: Mobilizing with a stick was significantly
associated with falling (v 2=4.619). It was noted that all
three patients who admitted to drinking more than 14 units of
alcohol a week were in the group who fell.
Table 2 gives information on sensory deficit, coexistent
morbidities, and polypharmacy. Visual impairment and
peripheral neuropathy were prevalent in both groups, more
common among fallers, but this difference did not reach
statistical significance. The only comorbidity that showed
significant association with falls was previous stroke, with a
v 2 value of 4.615.

4. Discussion
This study examined the prevalence of being a faller
within a group of older diabetic patients and sought to
investigate the association of being a faller with a range of
putative risk factors within this population. This is the first
study to prove that a significant relationship exists between
poor diabetic control and falls.
This study has several limitations. The study is retrospective. We did not enquire into the number of falls in
those who had fallen, and a longer period of recall may have
yielded a higher percentage of fallers. We studied a
relatively small number of participants, which may not
represent the average population of older diabetic patients,
limiting generalisability.
The results confirm that falls are prevalent among older
diabetic patients. Our figure of 39% is in line with other
studies into the incidence of falls in all older people (Masud
& Morris, 2001). However, we would expect the figure to
be higher, as we are proposing that diabetes increases the
risk of falls. It would therefore appear that estimation of falls
by patient self-reporting is too low. We identified an
increased risk in the older subset of diabetic patients, and
we have shown that women are at greater risk of falling than
men are. It is not clear why women should be predisposed to

falls, but this finding has previously been documented

(Schwartz et al., 2002).
The majority of patients were managing their diabetes
with insulin, tablets, or a combination of both. Glycaemic
control was not good, as evidenced by HbA1C values; a fear
of hypoglycaemic episodes, which was prevalent in both
groups of patients, may lead to less strict control, or it may be
that older people have poorer control of their diabetes
generally, which would act as a confounding variable. The
results of the UKPDS trial have shown that treatment to
improve overall glucose control significantly reduces the risk
of microvascular and macrovascular complications (UKPDS
38, 1998). We demonstrated the presence of both microvascular and macrovascular complications in our population.
Previous studies have shown that visual impairment and
peripheral neuropathy are important risk factors for falls
(UKPDS 35, 2000; UKPDS 36, 2000), consistent with the
data presented here. Visual impairment is particularly widespread within our population, and although this factor did not
show statistical association with falls, many patients reported
that they felt that it contributed to their fall. It might similarly
be expected that peripheral neuropathy could lead to impaired
balance and, therefore, falls, and 50% of those who fell in our
study reported suffering from this complication of diabetes.
Those who required walking aids were at greater risk of
falls. Peripheral neuropathy may contribute as outlined
above. We demonstrated that suffering a previous stroke
was a significant risk factor for falls. Blood pressure control
in the group was suboptimal; three quarters of patients had
readings over the recommended 135/85 (UKPDS 38, 1998).
All but 1 of the 14 people who had suffered a previous
stroke had blood pressure readings above the recommended
limits (data not shown). Hypertension is a risk factor for
stroke and, therefore, may indirectly contribute to falls in
this population; however, postural hypotension has also
been associated with hypertension (Krolewski et al., 1985).
Diabetes often coexists with other chronic disease in older
people. As a consequence of this, these patients are
prescribed many tablets (polypharmacy), the side effects of
which may increase their risk of falling. A frequently
observed side effect of antihypertensive medication is
postural hypotension, a recognised risk factor for falls. Oral

L.M. Tilling et al. / Journal of Diabetes and Its Complications 20 (2006) 158 162

Fig. 1. Involvement of healthcare professionalspercent of patients.

Ophthophthalmology; physiophysiotherapy; OToccupational therapy; f/ufollow.

or injectable hypoglycaemic agents may induce a level of

hypoglycaemia that may precipitate collapse. We have
acknowledged the existence of these potential confounding
factors in our questionnaire; that there may be more than one
cause for a fall is one of the challenges pertinent to elderly
care medicine, a focus of the falls prevention clinic.
The association with alcohol and falls should be noted.
Although only three patients admitted to drinking over the
14 units that we set as the weekly limit, it is possible this
figure is an underrepresentation, as some patients may be
unwilling to disclose this information or underestimate their
consumption. All three patients had fallen. If their alcohol
consumption was excessive, it could have contributed to
hypoglycaemia in the presence of diabetes.
Only four patients surveyed came from an institution
(residential or nursing home). This is a small number and
may be because diabetic monitoring is the responsibility of a
visiting general practitioner in many institutions. Our sample
population may therefore underrepresent such patients. The
participants in our study were relatively young (three
quarters of them aged less than 75 years) and we did not
see many frail or very old patients in the outpatient
department. This group of patients is likely to be at high
risk of falls; they may have osteoporotic bones and, as such,
be at greater risk of injury (Wei, Hu, Wang, & Hwang, 2001).
A large number of patients had regular appointments with
an ophthalmologist and chiropodist, but very few had contact
with the physiotherapist, occupational therapist, or elderly
care medicine specialist (see Fig. 1; binvolvementQ indicates
that the patient has seen this health care professional at least
once within the last year). This reflects the medical
professions vigilance towards diabetes care, but lack of
recognition of risk for falling in the same population. Of the
30 patients who had fallen, 11 required hospital treatment for
an injury sustained during a fall; although drawn from a
small sample, this figure is higher than reported for the
population as a whole. Previous studies have estimated the
number of patients seeking medical help following a fall to

161

be between 10% and 25% (Berg, Alessio, Mills, & Tong,

1997; Campbell et al., 1990). Only three had been referred
for physiotherapy, one for occupational therapy and one to
the falls clinic (data not shown).
Falls in older people place heavy demands on healthcare
systems (Alexander, Rivara, & Wolf, 1992), and interventions that target the risk factors contributing to falls are
highly recommended by the government (NSF Older
People, 2001). The British Diabetic Association guidelines
on the structure of diabetes services recommend a specialist
diabetes geriatrician in each district (Alexander, 1999).
Reducing the number of falls in older people depends on
identifying those most at risk of falling and coordinating
appropriate preventative action. Many people who fall do
not seek medical help, but they may be identified as being at
risk through the presence of risk factors.
In conclusion, reporting of falls was more common
among those with poor glycaemic control. Prospective study
is needed to establish if better control reduces subsequent
falls. The presence of diabetes in an older person should
raise the possibility of increased risk for falls, and the annual
diabetic clinic review provides an opportunity for screening.
Early recognition of specific risk factors, patient education,
and intervention, including referral for specific falls
prevention programmes such as strength and balance
training, may reduce the incidence of falls in this population
(Chang et al., 2004).
Acknowledgments
We would like to thank all the patients that participated in
this study. We also thank the department of Metabolic
Medicine at Homerton University Hospital for their support.
We are grateful to all the staff in the diabetes clinic and
medical records for their assistance in carrying out the study
in a busy diabetic clinic.
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