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Diabetes and bone health “It is important, where possible, to ensure that messages from different clinicians pertaining to lifestyle factors are aligned and overlap as much as possible.” Conclusion Diabetes and osteoporosis are increasingly prevalent diseases. Diabetes is an important clinical risk factor for osteoporosis and fracture, and as clinicians it is important to remember this association when managing people with diabetes. Diabetes-related complications, hypoglycaemia and obesity could increase the risk of falls and fragility fracture. HbA 1c targets should be individualised taking into consideration age, frailty, diabetes complications and falls risk. While there is much to learn regarding the associations between diabetes, osteoporosis and fractures, it is important to recognise the value of performing a multifactorial fracture risk assessment, including falls risk. Tools are available to conveniently assess this risk and measurement of BMD by performing a DXA scan may provide additional useful information to help target those patients who are most at risk of fracture with appropriate fracture prevention drug therapies. The value of lifestyle modification to address fracture and falls risk cannot be underestimated. It is also convenient that the lifestyle modifications required to optimise bone health very much overlap with the lifestyle guidance that is offered to optimise the management of the underlying diabetes and obesity. It is important, where possible, to ensure that our messages to patients pertaining to lifestyle factors are aligned and overlap as much as possible, rather than conveying different sets of instructions for different disease areas. This is where diabetes and osteoporosis management from a self-help perspective very much align. n Acknowledgement This article has been modified from one previously published in Diabetes & Primary Care (2016, 2: 68–74). Anatomy & Physiology (2013) Age and Bone Mass. Wikimedia Commons. Available at: https://commons.wikimedia.org/wiki/ File:615_Age_and_Bone_Mass.jpg (accessed 22.03.16) Blausen Medical Communications (2016) Osteoporosis locations. Wikimedia Commons. Available at: https://commons.wikimedia.org/ wiki/File:Osteoporosis_Locations.png (accessed 22.03.16) Bonjour J-P, Chevalley T (2014) Endocr Rev 35: 820–47 Botolin S, McCabe LR (2006) J Cell Physiol 209: 967–76 Cundy TF et al (1985) Diabet Med 2: 461–4 Dandona P, Dhindsa S (2011) J Clin Endocrinol Metab 96: 2643–51 Food and Drug Administration (2015) FDA Drug Safety Communication. FDA, Silver Spring, MD, USA. 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NICE, London, UK Pscherer S et al (2016) Diabetes Metab Syndr Obes 9: 17–23 Rubin MR et al (2013) Expert Rev Endocrinol Metab 8: 423–5 Schwartz AV et al (2008) Diabetes Care 31: 391–6 Schwartz AV et al (2011) JAMA 305: 2184–92 Shah VN et al (2015) Diabet Med 32: 1134–42 Signorovitch JE et al (2013) Diabetes Obes Metab 15: 335–41 Strotmeyer ES et al (2005) Arch Intern Med 165: 1612–7 Su B et al (2015) Endocrine 48: 107–15 Suzuki A et al (2006) Endocr J 53: 503–10 Tahrani AA et al (2010) Int J Clin Pract 64: 351–5 Vestergaard P (2007) Osteoporos Int 18: 427–44 Vestergaard P et al (2005) Diabetologia 48: 1292–9 Watts J, Abimanyi-Ochom, K, Sanders KM (2013) Osteoporosis is costing all Australian – a new burden of disease analysis – 2012 to 2022. Osteoporosis Australia, Glebe. Available at: http://bit.ly/2lvhHI4 (accessed 22.02.16) Zhu Z-N et al (2014) Bone 68: 115–2 68 Diabetes & Primary Care Australia Vol 2 No 2 2017
Article Falls prevention in older adults with diabetes: A clinical review of screening, assessment and management recommendations Anna Chapman, Claudia Meyer Older adults with diabetes have an increased rate of falls, recurrent falls and rate of fracture following a fall. Falls can contribute to a heightened fear of further falling, social isolation, avoidance of daily activities, and can increase the likelihood of premature admission to residential aged-care facilities. The most common risk factors for falls within this population group include peripheral neuropathy, foot complications, impaired postural control, polypharmacy and insulin use, sub-optimal glycaemic control and hypoglycaemia, as well as vision and cognitive impairment. Falls risk screening should be undertaken every 12 months for all older people with diabetes, followed by a more detailed falls assessment for those deemed high risk to identify the contributory risk factors and management strategies. Individualised strategies should be co-designed with individuals and where appropriate, their carer(s), may involve referral to other health professionals, and should be monitored and reviewed at regular intervals. Falls are a complication of diabetes and are being increasingly acknowledged as impacting the overall health and wellbeing of older adults (International Diabetes Federation [IDF], 2013). Within the general community-dwelling population of older adults, approximately one in three people fall per year (Moyer, 2012). The combination of age (≥65 years) and diabetes increases the risk of recurrent falls by 67% (Pijpers et al, 2012); and older adults with diabetes are twice as likely to have injurious falls (Roman de Mettelinge et al, 2013). At the individual level, falls can contribute to a loss of confidence and reduced activity levels, loss of lower-limb muscle and bone strength (Karinkanta et al, 2010), and a heightened fear of further falling (Zijlstra et al, 2007). For the public health system, there are expanding costs associated with falls-related hospitalisations (Bradley, 2012). Key to the prevention of falls is the identification of at-risk individuals and the implementation of appropriate interventions. Given the increased prevalence and negative consequences associated with falls among older adults with diabetes, falls prevention should be considered an integral component of diabetes care, and primary care practitioners are well-placed to offer proactive, comprehensive and individualised falls prevention strategies. This article will assist primary care practitioners in this role, providing an overview of potential screening tools and outlining fallsrelated risk factors pertinent to an older person with diabetes. In addition, this paper will consider the evidence and recommend actions for older adults with diabetes, specifically for the community-dwelling population (rather than the hospital or residential aged-care setting). Falls risk screening Falls risk screening refers to the process of identifying individuals who are at-risk of a fall, to determine if a detailed falls assessment is appropriate. To be effective, screening tools need Citation: Chapman A, Meyer C (2017) Falls prevention in older adults with diabetes: A clinical review of screening, assessment and management recommendations. Diabetes & Primary Care Australia 2: 69–74 Article points 1. Falls-related risk factors for older people with diabetes include peripheral neuropathy, impaired postural control, polypharmacy, visual impairment, cognitive impairment, foot complications, and suboptimal glycaemic control. 3. Valid and reliable risk screens exist to identify individuals at-risk of falls. As with all older adults, individuals with diabetes should be screened for falls at least once every year. 4. Individuals at increased risk of falls require a multifactorial assessment that examines the wide range of fallsrelated risk factors. 5. Falls prevention interventions should systematically address the risk factors identified and should be developed with the older person with diabetes, and where applicable their carer(s). Key words – Falls – Older people Authors Author details are on page 74. Diabetes & Primary Care Australia Vol 2 No 2 2017 69
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