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The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 60:1157-1162 (2005)
© 2005 The Gerontological Society of America

Diabetes Mellitus Is Associated With an Increased Risk of Falls in Elderly Residents of a Long-Term Care Facility

Mathew S. Maurer, Joyce Burcham and Huai Cheng

Columbia University, College of Physicians and Surgeons, New York.

Address correspondence to Mathew S. Maurer, MD, Columbia University, Clinical Cardiovascular Research Lab for the Elderly, Allen Pavilion, 5141 Broadway, 3 Field West, Room 035, New York, NY 10034. E-mail: msm10{at}columbia.edu


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
Background. Diabetes mellitus is common among elderly persons, with several potential complications that could contribute to falls. However, diabetes mellitus is not widely recognized as an important risk factor for falls among elderly persons. Accordingly, the purpose of the current study was to determine whether diabetes is an independent risk factor for falls in elderly residents of a long-term care facility.

Methods. Ours was a prospective cohort study of 139 elderly (88 ± 7 years, range 70–105 years), Caucasian (97%) residents (women, 84%) of a long-term care facility. Inclusion criteria were age ≥60 years, ability to rise from a seated position, informed consent obtained from participant or guardian. Multiple domains were assessed for the association with falls including: clinical diagnoses; medication use; orthostatic changes in blood pressure, gait, or balance; cognitive/mental status; general well being; activities of daily living; affect/behavior; range of motion and/or ambulation; and communication. Diabetes mellitus was determined by use of hypoglycemic agents. Time to first fall was determined by review of daily New York State mandated "Incident and Accident" reports.

Results. Over the follow-up period (mean 299 days), 49 participants (35%) experienced a fall. The fall incidence rate for the participants with and without diabetes mellitus was 78% and 30%, respectively (p <.001). The significant unadjusted hazard ratios of fall risk factors included diabetes mellitus, Berg Balance Scale score <45, number of medications, angiotensin-converting enzyme (ACE) inhibitors, hypertension, use of assistive device, inability to independently move a wheelchair, and use of antidepressants, with the latter two factors being protective. In multivariate analysis, only diabetes (adjusted hazard ratio 4.03; 95% confidence interval, 1.96–8.28) and gait and balance (adjusted hazard ratio 5.26; 95% confidence interval, 1.26–22.02) were significantly and independently associated with an increased risk of falls.

Conclusions. Our results suggest that diabetes mellitus is an independent fall risk factor among elderly nursing home residents.

THE current global prevalence of type 2 diabetes mellitus is about 150 million persons, and this is expected to reach 300 million persons by the year 2025 (1). Diabetes mellitus is a very common disease among elderly persons, afflicting about 20% of older adults aged 65–75 years and 40% of adults >80 years old (2,3). It is well known that diabetes mellitus causes high mortality and multiple cardiovascular and noncardiovascular complications (3). However, the relationship between diabetes mellitus and falls in older adults has not been well studied. Previous investigations have defined risk factors for falls (which included gait or balance disorder, vision impairment, medications, and others) among frail elderly nursing home residents, but diabetes mellitus is not consistently reported to be an independent risk factor for falls (4,5). Several potential complications from diabetes mellitus including peripheral neuropathy, diabetic retinopathy, autonomic neuropathy manifesting as orthostatic hypotension, diabetic foot ulcers, or inappropriate glycemic control resulting in hypoglycemia could be potential mechanisms for falls (6–9). This is supported by several recent studies suggesting that diabetes mellitus may be associated with falls among community-dwelling elderly persons (6–9), but no study has shown that diabetes is an independent risk factor for falls in the nursing home setting. Falls in the nursing home are very common (10), with an annual incidence ranging from 220 to 3600 per 1000 beds and of falls-related serious injuries ranging from 1% to 35% (5). The purpose of the present study was to examine the relation between falls and diabetes mellitus among frail elderly residents of a nursing homes to evaluate if diabetes is an independent risk factor for falls in this population.


   METHODS
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Results
 Discussion
 References
 
Study Participant Selection
This prospective cohort study drew participants from The Hebrew Home for the Aged (HHAR), a long-term care facility located in Riverdale, New York. Subjects were also participating in a study aimed at determining the risk of falls based on various measures of orthostatic blood pressure changes (11). Participants were recruited either directly through face-to-face interviews or, if cognitively impaired, after obtaining informed consent from their guardian. All residents of the HHAR were eligible to participate. Inclusion criteria were age ≥60, ability to rise from a seated position, and informed consent obtained from participant or guardian. Trained research coordinators collected chart data including age, sex, race, comorbidities, and medication use. Falls were determined prospectively by review of daily New York State-mandated "Incident and Accident" reports (12). Other variables known to affect risk for falls were assessed as follows.

Clinical Diagnoses
Relevant diagnoses were abstracted from the patient's medical record. The diagnosis of hypertension was based on either a clinical history of hypertension, an average blood pressure of >140/90 mmHg with beat-to-beat monitoring during sitting position for 10 minutes, or an active prescription of an antihypertensive agent. Diabetes was determined by prescription of oral hypoglycemic agent or insulin therapy.

Medications
Medications were determined from computerized pharmacy records with confirmation by review of the participant's medical chart to ensure active prescription of the particular drug at the time of the measurement of orthostatic changes in blood pressure; medication information gathered included name, dosage, and route of administration, and frequency and timing of dosage administration. Medications were categorized into specific groups that have been previously reported to increase the risk of falls including sedative–hypnotics (13), antidepressants (14,15), antipsychotics (16), vasodilators (17), and diuretics (18).

Orthostatic Changes in Blood Pressure
Participants underwent a determination of orthostatic changes in blood pressure by using noninvasive beat-to-beat monitoring as the participant arose from a seated position. This determination was made in each participant in the morning between 9:00 AM and 12:00 PM. Each participant had blood pressure and heart rate measured while sitting and after standing for up to 5 minutes with the use of a real time, noninvasive, beat-to-beat vital signs monitor as has been described previously (11). Blood pressure changes were evaluated in 111 participants (80%). Twenty-eight participants did not undergo evaluation because of scheduling conflicts (n = 5), refusal (n = 3), severe/extreme cognitive impairment (n = 11) limiting ability to cooperate, or inability to stand with the dominant arm in a sling (n = 9).

Institutional Comprehensive Assessment and Referral Evaluation
The Institutional Comprehensive Assessment and Referral Evaluation (INCARE), is an assessment tool, using a semistructured interview technique, that was developed by the staff at the Columbia University Center of Geriatrics and Gerontology and the New York Office of Mental Health and has been validated by the staff of the HHAR (19–21). The INCARE evaluates major health and social problems in individuals aged 65 or older who are admitted to an institutional setting. It includes items of information covering the evaluation of demographics and work history, cognitive and/or mental status, general well being, activities of daily living, affect and behavior, range of motion and/or ambulation, and communication. The answers, variables, or symptoms that are collected during the interview of the participants can be combined to give different indicator scales of various health and social problems such as depression, cognitive impairment, or arthritis. The INCARE contains indicator scales that combine several symptoms or indicators of a particular problem so that the measurement is less fallible. Several commonly used geriatric assessment scales are included in the INCARE (19,20). For our study, we were interested in certain indicator scales for the risk factors of falls. We evaluated indicator scales from the INCARE for the following risk factors: cognitive impairment, poor vision, depression, and mobility and/or use of an assistive device. Each participant underwent evaluation using the INCARE by personnel trained in the administration of the interview. One hundred thirty-six (98%) participants underwent evaluation with the INCARE.

Berg Balance Scale
The Berg Balance Scale (22) was used to measure a participant's degree of balance and strength in standing and walking, and as a diagnostic test for predicting a participant's potential for falling. It was administered by a licensed physical therapist to 117 participants (84%). Twenty-two participants did not undergo evaluation because of scheduling conflicts (n = 7), refusal (n = 4), or severe/extreme cognitive impairment (n = 11).

Statistical Analysis
Risk ratios for risk of falls, among all participants and within subgroups of those with and without diabetes mellitus, were estimated for each of the risk factors. Significance was estimated using Student's t test (for unpaired comparison of continuous variables) and chi square with Fisher's exact test (for dichotomous variables). Using Cox proportional hazard regression, unadjusted and adjusted hazard ratios were estimated for each risk factor. SAS 8.0 (Cary, NC) was used for all analyses.


   RESULTS
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Discussion
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The population studied was predominately elderly with a mean age of 88 ± 7 years (median 88 and range 70–105 years), Caucasian (97%), and female (84%). Our participants were representative of similar populations in long-term care facilities with a high degree of cognitive and physical ailments. A majority had evidence of gait or balance difficulties as evidenced by the mean score on the Berg Balance Scale (29 ± 15) and the use of assistive devices for ambulation (82% of participants). Participants on average had been in the nursing home for 1235 ± 1261 days (range 97–8854 days; median 990 days) prior to enrolling in the study and were followed for 299 ± 188 days (range 8–657 days, median 281 days). Over the follow-up period 49 participants (35%) experienced a fall.

Eighteen (13%) of the nursing home residents were classified as having diabetes, with two-thirds maintained on oral agents and one-third receiving insulin. The demographic and clinical characteristics of study participants based on the prevalence of diabetes are shown in Table 1. Participants classified as having diabetes were younger, more often obese (40% vs 5%), with a higher prevalence of hypertension (83% vs 51%) and more visual impairment (20% vs 8%), and were prescribed on average almost two more medications per day and almost one additional cardiovascular medication per day than were those participants not classified as having diabetes. However, those participants classified with diabetes did not differ from those without diabetes in sex, race, history of stroke, degree of cognitive impairment, scores on the Berg Balance Scale (27 ± 17 vs 30 ± 18), use of assistive devices, and the prevalence of orthostatic hypotension measured at 1 or 3 minutes after standing. The fall incidence rate for the participants with and without diabetes mellitus was 78% and 30%, respectively, which was very significant (p <.001).


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  		Table 1. Demographic and Clinical Characteristics of Study Population.

 
In our survival analysis using time to first fall as an event, the significant unadjusted hazard ratios of fall risk factors included diabetes mellitus, Berg score <45, number of medications, angiotensin-converting enzyme (ACE) inhibitors, hypertension, use of assistive device, inability to independently move a wheelchair, and use of antidepressants, with the latter two factors being protective. In multivariate analysis, only diabetes mellitus (adjusted hazard ratio 4.03; 95% confidence interval [CI], 1.96–8.28) and gait and balance (adjusted hazard ratio 5.26; 95% CI, 1.26–22.02) were significantly and independently associated with an increased risk for falls (Table 2 and Figure 1). After 1 year of follow-up, 73% of the diabetics had fallen as compared with 31% of those classified as nondiabetic. When coupled with objective evidence of gait or balance disorders as revealed by the Berg Balance Scale, 87% of participants with diabetes and gait or balance difficulties suffered a fall during the study, whereas only 11% had a fall during the study if they were free of diabetes and abnormal gait and balance (i.e., Berg Balance Scale score >45) on initial evaluation. The sensitivity of having both diabetes and a poor gait and balance for predicting subsequent falls in our population was 96% with a negative predictive value of 89%.


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  		Table 2. Unadjusted and Adjusted Hazard Ratios (HR) and 95% Confidence Intervals (CI).

 


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  		Figure 1. Time to first fall for elderly residents of a long-term care facility. Upper panel: time to first fall among participants with and without poor gait and balance (defined by a score on the Berg Balance Scale <45); lower panel: same for participants with and without diabetes mellitus (defined by use of hypoglycemic agents)

 

   DISCUSSION
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 Methods
 Results
 Discussion
References
 
The primary finding of this study is that, in addition to a well recognized risk factor for falls among elderly nursing home residents, namely gait or balance difficulties, both unadjusted and adjusted hazard ratios indicate that prevalent diabetes mellitus, defined by the need for treatment, is significantly and independently associated with fall risk in elderly nursing home residents. These data suggest that, in addition to the multiple cardiovascular complications attributable to the rising epidemic of diabetes in the United States (23), falls may be another consequence. Among multiple risk factors for falls in nursing home populations that have been delineated (5), our results suggest that, in residents of a long-term care facility, diabetes should be considered in risk stratification.

Association of Diabetes with Falls
The multiple and well recognized complications of long-standing diabetes mellitus including peripheral neuropathy, diabetic retinopathy, autonomic neuropathy, diabetic foot ulcer, or hypoglycemia from inappropriate glycemic control can each contribute meaningfully to fall risk through multiple mechanisms(3). Visual impairments either from proliferative diabetic retinopathy or related to poor glycemic control have been associated with an increased rate of falls (24,25). In our data, a global assessment of visual impairment demonstrated a trend toward greater visual impairment in diabetics as compared with nondiabetics (20% vs 8%), but this was not significant and thus may not solely account for the observed difference in fall rate. Additionally, although diabetes is associated with orthostatic hypotension secondary to underlying autonomic neuropathy (26–28), and this has been associated with an increased risk for falls in elderly persons (29,30), we did not detect any significant differences in the degree of orthostatic blood pressure changes as measured with continuous beat–to-beat technology during active standing (11). Therefore, it is unlikely that the higher fall rate that we observed in diabetics was attributable to differences in orthostatic changes in blood pressure. Previous studies suggested the possible link between falls and diabetes mellitus among the community-dwelling elderly population (6,31), with a significant portion of the risk being attributable to proprioceptive deficits (6,32,33) or reduced strength and work performance of leg muscles (34). Our data cannot definitively establish the reason underlying the empiric observation that elderly diabetic residents of the nursing home experience more falls than their nondiabetic counterparts. The lack of significant difference in prevalence of orthostatic hypotension or visual impairment suggests that other factors, perhaps related to peripheral neuropathies or diabetic foot complications, play a greater causal role. Further studies confirming these findings in larger data sets and evaluating for the putative mechanism would be required.

Gait and Balance
Using the Berg Balance Scale, we found that gait and balance was an independent predictor of falls in our population of elderly nursing home residents. Although numerous previous investigations have emphasized the importance of gait and balance difficulties in manifesting falls in nursing home residents (5,10,35,36), and several studies have documented the utility of the Berg Balance Scale for predicting falls in community-dwelling elderly population (37–39) and in acute inpatient rehabilitation (40), to our knowledge these data are the first to suggest a significant predictive value of the Berg Balance Scale for falls risk in elderly nursing home residents. In our data, as in others (5), gait and balance abnormalities were the single most important predictor of falls in this population.

Medications
Medications are often noted to be associated with an increased risk for falls, with several studies supporting a strong and linear association between the number of medications and falls risk in both community dwelling and nursing home populations (16,18,41,42). Whether this association represents a causal relationship or whether medications are simply a marker of falls risk has not been clarified. The association of falls and medication use is based on observational data, with minimal adjustment for confounders, dosage, or duration of therapy (18,42). For example, although observational data suggest a weak but significant association of diuretic use and falls in older individuals (18), data from randomized controlled trials did not reveal an association between diuretic use and falls (41). In our data, medications were associated in univariate analysis with fall risk such that for every medication the risk for falls increased by 10% and the risk was 2.5 times higher in those patients prescribed more than four medications compared with those prescribed fewer than four medications. However, in multivariate analysis, medication use was not a predictor of falls risk, suggesting that the medications may be a marker of other independent risk factors for falls. For example, although we found and previously reported that use of ACE inhibitors was associated with an increased risk for falls (43), ACE inhibitors were prescribed more often in diabetics and the risk attributable to them in multivariate analysis was no longer an independent predictor but was rather subsumed by the diagnosis of diabetes mellitus (Table 2). To ultimately clarify the role of medications in the genesis of falls, randomized controlled trials should add falls as an outcome variable and programs designed to decrease medication use should be evaluated for their impact on fall rates.

We found that antidepressants were associated with lower fall risk in univariate analysis, an unanticipated and unexpected finding that to our knowledge has not been previously reported. Previous studies have demonstrated that antidepressants are associated with an increased risk for falls (15,36,44). While potentially attributable to a beneficial effect of the antidepressants, participants receiving antidepressants had higher scores (i.e., more severe depression) than those patients not receiving antidepressants on the Feeling Tone Questionnaire (33 ± 27 vs 21 ± 24, p =.04); suggesting that this was not a treatment effect. Alternatively, it is possible that participants receiving antidepressants were significantly less likely to fall because of other factors not directly attributed to antidepressants. Further analysis revealed that participants prescribed antidepressants as compared with those not prescribed antidepressants were more often unable to stand alone (44% vs 30%), were more often immobile (42% of patients receiving antidepressants had a Berg Balance Scale score < 10, whereas 15% of participants who did not receive antidepressants had Berg scores <10), were more often in a wheelchair (45% vs 20%), and more often did not ambulate independently (26% vs 7%). These additional analyses suggest that antidepressants in our population were more often prescribed to severely immobile participants who were at baseline of lower risk and that the reduced falls risk associated with antidepressants was confounded by these other factors. Indeed, in multivariate analyses, the protective effect of antidepressants was attenuated (hazard ratio 0.38; 95% CI, 0.15–1.002, p =.051) and not included in the final model.

Limitations
There are several limitations to our study. First, the diagnostic criteria for diabetes mellitus were based only on the prescription of medications used to treat diabetes, not by standard laboratory criteria. Thus, there may have been misclassification, and we likely identified participants with either more severe or longer standing diabetes mellitus that required treatment. Second, some traditional fall risk factors were not included in our analysis because of the original design including lower extremity weakness and previous falls. Thus, a biased estimation of the risk factors studied cannot be excluded. Finally, some fall risk factors identified in previous studies were not confirmed as independent predictors of falls possibly because of our small sample size and hence limited power. However, by using a prospective study design and using a time-to-event analysis, we were able to improve statistical power because those participants with and without the outcome of interest were evaluated. Additionally, the prospective design can reduce several forms of bias—including confounding, ascertainment, and recall—that are present in retrospective studies. Prospective study designs tend to reduce these biases and have been used increasingly in studies of fall risk assessment in elderly nursing home residents (36,45,46). However, very few of these used a time-to-event analysis (45). Using such methodology and analyzing multiple domains of function (mobility, cognition, health status, medications, mood) facilitates development of a multivariate risk model for falls and may provide further evidence of causality in that the temporality of the association between a risk factor and outcome (in this case, falls) is incorporated into the association.

Summary
Diabetes mellitus, defined by the use of hypoglycemic agents, is an independent fall risk factor among frail nursing home residents. These results, coupled with the rising prevalence of diabetes, suggest that diabetes mellitus should be considered to be a risk factor for falls in this population. Indeed, identifying such patients as being at higher risk may facilitate preventive measures aimed at reducing the risk for falls.


   Acknowledgments
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 References
 
The study was supported by the American Federation for Aging Research (AFAR) and the Mary and David Hoar Fellowship in the Basic Causes of Dizziness and Other Factors Which Contribute to Falls and Fractures of the Hip from the New York Academy of Medicine. Dr. Maurer is supported by a Career Development Award from the National Institute on Aging (K23-AG00966).


   Footnotes
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Decision Editor: John E. Morley, MB, BCh

Received June 2, 2004

Accepted June 4, 2004


   References
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