Transcript Recurrent falls in an older woman with diabetes

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
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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:
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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
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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 nondrug 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