Prevention Of Falls In Older People With Diabetes Ng Jia Lin, Podiatrist Toylyn Lee, Snr Physiotherapist
Content Assessments - Foot assessment - Physical mobility Management - Footwear/callus - Exercise Conclusion
Introduction of falls Behavioural Environmental Falls risk factors Biological Socioeconomical
Diabetes and falls Risk factors: - Pharmacological complications - Visual impairment - Cognitive dysfunction - Previous complications affecting function e.g. stroke - Pain - Neuropathy: Sensory, motor and autonomic
Diabetes and falls Neuropathy in DM - Poorly controlled DM tends to affect the long nerves in the body - Sensory neuropathy: afferent nerves - Motor neuropathy: efferent nerves - Autonomic neuropathy: autonomic nerves controlling involuntary processes in the body
Diabetes and falls Sensory neuropathy symptoms - Numbness - Pins & needles / Parasthesia - Ants all over foot / itchy - Reduced sensitivity - Burning sensation - Allodynia
Diabetes and falls Risk factors: Decreased sensorimotor function - Peripheral neuropathy - Loss of proprioceptive feedback with postural instability Musculoskeletal/neuromuscular deficits - Poor postural control - Muscle strength
Assessment What can you do to assess an elderly s fall risk?
Assessment Things to check with the patient - Falls history - Lifestyle, functional decline
Assessment Physical assessment Lower extremity - Sensation - At risk pressure areas
Ipswhich Touch Test - Patients keep their eye closed at all times during this examination - Using your index finger to touch on the indicated sites lightly Hold it there for 1-2 seconds each sites Ensure no pushing or pressure causing indentations - Patient is to say yes when he/she feels that light touch Do not repeat the same site if it was not felt the first time - Total of 8 sites on bilateral feet to be tested 4 sites each foot - 2 out of 8 sites = insensate & positive for neuropathy
The 10 sites
Callus/Corns Calluses: - Due to increased pressure Corns: - Usually long-standing - Sharp pain Usually due to poor choice of footwear & foot deformity
Callus/Corns - Usually due to poor choice of footwear & foot deformity - Caused by prolonged repetitive pressure - Does not go away with use of corn plasters or one-off treatment (improper use can lead to more problems) - Can lead to disastrous outcomes if not treated in time
Assessment Mobility Physical assessment - Various physical parameters that affects daily mobility e.g. endurance, flexibility, power etc - For elderly, important parameters to focus on are: fall risk, balance, strength
Assessment Mobility Components Fall risk Assessment tools Timed up and Go test Balance Strength Functional reach test Romberg test Sharpened romberg test Sit to stand test
Components Predictor of Falls risk Functional Assessment tools Timed up and Go test - Assesses: basic mobility skills and risk of falls - Good interrater reliability, showed 87% specificity and sensitivity - Should not be used as a single measure to determine fall risk - Normative values: >13.5s: predictive of falls for community dwellers (Shumway-Cook et al 2000) >30s corresponds with functional dependence in persons with pathology (Bohannon 2006) Mean scores for >60 years old: 9.4s (Bohannon RW 2006)
Components Assessment tools Functional reach test - Assesses: dynamic standing balance and limits of stability - Showed 76% sensitivity and 34% specificity (Duncan et al 1990) - Normative values <7inches: limited functional balance (Duncan et al 1990) <15 inches: increased risk of frailty and fall (Thomas et al 2005) Balance
Components Balance Assessment tools Romberg & Sharpened Romberg test - Assesses: static balance with a narrowed base of support - Appropriate for: those with loss of vestibular function, sensory neuropathy etc. Romberg test - Feet together, eyes open - Feet together, eyes closed - 60s each Sharpened Romberg test - Feet heel to toe (dominant foot behind), eyes open - Feet heel to toe (dominant foot behind), eyes closed - 60s each
Components Strength (Lower limb) Assessment tools Sit to stand test - Assesses: strength, balance, functional mobility - Normative values: <8 scores (unassisted) were associated with lower levels of functional ability (Rikli & Jones 1999)
Assessment Practical Spilt into 2 groups and will practice the various assessment tool
Management How can we help our elderly patient with diabetes, prevent falls?
Callus/Corn Treatments 1. Good footwear for proper pressure relief & cushioning 2. Frequent debridement or filing to reduce pain 3. Emollient use to soften callus 4. Must educate that shoes & deformities are causative Consider surgical options to correct deformities for pressure relieve Paddings for shock absorption or alleviate pressure Do Not Encourage Self Treatment with Sharp Objects
Management Before After
Management Footwear to improve balance: Good heel support Should have restraining property As low-heel as possible Good gripping outsole
Footwear Footwear to reduce pain: Good cushioning property at the heel and ball of the foot Should be made of breathable materials Eg. Leather Should have wide and deep toe box
Footwear Tips on buying shoes: - Have both feet measured - Try on shoes at the end of the day - Bring socks along when buying shoes
Footwear Tips on buying shoes: - Try on both shoes and tie the laces - There should be a finger-width between longest toe and the end of the shoe - Test for comfort by walking around
Management Exercise Aim: Improve musculoskeletal deficits - Strength - Postural - Functional of LL control (balance) mobility retraining Aim: Prevent future and/or further deterioration - Physical - Other activity in general benefits e.g. better glycemic control, reduced cardiovascular mortality
Management Exercise (Balance) *For safety, hold on to wall/railing of needed
Management Exercise (Strengthening)
Management Education - Falls prevention environmental, behavioural - Falls recovery
Conclusion Having an appreciation of falls and diabetes Early detection of falls risk is essential