Falls are a major health issue for older adults, leading to adverse events and even death. Older persons with type 2 diabetes (T2DM) are at increased risk for falling compared with healthy adults of a similar age. Older adult patients with diabetes, therefore, require treatment plans that are focused on opportunities to reduce the risk of future falls and are adjusted on an ongoing basis to address increasing risks with advancing age.

In an article published in Endocrine Practice in September 2017, Per Aaron Vinik, MD, PhD, and colleagues explored areas of specific vulnerability in these diabetic older adults and reported specific recommendations that could be incorporated to reduce risk of falls. In an August 2017 interview with EndocrineWeb, Dr. Vinik, who led the development of these clinical recommendations, noted, “In patients over 65 with diabetes, there is a 17-fold increased likelihood of falling compared to their younger counterparts.”

Dr. Vinik and his colleagues identified several key factors that can lead to increased falls. The major risk factors include hypertension, diabetes, pain, and polypharmacy. Also, loss of strength is often associated with diabetes, along with changes in sensory perception and loss of balance secondary to peripheral neuropathy. These factors—combined with a decline in cognitive function—lead to an even greater risk of falling.

Designing a treatment plan that incorporates specific interventions to reduce polypharmacy, improve cognitive function, and apply less-strict treatment goals to avoid hypoglycemia and hypotension is recommended to “produce the greatest benefit for reducing falls in older persons with diabetes,” according to Dr. Vinik’s team.

Most diabetic older adults are diagnosed with T2DM, and, therefore, oral antidiabetic agents are the treatment of choice. Of the oral antidiabetic medications available, metformin is the recommended first-line agent because of its overall efficacy in reducing blood glucose, reported weight loss with use, fewer associated hypoglycemic episodes, and relatively low cost. The FDA recently lessened previous restrictions on the use of metformin in patients with moderate chronic kidney disease, making it even more accessible to older patients with diabetes. Now, the contraindication remains only for those with severe chronic kidney disease (<30 mL/minute per 1.73 m2).  

To reduce the risk of polypharmacy, it is critical to optimize metformin therapy at a goal of 2 g daily for a trial of no fewer than 3 months before considering augmentation whenever possible and clinically appropriate. Adherence to current therapy should always be confirmed; if older adults report intolerance, the use of slower dose escalations, conversion to extended-release formulations, and schedule modification to allow the dose to be taken with the largest meal of the day can confer improved results with metformin.

If add-on therapy becomes necessary, the other oral medications recommended in the guidelines should be considered, with specific focus on caveats for use in the older population. Some of the oral antidiabetic medications with predisposing risks for the elderly include, but are not limited to, the following agents (paired with associated factors): sulfonylureas (Beer’s list, hypoglycemia); thiazolidinediones (congestive heart failure [CHF] exacerbation, bone fractures); dipeptidyl peptidase 4 inhibitors (CHF exacerbation, arthralgia); and sodium-glucose cotransporter 2 inhibitors (increased risk of urinary tract infection).

In addition to the modifiable risk factors that contribute to hypoglycemic complications of diabetes, hypotensive episodes associated with overly aggressive treatment to achieve strict hypertension goals also contribute to increased risk of falls in older adults. The current literature and evidence support blood-pressure reduction to less than 140/90 mmHg, with improved clinical outcomes in most older adults with diabetes; this leaves stricter, lower blood pressure targets for those in whom the benefit exceeds the risk of tighter control.