Featured ArticleDeterminants of fear of falling in older adults with diabetes
Introduction
Globally, diabetes affects 25% of individuals aged 65 years and older, a population that is expected to include 642.7 million people by 2030.1 In Taiwan, 50.3% of patients with diabetes are older than 65 years.2 Caring for older adults with diabetes is a growing public concern in many countries due to increases in both the aging population and the prevalence of diabetes.3 Falling is a major concern for persons in this age group, as older adults with diabetes are at increased risk of falling and fall-related morbidity and mortality,4,5 so fall prevention represents an important issue when caring for older adults with diabetes.6
Fear of falling (FoF) has been identified as a critical factor that contributes to falls among older adults with diabetes.7,8 FoF describes individuals with low-perceived confidence in their abilities to avoid falls.9 Although FoF can cause older adults to be more aware of dangerous situations and prevent falls, FoF can also cause older adults to avoid the performance of essential and non-hazardous daily activities, leading to accelerated declines in physical function, which can further increase the risk of falling.10 Impairments of balance and gait stability in older adults could result in high levels of FoF.11,12 Diabetes can lower muscle strength at the ankle and knee by 7-17% in patients with Type 2 diabetes,13 which may be because of altering blood circulation in the lower limbs.14 Additionally, high blood glucose might damage peripheral nerve and negatively impact sensory and motor sensitivity in the feet and lower extremities.13,15 Up to 25% of patients with diabetes incurred peripheral nerve damage after 10 years of being diagnosed and this figure increased to above 50% 20 years after diagnosis.15 These deficits might negatively impact balance and gait stability, and finally associate with high FoF in older adults with diabetes.
Previous studies have also shown that high FoF in older adults with diabetes was significantly higher than older adults without diabetes.12,16 Although many studies have examined the determinants of FoF in older populations,7,17 determinants of FoF might be different because of differences in the nature of illnesses; additionally, these determinants have been frequently examined individually, ignoring the fact that they typically coexist.18 Few studies have examined such determinants specific to older adults with diabetes. Simultaneously considering all possible determinants and examining the relative importance among them will facilitate the development of specific interventions to improve FoF among older adults with diabetes.
Demographics and illness characteristics such as the female gender, older age, having less education, comorbidity with other chronic diseases, higher body mass index (BMI) and fall history have all been associated with high FoF among community-dwelling older populations,7,19,20 and similar associations could exist among older adults with diabetes.21 Additionally, diabetes-specific illness characteristics such as hemoglobin A1c (HbA1c) levels, hypoglycemia, insulin treatment and diabetes duration have also been associated with falls in older adults with diabetes8,22 and might affect FoF in this group. All these demographic and illness characteristics should be considered when exploring the determinants of FoF in older adults with diabetes.
Physical capability is crucial to performing activities of daily living among older adults and might affect FoF among older adults with diabetes. Muscle strength and the ability to maintain balance are important indicators of physical capability. Handgrip strength is frequently used as a proxy measurement for overall muscle strength.23 Handgrip strength among older adults with FoF is significantly lower than those without FoF,24 while poor handgrip strength is also significantly associated with higher FoF among older adults with diabetes.21 The Timed Up and Go (TUG) test is recommended for assessing dynamic balance in older adults.25 A longer time required to complete the TUG test has been associated with high FoF among older adults with diabetes.8,26 The evaluation of one-leg standing ability is used to assess static balance,27 which might be associated with FoF in older adults with diabetes. In sum, physical capabilities, including muscle strength and balance assessed by TUG, handgrip strength and the one-leg standing tests should be considered when exploring determinants of FoF among older adults with diabetes.
Sarcopenia, a geriatric syndrome in which skeletal muscle mass degenerates during the aging process,29 might result in decline in physical function and affects balance and gait, which might be associated with high FoF.28 FoF appears higher among community-dwelling older adults with sarcopenia than among those without sarcopenia.30 Patients with diabetes appeared to have high risk of developing sarcopenia at an earlier age because diabetes hastens the aging process31; however, the association between sarcopenia and FoF among older adults with diabetes has been less well-studied and deserves further attention.
Maladaptive emotional regulation exacerbates feelings of fear and can lead to an unrealistic appraisal of one's abilities.18 Depression has been found to associate with high FoF in older adults with diabetes.16,26 For patients with diabetes, diabetes distress is a common psychosocial experience expressed more often as a negative emotional reaction in response to the burdens involved with the demanding self-management of daily diabetes control,32 as reported by such patients.3 Further studies remain necessary to assess the association between diabetes distress and FoF in older adults with diabetes.
Decline in cognitive function can negatively impact balance and gait stability, which might be associated with high FoF.12 Poor cognitive function has been found to associate with FoF among older adults in general,33 and a similar association might also exist in older adults with diabetes. Although two previous studies have reported that poor cognitive function is associated with increased FoF among older adults with diabetes,21,34 these studies might be insufficient to enable full understanding of the association between cognitive function and FoF among older adults with diabetes, indicating that more studies are necessary to confirm these findings.
Consequently, this study aimed to examine the important determinants of FoF in older adults with diabetes. According to the aforementioned literature, this study hypothesized that demographic and illness characteristics, physical function and capability, psychosocial and cognitive factors were important determinants of FoF among older adults with diabetes.
Section snippets
Design and Sample
This study was a secondary data analysis of a cross-sectional study that assessed the risk factors of falls in older adults with diabetes.8 A convenience sampling method was used in this study. Considering performance of physical capability tests might harm older adults aged over 80 years, older adults aged between 65 and 80 years and diagnosed with Type 2 diabetes for at least 6 months were recruited from two endocrine clinics in Taiwan. Participants were excluded if physicians considered they
Distributions of independent variables and their associations with FoF
The distribution of demographic and illness characteristics among study participants and their associations with FoF are shown in Table 1. Participants included 147 women (61.41%) and 93 men (38.59%) with a mean age of 70.85 (4.24) years. The comorbidity of chronic diseases was not significantly associated with FoF; however, sex, age, education level, duration of diabetes, insulin treatment, HbA1c levels, experiencing a hypoglycemia episode during the past year and fall history for the past
Discussion
This study found that HbA1c levels, sarcopenia levels, diabetes distress and dynamic balance (as measured by the TUG test) were important determinants of FoF in older adults with diabetes. The findings of this study could provide new information and assist healthcare providers in designing specific interventions to improve FoF in older adults with diabetes.
A new finding of this study was that diabetes distress was a significant determinant of FoF in older adults with diabetes. A high level of
Conclusion
Sarcopenia levels and dynamic balance were found to significantly associate with FoF among older adults with diabetes, similar to the findings in the general population of older adults.24,30 Additionally, diabetes-specific factors including diabetes distress and HbA1c levels were important determinants of FoF in this study. These findings highlighted that important determinants of fear of falling might differ according to the nature of the disease. Diabetes-specific psychosocial and illness
Ethical Approval IRB code
KMUHIRB-F(I)-20190021 of Kaohsiung Medical University,TSGHIRB 1-108-05-140 of Tri-Service General Hospital
Funding source
This work was supported by the Ministry of Science and Technology, Taiwan (MOST 108-2314-B-037-105)
Authors contribution
Study conception, design, data analysis, interpretation, drafting of the manuscript, given final the approval for the version to be published: Ruey-Hsia Wang, Aini Inayati, Bih-O Lee
Data collection, drafting of the manuscript, given final approval for the version to be published: Shi-Yu Chen, Hui-Chun Hsu, Chieh-Hua Lu, Yau-Jiunn Lee
Declaration of Competing Interest
We have no known conflict of interest to disclose
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