Rosemary Kennedy, PHD, RN, MBA, FAAN
Dan Henderson, MD, MPH
Falls are a leading cause of injury and hospitalization among older adults. Individuals living with diabetes have a substantially higher risk. Complications from diabetes, such as neuropathy, retinopathy, and nephropathy, lead to gait instability and increase the likelihood of falls.
Several established risk factors for falls are more common in people with diabetes, including peripheral neuropathy, decreased physical and cognitive performance, poor vision, and increased use of antidepressant medication.
Additionally, older adults with diabetes face a higher risk of sustaining a fall-related injury requiring hospitalization than those without diabetes. In particular, adults using insulin are at a greater risk of an injurious fall leading to hospitalization.
For healthcare professionals and case managers, understanding these relationships is essential to improving outcomes and preventing avoidable injuries.
Diabetes and Falls Risk Among Older Adults
According to the American Heart Association, about 29.3 million Americans have been diagnosed with diabetes, another 9.7 million remain undiagnosed, and 115.9 million are considered to have prediabetes.
Older adults with diabetes have a significantly increased risk of falls and fall-related injuries. Research shows that those with Type 2 diabetes are 59% more likely to fall than non-diabetic peers — and for those using insulin, the risk jumps to 162%.
Older adults with diabetes have an increased risk of falling due to a number of factors, including:
- Diabetes complications – poor vision, lower extremity neuropathy, and postural hypotension
- Symptoms associated with extreme fluctuations of blood glucose
- Hypoglycemia (shakiness and blurred vision) and Hyperglycemia (weakness and blurred vision)
- Side effects of medications
- Fear of falling – leads to activity restriction, causing a decline in mobility
- Advanced Age – decreased strength and balance
- Home hazards – uneven surfaces, rugs, furniture, clutter
How Diabetic Complications Contribute to Falls
Peripheral Neuropathy (PN) is present in more than half of Type 2 diabetic patients aged 60 or older. It is caused by nerve damage from chronic high blood glucose levels. Damaged nerves can’t carry messages between the brain and other parts of the body, leading to numbness, loss of feeling, or pain in the hands, feet and legs.
About 60% to 70% of all people with diabetes will eventually develop neuropathy, especially older adults. In older adults with diabetes, PN is especially troublesome due to its effects on stability, sensorimotor function, gait, and activities of daily living. In the US, 28% of adults aged 70–79 years and 35% of adults aged ≥80 years have peripheral neuropathy.
Diabetic Retinopathy (DR)
Nearly 3 out of 4 diabetic patients develop retinopathy. Diabetic retinopathy (DR) is a common complication of diabetes that can lead to vision loss or impairment. It’s caused by high blood glucose levels damaging the retina, the part of the eye that detects light and sends signals to the brain. After 30 years of living with diabetes, nearly 100% of older adults develop retinopathy.
Symptoms include blurred or cloudy vision, depth perception deficits, and difficulty adjusting to changing lighting conditions. Due to these symptoms, falls in older adults represent a public health problem, with incidences as high as 40% in diabetic older adults.
Diabetic Nephropathy (DKD)
As many as 40% of older adult diabetics develop diabetic nephropathy. Chronic kidney disease (CKD) attributed to diabetes is often referred to as diabetic kidney disease (DKD) and is the major cause of CKD and end-stage kidney disease (ESKD) in those over 60 years old.
Adults aged 65 or older with CKD have increased risk of falling and suffering an injury compared with those without CKD. In CKD patients, factors such as chronic inflammation, vitamin D deficiency, and proteinuria can contribute to muscle loss, compromising muscle strength and balance, thereby increasing the risk of falls.
Sarcopenia
Sarcopenia is the progressive loss of skeletal muscle mass and strength. It is common in older adults, but those with diabetes are more likely to develop sarcopenia because of insulin resistance, inflammation, and lower activity levels, which can accelerate muscle loss. As muscles weaken, balance, stability, and reaction time decline, raising the risk of falls and injuries. On average, individuals with sarcopenia have a 58% higher risk of fracture than those without the condition. This is why identifying and addressing sarcopenia early with strength training, proper nutrition, and ongoing monitoring is essential to helping older adults with diabetes stay steady, strong, and independent.
The Human and Economic Costs
Falls among older adults with diabetes are common, costly, and often preventable. Beyond the immediate physical consequences, such as fractures and head injuries, these incidents can also lead to long-term disability and loss of independence.
The economic impact is also significant. The total burden of diagnosed diabetes in the U.S. is $412.9 billion annually, including over $306 billion in direct medical costs and $106.3 billion in indirect costs attributable to diabetes.
Given this high national cost and the fact that older adults with diabetes are hospitalized more often for fall-related injuries, fall prevention should be recognized as an essential component of comprehensive diabetes care coordination.
Strategies for Reducing Fall Risk in Diabetic Populations
Healthcare professionals and case managers can significantly reduce fall risk by incorporating targeted prevention strategies into care plans. Consider integrating the following evidence-based practices:
- Conduct regular fall-risk assessments using tools like the Timed Up and Go (TUG) Test and the Functional Reach Test.
- Review medications to identify those that may cause dizziness or postural hypotension.
- Schedule routine vision and hearing checks to catch impairments early.
- Promote balance and strength training, including programs like tai chi or physical therapy-led exercises.
- Encourage home safety modifications, such as removing clutter, securing rugs, and adding handrails or better lighting.
- Recommend appropriate footwear that provides adequate traction and support.
- Support optimal blood glucose management to minimize episodes of shakiness, weakness, or blurred vision.
- Encourage the use of medical alert technology, such as Connect America’s medical alert systems, which provide 24/7 monitoring and fall detection.
Empowering Older Adults Through Self-Care
Education is one of the most powerful tools for prevention. Teaching older adults how to rise safely after a fall and when to call for help can prevent further harm.
According to the Centers for Disease Control (CDC), one in five falls cause serious injuries such as a fracture or head trauma. In emergencies, medical alert systems help older adults get quick access to assistance, reducing complications associated with prolonged immobility, and increasing their confidence to live independently.
For healthcare professionals and case managers, understanding the correlation between diabetes and fall risk is essential to delivering proactive, whole-person care. By addressing the underlying physical, sensory, and environmental factors and leveraging fall detection, providers and care teams can help older adults with diabetes stay safer, healthier, and more independent at home.