Risk Factors for Falls in the Older Adult with Diabetes Mellitus: Systematic Review and Meta-Analysis

doi:10.21203/rs.3.rs-2993359/v1

Aim

To identify risk factors for falls in the older adults with Type 2 Diabetes Mellitus (T2DM).

Methods

The eligible studies identified factors associated with the risk of falls in older adults with DM. We searched PubMed, Cinahl, Web of Science, Scopus, and the Cochrane Library databases for studies beginning April 2020 through July 2021 (CRD42020193461).

Results

Twelve studies met the inclusion criteria, and eight studies were included in the meta-analysis. These studies included a total of 40,778 older adults with T2DM 60 to 101 years in. The risk of falls in T2DM older adults is 63% compared to the occurrence of falls in the non-diabetics (HR 1.63; 95% CI [1.30–2.05]). While the chance of falls in older adults with T2DM is 59% than non-diabetic older adults (OR 1.59; 95% CI [1.36–1.87]) and the chance of falls in older adults with T2DM who take insulin is 162% (OR 2.62; 95% CI [1.87–3.65]). No results were found in studies on diabetic polyneuropathy.

Conclusion

T2DM older adults have a higher risk of falls compared to non-diabetics. Among the T2DM older adults, the most important factor associated with a higher risk of falls was insulin use.

Trial registration:

Registered in the International Prospective Register of Systematic Reviews (CRD42020193461).

Type 2 Diabetes mellitus

falls

risk of falls

older adults

accidental falls

Diabetes Mellitus (DM) is a chronic disease that presents as a complex metabolic disorder, whose main characteristic is hyperglycemia^1,2. Such a characteristic is due to deficiency in the secretion of insulin, which is a hormone produced by pancreatic β-cells with the primary function of maintaining glucose homeostasis³. In the world, more than 90% of people with DM are type 2 and all the complications of the disease can reduce life expectancy significantly⁴. DM is the ninth leading cause of death worldwide, in which about 1 in 11 adults are diagnosed with the disease. The main causes of DM are increasing obesity, high energy density diets, an aging population, unhealthy eating habits, and sedentary lifestyles⁵.

The main complications of DM are retinopathy and polyneuropathy. Diabetic retinopathy causes vision loss and is associated with poor glycaemic control and prolonged duration of the disease⁶. Diabetic polyneuropathy (DPN) is associated with poor quality of life due to the frequent occurrence of neuropathic pain and ulcers of the feet⁷.

DPN is suggested to be a potential risk factor for falls⁸. Damage to the peripheral nervous system is classified as diabetic neuropathy. The main symptoms of DPN are numbness, insensitivity to injury, loss of postural stability, and intractable neuropathic pain⁹.

Due to these symptoms of DPN, falls in the older adults represent a public health problem, as it is thought that the incidence of falls can be as high as 40% in diabetic older adults. The increased risk of falls among older adults with DM may be associated with the presence of neuropathy and retinopathy¹⁰. Proper management of risk factors for falls in this population is of the utmost importance, as falls are a leading cause of fatal and non-fatal injuries among people aged 65^11,12, with 30% of people over 60 presenting with falls in any given year¹³. Falls are commonly defined as "an event during which a person unintentionally moves their body to the ground or a lower level"¹⁴.

The scientific literature in the area suffers from a paucity of studies investigating the factors associated with the risk of falls in diabetic older adults. The lack of studies is even more evident in the older adult diabetic population with DPN^8,15–18. In addition, studies on the risk factors for falls in older adults with DM have generated heterogeneous results^19–21. One of the causes for this heterogeneity may be the fact that the risk of falls was investigated from data derived from samples containing younger and older adults in the same cohort. In addition, from a data analysis point of view, authors presented the results mixing Odds and Hazard Ratios¹⁰.

Given the above, the objective of the present systematic review was to compare the incidence of falls in diabetic and non-diabetic older adults, as well as to verify whether diabetics on insulin or with polyneuropathy have a higher risk of falls than other diabetic patients.

The present systematic review was conducted according to the criteria of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)²² and registered in the International Prospective Register of Systematic Reviews (CRD42020193461).

The construction of the research question was based on the following PICO strategy. Population: men and women aged 60 years or older diagnosed with type 2 diabetes mellitus; Intervention: not applicable; Control: diabetics without diabetic polyneuropathy or non-diabetic older adults; Outcome: number of falls through questionnaires and/or self-reports; or the risk or chance of falls. The risk of falls can also be assessed by means of cut-off points of mobility, body balance, and gait instruments through functional tests.

Data sources and search strategy

Relevant articles published from inception to July 2021 were searched in five databases (PubMed, Cinahl, Web of Science, Scopus, and Cochrane Library) for studies beginning April 2020 through July 2021 (See “Additional_file_1_Table_S1”). There was no restriction imposed on the year of publication. A manual search for the articles was also performed.

The following keywords and search strategy were used for the electronic search and adapted for each database as necessary. We used a combination of the following terms: aged, diabetes mellitus type 2, accidental falls, aged AND diabetes mellitus type 2, aged AND diabetes mellitus type 2 AND accidental falls.

Study Selection and Inclusion Criteria

Studies with samples containing exclusively older adults, aged over 60 years, and clinically diagnosed with type 2 diabetes mellitus, with or without polyneuropathy and retinopathy, were selected. Diabetic participants may experience a combination of symptoms/signs that may include one or all the following: reduced sensation in the soles of the feet, hyper- or hypoglycemia and risk of falls or falls.

Studies considering older adults under the age of 60 years were included if data from the older adults were presented separately in the text or table. We included observational studies, prospective and retrospective cohorts, and cross-sectional studies in this review.

The articles considered for this review met the following criteria: cohort and cross-sectional studies published in English, Spanish, and Portuguese; studies that identify the risk of falls or falls in the older adults with diabetes mellitus. Retrospective studies were considered when data regarding the classification of the older adults as fallers and non-fallers were present.

Articles that presented one of the following characteristics were excluded: duplicate articles, data from unpublished studies, studies with other designs that do not allow studying the risk or chance of falling, studies with incomplete methodology (no diagnosis of DM, lack of data on number of falls and DM), when the sample did not include the older adults, as well as studies that had not presented the data on the age of the risk of falls in adults and the older adults separately; and finally, we excluded studies whose assessment of the risk of falls was not performed.

The studies were selected in two phases. In the first phase they were evaluated by title and abstract, and in the second phase by evaluation of the full text of the pre-selected studies to confirm eligibility. The selection process was carried out through the Rayyan platform (https://rayyan.qcri.org).

Data extraction and quality assessment

The data summary was performed using a spreadsheet built in Microsoft® Office Excel®, for each evaluator separately. The summarized results were compiled and presented in tables. Columns included the title, author, date, objective, type of study, type of participants, patient demographics, type of experiment, outcome, and quality score. All studies were assessed using the Newcastle-Ottawa tool^23,24. This tool includes 8 items, divided into 3 domains: selection, comparison and exposure or outcome. The risk of bias was assessed independently by two authors (LBF, MLS) using the Newcastle-Ottawa scale. The third reviewer (LPSP) resolved apparent discrepancies in the Quality Assessment and Risk of Bias process.

Data Overview and Analysis

We conducted the meta-analysis using 8 of the 12 studies selected in the systematic review. The reasons for exclusion of these 4 studies were as follows: 3 articles had OR and HR with divergent data and in one article the study data were not performed in the analysis. Analyses with OR and HR data were performed separately for each outcome. The logarithm calculation of the OR of the HR and forest plots were calculated using the packages Metan of statistical program Stata® version 14.

Selection in the literature

The electronic search identified 2,343 potentially relevant studies. After reading the title and abstract, we excluded 2,238 publications for the following reasons: duplicate articles, study design, sample did not include DM2 or older adults, did not assess falls. Based on reading the abstract, 30 studies were left. Of this total, 18 were excluded for not presenting data on the ages of the younger and older adults separately; three articles were excluded for not presenting outcome measures such as OR, HR, and RR; one article was excluded for being a review; and one article was excluded for comparing only physical performance. No attempt was made to access unpublished studies or other ‘grey’ literature. After we applied the inclusion and exclusion criteria, 12 publications and 8 studies were included for meta-analysis (See “Figure 1” in the text below.

Modified from: Moher et al. The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The PRISMA Statement. PLoS Med 6(7): e1000097. doi:10.1371/journal.pmed 1000097.

Study characteristics

The 12 included studies were published from 2002 to 2019 and conducted in eight different countries. The designs adopted in these studies were as follows: cohort^20,25−27; prospective cohort^28–31; cross-sectional^19,32; retrospective cross-sectional³³; prospective cross-sectional³⁴.

The sample size ranged from 77 to 22,200. A total of 40,778 participants were identified and analysed in the present review. The duration of follow-up was from 3 months to 10 years. The age of the participants ranged from 60 to 101 years. The sample of ten studies included older men and women, and two studies included only older women in their sample^28,29. The general characteristics of the included studies are listed in Table 1 (See file “Table_1”). Additional information about the characteristics of the cohort and cross-sectional of included studies were presented in Additional files for Review (“Additional_file_2_Table_S2” and “Additional_file_3_Table_S3” respectively).

Table 1

Baseline characteristics of the included studies
Study/year	Region	Design	Population	Subject (%women)	Age/ Range of mean	Ascertainment of falls	Falls number (%)	Follow-up duration	Punctuation NOS	DM diagnosis (DM number)
Schwartz et al. (2002)⁽³²⁾	USA	Prospective cohort study	Community	9.249 (100% women)	73.5 ± 5.0	Postcard / phone	1,640 (18%)	2 years	7	Self-reports (629)
Maurer et al (2005)⁽³⁰⁾	USA	Prospective cohort study	Long-stay institution	139 (84% women)	88 ± 7	Berg balance scale	49	Range 97-8854 days	8	Prescription of oral hypoglycemic agent or insulin therapy (extracted from medical records) (18)
Volpato et al (2005) ⁽²⁹⁾	USA	Cohort	Community	1.002 (100% women)	75.3 ± 6.5	Questionnaire	26,5	3 years	8	Specific disease investigation algorithm developed for this study (136)
Tilling et al. (2006) ⁽³⁶⁾	UK	Cross-sectional prospective	Hospital	77 (58.5% women)	73	Questionnaire	39%	5 months	5	Self-reports (77)
Schwartz et al. (2008) ⁽²⁸⁾	USA	Cohort	Community	3.075 (44.6% women)	73.6 ± 2.7	Questionnaire / self-reports	23%	5 years	8	Self-report, use of hypoglycemic medication or an elevated fasting glucose level (≥ 126 mg/dl) or 2-hour oral glucose tolerance test (≥ 200 mg/dl) (719)
Pijpers et al. (2011)⁽²⁰⁾	NL	Cohort	Community	1.145 (49.8% women)	75.4 ± 6.5	Calendar	232 (20,3%)	3 years	8	Self-report and use of glucose-lowering medication (85)
Roman de Mettilinge et al (2013)⁽³¹⁾	BE	Prospective cohort	Community	199 (68.3% women)	76.9 ± 9.4	Questionnaire	56 (28,4%)	12 months	6	General practitioner or specialist physician confirmed the presence or absence of DM (104)
Yau et al (2013) ⁽³³⁾	USA	Prospective cohort	Community	3.075 (52% women)	73.7 ± 2.8	Medical record	293	10 years	7	Self-reported medical diagnosis, self-reported use of antidiabetic medications, elevated fasting glucose level (≥ 126 mg/dL) or elevated levels on a 2-hour oral glucose tolerance test (≥ 200 mg/dL) (719)
Bruce et al. (2015)⁽¹⁹⁾	AU	Cross-sectional	Community	186 (50% women)	70.3 ± 10.1	Questionnaire	39 (20,9%)	-*	4	Self-report and fasting glucose levels (186)
Chiba et al. (2015)⁽³⁵⁾	JP	Cross-sectional retrospective	Community	211 (70,88% women)	76.2 ± 6.8	Questionnaire	62	Every 3 months for 3 years	5	Self-reports (168)
Randolph et al (2019)⁽²⁷⁾	USA	Cohort	Community	22.200 (63.3% women)	78.3 ± 6.9	Medical record	411	5 years	6	Medical record (11.000)
Rashedi et al (2019)⁽³⁴⁾	IR	Cross-sectional	Community	220 (58% women)	69.82 ± 9.9	Questionnaire	77 (38,5%)	-*	3	Medical record (220)
Source: Research data, 2022. -, Did not provide data on the duration of follow-up; DM, Diabetes Mellitus; NOS, NewCastle* Ottawa.

As can be seen in Table 1, a population older adult was studied in 10 research reports. Two other studies included older adults from other settings: the hospital setting and the long-term care facility setting. Furthermore, the number of subjects varied widely (from 77 to 22,200), as did the methods of defining a diagnosis of DM, ranging from studies using self-reports only^27,30,33; combining self-reports and laboratory tests^{19,20,26,28,31}; medical records^25,32; confirmation by a physician²⁹ or using an algorithm²⁷.

The classic definition of the outcome fall, which is well established in the literature¹⁴ was adopted in 3 studies^20,29,33. Schwartz et al.³⁰ added to this definition “falling and hitting an object such as a table or a ladder”.

Methodological quality of included studies

A low risk of bias was present in 11 studies and only in the study by Rashedi et al.³² was there a higher risk of bias. In addition, the complete evaluation of the studies in the Newcastle-Ottawa (NOS) was described in Table 2- Quality Assessment and Risk of Bias of included studies. (See file “Table_2”).

Table 2 - Quality Assessment and Risk of Bias of included studies.

Cross-sectional studies
Author	Year		Selection		Comparability	Outcome		Score	Quality
		Representativeness	Selection	Ascertainment	Adjustment for confounders	Assessment	Response rate
Bruce	2015	*	*	*	*	-	-	4	High
Chiba	2015	*	*	*	*	*	-	5	High
Rashedi	2019	*	-	*	*	-	-	3	Low
Tilling	2005	*	*	-	*	*	*	5	High

Source: Research data, 2022.

Cohort studies

Author

Year

Selection

Comparability

Outcome

Score

Quality

Representativeness

Selection

Ascertainment

Outcome

Adjustment for confounders

Assessment

Duration

Completeness of follow-up

Maurer

2005

*

8

High

Pijpers

2011

*

8

High

Randolph

2019

*

-

*

6

High

Roman de Mettilinge

2013

*

-

*

-

6

High

Schwartz

2002

*

-

7

High

Schwartz

2008

*

8

High

Volpato

2005

*

8

High

Yau

2013

*

-

7

High

Source: Research data, 2022.

Falls Outcome Assessment Method

The preferred method of falls outcome assessment used in the studies was the questionnaire, which was used in 7 studies^{19,26,27,29,32,33,34}. One study used the Berg Balance Scale²⁸, another study used a postcard³⁰, two other studies used medical records^25,31 and finally one used a calendar ²⁰.

Risk factors associated with falls

Twelve studies involving 14,061 diabetics reported 1,394 falls in diabetic older adults. The HR values, OR and p-value for the risk factors for falls and the adjustments for covariates of the cohort and cross-sectional studies are shown in Table S2 and S3 (“Additional_file_2_Table_S2” and “Additional_file_3_Table_S3” respectively).

For the cohort studies^20,25−31, participants with DM had a higher incidence rate of falling, recurrent falls, use of TCA / GABA-analog, insulin use, and being female. In these studies, the risk factors for falls were insulin use, followed by DM and medications (Table S2).

The risk factors for falls in the older adults in cross-sectional studies varied widely among the different studies: fear of falling, age, medication use, hypoglycemia, gait problems, body balance difficulty, hypotension, and elderly women (Table S3).

Multiple falls were reported in two studies^29,33, with Chiba et al. showing that hypoglycemia and the Fall Risk Index were significant for multiple falls in diabetic patients. Recurrent falls were more prevalent in individuals with DM²⁰ and women on insulin therapy^27,30.

Investigation of peripheral neuropathy as a risk factor for falls was reported in a single study, where recurrent falls and loss of pressure sensitivity were independently associated with the risk of falling more than once a year and accounted for 3–6% of the relationship between diabetes and falling³⁰. Visual impairment caused by DM is another complication of DM frequently reported as a risk factor for the older adults in the general population. However, we did not find studies investigating visual impairment and/or the presence of retinopathy as risk factors for falls in older adults with DM.

High glycated hemoglobin (HbA1C > 7%) was associated with a risk factor for falls and dependence on a walking aid, such as a cane³⁴.

Association between diabetes mellitus and risk of falls: results of meta-analysis

As observed in Figs. 3 and 4, there were significant differences among the analyzed studies. See “Figure_2”, “Figure_3”, and, “Figure_4”.

In Fig. 2, the risk of those exposed with diabetes developing the outcome falls is 63% in relation to non-diabetic (HR 1.63; 95% CI [1.30–2.05]). The heterogeneity of this analysis was considerable (I² = 71.5%). While the chance of falls in older adults with diabetes is 49% compared to non-diabetic older adults (OR 1.49; 95% CI [1.29–1.72]) with the heterogeneity (I² = 36.4%) moderate, as shown in Fig. 3).

The chance of falls in older adults with diabetes who take insulin is 162% (OR 2.62; 95% CI [1.87–3.65]) with heterogeneity in Fig. 4) (I² = 0.0%; low). No results were found in studies related to diabetic polyneuropathy.

This meta-analysis revealed that older adults with DM have a higher risk of falls compared to non-diabetics^{20, 26–29,31}. Another important finding was the higher propensity of falls in insulin-dependent older adults than in non-insulin-dependent older adults^26,27,30. It is known that diabetic older adults have a number of complications due to the complexity of the disease, the increased risk of comorbidities, advancing functional decline, and the concomitant risk of frailty and falls³⁵.

The use of insulin is especially concerning in older adults because of potential hypoglycemic events and the increased risk of falls³⁶. In Volpato´s²⁷ study, the percentage of recurrent falls was particularly high for diabetic women on insulin therapy (59%) and for Schwartz's³⁰ study, a higher proportion of women with diabetes fell more than once a year and more than twice a year compared to non-diabetic women. The highest risk of falls was observed in older diabetic women who used insulin³⁶.

These findings are confirmed in Yau's ³¹ study since participants who used insulin had a significantly higher risk of hospitalization due to a damaging fall than those who were non-diabetic.

In the meta-analysis, we did not observe an association between DM and medication use. Several studies included in the systematic review indicated that older adults with DM and who use medication^17,24,29,30 have an increased risk of falls. The authors of the longitudinal studies reported as intrinsic risk factors for falls: age, abnormal gait pattern and body balance, and diabetes mellitus. Medication and insulin use were regarded as extrinsic factors for falls.

Other authors have also reported the use of medications and insulin as extrinsic factors associated with falls in diabetic older adults^17,24,29,39. Such an association can be justified by the side effects of polypharmacy and drug interactions³⁷.

Accordingly, polypharmacy is frequently mentioned in the older adults population and is therefore not restricted to older adults with diabetes³⁸. Such drug effects were associated with recurrent falls and an increased risk in the domains: body balance and mobility, psychological risk factors, and sensory and neuromuscular function and were recognized as risk factors for falls³⁹.

The aging process and some chronic diseases, which are related to oxidative stress, low-grade inflammation, and insulin resistance represent conditions that increase with age, leading to frailty. Diabetes is one such disease. Diabetes and frailty are two conditions that are often found in older patients⁴⁰.

Another finding referred to in the systematic review studies was the association between the presence of hypoglycemia and increased risk of falling, worsened by the presence of neuropathy, impaired vision, and decreased cognitive and physical performance⁴¹. This can be observed in diabetic older adults in which hypoglycemia was significantly associated with falls (two or more per year)³³.

Falls in older adults are associated with morbidity and mortality because they may cause serious injuries³⁸. The higher prevalence of complications involving visual impairment and peripheral neuropathy was associated with excessive risk of falls due to poor glycemic control³⁹. The deficit in body balance and increased risk for falls in older adults with type 2 DM is often attributed to peripheral neuropathy⁴⁰. In this review, this hypothesis cannot be investigated, as only the study by Schwartz et al. (2002)³⁰ highlighted that peripheral neuropathy was reported in association with falling more than once a year and was associated with decreased sensitivity to vibration and loss of sensitivity to pressure. This loss of pressure sensitivity was associated with the risk of falls more than once a year.

In fact, DM-related complications feature loss of proprioceptive and tactile information and increased static standing postural sway, including diabetic polyneuropathy (DPN). Diabetics with neuropathy have body balance alterations and this is associated with sensory deficits indicating poor postural control. In DPN there is an extra decrease in reaction time with delayed response to postural change and loss of muscle strength secondary to increased muscle atrophy ⁴¹.

Fear of falling was another factor associated with the risk of falls mentioned by authors included in this review, in which diabetic older adults restrict their participation in indoor and outdoor activities¹⁹. Thus, intrinsic, extrinsic and behavioural factors contribute to the risk of falls in the older adults. Initial and recurrent falls play an important role in intrinsic factors, as they often reduce physical activity and mobility in older adults⁴². The very visual and proprioceptive impairment found in advanced cases of DM reduces safety while walking. By restricting their participation, reducing their living space, reducing their interaction with challenged environments, older adults may end up entering a vicious cycle, where falls and disabilities lead to functional limitation and more falls⁴³.

Maurer and Rashedi ^28,32 reported that altered gait patterns are a risk factor for falls in diabetic older adults. This change in gait pattern affects peripheral sensory and motor function which is related to an increased risk of falling⁴¹. Diabetic retinopathy leads to a loss of contrast sensitivity and depth perception, which could lead to an increased risk of falls. However, in this review, this finding was not reported in any of the included studies.

Falls were reported by questionnaires, calendar, medical records, self-reports or by the Berg Balance Scale. There is no consensus on the literature about the better tool for fall detection ⁴⁴.

In the present review, falls in community-dwelling older adults were reported in 10 studies^{19,20,25–27,29−33} and these may have been caused by the risk factors that most affect this scenario, such as: environmental factors, pharmacological agents, cognitive factors, and physiological factors⁴⁵. Only in two studies did the falls happen in the hospital^28,34 setting. Hospital falls are a frequent and worrisome problem in the world and have as prevention strategies the education of physicians, modification of the environment, assistive devices, hospital systems and medication reviews⁴⁶. As we have noted, in both hospital and community settings, intrinsic and extrinsic factors may contribute to an increased risk of falls in the population of older adults with DM.

It can be seen from this review that most of the studies were prospective^28–31 cohort studies that showed better follow-up of falls. Recent studies have used a 12-month^47–49 follow-up period while in this review the follow-up period ranged from 3 months to 10 years.

The main limitation of this systematic review was the lack of studies that presented data regarding falls in adults and older adults separately. We found a great heterogeneity in the methods adopted among the selected articles, such as: the difference in the duration of falls follow-up, the number of participants, the exclusion criteria, the study designs, the different population settings, different objectives among the studies, different definitions of falls, and different diagnostic criteria for diagnosis of DM.

Other hypotheses that could explain the increased risk of falls in the older adults with DM should be investigated by further studies, for example, elevated glycated hemoglobin, high blood pressure, presence or absence of hypoglycemia, presence or absence of diabetic polyneuropathy, presence or absence of diabetic retinopathy.

Interestingly, the main contribution of this study was to show that the same strategies used for treatment are the main risk factors for falls in diabetic older patients. This reinforces the importance of education in the rational use of medication and insulin, together with nutritional support and physical activities that may contribute to a decrease in the risk of falls in diabetic older adults. Another result of these preventive measures would be a reduction in health care costs, considering the high level of care required and the increased length of hospital stays associated with falls in this population^46,50.

Diabetic older adults have a higher risk of falls compared to non-diabetics. Among the diabetic older adults, the factors associated with a higher risk of falls were the use of insulin or other medications. General frailty also played a role.

Health care providers should be educated in the judicious use of medications and insulin to avoid iatrogenic falls. Physical therapy, adequate nutrition and other general measures have a potential to decrease the burden of fall complications of older adults diabetic patients on the health care system.

DM – Diabetes Mellitus
DPN - Diabetic polyneuropathy
GABA - Gamma-aminobutyric acid
HbA1C - High glycated hemoglobin
HR - Hazard Ratio
Newcastle-Ottawa (NOS)
OR - Odds Ratio
PRISMA - Criteria of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses
RR – Relative risk
T2DM - Type 2 Diabetes Mellitus
CAs - Tricyclic antidepressants

Ethics approval and consent to participate. All of studies included on this Systematic review were submitted on ethical committee.
Consent for publication: Not applicable.
Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. We agreed to share the output of the analysis from meta-analysis and tables containing the data extracted from studies. Detailed information about criteria considered in each item of the “New Castle Otawa Scale” for appraisal of risk of bias of cohort and cross-sectional studies is available in the file “Additional_file_ 4_Table_S5” in Additional Files for Review section.
Competing interests: The authors have no conflict of interest.
Funding: Not applicable.
Authors' contributions: LBF and LPSP Conceived the research question and the study design. MLS, MGCM, and LBF searched manuscripts, registered study protocol on Prospero, and extracted the data. LBF, LPSP, MGCM, WRM, and JPBN contributed to the analysis and interpretation of data. MLS, LPSP, and LBF contributed to the quality assessment, All authors contributed to the writing and editing of the manuscript and agreed to the final manuscript.
Acknowledgements: Not applicable.
Authors' information (optional): Not applicable.

Hewston P, Deshpande N. Fear of Falling and Balance Confidence in Older Adults With Type 2 Diabetes Mellitus: A Scoping Review. Can J diabetes. 2018 Dec;42(6):664–70.
Zaccardi F, Webb DR, Yates T, Davies MJ. Pathophysiology of type 1 and type 2 diabetes mellitus: a 90-year perspective. Postgrad Med J. 2016 Feb;92(1084):63–9.
Rachdaoui, N. Insulin: The Friend and the Foe in the Development of Type 2 Diabetes Mellitus. 2020 Mar; 21(5): 1770. 2020 Mar; 21(5): 1770.
Glovaci D, Fan W, Wong ND. Epidemiology of Diabetes Mellitus and Cardiovascular Disease. Curr Cardiol Rep. 2019;21(4):1–8.
Zheng Y, Ley SH, Hu FB. Global aetiology and epidemiology of type 2 diabetes mellitus and its complications. Nat Rev Endocrinol [Internet]. 2018;14(2):88–98. Available from: http://dx.doi.org/10.1038/nrendo.2017.151
Lechner, J. O'Leary J. Stitt, Alan. The pathology associated with diabetic retinopathy. Vision Research, 2017.
Ziegler, D. Current concepts in the management of diabetic polyneuropathy. J Diabetes Investig, 2021.
Bokan-Mirković V, Škarić-Karanikić Ž, Nejkov S, Vuković M, Ćirović D. Diabetic Polyneuropathy and Risk of Falls: Fear of Falling and Other Factors. Acta Clin Croat. 2017 Dec;56(4):721–7.
Zochodne DW. The challenges of diabetic polyneuropathy: a brief update. Curr Opin Neurol. 2019 Oct;32(5):666–75.
Yang Y, Hu X, Zhang Q, Zou R. Diabetes mellitus and risk of falls in older adults: A systematic review and meta-analysis. Age Ageing. 2016;45(6):761–7.
Callis N. Falls prevention: Identification of predictive fall risk factors. Appl Nurs Res. 2016 Feb;29:53–8.
Cuevas-Trisan R. Balance Problems and Fall Risks in the Elderly. Phys Med Rehabil Clin N Am. 2017 Nov;28(4):727–37.
Gerards MHG, McCrum C, Mansfield A, Meijer K. Perturbation-based balance training for falls reduction among older adults: Current evidence and implications for clinical practice. Geriatr Gerontol Int. 2017 Dec;17(12):2294–303.
Khow KSF, Visvanathan R. Falls in the Aging Population. Clin Geriatr Med [Internet]. 2017;33(3):357–68. Available from: http://dx.doi.org/10.1016/j.cger.2017.03.002
Jernigan SD, Pohl PS, Mahnken JD, Kluding PM. Diagnostic accuracy of fall risk assessment tools in people with diabetic peripheral neuropathy. Phys Ther. 2012 Nov;92(11):1461–70.
Powell MW, Carnegie DH, Burke TJ. Reversal of diabetic peripheral neuropathy with phototherapy (MIRE^TM) decreases falls and the fear of falling and improves activities of daily living in seniors. Age Ageing. 2006;35(1):11–6.
Timar B, Timar R, Gaiță L, Oancea C, Levai C, Lungeanu D. The Impact of Diabetic Neuropathy on Balance and on the Risk of Falls in Patients with Type 2 Diabetes Mellitus: A Cross-Sectional Study. PLoS One. 2016;11(4):e0154654.
Paton JS, Roberts A, Bruce GK, Marsden J. Does footwear affect balance?: the views and experiences of people with diabetes and neuropathy who have fallen. J Am Podiatr Med Assoc. 2013;103(6):508–15.
Bruce D, Hunter M, Peters K, Davis T, Davis W. Fear of falling is common in patients with type 2 diabetes and is associated with increased risk of falls. Age Ageing. 2015;44(4):687–90.
Pijpers E, Ferreira I, De jongh RT, Deeg DJ, Lips P, Stehouwer CDA, et al. Older individuals with diabetes have an increased risk of recurrent falls: Analysis of potential mediating factors: The Longitudinal Ageing Study Amsterdam. Age Ageing. 2012;41(3):358–65.
Chau RMW, Ng TKW, Kwan RLC, Choi C-H, Cheing GLY. Risk of fall for people with diabetes. Disabil Rehabil. 2013;35(23):1975–80.
Moher D, Hopewell S, Schulz KF, Montori V, Gotzsche PC, Devereaux PJ, et al. CONSORT 2010 Explanation and Elaboration: updated guidelines for reporting parallel group randomised trials. Bmj [Internet]. 2010;340(mar23 1):c869–c869. Available from: http://www.bmj.com/cgi/doi/10.1136/bmj.c869
Hartling L, Milne A, Hamm MP, Vandermeer B, Ansari M, Tsertsvadze A, et al. Testing the Newcastle Ottawa Scale showed low reliability between individual reviewers. J Clin Epidemiol [Internet]. 2013;66(9):982–93. Available from: http://dx.doi.org/10.1016/j.jclinepi.2013.03.003
Lo CWT, Tsang WWN, Yan CH, Lord SR, Hill KD, Wong AYL. Risk factors for falls in patients with total hip arthroplasty and total knee arthroplasty: a systematic review and meta-analysis. Osteoarthr Cartil. 2019;27(7):979–93.
Randolph AC, Lin Y-L, Volpi E, Kuo Y-F. Tricyclic Antidepressant and/or γ-Aminobutyric Acid-Analog Use Is Associated With Fall Risk in Diabetic Peripheral Neuropathy. J Am Geriatr Soc. 2019 Jun;67(6):1174–81.
Schwartz A V, Vittinghoff E, Sellmeyer DE, Feingold KR, de Rekeneire N, Strotmeyer ES, et al. Diabetes-related complications, glycemic control, and falls in older adults. Diabetes Care. 2008 Mar;31(3):391–6.
Volpato S, Leveille SG, Blaum C, Fried LP, Guralnik JM. Risk factors for falls in older disabled women with diabetes: the women’s health and aging study. J Gerontol A Biol Sci Med Sci. 2005 Dec;60(12):1539–45.
Maurer MS, Burcham J, Cheng H. Diabetes mellitus is associated with an increased risk of falls in elderly residents of a long-term care facility. J Gerontol A Biol Sci Med Sci. 2005 Sep;60(9):1157–62.
Roman de Mettelinge T, Cambier D, Calders P, Van Den Noortgate N, Delbaere K. Understanding the relationship between type 2 diabetes mellitus and falls in older adults: a prospective cohort study. PLoS One. 2013;8(6):e67055.
Schwartz A V, Hillier TA, Sellmeyer DE, Resnick HE, Gregg E, Ensrud KE, et al. Older women with diabetes have a higher risk of falls: a prospective study. Diabetes Care. 2002 Oct;25(10):1749–54.
Yau RK, Strotmeyer ES, Resnick HE, Sellmeyer DE, Feingold KR, Cauley JA, et al. Diabetes and risk of hospitalized fall injury among older adults. Diabetes Care. 2013 Dec;36(12):3985–91.
Rashedi V, Iranpour A, Mohseni M, Borhaninejad V. Risk factors for fall in elderly with diabetes mellitus type 2. Diabetes Metab Syndr. 2019;13(4):2347–51.
Chiba Y, Kimbara Y, Kodera R, Tsuboi Y, Sato K, Tamura Y, et al. Risk factors associated with falls in elderly patients with type 2 diabetes. J Diabetes Complications [Internet]. 2015;29(7):898–902. Available from: http://dx.doi.org/10.1016/j.jdiacomp.2015.05.016
Tilling LM, Darawil K, Britton M. Falls as a complication of diabetes mellitus in older people. J Diabetes Complications. 2006;20(3):158–62.
Chapman A, Meyer C, Renehan E, Hill K, Browning C. Exercise interventions for the improvement of falls-related outcomes among older adults with diabetes mellitus: A systematic review and meta-analyses. Journal of Diabetes and Its Complications, 2016.
Sarodnik C, Bours SPG, Schaper NC, van den Bergh JP, van Geel TACM. The risks of sarcopenia, falls and fractures in patients with type 2 diabetes mellitus. Maturitas. 2018 Mar;109:70–7.
Volpato S, Maraldi C, Fellin R. Type 2 diabetes and risk for functional decline and disability in older persons. Curr Diabetes Rev. 2010 May;6(3):134–43.
Vinik AI, Camacho P, Reddy S, Valencia WM, Trence D, Matsumoto AM, et al. AGING, DIABETES, AND FALLS. Endocr Pract Off J Am Coll Endocrinol Am Assoc Clin Endocrinol. 2017 Sep;23(9):1117–39.
Dhalwani NN, Fahami R, Sathanapally H, Seidu S, Davies MJ, Khunti K. Association between polypharmacy and falls in older adults: a longitudinal study from England. BMJ Open. 2017 Oct;7(10):e016358.
Jehu DA, Davis JC, Falck RS, Bennett KJ, Tai D, Souza MF, et al. Risk factors for recurrent falls in older adults: A systematic review with meta-analysis. Maturitas [Internet]. 2021;144(November 2020):23–8. Available from: https://doi.org/10.1016/j.maturitas.2020.10.021
Assar M El, Laosa O, Rodríguez Mañas L. Diabetes and frailty. Curr Opin Clin Nutr Metab Care. 2019;22(1):52–7.
Lu C-L, Hsu P-C, Shen H-N, Chang Y-H, Chen H-F, Li C-Y. Association Between History of Severe Hypoglycemia and Risk of Falls in Younger and Older Patients With Diabetes. Medicine (Baltimore). 2015 Aug;94(33):e1339.
Gu Y, Dennis SM. Are falls prevention programs effective at reducing the risk factors for falls in people with type-2 diabetes mellitus and peripheral neuropathy: A systematic review with narrative synthesis. J Diabetes Complications. 2017 Feb;31(2):504–16.
Hewston P, Deshpande N. Falls and Balance Impairments in Older Adults with Type 2 Diabetes: Thinking Beyond Diabetic Peripheral Neuropathy. Can J diabetes. 2016 Feb;40(1):6–9.
Vinik AI, Vinik EJ, Colberg SR, Morrison S. Falls risk in older adults with type 2 diabetes. Clin Geriatr Med [Internet]. 2015;31(1):89–99. Available from: http://dx.doi.org/10.1016/j.cger.2014.09.002
Bell DSH, Goncalves E. Why Do Falls and Lower Limb Fractures Occur More Frequently in the Diabetic Patient and How Can They Be Prevented? Diabetes Ther [Internet]. 2020;11(8):1687–94. Available from: https://doi.org/10.1007/s13300-020-00877-z
Samuelsson CM, Hansson PO, Persson CU. Determinants of Recurrent Falls Poststroke: A 1-Year Follow-up of the Fall Study of Gothenburg. Arch Phys Med Rehabil [Internet]. 2020;101(9):1541–8. Available from: https://doi.org/10.1016/j.apmr.2020.05.010
Finnegan S, Seers K, Bruce J. Long-term follow-up of exercise interventions aimed at preventing falls in older people living in the community: a systematic review and meta-analysis. Physiotherapy. 2019 Jun;105(2):187–99.
Ambrose AF, Paul G, Hausdorff JM. Risk factors for falls among older adults: a review of the literature. Maturitas. 2013 May;75(1):51–61.
LeLaurin JH, Shorr RI. Preventing Falls in Hospitalized Patients: State of the Science. Clin Geriatr Med. 2019 May;35(2):273–83.

No competing interests reported.

Risk Factors for Falls in the Older Adult with Diabetes Mellitus: Systematic Review and Meta-Analysis

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Abstract

Aim

Methods

Results

Conclusion

Trial registration:

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1. Background

2. Methods

3. Results

4. Discussion

5. Conclusion

Abbreviations

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References

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Supplementary Files

Status:

Journal Publication

Version 1