Increased Risk of Falls, Fall-related Injuries and Fractures in People with Type 1 and Type 2 Diabetes - A Nationwide Cohort Study
Authors: Rasmussen Nicklas H. , Dal Jakob , den Bergh Joop Van , de Vries Frank , Jensen Morten Hasselstrøm , Vestergaard Peter 
Published: September 2020

Introduction:
People with diabetes could have an increased risk of falls as they show
more complications, morbidity and use of medication compared to the general population. This
study aimed to estimate the risk of falls and to identify risk factors associated with falls in people
with diabetes. The second aim was to estimate fall-related injuries, such as lesions and fractures, including
their anatomic localization in people with diabetes compared with the general population.

Methods:
From the Danish National Patient Register, we identified people with Type 1 Diabetes
(T1D) (n=12,975) Type 2 Diabetes (T2D) (n=407,009). The cohort was divided into two groups,
with respective control groups matched on age and sex (1:1). All episodes of people hospitalized
with a first fall from 1996 to 2017 were analyzed using a Cox proportional-hazards model. Risk factors
such as age, sex, diabetic complications, a history of alcohol abuse and the use of medication
were included in an adjusted analysis. The incidence rate, incidence rate difference and incidence
rate ratio (IRR) of falls and the anatomic localization of fall-related injuries as lesions and fractures
were identified.

Results and Discussion:
The cumulative incidence, of falls requiring hospital treatment, was
13.3% in T1D, 11.9% in T2D. In the adjusted analysis, T1D and T2D were associated with a higher
risk of falls [T1D, Hazard Ratio (HR): 1.33 (95% CI: 1.25 - 1.43), T2D, HR: 1.19 (95% CI:1.16
- 1.22), respectively]. Women [group 1, HR 1.21 (CI:95%:1.13 - 1.29), group 2, HR 1.61
(CI:95%:1.58-1.64)], aged >65 years [groups 1, HR 1.52 (CI:95%:1.39 - 1.61), group 2, HR 1.32
(CI:95%:1.58-1.64)], use of selective serotonin receptor inhibitors (SSRI) [group 1, HR 1.35
(CI:95%:1.1.30 - 1.40), group 2, HR 1.32 (CI:95%:1.27-1.38)], opioids [group 1, HR 1.15
(CI:95%:1.12 - 1.19), group 2, HR 1.09 (CI:95%:1.05-1.12)] and a history of alcohol abuse [group
1, HR 1.77 (CI:95%:1.17 - 2.15), group 2, HR 1.88 (CI:95%:1.65-2.15)] were significantly associated
with an increased risk of falls in both groups. The IRR of fall-related injuries as hip, radius,
humerus and skull/facial fractures were higher in people with T2D than controls [IRR 1.02
(CI:95%:1.01-1.04), IRR 1.39 (CI:95%: 1.18-1.61), IRR 1.24 (CI:95%: 1.12-1.37) and IRR 1.15
(CI:95%:1.07-1.24)]. People with T1D had a higher IRR of hip fractures than controls [IRR: 1.11
(CI:95%:1.02 – 1.23)].

Conclusion:
People with diabetes have an increased risk of first fall and a higher incidence of fall-
related injuries, including fractures. Advanced aging and sex are non-modifiable risk factors,
whereas diabetes, the use of SSRIs and opioids and alcohol abuse could be potentially modifiable
risk factors for falls. Gaining information on risk factors for falls could guide the management of diabetes
treatment, i.e., choice of drugs, which enables us to improve treatment, particularly in people
with a high risk of falls and fractures associated with high mortality.