Nowadays, the number of diabetic patients is dramatically increasing worldwide. According to the International Diabetes Federation report, in 2019, there were a total of 463 million diabetic patients. It was further predicted that 628 million people would be diagnosed with diabetes by 2045. Unfortunately, 4 million people have died from diabetes [1]. In Thailand, the Ministry of public health reported that there were 2.81 million diabetic patients in 2019. Of these, 1.65 million people with diabetes were elderly. Diabetes Mellitus (DM) causes high plasma glucose levels and causes many complications in multiple organs, such as vision, the neurological system, the cardiovascular system, and the musculoskeletal system. Moreover, elderly people with diabetes have a high risk of falling and untimely death [2].

Falling can lead to injury and disability in the elderly. The most common injury is a bone fracture and traumatic brain injury [3], which can result in immobility, loss of activities of daily living, and death [4]. Falling not only requires significant treatment and rehabilitation but also more assistance from caregivers for activities of daily life [5, 6]. Worldwide, more than 37 million falls must be treated, and have killed more than 646,000 patients, mostly older people [7]. In 2017, the Ministry of Public Health of Thailand reported approximately 3 million cases of elderly people falling, with the risk of falls increasing with age, and with 1,046 cases per hundred thousand people resulting in death [8]. Medical conditions, such as diabetes, contributed to increased rates of falling in the elderly [7, 9].

Prior studies revealed a higher incidence of falls in older persons with diabetes who use insulin for controlling blood sugar, when compared to older persons without diabetes [10]. Approximately 39% of falls in one year were reported to be elderly diabetic individuals [11]. Therefore, elderly patients with DM need family or informal caregivers to provide care and pay close attention in order to prevent falls. The caregivers play an important role in caring for patients in multiple ways [12], including providing first aid, treating minor illnesses, managing medication, administering drug regimens, and providing physical and psychological support [13]. A family caregiver then is a protector who can help prevent falls and fall-related injuries.

According to a number of studies, awareness and concern in both seniors and their caregivers regarding falls may be an important factor for fall prevention among elderly people [15-17]. However, little is known about the influence of the caregiver’s awareness on falling in older adults with uncontrolled diabetes, who are at high risk. This study aimed to identify an association between the level of fall awareness of family caregivers and fall occurrence in elderly patients with DM, and to determine risk factors associated with falling.

A total of 136 pairs of elderly patients with uncontrollable DM and their respective informal caregivers participated in the study. The findings revealed a 1-year prevalence of falls of 45.6%, quite a high prevalence considering an estimated 30–40% of patients aged 65 and older will fall at least once yearly [19]. This may be because older people with DM, especially insulin-treated patients, have a greater risk of falling [9-11, 20]. Additionally, elderly DM patients with complications, including neuropathy or retinopathy, which cause a decline in sensory function, may have an increased risk of falls [21]. However, this study excluded patients with DM complications due to possible effects on many organ systems as well as on physical function and mobility. Almost all (93.6%) falls among elderly patients were indoor falls, or falls around the house. This is consistent with the previous study, which reported a greater chance of indoor falls in patients with diabetes [22]. These findings emphasized that falls are a concern for elderly adults with diabetes mellitus; therefore, a program for fall prevention should be promoted.

In the present study, fall risk was assessed by TUG test, which requires both static and dynamic balance, resulting in a mean of 12.7 seconds (means of 14.0 and 11.5 seconds for fallers and non-fallers, respectively). This is similar to the walking speed test used for elderly diabetic patients in the study of Chiba et al. [20], which reported a mean of 12.0 seconds (means of 13.6 and 11.0 seconds for fallers and non-fallers, respectively). In addition, the DM patients in the current study had, on average, a higher fall risk when compared to the general population of Thai community-dwelling elderly people, who have reported means of 11.7 seconds for fallers and 10.4 seconds for non-fallers [23]. According to another study of community-dwelling elderly people in Japan, the faller group had a mean score of 10.5 seconds, and the non-faller group had a mean of 8.3 seconds [24]. However, many factors influence walking speed, such as participants’ physical factors (height, age), shoes, surface textures, and height of the chair [18, 25].

In terms of fall awareness, it was found that informal caregivers had high scores of awareness regarding fall risk in elderly patients. This may be due to caregivers’ levels of education [26], as most had a bachelor’s degree. The present study is similar to a previous study of family caregivers of patients with cancer, in which most caregivers were a spouse or partner of the patients and were well-educated [17]. In addition, the study of Potter et al. [17] revealed that caregivers’ fall risk awareness improved after receiving standard education and a fall-prevention DVD program. Our findings show that family caregivers were aware of the risk of falls among DM patients in many dimensions, including daily activity support, psychological support, home environment organization, elderly health promotion, and warning and surveillance both indoors and outdoors. The low prevalence of outdoor falls among patients may reflect caregivers’ careful observance of the elderly patients when they travel outside, as this question had the highest score of awareness in this study. Likewise, the low prevalence of falls from stumbling over uneven ground (3.2%) may reflect caregivers’ high awareness about cautioning the elderly to be careful while walking on rough surfaces or in areas with uneven ground, which can increase fall rate [27, 28]. However, the lowest score, regarding caregivers’ awareness about floor care, may indicate one reason that slipping was so common among elderly patients, at 25.8%. This is also supported by a prior study that found that wet and slippery floors resulted in an increased risk of falling [27, 29]. Based on these findings, the awareness of caregivers may impact the risk of falls in elderly patients.

Both univariable and multivariable analysis revealed that family caregivers’ fall awareness was inversely related to fall occurrence among elderly patients with uncontrollable diabetes in the prior year, indicating a main influencing factor. This is supported by concepts and theories of awareness of situations, which is a preventative skill that reduces human error and environmental risk factors, solving problems before unwanted events occur [30]. When one has awareness, that awareness will cause a behavioral change [31]. It can be concluded, then, that if family caregivers have high awareness regarding the risk of falling, that awareness will lead to greater fall prevention, reducing occurrence of falls in elderly patients with DM. However, a previous study also found a relationship between older adults’ awareness and their own fall rate [32]. Therefore, elderly patients’ own fall awareness should be included in future studies. Regarding caregiver factors, education level and work in the health science field were both negatively associated with falls among the patients. This suggests that higher education level and occupational background related to health may influence knowledge and understanding about risk of falling, including risk factor elimination and prevention, which can affect severity in case of falls and reduce risk of falls in elderly patients. On the other hand, care characteristics, comprising number of days providing care, time providing care, and experience with elderly care, were not related to falls. The findings suggest that caregivers’ awareness about fall risk is a main protective factor for both indoor and outdoor falls among elderly patients.

Multivariable modelling revealed that balance problems and fall risk (tested by speed walking) were factors related to falls in the prior year among elderly patients with DM. Similarly, the study of Osoba et al. [33] found that visual system, posture balance control, and slower walking style among older adults can lead to falling, and the study of Shaw et al. [34] revealed a particularly high risk of falling among older adults with impaired orthostatic blood pressure control or who experienced loss of balance while changing positions. In addition, the elderly patients in the current study reported falling due to loss of balance when changing position at 22.6%. This is commonly found in the elderly due to age-related impairment of compensatory reflexes to the upright position. Age increase can cause degeneration of physiological systems, movement, balance and equilibrium, and the ability to do activities, resulting in a greater chance of falls [35]. Moreover, the age of elderly patients in this study was positively related to falls, which is consistent with a previous study, which found that fall rate increases with age [36]. Additionally, BMI was another personal factor of the elderly patients that was positively related to their falls. This is similar to previous research, which found that obesity affected fall risk [37].

Exercise is a key factor in promoting many aspects of body efficiency, including rehabilitation from non-communicable diseases. Specifically, it promoted efficient type 2 diabetes control and prevention, including possible combinations thereof [38]. Exercise also reduced the risk of falls among patients in this study. This is consistent with the study of Sherrington et al. [39], which found different types of exercise influenced fall risk reduction in older adults. Duration of DM diagnosis was associated with falls in the elderly patients because long-term diabetes may affect physiological systems, leading to higher fall risk [40]. Having other underlying diseases and taking other drugs in addition to DM drugs were also related to falls. Numerous studies revealed an increased risk of falls in older adults related to intake of medication such as polypharmacy, antihypertensive medications, and cardiac or analgesic drugs (digoxin, type IA antiarrhythmic, and diuretic use) [41-45]. This may be due to side effects of the drugs which include dizziness and orthostatic hypotension.

Other health problems of the elderly patients such as sleep problems, especially at the moderate level, urinary incontinence or constipation problems, and use of progressive lenses, were positively related to increased risk of falls in elderly patients. According to a prior study, sleep disturbance was associated with falls in older adults [46]. Also, the study of Soliman et al. [47] found that problems of urinary system control are related to falls and bone fractures. One possible explanation is that this may be caused by older adults’ hurrying and carelessness when walking into toilets [48]. Visual changes in older adults cause a decreased ability to adjust visual equilibrium. Wearing eyeglasses can improve vision, and progressive lenses, in particular, can help in various situations. However, elderly people who wear multifocal glasses may have a greater chance of falling due to misestimating surface textures, obstacles, uneven floors, or stairs while walking. This is consistent with the study of Lord et al. [49], which found that multifocal lenses increased fall risk in older adults.

Wearing shoes in the house was also related to falls in older adults in this study. A previous study found that elderly people wearing slippers had a higher risk of falling than those with bare feet [50]. Environmental factors such as home design and type of floor contributed to falls among elderly patients in this study. Having a bedroom on the ground floor can help patients avoid walking up and downstairs. As a result, a duplex or multi-story house increased the chance of fall risk. The findings showed that tile floors increased the risk of falls when compared to wood floors. This may be due to the decreased frictional force on smoother, more slippery tile floors. Therefore, types of tile should be investigated in further research to identify more slip-resistant flooring. Furthermore, some characteristics in different rooms of the participants’ houses were identified as risk factors related to falls, such as poor lighting in the bedroom, no handrail around a flush toilet, use of a squat toilet, a disorganized kitchen, carpeted walkways, objects or obstacles in the walkway, wet or slippery floors, and uneven areas. This is supported by previous studies, which found that insufficient lighting, objects such as rugs around the house, and lack of grab bars in the toilet may increase the risk of falls [19, 28, 48]. In particular, the main cause of falling among elderly patients was stumbling (48.8%). This suggests that designing, caring for, and organizing the home are important factors for indoor fall prevention.

Limitations of our study include i) potential for recall bias in the interviews regarding falls in the prior 12 months may have affected the results; ii) the participants chosen by convenience sampling had higher education levels and were younger elderly people, and may not be generalizable to the whole population; and iii) cross-sectional study design does not provide information about causal relationships, especially because caregivers’ current fall risk awareness may have changed overtime. However, this initial study highlighted that fall awareness of informal caregivers affects falls among elderly patients. For further research, a longitudinal study with random sampling to investigate the relationship between caregivers’ awareness and fall rate among elderly patients is recommended. Also, several factors not included in this study, such as other factors of the elderly patients (cognitive status, fall knowledge, fall awareness, etc.) and of the family caregivers (fall knowledge, health history, etc.), should be investigated.

In conclusion, there is a relationship between caregiver awareness and falls in older adults with uncontrollable diabetes. Personal factors of both caregivers and elderly patients, as well as environmental factors in the home, were related to falls. An intervention program to improve family caregiver awareness designed around daily activity and psychological support, home environment organization, elderly health promotion, and surveillance while traveling should be considered for fall prevention and reduction in elderly people.