Year : 2018 | Volume
: 23 | Issue : 2 | Page : 61--64
Management of diabetes in elderly
Rini Yadav, Ashish Goel
Department of Medicine, UCMS, New Delhi, India
Dr. Ashish Goel
Department of Medicine, UCMS, New Delhi
The population of elderly people is expected to rise significantly over the coming years. The prevalence of Diabetes is also increasing in elderly. In view of co-morbidities present in elderly diabetics the approach to manage diabetes in them vary significantly from that I younger population. To facilitate better management the International Diabetic Federation has classified diabetics in to three categories. The lifestyle modification and self-management education are the cornerstones. As far as possible poly pharmacy should be avoided. Beside pharmacological therapy, a multidisciplinary and holistic approach is needed to manage diabetes in elderly.
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Yadav R, Goel A. Management of diabetes in elderly.J Mahatma Gandhi Inst Med Sci 2018;23:61-64
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Yadav R, Goel A. Management of diabetes in elderly. J Mahatma Gandhi Inst Med Sci [serial online] 2018 [cited 2019 Jun 19 ];23:61-64
Available from: http://www.jmgims.co.in/text.asp?2018/23/2/61/243142
The last few decades have seen a rapid increase in the proportion of the older population in India. According to the census in 2011, 5.3% of the Indian population was >65 years of age. This proportion of people is expected to rise rapidly over the coming years reaching significant proportions.
The prevalence of diabetes in the elderly has been increasing steadily which makes it a major public health burden even in India. Further, there is also wide variation in diabetic care across different countries as various cultural and social-economic factors weigh heavily while selecting the appropriate therapy. An additional consideration in older people is the presence of co-morbidities and frailty. It has been shown that around 25% of diabetics are frail with diabetes itself acting as risk factor for frailty, cognitive dysfunction, vulnerability to hypoglycemia, and recurrent hospitalizations. Hence, a systematic approach is necessary in managing the older individuals with diabetes.
The International Diabetes Federation has identified three groups of older patients with diabetes to facilitate better management. Category 1 includes the functionally independent individuals who are capable of independent community existence and do not require support. Category 2 includes functionally dependent individuals and has been divided into frail and those with dementia. Category 3 has been identified as those individuals who are terminally ill and in need of end of life care. category 1, individuals do not pose much of the problems as they are able to take their own care. However to manage Category 2 is caregiver-dependent, because of frailty and/or dementia. They have impaired activities of daily living (ADL); hence, the inability of self-management. There is risk of hypoglycemia or hyperglycemia and repeated hospitalization. The family members and caregiver need to be specifically educated at the same time the target glucose levels need to be relaxed to avoid adverse events. The category three individuals need pain relief, and general care may require treatment for serious comorbidities and hospitalization.
Screening and diagnosis
Undiagnosed diabetes is common among older individuals, and the presentation may be with complications. The prevalence of impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) increases during old age. Many of them may have no symptoms. Due to long asymptomatic period, many complications and aggravation of existing comorbidities occur before a diagnosis is made. It has been seen that postprandial hyperglycemia is common and likely to be associated with morbidity and adverse health outcomes. Screening older adults would help in identifying people with IGT and raised fasting plasma glucose. They also need to be assessed for alterations in cognitive functions, and depression, mobility, instrumental ADL, and ADL and also for the complications related to diabetes such as retinopathy, nephropathy, neuropathy, and cardiovascular disease (CVD).
The clinical, mental, and functional heterogeneity complicate the management of diabetes in elderly. The progression to overt diabetes in those having IGT or IFG can be delayed or even prevented, observed by many investigators. Appropriate prevention strategies can be implemented most important being-lifestyle modification greatest effect seen in people over 60 years., As with all patients with diabetes, diabetes self-management education and ongoing diabetes self-management support are vital components of diabetes care for older adults and their caregivers.
Lifestyle modifications have been the cornerstone of every diabetes management program across the world. Modifications include dietary changes, exercise, and education regarding various aspects of diabetes. Important factors to be considered among elderly individuals are discussed below.
Malnutrition is common in older people owing to various factors including gastroparesis swallowing difficulties, dental problems, malabsorption, neurological, renal, and hepatic impairment.,, Hence, the meal plan should be age-related and person specific. Micronutrient deficiencies are common. Older people may be dehydrated and have electrolyte disturbances. Smaller and more frequent meals fortified with micronutrients and liquid supplements between meals are often used as strategies to counter these problems.
A regular exercise according to their functional capacities, reduces the number of falls among older persons and provides psychosocial benefits, due to an improved functional status and overall improvement in quality of life. Those who have a high risk of falling should consult a physiotherapist for balance and muscle strengthening exercises before taking up other exercises. While there is debate around the nature and the duration of exercise among older patients, most resistance training, and aerobic exercise regimens have shown promise and benefit in numerous trials in reducing sarcopenia, improving muscle mass, and reducing blood sugar levels.
Older people pose challenges in having established beliefs and may not be amenable to following a specific lifestyle change advice. They often disregard instructions and do not give due importance to their disease. Furthermore, cognitive impairment may also affect the decision-making process. It is important to adapt teaching style according to the individual, make repeated efforts and provide an optimal learning environment. It is equally important to include regular formal and informal caregivers in every step of the process.
Pharmacologic agents are started after an adequate trial of lifestyle interventions has been tried over 3 months. In older persons, it is important to avoid too many drugs at the same time. Polypharmacy has been shown to increase morbidity and is associated with a poor outcome among this group. It is important to start a drug at the lowest possible dose and increase slowly while assessing its side effect profile carefully and considering its cost as well as risk to benefit ratio.
Among the available agents, metformin is the initial drug of choice as it is better tolerated and has a lesser risk of producing hypoglycemia. It is important to monitor the epidermal growth factor receptor while administering drugs and titrating therapy., Sulfonylureas and dipeptidyl phosphodiesterase-4 inhibitors are the other drugs which can be used either when metformin is contraindicated or as add-on therapy to achieve glycemic control.,, GLP-1 receptor agonists and alpha-glucosidase inhibitors are other classes of drugs which can be considered among older persons.,,
Insulin is used, usually as basal or premixed regimen when glycemic control is not achieved with oral hypoglycemic agents. Older persons should be educated and trained carefully regarding the use of insulin. It is often noticed that older individuals have inhibitions to the use of insulin owing to cultural and societal influences. It is extremely important to carefully monitor compliance while starting insulin among them.
Management of associated conditions
Hypertension is usual among older persons. While earlier higher blood pressures were attributed to arterial vessel wall changes with age, recent studies have shown morbidity and mortality improvement with a tighter blood pressure control among older individuals. Blood pressure control is achieved with diet (dietary approaches to stop hypertension diet) and drugs. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) are used as first-line agents.
Dyslipidemia is common among diabetic older persons, and a decreased high-density lipoprotein level is often associated with increased risk for CVDs and ischemic stroke. Statins are often prescribed as the drugs of choice. Side effect of myalgias and myositis need to be monitored since these may be easily missed in this population and attributed to aging changes. Alternatively, fibrates may be used safely among older people. Nicotinic acid and bile acid sequestrants are generally avoided. While the former worsens hyperglycemia, the latter is known to have poor compliance and more side effects.,
Management of complications
Long-standing diabetes among older persons often results in the presence of complications either at the time of a delayed diagnosis or at the time of regular assessment. It is important to be aware of and monitor for the presence of complications.
Screening for nephropathy and resultant albuminuria is done by measuring urine albumin to creatinine ratio, micro, and macroalbuminuria. The estimation of protein loss over 24 h in urine may be needed. ACE inhibitors and ARBs should be used to control hypertension and reduce proteinuria.
Proliferative and nonproliferative changes are common at the time of diagnosis in Type 2 diabetes in older people. Sight-threatening retinopathy is seen in about 3% older adults at the time of diagnosis. Regular assessment of visual acuity, examination of fundus, and measurement of intraocular pressure are recommended at every visit to preserve sight and identify problems early.
Neuropathy may present in many forms, and patients complain of neuropathic pain, gastroparesis, urinary incontinence, erectile dysfunction, and sensory loss owing to peripheral neuropathy., Since problems in maintaining balance, muscular pains, prostatic hypertrophy, osteoarthritis, hearing disturbances, swallowing, and motility disturbances are common in older individuals, these may mask or mimic the features of neuropathy and delay diagnosis.
The involvement of foot is a frequent complication in diabetic older adults. It includes foot infections, ulcers, and nonhealing wounds. The presence of neuropathy and peripheral arterial disease are contributory factors. A regular review with a podiatrist if available and foot care education is important to prevent limb-threatening conditions.
Older diabetics are at an increased risk for CVD and consequent mortality and morbidity. Tight blood sugar control and management of other modifiable risk factors for CVD (hypertension, dyslipidemia, smoking, and obesity) are essential in this group.
A higher prevalence of hypoglycemia has been reported in older diabetics. Besides a hypoglycemia unawareness, there is an impaired counter-regulatory response and late development of symptoms. Long-acting sulfonylureas or insulin use, coupled with erratic meal timings, renal and hepatic impairment further complicates the situation. It is imperative to identify individuals at risk for developing hypoglycemia. Control of blood sugars to achieve a glycosylated hemoglobin A1c level <7% is an indication of potential overtreatment. It is essential to educate the individual patient as well as caregivers regarding hypoglycemia risk, how to identify a hypoglycemic episode and immediate countermeasures that can be taken at home to prevent long-term residual brain impact of prolonged low blood sugar.
Hyperglycemic nonketotic hyperosmolar state characterized by blood sugar levels usually >540 mg/dl and serum osmolality >320 mmol/l is common in older persons. This is often associated with severe dehydration. The precipitating causes are usually infections, stress, myocardial infarction, and stroke. They should be carefully searched for. It is important to hydrate adequately using intravenous fluids and to treat the precipitating cause. Although diabetic ketoacidosis is less common among older persons; nevertheless, it is associated with higher mortality.
Patients with ischemic stroke present with higher blood sugar levels at the time of admission. Thirty-day mortality is higher compared to a normogylcemic presentation. A strict glycemic control is warranted among these individuals.
It has been shown that nearly one-fourth of older people with diabetes suffer from depression. A geriatric depression scale is an easy tool that could be used to screen these patients. Depression can negatively impact glycemic control and increase the burden of diabetic complications and mortality. A regular screening for depression, counseling and use of anti-depressants when deemed appropriate may reduce mortality and improve quality of life in addition to improving blood glucose control among older persons.
It has been established that diabetes increases the risk of falls. Common contributory factors include motor and sensory neuropathy, muscle weakness, orthostatic hypotension, visual impairment, and frailty.,
Although the elderly persons form a significant proportion of people suffering from diabetes, their recognition as a special group requiring a multidisciplinary approach in managing diabetes is fairly recent. The current approach focuses on singularly managing blood sugar level and turns a blind eye toward active detection of complications and comorbidities needs to change. Various guidelines are in place dealing specifically with the challenges faced when treating an elderly diabetic, but their implementation in everyday practice is sadly lacking, especially in a developing country like ours. Hopefully, with evolving health-care facilities, the management of diabetes in the elderly population will also evolve resulting in decreased diabetes-related morbidity and mortality.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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