Diabetes is a growing problem in the elderly. The incidence is estimated to be 20% by the age of 75 (1). The elderly encompass a very diverse population and our clients will range from a healthy and fit “60 something” on multiple daily injections to a frail elderly patient in a nursing home with multiple co-morbidities. The CDA suggests that the term elderly reflects “an age continuum starting somewhere after age 60 and is characterized by a slow, progressive frailty that continues until the end of life (2).
Many of our clients feel frustrated by the medical system and complain about being largely ignored. This may relate to both their age and diagnosis of diabetes. It is important that we make their encounters as meaningful as possible and help them to feel capable and competent with respect to managing their diabetes. We also can’t underestimate the importance of the patient’s support system and in many cases we will counsel the extended family which can include children, spouses and caregivers.
This article will explore diabetes and the elderly â€“ symptoms, screening, prevention, complications, additional concerns in this population, as well as teaching strategies.
The presentation of diabetes can be different in this age group. The classic symptoms of increased thirst and urination and unexplained weight loss may be absent. There may be a change in behavioural, cognitive or functional status (i.e. falling, incontinence, agitation, dementia, delirium and depression) (1). The patient may also suffer from complications resulting from diabetes. Their diabetes may have been undiagnosed for a period of time suggesting more intensive screening in this population. In about 1/3 of older people with diabetes the disease remains undiagnosed (1). Both type 1 and type 2 diabetes occur in the elderly. The lean individual more likely presents with impaired glucose-induced insulin release. On the other hand the obese patient presents with insulin resistance secondary to insulin impairment, the usual scenario we see in a middle-aged person with type 2 diabetes.
The CDA guidelines (2008) advise screening for diabetes using a FPG every 3 years in individuals >or = 40 years of age and more frequently in those with additional risk factors which are common concerns in the elderly. This includes vascular disease, hypertension and dyslipidemia. In the US, 90% of nursing home residents with evidence of CAD, stroke and/or PVD have evidence of
Research has shown that lifestyle modification including modest weight loss and physical activity can delay the progression to type 2 diabetes in high risk individuals by almost 60%. A genetically susceptible individual will be at high risk of diabetes with aging.
Also, some medications are known to increase blood glucose and these include beta blockers, thiazide diuretics, corticosteroids, niacin, and pentamidine. The pharmacist can be a valuable addition to the diabetes team.
All diabetes complications can occur in the elderly at higher rates with sub-optimal control. This includes:
- Coronary heart disease
- Vision problems including retinopathy, cataracts, glaucoma
- Neuropathy -this is predominantly a disease of the older population with diabetes and can result in muscle weakness and gait imbalances resulting in an increased risk for falls and fractures. It has been reported that those 60 and older with diabetes are 2 to 3 times more likely to be unable to walk 1/4 of a mile, climb stairs and do housework (4). Seok Won Park (5) reports that elderly people with diabetes have an accelerated loss of knee extensor strength and quality compared with those without diabetes. We need to ensure that our suggestions for physical activity are appropriate.
Additional concerns in diabetes and the elderly
- Polypharmacy – Most elderly patients with type 2 diabetes have other diseases (e.g. hypertension) and the number of medications is often at least 4 to > 10. Long-term care residents with diabetes tend to have 6.4 major diagnoses compared to 2.4 in residents without diabetes (3). The definition of polypharmacy includes “the prescription, administration or use of more medications than are clinically indicated, inappropriate drug combinations and unnecessary medications” (6). Good suggests that in fragile, older patients non-pharmacological means should be added before a new drug when feasible (e.g., physiotherapy for knee pain). There should be a periodic review of all medications and that tight control is not ideal in some of our elderly patients with diabetes.
- Dementia – this is increasingly being linked to diabetes. One study has found that diabetes is associated with an increased risk of Alzheimer’s disease and vascular dementia and is stronger when the diabetes occurs in mid-life than in late life (7). Making the diabetes regimen as simple as possible and balancing good control with risk of hypoglycemia are key.
- Depression is more common among the elderly with diabetes. Assessment of support systems, treatment of sleep disorders and appropriate treatment of the depression can be helpful.
- The frail elderly – The American Geriatric Society recommends “in frail older adults, and with a life expectancy of < 5 years and others in whom the risks of intensive management outweigh the benefits, a less stringent A1c target such as 8% is appropriate”(3). The British Geriatric Society has set a target of 8.5% for the frail elderly. Similarly the CDA guidelines echo this by stating “In people with multiple co-morbidities, a high level of functional dependency and limited life expectancy, the goal should be less stringent, and clinicians should avoid symptoms of hyperglycemia and prevent hypoglycemia” (2). In the frail elderly hyperglycemia can increase the risk of UTI, falls, skin ulcers and weight loss and it impairs cognitive function and wound healing.
- Hypoglycemia – this is a concern as glucose counterreglation can be impaired in the elderly (involving glucagon, epinephrine and growth hormone) and so there is a reduction in autonomic warning symptoms. The CDA recommends that sulfonylureas should be used with caution and the use of premixed insulins may be preferred as the chance of dose errors may be lessened.
Teaching the elderly
Many of our patients will benefit from a multi-disciplinary diabetes program and the following strategies can be helpful:
- Adult learners want to know how they can use principles in everyday life
- Build on the learner’s experiences. This can help to build confidence. Remember many have been out of school for a long time.
- Ask for feedback throughout a teaching session
- Speak clearly and loudly while facing the class. Use a microphone.
- Use clear vocabulary. Avoid jargon.
- Hand out notes in large print.
- Teach to all learning styles. Use notes, board, provide group work for hands on learners.
- Tips for a patient with memory loss â€“ have lots of patience, keep sentences short and simple, try not to test the person’s memory with questions such as “what did you have for dinner?”, avoid arguing, limit choices (e.g., would you like soup or salad?).
- The clock drawing test (8) is a practical screening tool for cognitive function to assess patients with dementia and can be used to identify those who may have difficulty with insulin injections.
Elderly people with diabetes are a diverse group and every patient will have unique needs and concerns. The benefits of good glycemic control can be enormous and include increased energy, improvement in memory, mood, dementia and quality of life. On the other hand, the risks of hypoglycemia can be life-threatening to an elderly patient with dementia in a nursing home.
The number of people with diagnosed diabetes through to 2050 is projected to increase by 165% with the largest increase among those age 75 and older (1). Ideally working in a multi-disciplinary team we can provide the care that will benefit the patient and the extended family. It is important to remind ourselves when teaching the elderly that “age alone should not be used as an excuse for compromised BG control” (1).
- Schlater A. Diabetes in the Elderly: The Geriatricianâ€™s Perspective. Can J Diabetes. 2003;27: 172-175.
- CDA 2008 Clinical Practice Guidelines
- Clement M, Leung F. Diabetes and the Frail Elderly in Long-term Care. Can J Diabetes. 2009; 33: 114-121.
- Frellick M. Diabetic Epidemic Among the Elderly. 2009. HealthKey.com.
- Seok Won Park, Goodpaster BH, Strotmeyer ES et al. Accelerated Loss of Skeletal Muscle Strength in Older Adults with Type 2 diabetes. Diabetes Care.2007;30: 1507-1512.
- Good C. Polypharmacy in Elderly Patients with Diabetes. Diabetes Spectrum.2002; 15: 240-248.
- Xu W, Qiu C, Gatz M et al. Mid- and Late-Life Diabetes in Relation to the Risk of Dementia. A Population Based Twin study. Diabetes .2009; 58: 71-77.
- Trimble LA, Sundberg S, Markham L et al. Value of the Clock Drawing Test to Predict Problems with Insulin Skills in Older Adults. Can J Diabetes. 2005; 29: 102-104.