Considerations When Managing Diabetes in the Elderly
The percentage of elderly people in the United States is growing. This elderly population is also making up an increasing proportion of newly diagnosed diabetes patients. Managing type 2 diabetes in the elderly can be challenging. The elderly population tend to have more comorbidities (other health problems). Many are also low functioning which makes self-management difficult. In any other situation we would look to national guidelines for guidance, however, current guidelines do not often apply to elderly patients. Therefore, it’s important to be familiar with the nuances that make managing an elderly patient with type 2 diabetes sometimes challenging.
Age-related changes are an important consideration in this population. They can often make recognition of a new diabetic among elderly patients more difficult. For example, elderly patients do not normally demonstrate the typical symptoms of low blood sugar. Also, dry mouth may be absent because people can experience a dulled sense of thirst as they age. Finally, Elderly diabetic patients may display features of type 1 diabetes (islet cell antibodies, leading to a decrease or absence of insulin production). So it’s imperative to keep in mind that both type 1 and type 2 diabetes can be observed in the elderly population.
One of the biggest problems patients and caregivers face with elderly patients living with diabetes is low blood sugar. This is because the warning signs of hypoglycemia are often dulled in the elderly. Cognitive impairment may also be a factor in this situation.
According to the guidelines, the criteria for the diagnosis of diabetes are the same in the young and the elderly. Diagnosis involves one of the following;
Two fasting glucose levels of 126 mg/dL or higher on two separate occasions
A random glucose level of 200 mg/dL or higher with symptoms
A 2 hour oral glucose tolerance test (OGTT) of 200 mg/dL or higher.
It’s important that elderly patients are screened for diabetes annually.
Diabetes complications occur in the elderly at a higher rate. Some of these complications may include:
Diabetic neuropathic cachexia – peripheral neuropathy, anorexia, depression and weight loss
Diabetic neuropathy – pain due to nerve damage.
Muscle weakness and wasting – this should be considered in patients reporting difficulty arising from chairs.
Necrotizing otitis externa – this is a serious bacterial infection of the inner ear that spreads to the outer ear and surrounding tissues.
It’s important that goals of therapy for elderly diabetic patients take into consideration the patient’s life expectancy, financial health and functional status. The patient’s’ own goals for treatment should be discussed. However, if the patient has cognitive impairment, they may be limited in the ability to participate fully in the establishment of goals.
The guidelines have established a HgA1c goal of < 7%. This may be difficult to achieve in elderly patients due to the potential dulling of symptoms of low blood sugar and cognitive impairment in this population. Unfortunately, there has not yet been a large trial that demonstrates intensive blood glucose control is associated with improved outcomes in the geriatric population. Specifically, trials have yet to demonstrate an improvement in cognitive function with tight blood sugar control.
Besides cognitive impairment and increased risk of hypoglycemia, treatment should focus on reducing the risk of cardiovascular disease. Lifestyle changes should be emphasized. These factors may include smoking cessation, addition of exercise, weight loss and high blood pressure control. If appropriate for the patient, many long-term care and assisted living communities have exercise programs. The CMS Silver Sneakers plan may also be a cost-effective option for elderly adults who would like access to a gym but may not have one in their community. Exercise is a fantastic way to increase insulin sensitivity and lower blood sugar levels naturally. It's just important to make sure the patient’s medications are adjusted appropriately (i.e. insulin) when exercising. It is also a good idea for the patient to have rescue snack handy in case blood sugar levels dip too low during exercise.
The same can be said about starting a new diet. If the patient will be eliminating some carbohydrates from their diet, they will need to work with their doctor on decreasing their diabetes medications with the introduction of these new eating habits. Having a dietitian on board, like those at Empowered Medicine, can provide valuable insight.
Some of the therapies available for elderly patients with diabetes include:
Alpha-glucosidase inhibitors (acarbose (Precose®), and miglitol (Glycet®)) – These medications delay digestion of carbohydrates. These are typically used in elderly patients with mild diabetes. Patients may experience gastrointestinal side effects that may intolerable in some. Liver function may also be impaired.
Biguanides (metformin (Glucophage)) – This is a great option for the elderly because it does not cause hypoglycemia. The patient should be monitored, however, for anorexia and weight loss. It should also not be used in patients with poor kidney function (Creatinine clearance < 60 mg/dL).
Thiazolidinediones (rosiglitazone (Avandia®) and pioglitazone (Actos®)) – these medications sensitize the tissues to insulin. Although these drugs do not cause hypoglycemia, they should not be used in patients with heart failure.
Sulfonylurease (glipizide (Glucotrol®), glyburide (Micronase®, Diabeta®, Glynase®) – these cause the pancreas to secrete more insulin. These should be avoided in patients with liver disease.
Other secretagogues – repaglinide (Prandin®) and nateglinide (Starlix®)) – these are generally considered if sulfonylureas are not sufficient. These too should be avoided in patients with liver disease.
Insulin – Insulin must be used with care in elderly patients with diabetes because of the high risk of hypoglycemia. Factors like cognitive decline are important to consider. It’s impairative that the patient and/or caregiver are capable of obtaining a blood glucose reading and understand what actions to take and when.
The Bottom Line
Elderly patients living with diabetes pose unique challenges to health care providers and caregivers. Careful monitoring of blood sugar levels should be emphasized given the lack of symptoms of hypoglycemia that can sometimes be observed. Careful coordination between the patient and/or caregiver and the provider is crucial when dealing with medications that can cause hypoglycemia. Utilizing a dietitian to assist with meal choices may be beneficial.
If you have just been diagnosed with diabetes, do not worry. There are many good resources on the web to help you. However, do not underestimate the help of a good health professional. At Empowered Medicine, our health coaches are Nurse Practitioners, Clinical Pharmacists, Registered Dietitians and Personal Trainers. We help people living with diabetes lose weight, control their blood sugar, and improve their cholesterol profile. As a result, our clients are decreasing their risk of diabetes complications like heart disease, stroke, blindness, amputation and dialysis. We provide remote or in-person health and medicine coaching to clients in the comfort of their own home.
Christi Larson, Pharm. D.
Author, Lead HMCP, CEO Empowered Medicine, LLC