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Goal Setting for Older Adults With Diabetes

To successfully manage type 2 diabetes in older adults, clinicians must recognize and understand the unique challenges these individuals face. While the benefits of tight glycemic control in older adults are similar to those of younger patients, physicians need to understand that barriers may interfere with older adults’ ability to perform self-care before setting goals of care. When establishing overall health goals, there must be a balance between the perceived benefits of tight glycemic control and the risks of treatment, such as hypoglycemia. Diabetes management plans should be formulated for older adults after careful consideration of their health and social backgrounds. Recognize Comorbidities Older adults with diabetes are at higher risk for many medical conditions that are not typically associated with diabetes, including cognitive impairment, depression, and functional decline. Identifying these conditions before forming management plans is essential. Early identification of subtle cognitive dysfunction, especially executive dysfunction, can enable practitioners to simplify treatment plans to avoid complications. Executive functions are important for diabetes self-care. Depression in older adults with diabetes has been linked to poor glycemic control, decreased adherence to treatment strategies, increased functional disability, and higher mortality in clinical studies. To screen for depression, the Geriatric Depression Scale can be of help. Older people with diabetes are also at increased risk of falls due to lower limb dysfunction, cardiovascular disease, polypharmacy, and impaired balance. Since improved glycemic control can help prevent progression of diabetes-related microvascular and macrovascular complications, it may also decrease the fall risks. On the other hand, it’s important to prevent hypoglycemia as it may manifest as dizziness or weakness and increase fall risks. These patients...

Managing Common Diabetes Comorbidities: Going Beyond Standard Care

This Physician’s Weekly feature covering the management of common diabetes comorbidities was completed in cooperation with the experts at the American Diabetes Association. Throughout the medical literature, it has been well documented that patients with type 2 diabetes are at increased risk for developing cardiovascular disorders, including coronary artery disease and stroke. The constellation of symptoms that includes insulin resistance and obesity greatly increases the likelihood of additional comorbidities emerging. “In addition to the commonly appreciated comorbidities of obesity, hypertension, and dyslipidemia,” says Medha N. Munshi, MD, “diabetes is also associated with other diseases or conditions at rates higher than those of people without diabetes.” In keeping with patient-centered approaches to care, physicians should be aware of the wide spectrum of comorbidities their patients face when managing them throughout their disease course. When the risk for these comorbidities is elevated, patients should be treated accordingly. The American Diabetes Association reports that some of the more common comorbidities outside the realm of obesity, hypertension, and dyslipidemia include obstructive sleep apnea (OSA), fatty liver disease, cancer, and fractures (Table 1). “Clinicians should consider these other comorbidities during their care of patients with diabetes to optimize outcomes,” says Dr. Munshi. Obstructive Sleep Apnea OSA is the most common form of sleep-disordered breathing in patients with type 2 diabetes, accounting for over 80% of cases. In people with diabetes, the prevalence of OSA has been documented to be as high as 23% and the prevalence of some form of sleep disordered breathing may be as high as 58%. “Treating sleep apnea can significantly improve quality of life and blood pressure control,” Dr. Munshi...

Managing Diabetes in Older Adults

This Physician’s Weekly feature was completed in cooperation with the experts at the American Diabetes Association. Published research suggests that approximately 30% of people older than 65 have either diagnosed or undiagnosed diabetes, and the disease is of increasing concern for the aging population. It is expected that its incidence will grow rapidly in the coming decades as older individuals are living longer. “When compared with older adults without diabetes, those with the disease have higher rates of premature death, functional disability, and coexisting illnesses,” explains Medha N. Munshi, MD. These coexisting illnesses include coronary heart disease, stroke, peripheral vascular disease, renal failure, neuropathy, and retinopathy. In addition, older adults with diabetes are at greater risk for polypharmacy, depression, cognitive impairment, urinary incontinence, injuries from falls, and persistent pain. The care of older adults with diabetes can be challenging for physicians because of clinical and functional differences from patient to patient, Dr. Munshi says. “Some older individuals develop diabetes at an earlier age and may have complications by this time. Others develop the disease at an older age and present with a few diabetes-related complications.” Frailty, diabetes-related comorbidities, and other underlying chronic conditions are other important considerations for some older patients. Furthermore, the activity levels and comorbidities experienced by older adults vary considerably depending on each individual patient. Studies have shown that the life expectancy is highly variable for older patients, but often longer than clinicians realize. An Important Patient Population According to the American Diabetes Association’s Standards of Medical Care in Diabetes—2011, providers caring for older adults with diabetes must take the diversity of older patients into consideration when setting and...
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