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.
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 may benefit greatly from resistance training to improve strength and mobility. Initiating referrals to appropriate specialists (eg, physical and therapists, elder services, and social workers) may also be beneficial.
Several unique syndromes, although less common, may also be considered in older adults with diabetes. Diabetic amyotrophy, for example, occurs primarily in older male patients with the disease. Diabetic neuropathic cachexia is another syndrome that consists of peripheral neuropathy, depression, and weight loss among older diabetics. Accidental hypothermia and severe infections are also more common in older patients with diabetes.
Setting Goal of Care
When developing goals of care in older patients with diabetes, physicians and other healthcare providers should be cognizant of the following:
Duration of disease and age of diabetes onset.
Presence of complications and comorbidities.
Variable life expectancy.
Social support systems.
Hypoglycemia is a symptom that physicians try to avoid when treating all patients with diabetes, but there are different clinical features of it for older and younger patient groups. When compared with younger patients, older adults with have more neuroglycopenic manifestations of hypoglycemia (eg, dizziness, weakness, delirium and confusion) rather than adrenergic symptoms (eg, tremors and sweating). The autonomic warning symptoms of hypoglycemia are often reduced in older adults.
When complex treatment regimens are given to older patients in adverse clinical or psychosocial environments, there is a risk for decreased compliance and poor glycemic control. In these instances, it’s important to simplify all diabetes treatment regimens to avoid overwhelming patients and to perhaps help prevent medication errors. Most importantly, the goals of care should be reassessed at frequent intervals because health status can change very quickly in older adults.
Readings & Resources (click to view)
American Diabetes Association. Standards of Medical Care in Diabetes—2011. Diabetes Care. 2011;34:S11-S61. Available at: http://care.diabetesjournals.org/content/34/Supplement_1/S11.full.
McMullins D, Munshi MN. New ways to look at diabetes in older adults. On the Cutting Edge: Diabetes Care and Education. 2009;30:2.
Brown AF, Mangione CM, Saliba D, Sarkisian CA, California Healthcare Foundation/American Geriatrics Society Panel on Improving Care for Elders with Diabetes. Guidelines for improving the care of the older person with diabetes mellitus. J Am Geriatr Soc. 2003;51:S265-S280. Available at: http://www.americangeriatrics.org/files/documents/JAGSfinal05.pdf.
Beckett NS, Peters R, Fletcher AE, et al, HYVET Study Group. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358:1887-1898.
Sinclair AJ, Conroy SP, Bayer AJ. Impact of diabetes on physical function in older people. Diabetes Care. 2008;31:233-255.
Schwartz AV, Vittinghoff E, Sellmeyer DE, et al; Health, Aging, and Body Composition Study. Diabetes-related complications, glycemic control, and falls in older adults. Diabetes Care. 2008;31:391-396.