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 prioritizing treatment goals (Table 1). The document also recommends that older adults who are functionally and cognitively intact, and have significant life expectancy receive diabetes care using goals developed for younger adults. There are few long-term studies in older adults with diabetes, but patients should be given every opportunity to reap the benefits of long-term intensive diabetes management that is provided to younger patients. “If patients are active, have good cognitive function, and are able to follow treatment regimens as prescribed,” says Dr. Munshi, “they should be provided with the needed education and skills to do so.”
Less-intensive glycemic target goals may be reasonable for older patients with advanced diabetes complications, life-limiting comorbid illness, or substantial cognitive or functional impairment. “These patients are less likely to benefit from reducing the risk of long-term diabetes-related complications and more likely to suffer serious adverse effects from hypoglycemia, which can be a dangerous fast-onset problem,” Dr. Munshi says. “It’s also important to control other cardiovascular risk factors, especially hypertension, in the elderly,” Dr. Munshi says. There is less evidence for lipid-lowering and aspirin therapy, but the benefits of these prevention interventions are likely to apply to older adults with longer life expectancies.
Educate Patients on All Possibilities
The American Diabetes Association notes that special care is required in managing older adults with diabetes. It is important for providers to educate patients, family members, and caregivers about hypoglycemia and hyperglycemia at diagnosis, with reassessment and reinforcement periodically as needed. This includes education on precipitating factors, prevention, symptoms and monitoring, treatment, and when to notify a member of their healthcare team that their assistance is needed. Patient self-monitoring of blood glucose levels should be routinely reviewed by clinicians. Older individuals should also have their physical activity levels regularly evaluated and be informed of the benefits of exercise and available resources for becoming more active. “Exercise—regardless of the patient’s age—should always be encouraged during patient visits,” stresses Dr. Munshi. In addition, particular attention should be paid to complications that can develop over short periods of time and that could significantly impair functional status, such as visual and lower-extremity complications.
“Another important aspect of good diabetes care for older patients is how newly prescribed medications are addressed with patients,” says Dr. Munshi. “If new drugs are prescribed, education on the purpose of the medication, how to take it, common side effects, and important adverse reactions is critical. Taking the time to explain the rationale behind prescriptions may enhance drug adherence. At the same time, clinicians should strive to keep medication regimens as simple as possible in older adults. We need to look at the whole patient picture first, and then plan treatments accordingly.”
Screening for diabetes complications and other comorbidities in older adults should be individualized, Dr. Munshi says (Table 2). “With older adults, there are other factors that can have a significant impact on how well or poorly patients manage their diabetes. Regularly assessing these potential comorbidities will help patients keep their disease under control and may increase quality of life because we’re then caring for the whole patient rather than just diabetes.”
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.
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.
Curb JD, Pressel SL, Cutler JA, et al. Effect of diuretic-based antihypertensive treatment on cardiovascular disease risk in older diabetic patients with isolated systolic hypertension. Systolic Hypertension in the Elderly Program Cooperative Research Group. JAMA. 1996;276:1886-1892.
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.