Diabetes in the Elderly

Diabetes Ther (2018) 9:493–500 https://doi.org/10.1007/s13300-018-0380-x PRACTICAL APPROACH Diabetes in the Elderly Sanjay Kalra . Suresh K. Sharma Received: December 1, 2017 / Published online: February 19, 2018 Ó The Author(s) 2018. This article is an open access publication ABSTRACT The elderly are an important and distinct yet heterogeneous group of persons living with diabetes. The elderly have a unique biomedical, psychological, and social constitution. Their needs are different from those of younger adults. This implies that special care must be taken while evaluating and planning their nursing and management. Diabetes management in the elderly should focus on prevention and limitation of geriatric syndromes (medical conditions encountered in elderly persons), hypoglycemia (low blood glucose), and neurocognitive dysfunction (impairment in the functioning of the nervous system and brain). This review takes a practical approach to the assessment, nursing care, and medical treatment of diabetes in the elderly. It highlights major challenges and suggests solutions to these commonly encountered clinical problems. Enhanced content To view enhanced content for this article go to https://doi.org/10.6084/m9.figshare. 5868204. S. Kalra (&) Department of Endocrinology, Bharti Hospital, Karnal, India e-mail: S. K. Sharma College of Nursing, AIIMS, Rishikesh, India Keywords: Diabetes education; Diabetes nursing; End of life; Geriatric; Geriatric syndromes; Hypoglycemia; Neurocognitive dysfunction INTRODUCTION As the diabetes pandemic grows, and as persons with diabetes live longer, the prevalence of diabetes in the elderly is rising. The elderly constitute a significant proportion of all persons with diabetes. The elderly may seem to be a distinct and homogeneous class of individuals. In reality, however, the elderly are as heterogeneous as any other group of people. While many are as fit as younger adults, others experience challenges and limitations related to ageing. This review describes a practical approach to management of diabetes in elder persons who live with age-related medical and psychosocial health issues. The review also seeks to sensitize readers to deal with older persons in an appropriate manner. This article is based on previously conducted studies and does not involve any new studies of human or animal subjects performed by any of the authors. This practical approach paper will be reviewed on a biennial basis, or earlier if required, incorporating updates in the field of diabetes management in the elderly. The definition of elderly or older is itself uncertain. While the International Diabetes 494 Federation limits the use of this adjective to describe those above 70 years of age [1], the American Diabetes Association (ADA) includes all aged over 65 years as older [2]. The World Health Organization extends this label to persons who are 60 years or more of age [3]. The unique physiological constitution, biomedical needs, and psychosocial challenges of the elderly call for an individualized approach to their management. Such management should be tailored to the particular person’s requirements and should involve comprehensive interdisciplinary input from both nursing and medical care providers [4]. GLUCOSE METABOLISM AND AGE Diabetes is a disorder of glucose metabolism. It is not appreciated, however, that glucose metabolism varies with age in normal individuals as well. Glucose homeostasis, or balance, depends upon adequate insulin secretion from the pancreas and appropriate sensitivity of insulin receptors to the hormone. Both insulin secretion and insulin sensitivity are impaired with increasing age. Various factors frequently encountered in old age contribute to, or are associated with, insulin resistance. These include central obesity, induced by various environmental factors, secretion of AVP (arginine vasopressin) or its C-terminal fragment (copeptin). Vitamin D deficiency and hypomagnesemia have also been incriminated in the pathogenesis of diabetes in the elderly. Insulin secretion is impaired with advancing age as well [5]. Thus a 1–2 mg% increase in fasting blood glucose is noted with each decade. A 15 mg% rise in postprandial or post-challenge glucose levels is also seen after the third decade of life [6]. SCREENING Screening for diabetes is important in the elderly. The higher prevalence of diabetes in this age group suggests the need for a higher intensity of case-detection measures. The Diabetes Ther (2018) 9:493–500 diagnostic criteria for diabetes are similar in the elderly and in young adults. However, screening strategies and semiology may vary. Screening should be performed annually in the elderly, and opportunistic screening is recommended. This implies that plasma glucose should be checked whenever an elderly individual undergoes a routine or medically indicated blood test. A post-challenge or postprandial glucose test may be a better screening strategy than a fasting glucose estimation. Glycated hemoglobin, which assesses glucose control over the preceding 3 months, is a globally accepted parameter for diagnosis of diabetes. In the elderly, however, it has limited utility in diagnosis. This is because situations which affect red blood cell life-span (anemia, acute illness) occur frequently in the elderly [7]. SYMPTOMATOLOGY In the healthy person, glucose is reabsorbed by the kidney to ensure normal levels of glucose in the blood. In a person with diabetes, glucose is excreted through the kidney if it crosses a particular level, termed the renal threshold. The renal threshold for glucose increases with age, and thirst mechanisms are impaired. Thus the symptoms of polyuria (excessive urination) and polydipsia (excessive thirst) may not present early in elderly persons with diabetes. Patients may present with easy fatigability, refractory or recurrent infections, weight loss, or chronic vascular complications. Most of the common geriatric syndromes may be due to diabetes. Geriatric syndromes are commonly encountered clinical situations that have a substantial impact on functionality and quality of life in the elderly. These include pressure ulcers, incontinence, falls, functional decline, and delirium. Other geriatric syndromes that are accepted as such include dementia, hearing impairment, visual impairment, sarcopenia, malnutrition, frailty, immobility, and gait disturbance (Table 1). Four risk factors (older age, baseline cognitive impairment, baseline functional impairment, and impaired mobility) contribute to the majority of geriatric syndromes [8]. Diabetes can contribute Diabetes Ther (2018) 9:493–500 Table 1 Geriatric syndromes in the elderly with diabetes Hyperglycemia/metabolic decompensation Hypoglycemia Cognitive impairment Motor functional impairment Falls Visual impairment Auditory impairment Psychosocial impairment Polypharmacy Dependency to all these syndromes (Table 1), either directly through its sym (...truncated)