Managing diabetes in the elderly: Go easy, individualize
ABSTRACTThe care of elderly patients with diabetes should be individualized, taking into account the patient's comorbidities, other medications, cognitive abilities, home care situation, and life expectancy. Especially in frail, elderly patients, there should be less emphasis on strict glycemic control than on avoiding malnutrition and hypoglycemia and achieving the best quality of life possible.
KEY POINTS
- The diagnosis of diabetes in the elderly is often missed because its symptoms, such as dizziness, confusion, and nocturia, are often common and nonspecific.
- Elderly people at risk of malnutrition should have unrestricted meals and snacks; medications should be adjusted as necessary to control blood glucose levels.
- Tight control of blood glucose reduces the risk of death and diabetes-related complications but poses the risk of hypoglycemia.
INDIVIDUALIZED MANAGEMENT IS BEST
Despite disease differences, the general goals for diabetes care are the same for all ages:
- To control hyperglycemia and its symptoms
- To prevent, evaluate, and treat macrovascular and microvascular complications
- To teach patients to manage themselves
- To maintain or improve the patient’s general health status.
Unfortunately, most specific recommendations are based on studies in younger people. Guidelines should ideally reflect the complexities of a particular clinical situation, but most recommendations are applied to the young and old alike, as well as to the relatively healthy and the frail and ill.15–17 Consideration should be given to a patient’s health beliefs, severity of vascular complications and other medical problems, economic situation, life expectancy ,functional status, and availability of support services. In addition, some patients prefer aggressive treatment, while others would rather compromise some aspects of care in order to maintain a certain quality of life, to save money, or to avoid having caregivers provide treatment.
Age-related changes in pharmacokinetics as well as polypharmacy increase the risk of drug interactions and adverse effects, especially drug-induced hypoglycemia. In addition, age-associated changes in cognitive, visual, and physical function, dentition, and taste perception can reduce a patient’s ability to carry out treatment. Frequent hospitalizations also disrupt outpatient regimens.
Comorbidities make treatment more challenging, but some conditions—such as hypertension, renal insufficiency and eye disorders—make doctors more likely to control hyperglycemia more aggressively, fearing that the loss of a little more function in an impaired organ may lead to failure.
The benefits of tight glycemic control should be weighed against the risks and the realities of an individual situation. Priority should be given to achieving the best quality of life possible.17 Recent guidelines from the California Health Foundation and the American Geriatrics Association focused on the major health threats to older patients and prioritizing care for each person.15 The guidelines recommend screening for geriatric syndromes that are more prevalent inpatients with diabetes or are strongly affected by the disease or its treatment. Diabetes care should be examined in the setting of common geriatric problems: depression, polypharmacy, cognitive impairment, urinary incontinence, falls, and pain.
Heart risk trumps glycemic control
The expert panel15 concluded that rates of disease and death can be reduced more by targeting cardiovascular risk factors than by intensively managing hyperglycemia. One rationale is that it takes 8 years for aggressive glycemic control to reduce the risk of diabetic retinopathy or renal disease but only 2 years of treating hypertension and dyslipidemia to reduce the risk of cardiovascular disease.15,17–21 A recent Japanese study found normal mortality rates in elderly patients under long-term, intensive multifactorial diabetes control.22 High-functioning, motivated patients could benefit from therapy aimed at achieving most or all of the recommended goals, but frail patients may suffer from applying all therapies and may benefit from only some of them.
If appropriate goals cannot be met, it may help to refer patients to a geriatric specialist to evaluate possible barriers to adherence such as depression or poor cognition, physical functioning, or support.
MANAGEMENT STRATEGIES
Weight loss and exercise help prevent diabetes
The Diabetes Prevention Program23 randomized 3,234 people (mean age 51 years) with impaired glucose tolerance to receive either metformin (Fortamet, Glucophage) 850 mg twice daily or placebo or to undertake lifestyle modifications with goals of at least a 7% weight loss and at least 150 minutes of physical activity per week. Compared with the placebo group, the lifestyle modification group had a 58% lower incidence of diabetes while those in the metformin group had only a 31% lower incidence. Among those older than 60 years, the advantage of lifestyle modification over metformin was even greater.
