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Preventing and managing diabetic complications in elderly patients

Cleveland Clinic Journal of Medicine. 2008 February;75(2):153-158
February 1, 2008|Type 2 Diabetes ICYMI
Thomas Hornick, MD;David C. Aron, MD, MS
Author and Disclosure Information

Thomas Hornick, MD
Associate Professor of Medicine, Division of Geriatrics, Department of Medicine, Case Western Reserve University School of Medicine; and Director, Geriatrics Research Education and Clinical Center, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland

David C. Aron, MD, MS
Professor of Medicine and Epidemiology and Biostatistics, Divisions of Clinical and Molecular Endocrinology and Epidemiology and Biostatistics, Department of Medicine, Case Western Reserve University School of Medicine; Associate Chief of Staff/Education and Associate Director (Health Services Research), Geriatrics Research Education and Clinical Center, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland; member of the Performance Measures Subcommittee of the Endocrine Society, and Chair, Diabetes/Endocrine Field Advisory Committee, Department of Veterans Affairs

Address: David C. Aron, MD, MS, Education Office 14(W), Louis Stokes Cleveland Department of Veterans Affairs Medical Center, 10701 East Boulevard, Cleveland, OH 44106; e-mail david.aron@va.gov

ABSTRACTElderly patients with diabetes are prone to a number of complications, some of which take precedence over or hinder or preclude the intensive glucose control recommended for younger diabetic patients. This article reviews some of these complications, including coronary artery disease, retinopathy, neuropathy, nephropathy, and others.

KEY POINTS

  • Compared with strict glycemic control, treating cardiovascular risk factors offers more benefit in a shorter time and should be a higher priority.
  • Diabetic retinopathy is a leading cause of blindness. Yearly eye examinations are recommended.
  • Elderly patients with diabetes are prone to rapidly progressive nephropathy, especially after receiving iodinated contrast agents. Good glycemic control and control of blood pressure, especially with angiotensin-converting enzyme inhibitors, reduce the risk and the rate of progression.
  • Elderly patients with diabetes are at higher risk of cognitive decline, depression, and polypharmacy, all of which impede good diabetes management.

POLYPHARMACY

Many elderly patients take multiple medications. Polypharmacy increases the risk of drug side effects, interactions, and nonadherence to taking medications.37–39 This problem is increased in diabetes, in which several medications are necessary to manage hyper-glycemia, hyperlipidemia, hypertension, and other associated conditions.

Patients should keep accurate medication lists, including over-the-counter medications, herbs, and nutritional supplements. Physicians should carefully review each medication to check if it is appropriate and used correctly.

FALLS

Elderly patients with diabetes mellitus are at increased risk of injurious falls, which are associated with high rates of complications, death, and functional decline.40,41 Risk factors include frailty and functional disability, visual impairment, peripheral or autonomic neuropathy, hypoglycemia, and polypharmacy.

Elderly patients should be screened for their risk of falls, and appropriate measures should be instituted. The American Geriatrics Society has guidelines for preventing falls in the elderly.41

URINARY INCONTINENCE

Elderly women with diabetes are at increased risk of developing urinary incontinence. Risk factors include autonomic neuropathy (causing either neurogenic bladder or fecal impaction), polyuria due to hyperglycemia, and urinary tract and vaginal infections. Although evidence is lacking that urinary incontinence affects glycemic control, assessing and treating the condition improves quality of life.

SUMMARY

Diabetes is a common problem in the elderly, accounting for considerable morbidity and mortality. In a large longitudinal analysis (> 50,000 patients), elderly persons newly diagnosed as having diabetes experienced high rates of complications during 10-year follow-up, far in excess of elderly persons without diabetes.42 Diabetes is underdiagnosed in the elderly and is frequently undertreated. Management of the elderly with diabetes presents unique challenges because of associated comorbidities, but with attention to detail and individualized approaches, quality and duration of life can be optimized. The greatest attention should be given to reduction of overall cardiovascular risk. Glycemic goals and the treatment regimens to achieve those goals should be individualized and chosen to control hyperglycemic symptoms and achieve the maximal glycemic control possible while minimizing the risk of hypoglycemia. Diabetes will continue to be a challenge to the patient, the physician, the care team, and the health care system.

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