Diabetes is different in the older population
Teamwork for managing diabetes in older people
Self-management in older patients
Modern lifestyles and the rate of population ageing have shifted the epidemiology of diabetes towards old age particularly those aged 60-79 years.1 Diabetes and ageing both are considered as important risk factors for disability and functional decline that adversely affect the quality of life.2 Diabetes-related vascular complications appear to account for less than half of diabetes-related disability in elderly and it is proven that sarcopenia and frailty are the new complications of diabetes and major factors for disability.3
However, aggressive control of diabetes can lead to other unrecognisable complications like hypoglycemia in older people. Therefore, while treating diabetes in the elderly, management should be individualised taking other factors like frailty score, home situation, cognitive abilities, self-management capability.4
The term “elderly” comprises a heterogeneous group of people aged more than 65 years with widely varying life expectancy, physiologic profile and functional capabilities. Ageing is associated with a reduction in beta-cell function and lower blood insulin levels with or without insulin resistance.
The risk of developing type 2 diabetes mellitus increases with ageing due to obesity, lack of physical activity, and loss of muscle mass.5 Patients who develop diabetes at an older age have normal hepatic glucose production, in contrast to those who develop in the middle age. Additionally, those groups of patients will have near-normal fasting glucose and significantly raised post-prandial hyperglycemia.6
Diabetes is common condition in the older patient. By the age of 75 years approximately 20% of the population are affected. The estimated prevalence of diabetes adjusted to the national population in the UK will increase to 7.5% in 2030 from 6.8% in 2011, with the mean annual increment of 31,000 diabetic patients.7
Symptoms are often not specific in elderly patients
Diagnosis of diabetes in older people is often missed or delayed because the presenting symptoms many times are nonspecific, e.g. weight loss, tiredness, falls, confusion, dizziness, nocturia, or urinary tract infection.
The classical symptoms like polyuria, polydipsia usually occur only when blood glucose levels are more than 11.1 mmol/L. This is because the renal threshold for glucose increases with age. Elderly patients with lesser degrees of hyperglycemia might not have symptoms or may present with a reduction in cognition or weight loss or symptoms of chronic infections like genitourinary or skin infection.8 In frail nursing home patients, nonketotic hyperosmolar coma may be the first presentation. Diabetic cachexia presents as weight loss, depression, neuropathy.
Diabetic older patients are less likely to be obese and more hypertensive than younger patients. Though The American Diabetes Association recommends screening for diabetes by measuring the fasting plasma glucose level every three yearly beginning at 45 years, some experts think that it is not adequate for the elderly population.9
Lack of guidelines or evidence for the effective management
There is a lack of evidence for the effective management of diabetes in older age groups because the most specific recommendations are based on studies in younger people. Elderly have been previously excluded from the clinical trials. Only 1.4% of clinical trials recruit older people and small percentage still specifically work with frail population.10.
Individualised management is the best management
The general target for diabetes care is the same for all age groups:
- To control and treat hyperglycemia
- To manage vascular complications
- Patient and carer education
- To improve the overall general health of patients
Unfortunately, the most specific recommendations are based on studies done in young people. However, a health care provider should also consider patients’ health belief, vascular complications, other medical problems, life expectancy, and functional status. Changes in pharmacokinetics and polypharmacy increase the risk of adverse effects, drug interactions, drug-induced hypoglycemia. Anatomic and physiologic changes in cognition, vision, function, teeth care, and taste perception can affect the patient’s ability to carry out the treatment. Recurrent hospital admissions can also alter diabetic regimens.
Other comorbidities like hypertension, renal dysfunction, and ophthalmic problems may prompt clinicians to control hyperglycemia more aggressively. However, the benefits and risks of aggressive glycaemic control should always be considered based on the individual situation. The best quality of life should be given a priority.11 The recent national collaborative stakeholder initiative recommends routine clinical assessment for frailty in diabetes care system, high quality individualised and safer care of people with diabetes.12
Detecting frailty and developing assessment toolkit in the community
The earlier we can detect frailty, the better-targeted interventions can be implemented which can decrease the functional decline and the risk of disability.12 Using a validated tool like Electronic Frailty Index in early stages of the condition has been supported by NHS England and British Medical Association for the early identification of frailty in people aged >65 years in 2017/2018 General Practitioner Contract.13
In the later and more severe states of frailty, the adaptation of other tools such as Gait speed assessment, application of Clinical Frailty Scale,13 the five-item FRAIL score can be useful. One study suggests using these developments into diabetes care system/pathways in both primary and secondary care.12 Figure 1 depicts the steps for detecting frailty in older adults with diabetes including additional roles of specialist review.
Frailty assessment pathway in diabetes
Figure 1: Implementable frailty assessment scheme
Framework for individualised goal setting
Use of polypharmacy in the elderly population can lead to a higher risk of recurrent falls and functional impairment that can ultimately lead to non-adherence and adverse drug reactions.14 Although various international guidelines such as NICE, the European Association for the Study of Diabetes and American Diabetes Association suggest the glycaemic targets of HbA1c 53-59 mmol/mol (7-7.5%) these are too tight for frail older individuals.15
The established guidelines are suggested by W.D. Strain et al,12 for older people who have been through the assessment process discussed in Figure 1. These guidelines are consensus-based rather than evidence-based because of a lack of outcome data for individualised goal setting. However, this approach is based on the best available evidence. The main importance is on frail individuals who are at high risk of over-treatment with glucose-lowering medications. The recommendations for deprescribing are also included in this approach. This leads to the overall best possible care and safety with the least harm to the elderly population.16
Due to the complexity of the medical and social issues in the older patient, it is important for medical practitioners to work together with dietician, social worker, pharmacists and diabetes educator. The carer also needs education in diabetes care.
Non-pharmacologic therapy: Though, non-pharmacologic steps like diet and exercise are limited in the elderly, these should be implemented if possible.
Diet: Carbohydrate restrictions can be harmful in the elderly, especially those living in long-term health care facilities because of the risk of malnutrition. Those who are in danger of malnutrition should be given unrestricted meals with a fair amount of carbohydrate at meals and snacks. Medications, rather, should be adjusted to control blood sugars if required.17
Multi-vitamin supplementations can be useful and may improve glycaemic control.18
Exercise: In addition to the reduction in insulin resistance, weight and blood pressure, exercise also increases muscle mass, and improves lipid levels. Aerobic and Nonaerobic exercises are beneficial.19 The best time to exercise is 1 to 2 hours after a meal.
Metformin remains ideal first-line drug for obese older patients. There is age related risk of serious or even fatal hypoglycemia with sulfonylureas in this age group depending on type of sulphonylurea, polypharmacy, renal dysfunction and alcohol consumption.
A recent review has found that the older agents (metformin, second-generation sulfonylurea) have similar or superior effects on glycemic control, lipids compared to newer and more expensive agents (thiazolidinediones, alpha-glucosidase inhibitors and meglitinides).20 For older patients, the recommendation is to start with about half the recommended dosage.
Insulin therapy is required, usually for patients with moderate or severe hyperglycemia and/or those with renal or hepatic insufficiency, if a combination of oral therapy is insufficient. However, before considering insulin therapy to elderly patients, we need to evaluate their visual function, sensations, cognition, family and/or community support, as there is a high risk of complications like hypoglycemia. Nonetheless, many studies have shown the improvement in the quality of life in the year after starting insulin for patients whose blood sugar was previously uncontrolled with oral agents.21
An evening dose of long-acting insulin-like neutral protamine hagedorn (NPH) insulin is a good way to start insulin therapy. There are other options like premixed insulin preparations are available, which may improve accuracy, acceptability and ease of use but may increase the risk of hypoglycemia.
Some patients may not achieve good control on fixed-dose regimens,22 Sometimes small, titrated dose of short-acting insulin might be useful, but these regimens may be too complex for the elderly population and a good patient support system must be in place before recommending this therapy. Most of the insulin preparations are available in vials and in pens. Pens are easy and quick to use, provide precise doses and managed well by many elderly patients.
Newer anti-diabetic drugs
Incretins, such as glucagon-like peptide-1, are hormones released from the gut which secrete insulin by non-glucose related pathways. Exenatide, a 39-amino-acid peptide incretin mimetic, is approved for treating type 2 diabetes, it is given subcutaneously.23
Oral dipeptidyl peptidase-4 inhibitors (sitagliptin, vildagliptin, linagliptin) prolong the action of incretins by decreasing its degradation and prolonging half-life.24 As the key mechanism for diabetes in the elderly is a gradual decline in glucose-mediated beta-cell insulin secretion, these drugs might be helpful for this population. However, further research and experience is needed before specific recommendations for elderly patients can be made.
Patient education is the key
Patient education is crucial for diabetes self-management25 and is of paramount importance especially for patients with cognitive impairment or limited language proficiency.
Home glucose monitoring is simpler now
Ideally, all insulin regimen should be tailored as per home blood glucose level monitoring daily e.g. before and after meals and at bedtime. It is easy and reliable to teach most elderly patients to monitor their own blood glucose without effects on their quality of life. Talking glucometers are also available for blind patients.
Both life expectancy and prevalence of diabetes are continuing to increase. Management of diabetes in older patients is challenging due to the complex medical, physiological, social, environmental factors. Diagnosing and treating diabetes in elderly requires a flexible and unique approach with most important goal of avoiding hypoglycemia.
Assessment of frailty, involving the multidisciplinary team and managing polypharmacy and comorbidity are the key aspects of management.
Kalyan Mansukhbhai Shekhda, Specialty Doctor, Stroke Medicine, Lister Hospital, East and North Hertfordshire NHS trust, Stevenage
Dr Abhaya Gupta, Consultant Physician and Geriatrician, Glangwili Hospital, HywellDda University Health Board, Carmarthen, Wales
- Diagnosis of diabetes in the older patient is often missed or delayed because symptoms like confusion, dizziness, nocturia are common and are often non-specific.
- Though strict glycaemic control reduces the risk of death and diabetes-related complications, it poses a greater risk of life-threatening hypoglycemia in the elderly.
- Sulfonylureas increase risk of life threatening hypoglycemia in elderly.
- Those who are at high risk of malnutrition should have unrestricted meal and food; the medications should be adjusted as needed to manage diabetes.
- Assessment of frailty, consideration of polypharmacy, comorbidity, carer education, multidisciplinary care are key aspects of management.
- Whiting DR, Guariguata L, Weil C, Shaw J. IDF Diabetes Atlas: Global estimates of the prevalence of diabetes for 2011 and 2030. Diabetes Res ClinPract 2011; 94: 311–321.
- Wong E, Backholer K, Gearon E, Harding J, Freak-Poli R, Stevenson C et al. Diabetes and risk of physical disability in adults: a systematic review and meta-analysis. Lancet Diabetes Endocrinol 2013; 1: 106–114.
- Maggi S, Noale M, Gallina P, Marzari C, Bianchi D, Limongi F et al. Physical disability among older Italians with diabetes. The ILSA Study. Diabetologia 2004; 47: 1957–1962.
- Sinclair AJ, Abdelhafiz AH, Rodrıguez-Ma~nas L. Frailty and sarcopenia - newly emerging and high impact complications of diabetes. J Diabetes Complications 2017; 31: 1465–1473.
- Edelstein SL, Knowler WC, Bain RP, et al. Predictors of progression from impaired glucose tolerance to NIDDM: an analysis of six prospective studies. Diabetes 1997; 46:701–710.
- Meneilly GS, Tessier D. Diabetes in elderly adults. J Gerontol A BiolSci Med Sci 2001; 56:M5–M13.
- Whiting, David &Guariguata, Leonor & Weil, Clara & Shaw, Jonathan. IDF Diabetes Atlas: Global estimates of the prevalence of diabetes for 2011 and 2030. Diabetes research and clinical practice. 2001;94. 311-21. 10.1016/j.diabres.2011.10.029.
- Motta M, Bennati E, Ferlito L, Malaguarnera M. Diabetes mellitus in the elderly: diagnostic features. Arch GerontolGeriatr 2006; 42:101–106.
- Hoerger TJ, Harris R, Hicks KA, Donahue K, Sorensen S, Engelgau M. Screening for type 2 diabetes mellitus: a cost effective analysis. Ann Intern Med 2004; 140:689–699.
- Cruz-Jentoft AJ, Michel JP. Sarcopenia: A useful paradigm for physical frailty. EurGeriatr Med 2013; 4: 102–105.
- Durso SC. Using clinical guidelines designed for older adults with diabetes mellitus and complex health status. JAMA 2006; 295:1935–1940.
- Strain W, Hope S, Green A, Kar P, Valabhji J, Sinclair A. Type 2 diabetes mellitus in older people: a brief statement of key principles of modern day management including the assessment of frailty. A national collaborative stakeholder initiative. Diabetic Medicine. 2018;35(7):838-845.
- NHS England. NHS Five Year Forward View. NHS England, 2014.
- Hubbard RE, Andrew MK, Fallah N, Rockwood K. Comparison of the prognostic importance of diagnosed diabetes, co-morbidity and frailty in older people. Diabet Med 2010; 27: 603–606.
- Tjia J, Velten SJ, Parsons C, Valluri S, Briesacher BA. Studies to Reduce Unnecessary Medication Use in Frail Older Adults: A Systematic Review. Drugs Aging 2013; 30: 285–307.
- Lipska KJ, Ross JS, Miao Y, Shah ND, Lee SJ, Steinman MA et al. Potential overtreatment of diabetes mellitus in older adults with tight glycemic control. JAMA Intern Med 2015; 175: 356–362.
- Sjoblom P, Anders T, L€ofgren UB, Lannering C, Anderberg N, Rosenqvist U et al. Can diabetes medication be reduced in elderly patients? Diabetes Res ClinPract 2008; 82: 197–202.
- Coulston AM, Mandelbaum D, Reaven GM. Dietary management of nursing home residents with non-insulin-dependent diabetes mellitus. Am J ClinNutr 1990; 51:67–71.
- Agurs-Collins TD, Kumanyika SK, Ten Have TR, Adams-Campbell LL. A randomized controlled trail of weight reduction and exercise for diabetes management in older African-American subjects. Diabetes Care 1997; 200:1503–1511.
- Bolen S, Feldman L, Vassy J, et al. Systematic review: comparative effectiveness and safety of oral medications for type 2 diabetes mellitus. Ann Intern Med 2007; 147:386–399.
- Reza M, Taylor CD, Towse K, Ward JD, Hendra TJ. Insulin improves well-being for selected elderly type 2 diabetic subjects. Diabetes Res ClinPract 2002; 55:201–207.
- Janka HU, Plewe G, Busch K. Combination of oral antidiabetic agents with basal insulin versus premixed insulin alone in randomized elderly patients with type 2 diabetes mellitus. J Am Geriatrics Soc 2007; 55:182–188.
- Kendall DM, Riddle MC, Rosenstock J, et al. Effects of exenatide (exendin-4) on glycemic control over 30 weeks in patients with type 2 diabetes treated with metformin and a sulfonylurea. Diabetes Care 2005; 28:1083–1091.
- Mathieu C, Bollaerts K. Antihyperglycaemic therapy in elderly patients with type 2 diabetes: potential role of incretinmimetics and DPP-4 inhibitors. Int J ClinPract 2007; 61(suppl 154):29–37.
- Huang ES, Gorawara-Bhat R, Chin MH. Self-reported goals of older patients with type 2 diabetes mellitus. J Am GeriatrSoc 2005; 53:306–311.