Introduction
Diabetes is different in the older population
Management strategies
Teamwork for managing diabetes in older people
Pharmacological therapy
Self-management in older patients
Conclusion
References

Introduction

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  

Diabetes is different in the older population

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

Epidemiology

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: 

  1. To control and treat hyperglycemia 
  2. To manage vascular complications 
  3. Patient and carer education
  4. 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 

Management strategies

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

Teamwork for managing diabetes in older people

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.

Pharmacological therapy

Oral medications

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

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. 

Self-management in older patients

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.

Conclusion

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

kalokly@gmail.com 

Dr Abhaya Gupta, Consultant Physician and Geriatrician, Glangwili Hospital, HywellDda University Health Board, Carmarthen, Wales

abhaya.Gupta@wales.nhs.uk


Key points 

  • 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.

References

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