Volume 12 Number 2, 1999, Pages 70 77
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Diabetes Care for Older Adults
Arshag D. Mooradian, MD, Sue McLaughlin, RD, CDE, Cecilia Casey Boyer, RN, MSN, CDE, and Jewel Winter, BSN, GNP
Diabetes is a common problem in older adults. Approximately 20% of individuals over 65 years of age have diabetes mellitus, and almost half of these individuals have not been diagnosed. However, there are widespread misconceptions about possible consequences of uncontrolled hyperglycemia, the rate at which diabetic complications develop, and the role of multidisciplinary management.
Overall, management strategies for diabetes in older adults are no different from those of diabetes in younger groups, with some exceptions. Unlike younger people with type 2 diabetes, who are often overweight, obesity is not that common among older diabetes patients. In nursing homes, the problem of being underweight is as common as that of being overweight. Thus, nutritional management should focus on weight gain for underweight elderly patients as much as it is focused on weight loss for obese patients.
In addition to diet and exercise, pharmacological therapy is often required for optimizing blood glucose control. Target blood glucose ranges should be individualized. In frail patients, fasting plasma glucose levels should range from 100 to 140 mg/dl, and postprandial values should be <200 mg/dl. Older subjects may require extra educational support to become proficient in self-monitoring of blood glucose.
The discovery of several classes of oral antidiabetic agents has increased the prospects of achieving better control of hyperglycemia with reduced risk of severe adverse events. Some of these agents, such as acarbose, miglitol, metformin, and troglitazone, do not cause hypoglycemia when used as monotherapy. As such, they are safer agents. On the other hand, the low cost of some sulfonylurea agents and a once- or twice-daily administration schedule make them an attractive option. Metformin appears to be especially useful in obese insulin-resistant patients. The available data on safety and efficacy of troglitazone in the elderly is insufficient. In addition, the cost of this agent is prohibitive for most patients with limited financial resources.
The use of a combination of two or three oral antidiabetic agents to delay the need for insulin therapy is now possible. The long-term effects of this approach are not known, and the cost of polypharmacy is of concern.
The recent data from the U.S. Census Bureau clearly show that older Americans are becoming an increasingly larger segment of the population.1 In 1994, one of eight Americans was over the age of 65, and it is estimated that by 2020, one in every six Americans will be over the age of 65.1
Increasing age is a major risk factor for the development of type 2 diabetes. The Third National Health and Nutrition Examination Survey (NHANES III) indicated that 18.5% of people aged 6574 years have diabetes.2 One-half of this group had not been previously diagnosed as having diabetes by their health care providers.2 When subjects with impaired glucose tolerance (IGT) are also included, approximately 40% of the older population has some degree of carbohydrate intolerance.2
In certain ethnic groups, such as Mexican Americans and to a lesser extent African Americans, the prevalence of diabetes is more than twice as high as for Caucasians. Pima Indians have the highest incidence of diabetes, with the prevalence of the disease in older adults of this population exceeding 50%.
The economic implications of this highly prevalent disease are enormous. It is estimated that the annual cost of diabetes care of older adults exceeds $5 billion.3 Despite the magnitude of the problem and its economic, social, and health implications, diabetes in older adults is often unrecognized and undertreated.
Widespread misconceptions among both health care providers and the public are a major barrier to the optimal management of diabetes in older adults.4 Some of these misconceptions are summarized in Table 1. We will attempt here to address these misconceptions. In addition, we will discuss current management strategies involving the interdisciplinary team.
Pathogenesis of Diabetes in Older Adults
This observation suggests that much of the diabetes in older adults in the United States is essentially preventable. The three most important risk factors in the pathogenesis of this disease in older adultssedentary lifestyle, poor dietary habits, and changes in body compositionare essentially modifiable risks.
Other pathogenetic factors are more difficult to circumvent. These include coexisting diseases, the use of medications with known adverse effects on carbohydrate (CHO) tolerance, and age-related changes in insulin secretion or action reported in various animal models and human subjects.6-9
The precise mechanisms of age-related changes in insulin secretory reserve or insulin action at target sites remain unknown. It is noteworthy that, although the majority of older adults with diabetes have type 2 diabetes, some may present with type 1 diabetes or may progress over time from a non-insulin-dependent state to an insulin-requiring state.
This time-dependent deterioration of CHO intolerance, irrespective of the antidiabetic regimen used, was well demonstrated in the recently published data from the United Kingdom Prospective Diabetes Study (UKPDS).10 This change appears to be at least partly related to the gradual depletion of pancreatic insulin secretory capacity. Studies in animal models indicate that aging is associated with altered insulin secretory activity along with alterations in gene expression within the pancreatic islet cells.8,9 In addition, clinical studies confirm the reduced insulin activity in aged subjects.6,7
Overall, it appears that although an age-dependent increase in CHO intolerance is common, much of the diabetes in the elderly is potentially preventable.
Diabetic Complications in Older Adults
In addition to the increased mortality risk associated with diabetes, there is significant morbidity associated with this disease. Increased urination can be a cause of urinary incontinence, interferes with sleep, causes dehydration, and increases the risk of falls. Poor vision secondary to hyperglycemia-associated changes in the lens may also increase the risk of falls. The fear of falling will force these patients to reduce their mobility. Hyperglycemia also increases platelet adhesiveness, which may increase the risk of stroke, MI, intermittent claudication, and impotence.20,21 Hyper-glycemia also decreases pain tolerance,22 which may lead to increased use of analgesics. Several studies have shown that hyperglycemia is associated with cognitive changes that would interfere with compliance.23-25 These cognitive changes improve with better glycemic control.24,25 Hyperglycemia can also interfere with immune system function and may increase the potential risk of infections and interfere with wound healing.
Older patients may be more vulnerable to most of the diabetes-related complications since these complications can develop in elderly subjects at an accelerated rate.26 This may be the result of the age-related homeostenosis whereby defense mechanisms against glucotoxicity are reduced. Alternatively, the apparent increase in susceptibility of elderly subjects to the ravages of uncontrolled hyperglycemia may be secondary to having diabetes undiagnosed for years before presentation with a complication.
The prevalence rate of retinopathy in diabetic subjects over 74 years of age ranges between 25 and 70%.27 Age itself is a predictor of retinopathy in older diabetic patients.27 Cataracts and glaucoma are also common complications in elderly diabetic subjects. Older people may be at increased risk of nephropathy as a result of increased use of nephrotoxic agents, such as non-steroidal antiinflammatory drugs (NSAIDs), in addition to the known age-related decline in renal function.
Painful peripheral neuropathy is also common in this age group. In one study over a 1-year period, 76.8% of diabetic subjects aged 6070 years complained of lower extremity pain compared to only 38.7% of control subjects.27 In addition, painful diabetic amyotrophy and diabetic neuropathic cachexia usually occurs in older patients with diabetes.27
MI, cerebrovascular accidents, and the increased incidence of amputations in older patients with diabetes are major causes of morbidity and mortality.27-29 The emergence of these complications also appears to be accelerated in the older patients.29
Finally, psychosocial complications, including depression, social isolation, and poverty, are more common in the elderly population.30 These coexisting psychosocial problems further complicate the management of these patients.
Management of Diabetes
Assessment of older patients
It should be kept in mind that symptoms of diabetes in the elderly can be atypical. Anorexia and weight loss, rather than the typical polyphagia, can be the presenting symptoms.34 Other atypical presentations include incontinence, falls, cognitive or behavioral changes, and pain intolerance. Many patients, however, may have no preceding symptoms and are admitted to the hospital with an acute diabetes emergency, such as hyperosmolar coma.
In addition to history, physical examination, and diagnostic testing, a comprehensive geriatric assessment should include evaluation of nutritional status, review of the individual's functional capabilities and psychosocial problems, and a thorough evaluation of gait and balance.
The functional assessment is a critical part of older subjects' evaluation. A commonly employed tool is evaluation of the activities of daily living (ADL), as well as instrumental activities of daily living (IADL), which include more complex and demanding activities than ADLs, such as answering the telephone, traveling, and managing money.35 The psychosocial evaluation should include at a minimum the Mini Mental Status Examination (MMSE)35 and a depression scale, such as the Geriatric Depression Scale (GDS).35 In addition, patients' environment and social life should be carefully assessed to address issues such as social isolation, dependency, poverty, and financial limitations.
The criteria for diagnosis of diabetes in the elderly are not different from those used for the general population.36 There is no reason to believe that the diagnostic criteria for diabetes should be modified for older adults.
The components of complete assessment are listed in Table 2.
Management goals should be individualized. Each case should be subjected to a vigorous risk/benefit analysis. Several considerations should be taken into account.
Life expectancy for a given individual is hard to estimate. Nevertheless, if the patient has a terminal condition, then multiple insulin injections and frequent (46 times/day) blood glucose monitoring cannot be justified.
The individual's functional capabilities and level of dependency should also be taken into account when management goals are set. Indeed, for patients with high levels of dependency, the risks of hypoglycemia outweigh the benefits of tight glycemic control. Unrealistic expectations for an older individual who has poor vision, poor dexterity, and no social support system are counterproductive.
All of these factors should be kept in mind. However, age per se should not be an excuse for denying optimal glycemic control to older subjects with diabetes.
Medical nutrition therapy
A nutrition assessment includes evaluation of medical diagnosis, measurements of anthropometric parameters and biochemical indices, and review of medications.38 A thorough nutrition history would include evaluation of the patient's food choices and eating patterns, use of alcohol or micronutrient supplements, weight history, and nutrient needs. Other elements in nutrition assessment include assessment of exercise history and existing psychosocial problems and of the patient's knowledge base pertaining to diabetes and nutrition, as well as the patient's willingness and ability to change. These elements of assessment are shown in Table 3.
Older adults, especially those with uncontrolled hyperglycemia, are at risk for nutritional deficiencies. The age-related changes in various physiological functions, including alteration in taste, smell, and gastric acidity, increase the risk of nutritional deficiency. Older diabetic subjects appear to be at greatest risk for vitamin B1, B12, C, D, and folate deficiency, as well as deficiency in various minerals, including calcium, zinc, and magnesium.39
Therefore, practitioners should watch for the clinical indicators of poor nutritional status. The most important indicator is a body weight change based on a range of normal (RON), i.e., the weight range at which a person appears to have stabilized during the past several years. In general, involuntary weight loss or gain of 10 lb. or more in 6 months is considered an indicator of poor nutritional status.40 Other indicators of poor nutritional status are listed in Table 4.
Because the so-called American Diabetes Association diet is no longer recommended, the nutritional therapy of subjects with diabetes should be individualized.
In general, caloric requirements decrease by 2030% in older adults. In addition to age, a number of factors determine the caloric requirements. These include gender, body size, body composition, and activity patterns.
The need for weight loss should be carefully evaluated. Low body weight has been associated with greater morbidity and mortality in the elderly. Older diabetic subjects, especially those in nursing homes, tend to be underweight rather than overweight.41
The protein content of the diet should constitute 1020% of calories, and under no circumstances should it be <0.8 g/kg/day. Increased protein and calorie requirements during wound healing, infection, and other stresses are acknowledged.42
The percentage of CHO in the diet should be individualized. In general, the total amount of CHO is more important than the source. Sucrose or sucrose-containing foods can substitute for other CHO in the meal plan.43,44
The fat content of the diet should also be individualized.44 Before prescribing a low-cholesterol, low-saturated-fat diet, the risk of aggravating cardiovascular disease risk should be weighed against the risk of malnutrition. If a low-cholesterol diet is initiated, restrictions should be limited to American Heart Association Step One guidelines.
The current recommendation of 2035 g of fiber per day may be too high for some older subjects. Fiber intake should be increased gradually and should be accompanied by adequate fluid intake or physical activity. Increasing fiber intake in bedridden, dehydrated, older subjects may precipitate the terminal reservoir syndrome, a condition that occurs in some individuals with poor gut motility whereby increasing fecal materials will accumulate in the last segment of sigmoid colon.
The current recommendation to limit alcoholic drinks to 2/day44 may also be excessive for many older adults who often have decreased tolerance to alcohol. The degree of sodium restriction <2,400 mg/day for treatment of hypertension or congestive heart failure should be carefully evaluated. The decreased taste perception associated with aging in combination with severe sodium restriction may result in inadequate food intake.
Micronutrient supplementation should be individualized based on suspected or documented micronutrient deficiency.45 For those with poor dietary intake, a daily multivitamin supplement may be appropriate. All older adults should be encouraged to take at least 1,000 mg of elemental calcium daily. In general, large doses of vitamins should be avoided.44,45
In long-term care settings, malnutrition is a serious problem, and dehydration is common.41,46 The common causes of malnutrition related to food services in long-term care include inappropriate restrictions, poor quality of food, lack of choice and variety, and lack of consideration for ethnic and cultural preferences.
If an older person is unable to meet nutritional needs through a normal solid food diet, then nutrition support intervention is indicated. This can be as simple as modifying the usual food intake by changing nutrient content, food density, or texture, or it can be a more complex regimen using enteral and parenteral supplementation.
The old ADA diet had no significant effect on glycemic control in diabetic residents in long-term care.47 The "consistent CHO meal plan" is a new system recommended for long-term care facilities.48 The plan incorporates the basic principles of sound diet and distributes CHO throughout the day. It includes small portions of regular desserts, and CHO provided at meals and snacks, as long as they are consistent from one day to the next. This plan focuses on providing diabetic residents of long-term care facilities with food that is appealing and similar to that provided to other residents, but that does not have adverse effects on glycemic control.
However, potential risks should be borne in mind. These include fluctuations in blood glucose levels, soft tissue or bone injury, arrhythmias, MI or sudden death, and possibly vitreous hemorrhage or retinal detachment with strenuous isometric exercises. The latter is of concern in those with proliferative diabetic retinopathy or those with a history of retinal bleed.
Thus, safety guidelines should be strictly followed. Complete medical evaluation with electrocardiograms and exercise tolerance testing is recommended. The patient should be told to start slowly and advance as tolerated. At least 10 minutes of warm up and 10 minutes of cool down periods should be included.
Blood glucose levels should be monitored before and after exercise to establish blood glucose response patterns to the exercise regimen. If blood glucose is >250 mg/dl, the patient should delay the exercise session. If blood glucose is <120 mg/dl, then a snack may be appropriate. To avoid hypoglycemia, patients should avoid exercising during peak insulin action and should use the abdominal area for insulin injections for consistency of insulin absorption. It is also advisable to carry a CHO source and personal identification, and, if any discomfort occurs during exercising, to stop the activity and notify the physician.
Currently, there are five classes of oral antidiabetic agents. These include sulfonylureas, biguanides (e.g., metformin), alpha-glucosidase inhibitors (e.g., acarbose or miglitol), thiazolidinediones (e.g., troglitazone), and meglitinide analogs (e.g., repaglinide).
Clinical experience with troglitazone is very limited, and the cost may be prohibitive for some patients. In addition, the clinical efficacy may not be appreciated for up to 2 months of treatment, making it an unsuitable agent for those who would require more prompt blood glucose control. Patients on troglitazone should have their liver enzymes monitored closely. Monotherapy indication for troglitazone was recently withdrawn.
The clinical advantage of repaglinide compared to short-acting sulfonylureas is not established.
There is a wealth of clinical experience with sulfonylureas, and the cost of some preparations is very affordable. With the exception of chlorpropamide, the clinical efficacy and safety of various sulfonylurea agents are comparable. However, some pharmacokinetic and pharmacodynamic considerations may favor the use of glipizide in older patients. The clinical significance, however, of the differences in the pharmacology of these agents is not known. Because of the very long half-life and antidiuretic hormone-potentiating effects, chlorpropamide should not be used in the older patient population. The potential concerns with sulfonylureas and repaglinide include increased incidence of hypoglycemia, weight gain, and hyperinsulinemia.
The other two classes of agents, biguanides and alpha-glucosidase inhibitors, are not associated with hypoglycemia when used as monotherapy. However, the two agents currently available, namely metformin and acarbose respectively, often require multiple administration schedules, and both are associated with high incidence of gastrointestinal discomfort. Thus, dosing should always start at low levels (such as metformin 500 mg once or twice a day or acarbose 25 mg once a day with the first bite of a meal), and dose escalation should be gradual and slow. Of concern is that the multiple coexisting diseases and impaired renal function commonly found in elderly subjects may increase the risk of metformin-associated lactic acidosis. In addition, the drop in plasma vitamin B12 level, although not of clinical significance in the majority of patients, should be monitored considering the increased propensity of older patients to vitamin B12 deficiency.50
With the availability of antihyperglycemic agents that do not cause hypoglycemia when used as monotherapy, it is now possible to lower blood glucose levels in many frail, elderly patients without undue risk of hypoglycemia.
Advanced age should not preclude the use of insulin. The choice of the type of insulin depends on the desired onset and duration of action. Insulin administration should match food intake schedule. It should be kept in mind that up to 20% error in insulin dosage may occur and that premixed insulins are alternatives.52 The latter preparations, however, should not be given at bedtime or used in a sliding scale or in supplemental insulin regimens. Many insulin injection aids are now available to help achieve more independence and self-management of diabetes in older adults with visual impairment or poor dexterity.
As stated earlier, the initial choice of antidiabetic agents should be individualized. A general algorithm of drug therapy in elderly patients is suggested in Figure 1.50
Patients with IGT, namely those with fasting plasma glucose (FPG) of <140 mg/dl and postprandial plasma glucose (PPG) of >200 mg/dl may benefit from dietary and exercise recommendations tailored to individual capabilities. If PPG is persistently >200 mg/dl, then acarbose or miglitol treatment can be initiated unless there is a contraindication. If FPG levels are consistently >300 mg/dl, initiation of insulin therapy is appropriate, along with diet and exercise. Many of these patients may be able to have their insulin discontinued and have their blood glucose levels maintained on diet with or without an oral agent.
If the patient is symptomatic and there is clinical evidence of dehydration or hyperosmolarity, then insulin therapy should be initiated in a hospital setting. Otherwise, outpatient education and initiation of insulin is appropriate.
If FPG is consistently <300 mg/dl, then the options are insulin, sulfonylurea, alpha-glucosidase inhibitors such as acarbose or miglitol, and metformin if no contraindications to its use can be identified. Certain individuals may be better candidates for specific agents. For example, metformin may be a better choice for an obese individual, while patients with predominant postprandial hyperglycemia are good candidates for acarbose. However, more studies are needed to define the drug of choice in various patient subgroups.
If monotherapy does not achieve the glycemic goals, then combination therapy should be considered. The likelihood of achieving and maintaining near-normoglycemia with a single agent is small. However, the increased cost and possibly increased adverse events as a result of drugdrug interactions during combination therapy are of concern.
The goals of management should be individualized. Coexisting cardiac risk factors, such as hypertension, hyperlipidemia, and cigarette smoking, must be addressed. The principal goal of therapy is to enhance quality of life without undue risk of hypoglycemia. In general, it is desirable to achieve FPG of <140 mg/dl and PPG levels of <200 mg/dl.
In the frail elderly, especially those in nursing homes, it is best to avoid FPG or bedtime plasma glucose levels of <100 mg/dl if the patient is on insulin or sulfonylurea therapy. In this population, the life expectancy of the individual is an important determinant of the glycemic goals.46
Patient education and monitoring
Effective education starts with an assessment of educational needs and readiness to learn. Just as diabetes treatment needs to be individualized, so do educational needs. Many people with diabetes have had no formal diabetes education, often despite years of living with diabetes. There may be many misconceptions, fears, and/or myths that need to be explored or acknowledged. Health beliefs, culture, and religious beliefs may also influence adherence to diabetes treatment and management plans.
It is important to utilize principles of adult learning when providing education to older adults with diabetes. These principles include recognizing previous experiences, using a variety of teaching methods, adapting teaching materials to accommodate learning (i.e., large print, additional time for practicing skills), using a variety of teaching materials, making the education relevant, and actively including the person in the learning process.
Breaking more complicated skills/information into smaller, simpler steps may assist with retention and mastery. Providing opportunities to practice skills and ask questions, as well as providing positive feedback, are all important.
One-on-one and group classes can provide needed socialization and support for older adults. Other factors that may influence learning include the aging process, other medical conditions/medications, and emotions. Including the family/caregivers in the assessment and education process is essential since they may be providing the care as well as reinforcing education/monitoring practices. Utilization of community resources (i.e., Meals on Wheels, Red Cross for transportation, local diabetes organizations for education and support groups, home care nurses/aides) is also important.
Follow-up is important to clarify questions and concerns, as well as to encourage and motivate patients. Phone follow-up may be more realistic due to transportation problems and can be helpful in providing education in conjunction with regular follow-up appointments or in using community resources.
Appropriate tools or aids should be provided to circumvent some of the limitations associated with poor vision and poor dexterity. The glucose meters provided should be easy to use, have large display screens, require no cleaning, and have memory capabilities.
Older adults with diabetes are often incorrectly stereotyped as being slow and unmotivated in managing their diabetes. In fact, many older adults with diabetes are enthusiastic, motivated learners actively involved in all aspects of their diabetes treatment plan. When older patients are appropriately educated, they are capable of carrying out self-monitoring of blood glucose as accurately as do younger people.53 The frequency of monitoring should be individualized based on the type of diabetes treatment and frequency of dose adjustment and financial resources of the individual.
The older diabetes population is a highly heterogeneous group. Nutritional, psychosocial issues, and coexisting medical problems further complicate diabetes management. Therefore, management should begin with a comprehensive assessment and should be individualized.
With the availability of new antihyperglycemic agents, it is now possible to control blood glucose levels without the risk of hypoglycemia. More studies as to the cost-benefit ratio of each pharmacological agent would be helpful.
Given the complexity of the disease itself and the multiple complicating factors, an interdisciplinary team working in conjunction with community resources is needed for optimal management of diabetes in older patients.
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The authors would like to thank Linda Cann and Phyllis Barrier of the American Diabetes Association for their helpful suggestions. The authors also thank Abbott Laboratories, Ross Products Division, for their financial support.
Arshag D. Mooradian, MD, is a professor of internal medicine and director of the Division of Endocrinology, Diabetes, and Metabolism at St. Louis University in St. Louis, MO. Sue McLaughlin, RD, CDE, is a consultant nutritionist in Omaha, Neb. Cecilia Casey Boyer, RN, MSN, CDE, is a diabetes clinical nurse specialist at Ohio State University in Columbus. Jewel Winter, BSN, GNP, was the 1994-95 president of the National Conference of Gerontological Nurse Practitioners in Denver, Colo. All of the authors are members of the American Diabetes Association Task Force for Developing a Continuing Education Program on Diabetes in Older Adults.
Note of disclosure. Dr. Mooradian has received honoraria and grant research support from Bristol-Myers Squibb, Bayer Corp., Eli Lilly, and Pfizer; Ms. McLaughlin has received consulting fees from Lifescan Corp; and Ms. Boyer has received honoraria from Eli Lilly and Parke-Davis. All of these companies manufacture or market products for the treatment or management of diabetes in the elderly.
Address correspondence and reprint requests to: Arshag D. Mooradian, MD, Division of Endocrinology, St. Louis University, 1402 S. Grand Blvd., St. Louis, MO 63104.
Copyright © 1999 American Diabetes Association
Last updated: 5/99