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Diabetes in the Elderly

by Rinku Khumukcham
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By: Dr. Chakshu Ch.
With improving life expectancy, better availability of healthcare, and increased awareness about diabetes, the prevalence of diabetes in the elderly (above 70 years of age) is gradually increasing in India. The geriatric population now forms an important subset of our patients attending OPD for diabetes management. Even in the inpatient admissions, diabetes is very common accompaniment in elderly population. Guidelines published nationally or internationally may not always apply to elderly population. Generally diabetes management is pursued comprehensively in the elderly, and treatment offered is often inadequate. .
Diabetes in elderly is different. In elderly patients, the classical symptoms of high sugar or hyperglycemia like polyuria i.e. increased urinary frequency and increased thirst may not be present. This is because of metabolic rearrangements in the body. Due to physiological changes, there are variations in drug absorption, metabolism and clearance which must be taken into account while treating diabetes in elderly.
Complications like major amputations of lower limb, heart attack (myocardial infarction), visual impairment and end stage kidney disease occur with a higher frequency in elderly diabetic patients compared to any other age group. The elderly have a much higher rate of emergency department visits with hypoglycemia when compared to younger diabetics.
Cognitive or mental dysfunction and depression because of Alzheimer’s disease and other vascular dementia, affects patient ability to perform glucose monitoring, to titrate insulin dose and to follow dietary restriction.
Visual and hearing impairment along with nerve damage leads to unstable gait and increase risk of falls and fractures.
Polypharmacy means multiple medications are common in elderly diabetic patients. Usually they are prescribed more than 4-5 medicines, which increase the risk of drug adverse effects and interactions. Also, several other medical issues like urinary incontinence are more common.
Management: Older adults who are functional and mentally strong have significant life expectancy should receive diabetes care with goals similar to those developed for young adults.
* Blood sugar goals for some older adults might be relaxed, using individual criteria, but hyperglycemia or high blood glucose leading to complication should be avoided.
* Screening for diabetes complications should be individualized in older adults, but particular attention should be paid to those complications, that would lead to functional impairment.
* It is important to educate the patient and or primary caregiver or family member about few important things. These are
i. Symptoms of hyper/hypo glycemia i.e., low & high sugar levels and their immediate management.
ii. Use of glucometer
iii. Use of Insulin
iv. Education about risk factors for foot ulcers and foot care.
* Use of information booklets should be considered.
Nutrition in elderly with diabetes: Older adults with diabetes are at risk for undernutrition due to anorexia, (low appetite) altered taste and smell, swallowing difficulties, dental problems and functional impairment. They are also at risk for micronutrient deficiency as they are unable to meet their daily required uptake because of low calorie intake. Over-restrictive dietary patterns may prove detrimental in this population as it may lead to nutritional deficiencies. Addition of dietary fibre may improve blood sugar levels after a meal and also help in relieving constipation, which is common problem in this age group. Dietician advice will be helpful in elderly diabetic patients.
Physical Activity in Elderly Diabetic Patients: There is evidence that progressive decrease in fitness and muscle mass and strength with ageing is in part preventable by maintaining regular physical activity. Older adults with diabetes who are otherwise healthy and functional should be encouraged to exercise in moderation. Even in patients with poorer health status benefit from modest increase in physical activity. Flexibility training or stretching are recommended 2 to 3 times per week in elderly diabetic patients. Yoga can also be included based on personal preferences.
Severe hypoglycemia (low sugar levels) carries a bad prognosis and mortality. It should be prevented by change or adjusting medications.
Elderly diabetes care should be done properly under the guidance and support of clinicians and family members.
Goal should be good quality of life and not only control of blood sugar.
(The author is a MD (General Medicine), Postgraduate Course in Advanced Diabetes (Harvard Medical School), Consultant Physician, Shija Hospitals)

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