November 14, 2023
Diabetes is a multifactorial disease with both genetic and lifestyle contributions. Uncontrolled diabetes leads to significant increase in the healthcare expenditure due to complications of diabetes. According to the International Diabetes Federation (IDF), around 463 million adults were living with diabetes in 2019, with 4.2 million deaths worldwide in 2019 due to diabetes. (1) Diabetes is a disease classically seen in elderly subjects, because with age the pancreatic β cell function declines, hence the insulin producing capacity of pancreas become less.
The prevalence of diabetes in elderly above 65 years is around 22-23 % with high postprandial sugars being a common problem.
Problems with diabetes in Elderly
Diabetes in older subjects is linked to lesser functional status and increased risk of hospitalization due to multiple comorbidities. Due to multiple comorbidities, these patients may have to visit more than 1 doctor due to which there may be overlaps in the prescriptions, or drug interactions which have to be looked into more deeply. Sometimes, due to polypharmacy, patients may have poor adherence to medical treatment- hence the regimens have to be simplified. Elderly subjects have higher risk of falls and fractures- due to neuropathy, muscle wasting and poor vision. Poor mobility, visual and hearing impairment makes them dependent on others. These patients are at increased risk of urinary tract infection which could be a common reason for hospital visits. The elderly diabetic subjects are also at risk for hypoglycemia (low sugars) which could make it difficult to reach the diabetic goals.
Goals of therapy
The Goals of management of diabetes are similar to that of young adults. The fasting blood sugar should be between 80-120 mg/dl and post prandial blood sugar levels should be between 100-160 mg/dl. HbA1C levels should be aimed to keep it below 7%. However, subjects with many comorbidities or frail elderly individuals may have less stringent goals, such as HbA1C values < 7.5–8.0% and postprandial levels < 180 mg/dl.
1. Avoid exercise empty stomach to prevent hypoglycemia.
2. Avoid hypoglycemia at night by eating a bedtime snack like milk, cookies, or fruits before turning in.
3. Patients whose blood sugar levels fluctuate should use the Continuous Glucose Monitoring System (CGMS).
4. Avoid complicated drug regimens to prevent medication errors
5. Social support
6. Evaluation of other systems
a. Cardiac evaluation
b. Eye check-up - to look for diabetic retinopathy and cataract
7. Drug therapy
a. Drugs with do not cause hypoglycemia like metformin, gliptins, …etc should be preferred over drugs which can cause hypoglycemia
b. Drugs with lesser glycemic variability (GV) are preferred
Summary of recommendations
The functional capacity and cognitive function should be assessed in elderly diabetic patients. Treatment plans should be simple and individualized in these patients as per their needs and goals. Drug therapy should be tailored to avoid hypoglycemia. The family and caregiver should be educated and sensitized towards monitoring of sugars and avoiding complications.
1. International Diabetes Federation. Diabetes Atlas 9th Edition 2019.
2. Szoke E, at al. Effect of aging on glucose homeostasis: accelerated deterioration of beta cell function in individuals of beta cell function in individuals with impaired glucose tolerance. Diabetes 2008; 31: 539-543