Managing Diabetes In The Elderly: Go Easy, Individualize.
Abstract The care of elderly patients with diabetes should be individualized, taking into account the patient's comorbidities, other medications, cognitive abilities, home care situation, and life expectancy. Especially in frail, elderly patients, there should be less emphasis on strict glycemic control than on avoiding malnutrition and hypoglycemia and achieving the best quality of life possible. Continue reading >>
Treating The Elderly Diabetic Patient: Special Considerations
Go to: Evidence that supports treatment and individualized glycemic target Despite years of diabetes research, specific data about the benefits of diabetes treatment on older adults are scarce. The UK Prospective Diabetes Study (UKPDS) was the first large randomized controlled trial to provide concrete evidence of the value of glycemic control on diabetic microvascular complications, but it excluded patients aged 65 and older at the time of enrollment to the study.6,7 Since then, studies that were designed to study patients with long-standing DM2 have examined an older population, with mixed results. In accordance with the results of the UKPDS, the Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation (ADVANCE) trial8 showed a reduction of diabetic nephropathy with intensive glycemic control, but failed to demonstrate a cardiovascular benefit after a median follow-up of 5 years. The trial only enrolled patients 55 years and older and included a subgroup analysis of patients over 65 with no statistical difference in the outcomes. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial9 demonstrated a decrease only in diabetic nephropathy with intensive glycemic control even though patients on this arm of the study were transitioned to standard therapy after a median follow-up of 3.7 years due to an increase in total and cardiovascular mortality. The mean age was 62.2 years and a subgroup analysis suggested that the risk for cardiovascular mortality was disproportionally high among patients under 65 years of age. Finally, the Veteran’s Affairs Diabetes Trial,10 found that intensive glucose control in patients with poorly controlled DM2 and a mean age of 60 years had no significant effect on the rates of major cardiovascula Continue reading >>
Diabetes In Older Adults
What is the epidemiology and pathogenesis of diabetes in older adults? According to the most recent surveillance data, the prevalence of diabetes among U.S. adults aged ≥65 years varies from 22 to 33%, Continue reading >>
I Have Diabetes Mellitus But Am Very Responsible, Checking Levels Regularly. I Get A Hgba1c Blood Test Every 3 Months & Even If It Increases Minimally, It Freaks Out My Doctors. What Does It Impact?
What are you on against your diabetes, tablets, insulin, or both? It has been shown that self measurement of blood glucose levels in those on tablets did improve diabetic control, by giving their doc an earlier feedback so treatment could be adjusted, see Is self-monitoring of blood glucose effective in improving glycaemic control in type 2 diabetes without insulin treatment: a meta-analysis of randomised controlled trials; and it’s an essential part of diabetes management, enabling one to adjust insulin dosing according the the blood glucose levels measured. Any lifestyle modifications like regular exercise and weight control? Please see the 50% success of this latest trial reported one year after people lost 15 kg after being on a liquid 600 Cal diet for 6 months, 50% of the participants were cured of their diabetes Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial What are your HbA1c values this last year? Has it lead to changes in your treatment at all? This graph shows you the impact of badly controlled diabetes as shown by too high HbA1c values, so in younger people we strive for values between 6.5 to 7% In the elderly we should strive for higher HbA1c values of 7 to 7.5%, since lower values are correlated with more deaths, and more cognitive loss: A later June 2011 paper studying diabetics older than 60 yo Glycemic Control, Complications, and Death in Older Diabetic Patients: The Diabetes and Aging Study showed that a optimal HBA1c in relation to mortality is between 6.0% to 7.9%, even up to 8.9%: In geriatric patients (mean age 80 years old) it seemed that a HBA1c of 8% - 8.9% had the lowest mortality see this Juli 2012 paper Hemoglobin A1c and Functional Decline in Community-Dwelling, Nursing Continue reading >>
What's An Unforgettable Statement That Your Boss Told You?
I sucked at my work. I failed to complete most tasks on time. My peers would joke about how me to sticking to a deadline was akin to a politician living up to his word. I would put in 10 — 12 hours each day. But I never moved forward. One day, my boss emailed me asking for a list of tasks I perform during that day. I freaked out. Surely I was going to lose my job. I sent him my list after 3 days — after all, I had to live up to my reputation of missing deadlines. I didn’t sleep that night. The next day, my boss called me into his cabin. This is it, I thought. I’m gonna get fired for the first time in my life. I should start preparing for the handover process. But that didn’t happen. He made me sit down and offered a glass of water. Then he said, “Vishal, I noticed you cannot perform important tasks. You do a hundred things, but I can’t see any results.” “I try sir, but I keep getting burdened with additional work,” I said. Beads of sweat formed on my brow despite the cool temperature in his cabin. “Team members tell me their work is urgent. I know I get distracted. But I want to help everyone. When I try to say ‘no’, it doesn’t work. Yesterday Nishant scolded me for turning down his work.” The last sentence was a (harmless) lie. But hey, I was trying to defend myself. The ABCD of the Professional World I think my boss saw through the lie. Because he smiled and said, “Vishal, today I’ll share a piece of wisdom with you, which I got from the boss I learned the most from. It’s this: When you work in the corporate, prioritize your work as ABCD. A — Apna kaam (your own work) B — Boss ka kaam (your boss’ work) C — Company ka kaam (your organization’s work) D — Doosron ka kaam (others’ work).” How to Apply ABCD 1. Apna Kaam P Continue reading >>
Diabetes Management Guidelines
Prevalence and epidemiology 22% to 33% of US adults aged ≥65 years have diabetes, depending on diagnostic criteria used 1/3 of US older adults have undiagnosed diabetes (based on A1C, FPG diagnostic criteria) Increased type 2 diabetes rates are linked to increasing prevalence of obesity, overweight Even if diabetes rates level off, CDC estimates suggest doubling of diabetes prevalence in next 20 years, due in part to aging of population 4.5-fold projected increase in diagnosed diabetes in those aged ≥65 years between 2005 and 2050 Diabetes incidence, prevalence increase with age until ~age 65 years, when rates level off Older adults with diabetes: higher rates of major lower-extremity amputation, MI, visual impairment, ESRD, death from hyperglycemia vs other age groups Complications increased for adults aged ≥75 years Combined effects of increasing insulin resistance, impaired pancreatic islet function with aging are cause for high risk of diabetes development in older adults Back to top Individualized treatment Diabetes is associated with increased risk of multiple coexisting medical conditions in older adults that may impact self-care abilities and health outcomes, including QoL Comorbidities: cardiovascular and macrovascular disease Geriatric syndromes: cognitive dysfunction; functional impairment; falls and fractures; depression; visual and hearing impairment Nutrition issues: risk for undernutrition; restrictive eating patterns Special needs in DSME/T and support: may need to account for sensation, cognition, and functional/physical impairments Ability to perform physical activity: decreased muscle mass, strength, fitness may be present Life expectancy: take into account when making decisions re: treatment targets, interventions Pharmacotherapy: age-related c Continue reading >>
Treatment Of Type 2 Diabetes Mellitus In The Older Patient
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc. All topics are updated as new evidence becomes available and our peer review process is complete. INTRODUCTION — The prevalence of type 2 diabetes continues to increase steadily as more people live longer and grow heavier. Older adults with diabetes are at risk of developing a similar spectrum of macrovascular and microvascular complications as their younger counterparts with diabetes. In addition, they are at high risk for polypharmacy, functional disabilities, and common geriatric syndromes that include cognitive impairment, depression, urinary incontinence, falls, and persistent pain [1]. This topic will review diabetes management in older patients and how management priorities and treatment choices may differ between older and younger patients. The general management of type 2 diabetes is reviewed separately. (See "Overview of medical care in adults with diabetes mellitus" and "Initial management of blood glucose in adults with type 2 diabetes mellitus" and "Management of persistent hyperglycemia in type 2 diabetes mellitus".) TREATMENT GOALS — The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycemia and risk factors. Older adults with diabetes are a heterogeneous population that includes persons residing independently in communities, in assisted care facilities, or in nursing homes. They can be fit and healthy or frail with many como Continue reading >>
The Elderly And Diabetes: Everything You Need To Know
According to the American Diabetes Association, as we get older, our chances of getting Type 2 diabetes increases. They claim that one in four Americans over the age of 60 has diabetes.1 Carolyn contacted The Diabetes Council… When Carolyn contacted TheDiabetesCouncil, she was concerned about her mother who is elderly and is living with diabetes. She didn’t know much about her medications, or how they might interact with her other medications. She was worried that her mother’s low blood sugar while she was home alone may be related to her worsening memory. In addition to referring Carolyn to a local Certified Diabetes Educator, we, at TheDiabetesCouncil, decided to write a guide for the elderly with diabetes that people like Carolyn could refer to. In the following article we will explore many different guidelines and recommendations, along with nutritional, activity, pharmaceutical, and financial and estate planning considerations. Those are just a few of the issues that we will touch on related to the elderly with diabetes. So let’s get started with some general and medication considerations first… General guidelines for the elderly with diabetes The following are some general guidelines to consider when treating the elderly with diabetes: Recommendation for the Eldery with Diabetes Depression screening in the elderly population with diabetes is of great importance, as elderly patients with diabetes experience more isolation, less support, and more feeling of hopelessness Avoiding low blood sugar is of paramount importance, and A1C and blood sugar goals should be adjusted, along with careful pharmaceutical management The elderly with diabetes who are capable of activities of daily living without assistance, and who have no cognitive impairment should have A1 Continue reading >>
Diabetes Treatment Considerations In Elderly Patients
Dr. Shivam Patel has graduated from Lake Erie College of Osteopathic Medicine (LECOM) School of Pharmacy with a Doctor of Pharmacy degree. He is a PGY1 Pharmacy Resident at Martinsburg VA Medical Center. His professional interests include critical care, infectious disease, and ambulatory care. After completion of his PGY1 residency, Dr. Patel hopes to continue to serve veterans and become a Clinical Pharmacy Specialist. About 11 million patients 65 years or older were diagnosed with diabetes in 2012 alone.1 Clinical judgements for a 25-year-old patient will be different than those for a 65-year-old patient because of changes in kidney function, weight distribution, metabolism, and many other age-associated factors. Still, some aspects of diabetes treatment for younger patients remain the same for the elderly. For instance, all smokers with diabetes are recommended to take smoking cessation measures regardless of age. Meanwhile, hypertension treatment has shown benefit in all patients with diabetes, including those 80 years or older. Plus, the benefits of lipid-lowering statin therapy are similar in older and younger patients with diabetes, but older patients see greater benefits overall.2 As recommended for younger patients, exercise and diet modifications are important for properly managing diabetes in older patients. In terms of pharmacotherapy, the first-line recommendation for type 2 diabetes in elderly patients is metformin.2,3 Elderly patients who lack contraindications like renal impairment or heart failure are able to safely take metformin. For those with a contraindication or intolerance to metformin, a short-acting sulfonylurea like glipizide is recommended as initial therapy.2 Long-acting sulfonylureas like chlorpropamide, glyburide, and glimepiride aren’t Continue reading >>
Management Of Type 2 Diabetes Mellitus In Older Patients: Current And Emerging Treatment Options
Go to: Introduction Among persons aged 65 years and older living in the United States, the estimated prevalence of diabetes mellitus ranges from 22% to 33% [1]. The number of older individuals with diabetes is expected to grow as the US population ages [1]. By 2050, projections suggest that almost 26.7 million persons aged 65 years and older living in the United States will be diagnosed with diabetes [2, 3]. Type 2 diabetes mellitus (T2DM) accounts for 90–95% of diabetes cases in adults [4]. As with younger adults, achieving and maintaining glycemic control is important in elderly patients with T2DM to prevent acute complications of hyperglycemia and reduce the risk of long-term complications [5, 6]. Although some elderly patients will be able to maintain glycemic control with lifestyle modification and oral antidiabetic drugs (OADs), most will eventually require insulin because of the progression of T2DM [7–9]. Management of T2DM in elderly patients is complicated by the clinical and functional heterogeneity of this patient population [6]. Some older patients with T2DM may have developed the disease in middle age and experienced years of comorbidity, whereas others may be newly diagnosed or may have had years of undiagnosed comorbidity or few complications. Older adults also differ with regard to physical robustness, physical and cognitive functioning, health status, and life expectancy. Clinicians who treat elderly patients with T2DM must consider this heterogeneity when setting and prioritizing treatment goals. Furthermore, older adults with diabetes are more likely than older non-diabetic adults to suffer from geriatric syndromes, including conditions such as polypharmacy, depression, cognitive impairment, urinary incontinence, chronic pain, and injurious falls Continue reading >>
How Do You Treat Diabetic Neuropathy?
Medications are used to control the pain associated with peripheral diabetic neuropathy. Unfortunately, at this time, there aren’t any medications to treat and prevent diabetic nerve pain (another name for diabetic neuropathy); the only way to do that is through careful control of blood glucose levels. There are many medication options to relieve pain associated with peripheral nerve damage. You should work carefully with your doctor to figure out what medications are best for you. For diabetic neuropathy, you may want to try: Acetaminophen: This is a painkiller, also known as an analgesic. Tylenol is an example of acetaminophen, and it works by blocking pain messages to the brain. In essence, acetaminophen makes it harder for the “pain” signal to travel through the nerves and to the brain, and therefore, the brain doesn’t know that it should be feeling pain. Non-steroidal anti-inflammatory drugs (NSAIDs): NSAIDs have a two-fold effect—they work as painkillers and they fight inflammation. They work by blocking the body from creating prostaglandins, which are chemicals that cause inflammation and pain. By taking an NSAID, you prevent your body from making as many prostaglandins, thereby decreasing inflammation and pain. Topical Medication: There are several medications available that you apply directly to your skin; these are called topical medications. One option is capsaicin cream. Capsaicin is what makes chili peppers hot, and it can also relieve your pain. It just temporarily reduces your pain, though, so you'll need to keep re-applying. Typically, these topical medications are used by people who have foot pain (common in diabetic peripheral neuropathy). Continue reading >>
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Managing Diabetes In The Elderly: Go Easy, Individualize
Especially in frail, elderly patients, strict glycemic control should be emphasized less than avoiding malnutrition and hypoglycemia and achieving the best quality of life possible. The care of elderly patients with diabetes should be individualized, taking into account the patient's comorbidities, other medications, cognitive abilities, home care situation, and life expectancy. Especially in frail, elderly patients, there should be less emphasis on strict glycemic control than on avoiding malnutrition and hypoglycemia and achieving the best quality of life possible. KEY POINTS The diagnosis of diabetes in the elderly is often missed because its symptoms, such as dizziness, confusion, and nocturia, are often common and nonspecific. Elderly people at risk of malnutrition should have unrestricted meals and snacks; medications should be adjusted as necessary to control blood glucose levels. Tight control of blood glucose reduces the risk of death and diabetes-related complications but poses the risk of hypoglycemia. Continue reading >>
Clinical Management Of Diabetes In The Elderly
The population of the United States is aging. The elderly are increasingly comprising a larger proportion of newly diagnosed diabetic patients. In 1993, 41% of the 7.8 million people diagnosed with diabetes were over 65 years of age.1 Managing type 2 diabetes in the elderly population is difficult because of complex comorbid medical issues and the generally lower functional status of elderly patients. Nationally published guidelines often do not apply to geriatric care, and practitioners’ individualized approaches to therapy are highly variable. Understanding the special dynamics of geriatric patients will aid in the optimum management of their diabetes. Physiology of Aging Many age-related changes affect the clinical presentation of diabetes. These changes can make the recognition and treatment of diabetes problematic. It is said that at least half of the diabetic elderly population do not even know they have the disease.2 Part of the problem is that, because of the normal physiological changes associated with aging, elderly diabetic patients rarely present with the typical symptoms of hyperglycemia.3 The renal threshold for glucose increases with advanced age, and glucosuria is not seen at usual levels.4 Polydipsia is usually absent because of decreased thirst associated with advanced age. Dehydration is often more common with hyperglycemia because of elderly patients’ altered thirst perception and delayed fluid supplementation. More often, changes such as confusion, incontinence, or complications relating to diabetes are the presenting symptoms. Alterations in carbohydrate metabolism in the elderly include the loss of first-phase insulin release.5 The initial surge in postprandial insulin does not occur in all elderly diabetic patients.6 In contrast to lean elder Continue reading >>
Is India The Diabetes Capital Of The World?
News and opinion on healthy longevity from a unique perspective P Pushpam, a resident of Chennai, India, was denied her job appointment with the Indian Railways on the grounds that she was a chronic diabetic. The court ruled in her favor and pointed out the impracticality of discriminating against people suffering from diabetes in a country that has over 40 million diabetics. As India makes its demographic transition toward lower birth rates and higher life expectancy, the prevalence of non-communicable diseases is on the rise. India is the Diabetes Capital of the World with over 60 million diabetics in the country, that is projected to at least double by 2030. The country ranks second, between China with 90 million and USA with 24 million diabetics. About 17% of the country has diabetes and about 77 million are considered to be pre-diabetic, which refers to those individuals who have higher than normal blood glucose levels, but not high enough to categorize them as diabetic. Smoking, poor physical activity and alcohol use are some pertinent risk factors of diabetes in India. A survey revealed that close to 40% of Indian men are daily smokers and approximately 18% of the study respondents had poor physical activity levels. The survey also suggested that in addition to these individual level risk factors, environmental factors, specifically indoor air pollution contributes to the increasing prevalence of diabetes. The incidence of solid fuel use, contributing to air pollution in India is 83.5%. An urban lifestyle, and increasing strength of the food, fertilizer, pharmaceutical and beverage industries in the past decades, also contributes to a higher prevalence of diabetes. The increasing prevalence of diabetes management among the elderly places a huge burden on the Indi Continue reading >>
Management Of Diabetes Mellitus Type-2 In The Geriatric Population: Current Perspectives
Go to: Abstract The prevalence of diabetes mellitus (DM) has increased exponentially throughout the world and there is rapid increase in elderly diabetics. DM is associated with increased mortality and considerable morbidity including stroke, heart disease, and diminished quality of life in the elderly. However, the unique features of geriatric diabetes have not been given due a prominence in medical literature. Hypoglycemia remains the biggest complicating factor and needs to be avoided in the elderly. Most people in the geriatric age group have some degree of renal insufficiency and medications need to be adjusted wisely with changing renal profile. Because safer and more effective pharmacological therapy is available, an individual approach to DM in the elderly is essential. KEY WORDS: Chronic kidney disease, diabetes mellitus, geriatric, new onset diabetes after transplant The epidemic of diabetes mellitus (DM) has engulfed the entire globe and the prevalence is increasing exponentially across the nations. Factors such as increase in life expectancy, increased health awareness and literacy rate, obesity, and sedentary lifestyle has resulted in more and more of DM prevalence in the elderly.[1,2] About 80% of the elderly in the United States are either prediabetic or diabetic. As it is in the treatment of any disease, the benefit to risk ratio is to be assessed when treating this particular patient population. This particular article is aimed at making the reader understand the changing body physiology with aging and how it affects the treatment of diabetes in the elderly. For our discussion, elderly is defined as people with chronological age more than or equal to 65 years. Go to: Changing Body Physiology with Aging Pathophysiological changes of aging causes increase Continue reading >>
