Diabetes management in Geriatrics

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Sateesh B

Sateesh B

Diabetes mellitus is the most common chronic disease among geriatric population.

It is present in up to 18% of persons older than 65, comprising more than 40% of all persons with Diabetes in the United States.1,2 In 1993, 43% of the approximately 7.8 million people diagnosed with diabetes were over 65 years of age.3,4 Diabetes has a major influence on the health of geriatric patients and also on health care utilization and costs. It is the seventh leading cause of visits to primary care physicians where 60% of diabetic patients on Medicare has been estimated to pay 45.5% of office visits for diabetes.5 The total per capita annual health care expenditures for diabetic patients have been estimated as four times greater than for non-diabetic persons.

Diagnosis and treatment of the geriatric population have unique challenges. Due to physiologic changes associated with aging, the elderly patient with diabetes may not present with classic symptoms.4 Geriatric patients are different in many ways: (a) Prevalence of complications in older patients have a large influence on health service utilization and costs. Thus, even minor successes of management interventions in preventing or mitigating complications can potentially have a large effect on the health status of the older population and health care utilization. (b) Older patients are heterogeneous, and with age, there is an increased prevalence of functional disability and comorbid illness that contributes to the complexity of managing diabetes.4 (c) Some older patients may be more symptomatic from hyperglycemia than younger patients, but at the same time are also more prone to complications of treatment. (d) Special evaluation and treatment goals must be devised for the “frial” elderly population.

Thus, treatment of the geriatric patient with diabetes must not only consider the standard microvascular and macrovascular complications, but also the conditions such as cognitive impairment, falls and impaired function.5

Management

Diabetes is the most complicated disease regularly managed by primary care physicians. But for elderly diabetic patients, the primary care physician is often doubly challenged to combine principles of geriatric medicine with diabetic management decisions.

A) Goals of Diabetes Management in Geriatric patients with Diabetes

The goals of diabetic management in geriatric patients are not substantially different from other diabetic patients but rather involve treatment beyond hyperglycemia. These goals are summarized below:

  • Alleviation of symptomatic hyperglycemia.
  • Treatment of risk factors for atherosclerotic disease.
  • Identification and treatment of diabetic complications and related comorbid disease.
  • Improvement of general health status by attention to nutrition, physical conditioning, and functional status.
  • Diabetes self-management education and counseling.
  • Possible prevention of the development or worsening of diabetic complications by lowering glucose levels.

There is accumulating evidence of systematic under treatment of older diabetic patients, with respect to risk factor detection, treatment and management of hyperglycemia.7 Preventative treatment may not be a priority for older diabetic patients with advanced disability or dementia or preterminal diasease. Thus, the development of an individualized management plan that fits the goals and health status of each older patient is an essential component of diabetic care in the elderly.

B) Assessment of the Geriatric diabetic patients

The key to develop an appropriate treatment plan for geriatric diabetic patients involves the following:

  • Comprehensive assessment of the health status.
  • Assessment of signs and symptoms related to hyperglycemia and diabetic complications.
  • Evaluation of hyperlipidemia, hypertension, and other risk factors associated with atherosclerosis by using medical history and physical examination.
  • Evaluation of patient’s medications, dietary and exercise habits, nutritional, functional, and cognitive status, attitudes towards his or health, and financial and social status.

Similarly for patients with disabilities and multiple chronic diseases, who may also face problems with financial or social support, assessment by a geriatrician and multidisciplinary team may be necessary. Subspeciality consultation may also be necessary for ophthalmological, neurological, podiatric, and other complications. Thus, without a thorough evaluation, a safe and effective treatment plan cannot be developed.

The various components of the comprehensive assessment of an older diabetic patient are:

  • History and physical
  • Function
  • Cognition and affect
  • Nutritional status
  • Medication use and possible inappropriate polypharmacy
  • Social situation and support

1. Treatment of Symptomatic Hyperglycemia

Treatment of symptomatic hyperglycemia is always indicated as in older persons these symptoms may be similar to symptoms of other conditions, or may exacerbate symptoms from other conditions. Symptoms may be atypical and could include cognitive changes, anorexia, falls and incontinence.

2. Prevention and Treatment of risk factors for Atherosclerotic disease

Identification and treatment of risk factors for atherosclerotic disease improve both morbidity and mortality in younger diabetic patients.8 In older persons, the evidence is not as extensive but the most significant morbidity and mortality is attributable to atherosclerotic disease. Smoking also confers a markedly increased risk of atherosclerotic complications and may also lead to worsening of disease in all population groups and therefore, stopping smoking improves both morbidity and mortality in elderly former smokers.9

Treatment of hypertension in geriatric diabetic patients has been demonstrated to lower the risk of atherosclerotic events and mortality, including coronary artery disease and stroke.8 Angiotensin-converting enzyme (ACE) inhibitors are a good choice for hypertension treatment in older patients due to their protective effect on renal function in diabetes. However, elderly patients show some side effects to this therapy like cough, peripheral vascular disease, renal artery stenosis, hyperkalemia and also decreased renal function with non-steroidal anti-inflammatory drug (NSAID) combination therapy. So, these patients should be carefully evaluated for potential drug-drug interactions if receiving additional therapies. Similarly, low dose thiazides and cardioselective beta-blockers can be used with minimal side effects.10

A high proportion of older diabetic patients also have hyperlipidemia. The presence of both older age and diabetes clearly confers high risk, and because of the high prevalence of coronary artery disease in these patients, they should be screened and treated for hyperlipidemia, regardless of age, unless there is severe functional or cognitive disability, or a preterminal state. Treatment with 3-Hydroxy-3-methylglutaryl coenzyme A (HMGCoA) reductase inhibitors is a best option, but shows increased frequency of side effects such as muscle symptoms and so these patients must be monitored properly. Increased triglycerides are an important risk factor for atherosclerotic disease in patients with diabetes.11 Diet, exercise and improved glycemic control are the first-line therapy for hypertriglyceridemia and if these are ineffective, pharmacological treatment is indicated. Gemfibrozil is preferred over nicotinic acid as it worsens hyperglycemia and may cause increased side effects in older patients. Aspirin (ASA) can also be used as it shows cardiovascular protection in older diabetic patients and is not associated with an increased incidence of ocular bleeding.12,13

3. Diabetic Complications: Prevention and Treatment

Diabetic peripheral neuropathy especially that which results in foot ulcers and amputations is a particular problem for older diabetic patients. Amputations which result from both microvascular and macrovascular diabetes complications and foot ulcers which are one of the major causes of hospitalization are most prevalent in older diabetic patients.14 Therefore, early detection of diabetic neuropathy will reduce hospital admissions for foot ulcers and amputation.15 All older diabetic patients should have foot care education emphasized and the foot examination prioritized by their primary care physician.

Yearly dilated retinal examinations will lower the incidence of blindness in diabetic patients by early detection and treatment of diabetic retinopathy.16 Older diabetic patients experience diabetic eye diseases which are different from that of younger patients. First, older patients tend to have less progression of diabetic retinopathy, and it is more often macular edema than proliferative retinopathy.17 Visual loss caused by macular edema can be prevented by photocoagulation therapy. Second, older diabetic patients have a higher frequency of older diabetes-related eye diseases, such as glaucoma and cataracts, than younger patients. Thus, older diabetic patients have a higher prevalence of visual impairment than younger patients18 and would clearly benefit from yearly ophthalmological evaluations.

In type 2 diabetic patients, adequate systemic blood pressure control and use of ACE inhibitors reduce the rate of progression of early renal disease.12,13,19,20 Assessment of microalbuminuria is an appropriate screen for early renal disease and decrease progression of such disease in type 1 diabetes. In addition, there is a higher prevalence of other causes of renal insufficiency, including most commonly, hypertensive renal disease or reaction to medications.

Long term macrovascular complications like cardiovascular, cerebrovascular and peripheral vascular disease can cause conciderable functional impairment in elderly patients.21,22 Diabetes is also associated with lower levels of cognitive functioning and greater cognitive decline in the elderly and so, therapy should be individualized based on the patients risk for hypoglycemia.23,24

4. General Health Status improvement by Attention to Functional Status

Assessment of the effect of chronic diseases and comorbid conditions on their ability to function is important in older patients. Older diabetic patients may also have coexisting problems which may be related or unrelated to their disease, that impair their ability to function. Various problems like poor nutritional status, sensory deficits (vision), depression, impaired mobility, cognitive decline and social problems (social isolation) have a higher prevalence in older diabetic patients than in younger patients and many of these problems can be overlooked if physician does not consider them. Development of management plans using geriatric assessment will help to address these problems. For example; poor nutritional status can be handled by nutritional referral, attention to caregiver status; and careful monitoring; depression can be appropriately diagnosed and treated; mobility impairments may respond to physical therapy.

5. Diabetes Self-Management Education and Counseling

Diabetes is primarily a disease of self-management. Education in self-management of diabetes can improve many important outcomes, such as diabetes knowledge and self-care behaviors.17 Diabetes self-management and improved self-care behaviors are also associated with improved metabolic control.25,26 Older patients may be very receptive to educational interventions and highly compliant with self-management techniques. There are two extremely important components of self-management education that should be emphasized in older patients: hypoglycemia awareness education, because of the risk of hypoglycemia in older patients, and medication teaching, because older patients are likely to be taking multiple medications. They must therefore be educated to inform prescribing physicians about their various medications, and to inquire about potential drug-drug and drug-diabetes interactions.

6. Pharmacological Therapy of Hyperglycemia

The management of the geriatric patient with type 2 diabetes has different goals and objectives than does that of the younger patient. Several factors must be considered in choosing pharmacological therapy of hyperglycemia for elderly patients. These include efficacy of the chosen agent and potential adverse effects. At the same time, the target level of glycemic management, the life expectancy and comorbidities of the patient, the patient’s potential for compliance and self-management, and the patient’s risk of hypoglycemia also has to be considered in the choice of the exact agent.4,27 The following agents require modifications when used in elderly.

Sulfonylureas have been available for many years and there is wide experience with their use. First-generation sulfonylurea agents (e.g., chlorpropamide {Diabinese]) should be avoided in the elderly because of their longer half-life and increased propensity for hypoglycemia.5 In older patients, there is an advantage to the second generation agents as they are nonionically protein-bound, which could theoretically lessen drug-drug interactions with acidic drugs like warfarin or salicylates.28 All sulfonylurea drugs are rapidly absorbed from the gastrointestinal tract and are metabolized to some degree by the liver and excreted by kidneys. Thus, these drugs should be used with caution when significant liver or kidney disease is present. The risk of prolonged hypoglycemia is greater with such drugs.

Biguanides like metformin (Glucophage) has a potential advantage in some older patients as it is not associated with hypoglycemia when used alone4 and when combined with a sulfonylurea agent, it can precipitate hypoglycemia. However, they need to be used with caution in older patients because they can cause anorexia and weight loss.4,29 Older patients are more likely to have comorbid diseases (renal insufficiency, and cardiac or hepatic failure) or may use other medications that would interact with metformin. It is useful in diabetic patients without significant comorbidities and also in obese diabetic patients as it may decrease diabetic complications and have fewer side effects than insulin and sulfonylureas.30,31

1,3 alpha-Glucosidase inhibitors are newer agents for treating diabetes. These drugs do not cause hypoglycemia when used alone and have fewer side effects. Example; use of miglitol (Glyset) results in a significant reduction in hyperglycemia and shows fewer side effects in older diabetic patients.31

1,4-thiazolidinediones are another newer class of drugs used for treating hyperglycemia and are mostly useful in obese, insulin-resistant patients. Example; troglitazone, is effective as both monotherapy and in combination. Rare severe hepatic damage has been reported and so it should not be used in patients with hepatic problems. Rosiglitazone (Avandia) and pioglitazone (Actos) are not indicated in elderly patients with evidence of heart failure or liver disease. In elderly patients who do not have these contraindications, these medications can be given as monotherapies since they do not cause hypoglycemia.4

The issue of combination drug therapy for type 2 diabetes is of particular importance in older patients. As newer classes of drugs are becoming increasingly available, the issue of combining medications from different classes for complementary effects, or combining them with insulin therapy, will be one of the major therapeutic concepts for research. But there are potential pitfalls of this approach with older patients, including increased risk of hypoglycemia, unknown tolerance for adverse effects of newer medications, compliance problems with multiple drug regimens, and affordability.

Patients who are not appropriate for oral antihyperglycemic therapy, will need to take insulin as its use is flexible and precise dosing is possible, but show increased risk of hypoglycemia.4,32 Initiation of insulin in elderly patients with type 2 diabetes should be done with the involvement of the multidisciplinary team. A complete geriatric assessment should be performed first to assure that patients can comply with their regimens and to identify potential complicating factors. If there are caregivers, provisions for adequate respite programs should be made and offered to avoid caregiver burnout.4

Thus, physicians caring for older patients will need to monitor effectiveness information as it is published, and use their growing clinical experience with combination regimens to assess whether older patients will truly benefit without undue risk.28

7. Targets and Rationale: Control of Hyperglycemia in Geriatric diabetic patients:

The heterogeneity of diabetes and general clinical status of older diabetic patients affects the targeted level of glycemic control, the types of dietary and exercise programs, and the choice of pharmacological agent to assist management. There is currently no conclusive evidence that achieving near-normal glucose levels can prevent or decrease the complications of diabetes in older diabetic patients.48 But, some observational and clinical studies give certain evidences that intensive metformin regimen resulted in decreased diabetic complications like diabetic retinopathy which is highly related to degree of hyperglycemia, and may slow progression or even improve with glycemic control.30,34,35 Thus tight glycemic control is a reasonable therapeutic goal in elderly diabetic patients.19,20,36

The development of microvascular complications is linked to the duration of diabetes, and many older diabetic patients have a long duration of disease. As life expectancy continues to increase, this problem will worsen. Furthermore, if diabetic complications add to or intensify the aging process, it will become even more important to explore ways of preventing or mitigating these complications. Control of hyperglycemia by using intensive antihyperglycemic therapy can decrease the rate of progression of complications. Here, intensive therapy means a target value for glycosylated hemoglobin within 1% of the upper limit of normal.

The different characteristics of older patients who might benefit from tight glycemic control (Near-Normal Glycemic control*) are listed below:

  • Minimal or no functional impairments
  • Few comorbidities
  • Early or no diabetes complications
  • High motivation
  • Relatively long life expectancy
  • Good social support

{*Glycosylated hemoglobin within 1% of upper limit of normal.}

Even relatively advanced age should not be a contraindication to intensive therapy and so older diabetic patients should not be denied intensive antihyperglycemic therapy on the basis of age alone.

For older patients, certain characteristics such as frequent hypoglycemia or cognitive impairment, would suggest high risk, whereas a preterminal state or advanced disability would suggest that there would be no benefit from tight glycemic control.25

The therapeutic options for treating hyperglycemia in older patients are the same as with younger patients. Caloric restriction is an useful approach as majority of older diabetic patients are obese37 except early diabetic patients who are thin or of normal body weight.  Dietary therapy will also remain an important part of the patient’s diabetes self-management program. Glycemic control may also be substantially improved with a modest weight loss. In addition, homebound, poor or disabled elderly may have poor nutritional status, which must be addressed by increased caloric intake and management of subsequent hyperglycemia to improve their catabolic state and allow improvement of nutritional status. Many older diabetic patients can benefit from exercise and even achieve improved metabolic control, but the major barrier is adherence to an exercise regimen.38

Diabetes Management of Frail Elderly

Among geriatric diabetic patients, there is a group with severe disabilities and multiple comorbidities, a poor quality of life and diminished life expectancy. Many of these patients live in nursing homes, although they may also live in the community, generally with extensive help from caregivers. In these patients referred to as “frail elderly,” there is no role for preventative interventions, self-management techniques, or management of hyperglycemia. However, it is precisely in this group of patients that appropriate basic diabetes management can improve patient symptomatology, prevent or slow functional deterioration, and assist caregivers in their difficult job.

There is no clear clinical definition of “frail elderly.” In general, frail elderly can be considered as those patients with limited physiological reserve who have significant functional impairments and multiple comorbid conditions. Such patients have one or often several additional problems such as dependency in ADLs, cognitive impairment, sensory impairment, depression, malnutrition and may experience falls and urinary incontinence.

Basic diabetes management is appropriate for these groups of patients which are listed below:

  • Treatment of symptomatic hyperglycemia
  • Attention to nutritional status
  • Attention to social support
  • Prevention and treatment of diabetes complications that might threaten functional status and increase caregiver burden

Frail elderly diabetic patients can be extremely symptomatic from uncontrolled hyperglycemia. Because of an impaired thirst response, or an inability to take care of themselves, they are at risk for volume depletion and also with other complications like incontinence, urinary tract infections, falls and increased mental confusion resulting from polyuria.

A large number of these patients have undernutrition, rather than obesity and may be in a continuous catabolic state due to poor metabolic control, which will exacerbate malnutrition, which may lead to significant morbidity like increased pressure ulcers and increased infectious complications.39 Appropriate caloric intake and micronutrient supplementation and consultation with a nutritionist is generally necessary. These patients may be dependent on caregiver support for basic ADLs, and often need assistance with dressing, bathing, or even eating, taking medications and maintaining a household. Here, the physician often with the help of a social worker or geriatric nurse practitioner will need to identify and work closely with the caregiver to develop, implement and monitor a diabetes management plan for elderly diabetic patients.

Finally, the major goal of management of frail elderly patient is to maintain functional status or at least slow the rate of its decline and this approach can help the clinician to assess the cost-benefit of diabetic management interventions.

Conclusion:

Ideal geriatric care requires a multidisciplinary approach. Successful diabetes care in the aging population requires an understanding of the physiology of aging and recognition of the special issues facing the elderly. As with any patient with diabetes, overall goals should aim at reduction of complications. In older patients, therapy should be individualized and include a functional assessment. Goals of therapy should aim toward optimizing function and minimizing complications that may cause loss of independence or early institutionalization.4

In future, we may see a substantial increase in our knowledge about appropriate management of diabetes in growing elderly population.

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About Authors:

School of Pharmacy and Technology Management, NMIMS University, V.L. Mehta Road , Vile Parle (W), Mumbai – 400 056, Maharashtra, India.

Sateesh B

Sateesh B

Dayanidhi B

Dayanidhi B