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Finding a balance between simple methods of lowering blood sugar levels to managing more complex additional health conditions related to diabetes for older people.
By Dr Ahmed Abdelhafiz and Professor Alan Sinclair, of the Department of Geriatric Medicine, Rotherham General Hospital, University of Aston and Foundation for Diabetes Research in Older People.
The number of people being diagnosed with diabetes is increasing worldwide. Many new cases of the condition are in older people and this is related to poor lifestyle choices, including an unhealthy diet and lack of exercise, and obesity associated with increased life expectancy. Nevertheless, diabetes in old age can be managed effectively and quality of life maintained for a long period.
In old age, diabetes is associated with additional health complications, including polypharmacy (taking multiple, often unnecessary medications), chronic pain, falls, dementia, incontinence (unintentional passing of urine) and depression, in addition to traditional vascular complications (like diseases in blood vessels) usually found in younger people. Therefore, care for older people with diabetes is challenging.
In this article we will look at some of the key areas of care for older people with diabetes, with special attention to dementia, frailty and hypoglycaemia (low blood sugar levels) all of which may lead to varying degrees of disability if no action is taken.
Diagnosis and clinical presentation
Diagnosis of diabetes is similar in all age groups. However, in up to 50% of older people there may be no obvious symptoms of the condition. Symptoms can also be non-specific, such as general illness, tiredness or lack of energy and could be put down to ageing, leading to delayed diagnosis. A change in memory or an unexplained fall could be the first symptom of diabetes.
Therefore, checking for signs of diabetes in older people should be considered at every available opportunity, for example, on admission into hospital or a care home, or showing signs of a severe illness to a GP in primary care.
The noticeable signs of diabetes in old age are highly variable and can be affected by the prevalence of comorbidities (or additional diseases). The number of cases of dementia, hypoglycaemia and frailty increases in older people with diabetes and, if untreated, can lead to a vicious circle of deterioration into disability. Therefore, in addition to the routine care of diabetes relevant to younger people, special consideration should be made to address these unique complications in older people.
Diabetes increases the risk of dementia through various mechanisms including hyperglycaemia (high blood glucose levels), hypoglycaemia and the associated vascular and metabolic complications. The number of cases of cognitive impairment (usually loss of memory) among older people with diabetes is around 29%.
In care homes the prevalence of cognitive impairment is higher reaching up to 56% of those with diabetes. On the other hand, diabetes affects about 13% to 20% of people with dementia. The number of cases of people diagnosed with diabetes and dementia is expected to double over the next few decades.
The annual incidence of hypoglycaemia in older people with diabetes living in the community is around 14% but is higher in care homes - reaching up to 42% because of the increased additional illnesses a resident may have. The recognition of hypoglycaemia in old age can be diffi cult. For example, hypoglycaemia may show symptoms such as dizziness or visual disturbance resulting in misdiagnosis.
Another challenge for healthcare professionals when making a diagnosis is the similarity in the appearance of hypoglycaemia with that of dementia where people may show signs of nervousness, increased confusion and other behavioural changes. These latter symptoms can also be interpreted as signs of a stroke. Symptoms of hypoglycaemia tend to be less specific such as feeling generally unwell, tired or weak, making any possible diagnosis of hypoglycaemic episodes more difficult for healthcare professionals.
Frailty is a condition characterised by a loss of physical energy and in the ability to resist physical or psychological stressors. Its definition was originally based on the presence of three or more physical signs, including weight loss, weakness, decreased physical activity, exhaustion and slow walking speed. Sarcopenia, or muscle mass loss, is a sign of frailty which can be accelerated in people with diabetes. This could be due to reduced production of muscle protein and increased breakdown of muscle protein, caused by a higher rate of inflammation, or the body’s response to healing damaged tissue. Poor dental health, including such as bad teeth, dry mouth and reduced taste sensation could be a contributing factor to hunger and frailty.
The combined effect of dementia, hypoglycaemia and frailty can eventually lead to disability.
Diabetes in old age can be linked with a severe decline in physical ability. Main causes include: loss of muscle mass, peripheral neuropathy (nerve damage in feet and hands), stroke, depression, hypoglycaemia, dementia, frailty and peripheral vascular disease (poor blood circulation). Other signs could include limited range of movement in the shoulders and less hand strength and sensation that could lead to being less able to perform normal day-to-day tasks.
Medical interventions in older people with diabetes should be proportionate to their ability to perform physical tasks, in addition to more life-threatening complications, including loss of sight, kidney failure or heart failure.
Tighter blood glucose control in strong healthy older people and more relaxed health targets as physical ability declines is a simplified but suitable approach.
Screening for cognitive dysfunction, such as loss of memory, should be performed annually or sooner if self-management of diabetes is not under control. Frailty can be prevented if recognised and treated early. In addition, patients at risk of hypoglycaemia should also be identified.
The condition can be screened for using the FRAIL scale (see box below).
Healthcare professionals should be aware that blood glucose levels should not be treated on their own but as a part of many different approaches to reduce the overall risk of developing heart disease. This should include good control of blood pressure levels. Any intervention should be tailored to help each person, with the reasonable aim of setting goals depending on their symptoms. Patient’s appointments with healthcare professionals need to be long enough to allow individualised care planning, with a focus on improvements in function and quality of life for their ongoing health treatment.
Reducing the risk of hypoglycaemia
Safety needs to come first. From a healthcare professional’s point of view treatments with the least risk of having hypoglycaemic episodes as a side effect should be considered.
- Patients should be directly asked about hypoglycaemia and medications should be reviewed every time they experience a hypoglycaemic episode - even if it was just a “funny turn”.
- Regular reviews of medications and taking less, or withdrawing completely from certain medications is recommended for patients who have lost a lot of weight or are at high risk of regular hypoglycaemia.
- Reducing the amount of insulin taken to once daily could also be a good option.
- A “little and often” approach to meal planning can also be safer - and help avoid missing meals, which could lead to an increased risk of hypoglycaemia.
Professor Alan Sinclair discusses health care with an older person with diabetes
Reducing the risk of frailty
Adequate nutrition with a good protein intake, of up to 30% of total calories, is recommended. A diet rich in vitamin D and whey protein, rich in the essential amino acid leucine, has been shown to increase muscle mass and improve muscle function. Progressive resistance training exercise (like push-ups and other strength building exercises), along with taking protein supplements could improve muscle performance.
Healthy lifestyle changes to diet and exercise that can help people reach their ideal body weight could also improve mobility and reduce the risk of dementia. However, rapid weight loss should be avoided. As decline in function progresses with the development of disability, diet should not be too restrictive but tailored to personal choices and the diabetes treatment adjusted accordingly. Use of supplements could be necessary to maintain weight.
It is recommended that every older person with diabetes should receive a comprehensive assessment of their clinical needs with an individualised management plan.
If management is inconsistent or delayed, diabetes in older people can be associated with complications that can lead to deterioration in mental and physical health and eventually to disability. Healthcare professionals need to be aware of these complications as early identifi cation and intervention could help improve outcomes.
Effective management of diabetes in older people will require a change in the mind-set of healthcare professionals, from having a focus on blood sugar levels, to a holistic multidisciplinary team approach. This will ensure that diabetes management will also review associated complications, other illnesses and conditions related to old age, at one point of care with a focus on improving function, minimising complications and maintaining quality of life.
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This article was originally published in Diabetes Wellness News (September 2017 issue). To find out more about how to subscribe please visit here