The worldwide prevalence of diabetes is on the increase as people are living for much longer. In Ireland, the incidence of type 2 diabetes is predicted to rise rapidly. 

It must be considered that much of this increase will occur in the older population due to a combination of risk factors such as ageing and co-existing comorbidities (eg. cardiovascular disease). Other risk factors include: decreased physical activity; drugs; genetics; obesity; age-related decreased insulin secretion; and age-related insulin resistance

It is estimated that 10 out of every 100 people over the age of 65 in Ireland have diabetes – 95% of these have type 2 diabetes.¹ Half of the nursing home residents have diagnosed or undiagnosed diabetes. The Diabetes UK taskforce looking into the care of residents in nursing homes or residential care settings recommended that every resident should be screened annually for diabetes.²

Diabetes management

Managing diabetes in the older person may rely on a diverse approach, taking an individualised holistic view of the condition. Many older people with diabetes are fit and healthy and live independently in the community, or live in the community with home help and carer support. Other older people with diabetes may be frail, have disabilities or comorbidities and live in residential care settings, making their care more complex. 

Older adults with diabetes are at risk of developing similar complications as their younger counterparts. However, in the older adult, avoidance of hypoglycaemia, hypotension, polypharmacy, drug interactions and prolonged hyperglycaemia are a cause for greater concern in the overall management of their diabetes. 

Lifestyle modification

Poor dietary habits, mobility issues and changes in body composition present problems when implementing lifestyle interventions in the older adult. The issue of older adults being underweight is just as prevalent as younger people being overweight in type 2 diabetes. Therefore, nutritional management must be tailored to the individual so that weight gain is as much as a focus as weight loss in a younger person with diabetes.

Another dietary issue present in older people with diabetes is an intolerance to carbohydrates due to age-related changes in insulin secretion and action. This is well documented in the UK Prospective Diabetes Study (UKPDS).³ Managing this issue should be implemented with a multidisciplinary approach, such as referral to a community dietician. 

There are few contra-indications to exercise that exist and the majority of older people with diabetes can benefit from some form of physical activity that focuses on strength training, balance and mobility. When implementing any physical activity programme, each person will be individually assessed by a physical activity leader/physiotherapist for motivation and assessment of limitations. 

Glycaemic targets

There are many misconceptions surrounding the glycaemic management of an older person with diabetes. Little research exists on addressing optimal glycaemic targets in the elderly, so it is important to take an individual approach. 

The danger of low glycaemic targets in the elderly is that it may increase the frequency of hypoglycaemia, which can result in poor outcomes, such as falls and exacerbation of comorbid conditions. Furthermore, older patients may tolerate high blood sugar levels before it manifests in symptoms such as urinary incontinence, confusion and repeated infections. Prolonged uncontrolled hyperglycaemia may lead to complications such as ketoacidosis and hyperosmolar non-ketosis (HONK), which can be fatal.

According to the ACCORD study, an HbA1c target for fit older adults with a life expectancy of more than 10 years is similar to those of a younger person with diabetes, which is ≤ 7.0%. For those with long standing type 2 diabetes with co-existing cardiovascular disease, a HbA1c target of 7-7.9% may be more appropriate. In frail elderly patients, with comorbidities and a life expectancy of less than 10 years, a HbA1c target of ≤8.0% is sufficient.⁴ 

Medication management

Combination therapy is now regarded as a far more effective method of managing overall glycaemic control than one sole oral hypoglycaemic agent (OHAs) and slows down the progression to insulin. Because of the availability and choice of many agents, depending on OHAs such as sulfonylureas is greatly reduced and subsequently reduces the incidence of hypoglycaemia, especially in the elderly. But this approach fosters polypharmacy and increases drug errors. 

Understanding medications and education is essential in the elderly community to reduce the incidence of drug errors and to increase adherence to medications.⁵ Regular medication reviews are essential, based on an individual’s abilities and comorbidities. ‘Start low and go slow’ is a good principle to follow when starting new medications in the older person. 

Good education and awareness on the part of diabetes patient and those involved in their residential care, is paramount. Drafting local policies based on national and international guidelines is essential for safe and effective practice. 

References

1. Older People in Ireland: A Profile of Health Status, Lifestyle and Socio-Economic Factors from SLÁN, Dr Frances Shiely and Professor Cecily Kelleher (University College Dublin) National Council on Ageing and Older People, 2004
2. Good clinical practice guidelines for care home residents with diabetes: A revision document prepared by a Task and Finish Group of Diabetes UK , January 2010
3. U.K. Prospective Diabetes Study Group: Intensive blood glucose control with sulfonylurea’s or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 352:837-53, 1998
4. Gerstein HC, Riddle MC, Kendall DM, Cohen RM, Goland R, Feinglos MN, et al. Glycaemia treatment strategies in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. Am J Cardiol. 2007;99(suppl):34i–43i
5. Cristín Ryan, Denis O’Mahony, Julia Kennedy, Peter Weedle, Stephen Byrne, Potentially inappropriate prescribing in an Irish elderly population in primary care, Br J Clin Pharmacol. 2009 December; 68(6): 936- 947. doi: 10.1111/j.1365-2125.2009