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A Primer on Diabetes in the Elderly

Defining the elderly population can be tricky. In most developed countries, the chronological age of 65 years as a definition of ‘elderly’ or older person, is widely accepted or often, associated with the age at which one can begin to receive pension benefits. Although it is common to use the calendar age to mark the threshold for old age, it is not necessarily synonymous with the biological age. Region where one lives, smoking and alcohol history, existing medical conditions, physical appearance and even social standing all contribute to the so called biological age.

Doctors would also differentiate this group as fit or frail. Fit, meaning no significant medical problem and living independently, while frail elderly are dependent on others for activities of daily living or have significant medical problems especially conditions that contribute to frailty like stroke, Alzheimer’s disease or fracture.

This informal categorization of fit and frail becomes relevant on deciding how aggressive a person with diabetes is managed most of the time. Generally, hypoglycaemia is avoided more so with the frail individual especially if he/she cannot communicate his/her symptoms (bedridden, stroke patients, Alzheimer’s, etc.). When starting somebody on insulin, one is also more careful with the frail individual and subsequently influences how the insulin is titrated. A fit elderly who still engages in parties, is still active in business meetings and socializes may also receive more oral anti-diabetic agents or insulin, because of the nature of their lifestyle.

Glycemic Goals
The duration of diabetes also influences how a person is managed; in longstanding diabetes, arbitrarily more than 8-10 years, the target A1c (HbA1c) is not as strict as someone who is newly diagnosed. An A1c of 7% or below without significant hypoglycemia is good enough if the diabetes is longstanding. The target goal can go up to 8% especially if there are multiple medications, big doses of insulin, increasing age, poor nutritional intake, isolation and expected shortened life span. A more realistic goal of reducing symptoms of hyperglycemia like polyuria or fatigue may be more practical in these individuals.

Complications
Like in younger individuals, efforts must be directed in avoiding complications. Data suggest that older diabetic patients should be treated as aggressively for diabetes and cardiovascular risk factors as with people with known cardiovascular disease. Some of these modifiable risk factors include obesity, LDL-cholesterol (bad cholesterol), blood pressure and smoking.

Blindness and renal failure remain frequent complications of diabetes especially with increasing duration of diabetes and worsening glucose control. Although it’s our aim to prevent such catastrophe, keep in mind also that the complication rate may be naturally lower for type 2 than for type 1 diabetes (insulin requiring autoimmune diabetes), perhaps due to older age of onset of type 2, and thus less time to develop the complications.

Also be careful in trying to reach the desired blood pressure, older individuals may not tolerate sudden drops or very low blood pressure. The usual goal of 120/80 may suffice, especially if there are concomitant medications that can lower blood pressure (example: prostate medicines like the alpha blockers can cause hypotension).

Hypoglycemia
Finally, recognize factors that might increase hypoglycemia, the complication that is dreaded in any age group. Be wary of medicines like sulfonylurea and insulin that are known to cause hypoglycemia. Medicines like metformin, pioglitazone, alpha-glucosidase inhibitors (e.g., voglibose and acarbose) and DPP-4 inhibitors (sitagliptin, vildagliptin and saxagliptin) given alone may be considered to avoid severe hypoglycemia. Co-morbidities like depression, Alzheimer’s disease, poor appetite, isolation and polypharmacy (taking multiple medications) may be predisposing factors for hypoglycemia.

In conclusion, the older population has special needs and different target goals compared to the younger adults. But like their younger counterparts, each patient should be managed individually with quality of life and avoiding major diabetes complications in mind.

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