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12 | September 2015 |
DIABETES
Diabetes, in the elderly, is a common condition which requires the most
careful of clinical application. The complexity of issues surrounding a patient
over the age of 50 with diabetes, especially the very elderly and frail, require a
healthcare professional to have a sound understanding of dierent scenarios
encountered.
DIABETES IN THE OVER 50
YEARS AGE GROUP
This review, using a clinical case scenario, aims
to give a comprehensive overview of some of
these pertinent problems. These topics include
blood glucose management and glycaemic targets,
hypoglycaemia, cardiovascular risk protection,
medication use, microvascular disease and other
common problems encountered in the elderly. Using
consideration of all these matters, the clinician
can have a sound foundation to assist with clinical
decision making.
Case study
An 83-year-old female with a background history
of vascular dementia who is being treated with
insulin for her type 2 diabetes presents to the
Accident and Emergency Department after being
found unconscious at her nursing home. When
the paramedics arrived it was discovered that she
was hypoglycaemic with a capillary blood glucose
reading of 1.8 mmol/L. She was successfully treated
with a bolus of intravenous glucose. By the time
of her arrival to the hospital her conscious level
had improved and her blood glucose reading
had normalised to 6.3mmol/L. On review, the
admitting team established that she had been
suffering with diarrhoea and vomiting for the last
two days with reduced oral intake. Her insulin
had been administered the morning of admission
at her usual dose (she was taking a twice daily
pre-mixed preparation of insulin). The diagnosis
was insulin induced hypoglycaemia in the context
of a viral gastroenteritis. Her hypoglycaemia and
gastroenteritis were managed in hospital and she
was discharged back to her nursing home on a once
daily preparation of insulin which was solely a ‘long-
acting’ preparation upon the advice of the attending
diabetes specialist nurse.
This case highlights the one of the many
challenges that are faced by clinicians managing all
patients but specically elderly persons with diabetes.
Diabetes, worryingly, is showing an increasing trend
worldwide. It is thus imperative that all clinicians
have familiarity and condence in dealing with
patients who suffer with the illness. The rate of
newly diagnosed diabetes exponentially increases
with age but tends to plateau after age 85 years with
approximately 25% of people over the age of 65
suffering from the condition.1 Because of the high
prevalence of co-morbidities, there are many factors
to consider in order to safely manage this cohort of
patients.2
Glycaemic targets
Traditionally diabetes-related research
has championed intensive management of
hyperglycaemia with the aim to achieve lower
haemoglobin A1C (HbA1c) concentrations. This
is paramount as lowering the HbA1c is associated
with reduction of both micro- and macro-vascular
complications of diabetes. Reduction in blood
glucose readings generally also prevents dangerous
emergencies associated with diabetes – hyperosmolar
hyperglycaemic state and diabetic ketoacidosis.
These conditions carry a high mortality rate and
every effort to prevent their development is crucial.
Consistent hyperglycaemia can lead to osmotic
symptoms which can pre-dispose to uid and
electrolyte disturbances.
It is important to note that the larger and most
reliable studies advocating the lowering of HbA1c
were conducted exclusively in patients under the
age of 65.3, 4 There are however studies that have
specically looked at an older group of patients with
greater burden of pre-existing cardiovascular disease
and these have stressed caution with intensive glucose
control especially given the risk of hypoglycaemia.
One study highlighting this risk has shown a ‘U-
shaped’ relationship between HbA1 and mortality in
patients with diabetes aged ≥ 60 years.5
The ACCORD study showed increased mortality
with intensive glycaemic management in the elderly6
whilst other studies have shown an overall non-
benecial role in reducing cardiovascular mortality
when intensive blood glucose management is sought
Safwaan Adam
Department of
Diabetes and
Endocrinology,
University
Hospital
of South
Manchester,
Manchester
Basil Issa
Department of
Diabetes and
Endocrinology,
University
Hospital
of South
Manchester,
Manchester
s.adam@
doctors.org.uk
| September 2015 | 13
DIABETES
despite there being a reduction in diabetes related
nephropathy.7, 8 This is essential when considering
what our traditional HbA1C targets are—to reduce
the risk of complications the optimal HbA1c is
considered to be less than 7% (or 53mmol/mol).
The European Diabetes Working Party for Older
People 2011 Clinical Guidelines for Type 2 Diabetes
aims to suggest achievable and safe glycaemic targets
in those over the age of 70—in patients who are
free of major comorbid disease a target HbA1c of
7–7.5% (53–59mmol/mol) should be sought, whilst
those with frailty (signicant co-morbidity, care home
resident and with high risk of hypoglycaemia) this
target should be relaxed to 7.6–8.5% (60–69 mmol/
mol). Below those age groups and in the absence of
disabling co-morbidity, the HbA1c target should be
intensied for the reasons highlighted above.
It is vital to stress that the studies alluded to above
have shown a correlation with duration of diabetes
and ability to prevent both morbidity and mortality—
the UKPDS, a landmark study in diabetes, in its 10
year follow up study showed a “legacy effect” for
treating hyperglycaemia suggesting that starting with
intensive therapy at diagnosis led to better long term
outcomes thus encouraging urgency in treating newly
diagnosed diabetics. The aforementioned studies
which showed less benecial outcomes were carried
out in patients with established diabetes for several
years. This leads to the conclusion that addressing
glycaemia at a later course in the disease process is
less benecial. This is key because the commonest
age range for a new diagnosis of diabetes is 45–649
and hence if diabetes is treated early, the long term
success will be better.
Hypoglycaemia
Hypoglycaemia can be an extremely debilitating
symptom as well as carrying potentially dangerous
consequences with it. Older patients in general may
be more prone to severe hypoglycaemia compared
to younger persons possibly as a result of less severe
warning symptoms.10 Not surprisingly, the risk is
inversely proportionate to the level of glycaemic
control with patients with an HbA1c of ≤6.0% (42
mmol/mol) being at the highest risk.5 The choice
of medication inuences the development of a
low blood glucose with insulin and sulfonylureas
carrying the highest risk. Older patients are more
likely to have concurrent renal disease,11 which in
itself is an independent risk factor for medication
induced hypoglycaemia.12
Hypoglycaemia can cause signicant psychological
distress as well as negatively affect the general
condence of the elderly patient.13 It is also
associated with other forms of serious morbidity, for
example, precipitating events such as cerebrovascular
and myocardial ischaemia alongside signicant
physical injury.14 Therefore it is vital that every effort
is made to prevent hypoglycaemic events, such as
relaxing blood glucose targets, exercising caution
with the dosage of medication as well as educating
both patients and their carers both on prevention and
treatment of hypoglycaemia. Those with impaired
ability to self-manage or communicate symptoms
of hypoglycaemia should have a particular focus on
preventative measures.
Microvascular complications of
diabetes
Older people are more likely to suffer with crippling
effects of the microvascular complications of
diabetes. Eye disease, renal disease and foot disease
all carry unique problems associated with them, but
they all share in common a devitalising effect on an
individual. All of these complications are more likely
to occur with a longer duration of diabetes.15 People
with visual disturbance16 or foot disease17 are more
likely to suffer with falls. Foot disease can also lead
to debilitating foot amputation which also has a
higher prevalence in the over 50 age group.
Diabetes related renal disease is one of the
important and common conditions requiring dialysis.
Nephropathy in its own right signies greater
cardiovascular risk, but it is paramount to think
about the implications of dialysis and the issues
surrounding that such as frequent hospital visits,
infections (both with peritoneal and haemodialysis),
depression, impaired quality of life and mortality.
In an older person with diabetes, it is thus
imperative to consider pre-existing complications and
their impact as well as screen for and prevent any
further complications. This further adds to the case of
individualised care.
Cardiovascular risk prevention
Diabetes as a disease entity is a major risk factor for
the development of cardiovascular disease.18 Though
optimisation of glycaemic control is essential, the
other facets for preventing cardiovascular disease
need to be managed appropriately especially given
that increasing age is in itself a compelling risk factor
for cardiovascular mortality and morbidity.19 Issues
such as hypertension need to be treated effectively
but careful consideration should be given to adverse
events related to over-treatment such as hypotension
related syncope and falls. Lipid lowering therapy
should be used where appropriate as this has a key
role in improving cardiovascular outcomes, even in
the elderly.20, 21 This benet has also got to be weighed
against the risk of side-effects that are potentially
related to drug treatment such as myalgia which
can affect quality of life.21 Other factors such as
encouragement of exercise and healthy diet as well as
smoking cessation should continue to be promoted,
where appropriate.
Aspirin use for prevention of cardiovascular
disease is an area which has been debated extensively.
There is no doubt that aspirin confers a net benet
14 | September 2015 |
DIABETES
in secondary prevention in those with established
cardiovascular disease.22 Its role in primary
prevention is questionable because of the increased
bleeding risk associated with the drug).
There is insufcient evidence to advocate for the
use of aspirin in people with diabetes for the sake
of primary prevention in individuals who would
otherwise be at low risk for cardiovascular disease.23
Thus, by inference, a careful assessment considering
the risk of cardiovascular disease should be balanced
against the bleeding risk before prescribing aspirin as
a prophylactic life prolonging measure.
Specific medication
There needs to be a prudent approach when
considering medication use in the elderly. Within
the scope of diabetes there is now a plethora of
options with regards to pharmaceutical management.
Arguably, there is a role for every type of anti-
hyperglycaemic agent but that role must be clearly
dened and the drug choice made on the basis of a
careful individual care plan with a focus on shared
decision making. The choice of treatment should take
into account factors such as hypoglycaemia, renal
function, drug interactions with other medication (in
a group of patients often on polypharmacy), side-
effects, contraindications, ease of use for the patient,
storage issues and patient choice.
Specific drugs for type 2 diabetes
Metformin
Metformin should be considered as the rst-line oral
anti-diabetic drug in elderly patients with type 2
diabetes.24 The advantages include metformin being
effective and lowering diabetes related end-points
including reduction in cardiovascular and all-cause
mortality.4 It is generally well-tolerated, does not
cause hypoglycaemia (when used as monotherapy)
and has a favourable cost. However, it must be used
with caution in the elderly considering the potential
for gastro-intestinal side effects as well as the risk of
lactic acidosis in end-organ dysfunction, in particular
renal disease.25
Sulfonylureas
Sulfonylureas are generally considered as second-line
therapy for type 2 diabetes, even in the elderly.24 As
with metformin, this class of drug is generally well
tolerated but by far the most important concern is the
predisposition towards hypoglycaemia.
The risk of hypoglycaemia is particularly
problematic with longer-acting sulfonylureas such
as glibenclamide.26, 27 This risk of hypoglycaemia is
enhanced in those with kidney disease28 and in those
using combination therapy with other anti-diabetic
agents.29
Dipeptidyl Dipeptidase 4 (DPP-IV)
inhibitors
Dipeptidyl Dipeptidase 4 (DPP-IV) inhibitors provide
a useful choice as these, like metformin, are not
individually causally linked with hypoglycaemia and
have been shown to enhance insulin sensitivity.30
The other advantage this class of drug confers is the
relative safety in renal dysfunction.31 There are also
studies that show that DPP-IV inhibitors are both
effective and well tolerated in the elderly.32 The cost
of these drugs must be borne-in-mind and as such
this can prove to be a limiting factor.
Glucagon like peptide (GLP) 1 agonists
Glucagon like peptide (GLP) 1 agonists can be
considered in the elderly, but must be used with
caution. These drugs need to be delivered by
injection with the frequency of drug, depending
on preparation, varying between twice daily and
once weekly. This exibility can be useful especially
if the ability of the individual to self-administer
such medication is in doubt. As with other anti-
hyperglycaemic agents, they need to be used with
caution in those with renal disease.33 The other
important considerations include their effect on
weight (these drugs generally promote weight loss
which is not always desirable in the elderly) as well as
their potential adverse gastro-intestinal side-effects.34
This limits their use in frail and underweight patients,
but could be useful in obese patients. The cost of
these drugs, as with DPP-IV inhibitors, can also be an
obstacle.
Sodium glucose co-transporter 2
(SGLT-2)
Sodium glucose co-transporter 2 (SGLT-2) inhibitors
are a new and interesting class of drugs. They work
by promoting renal excretion of glucose by lowering
the renal threshold for glycosuria. Certain drugs
within the class have certainly been shown to be
effective within the elderly population and they are
generally safe.35 This benet must be weighed against
the potential side effects which include increased
pre-disposition towards urinary tract infections and
genital mycotic infections which can be a signicant
concern in the elderly.35 The cost of these drugs is
also a factor that needs to be evaluated carefully
before choosing them. As with GLP-1 agonists, they
also promote weight loss, albeit to a lesser extent,
which can be either advantageous or disadvantageous
depending on the individual.
Thiozolinediones improve insulin sensitivity
however their use has been limited because of
increased risk of uid retention and therefore the
potential for worsening heart failure, weight gain and
the development of oedema , increased fracture risk,
and concerns over malignancy of the bladder.36
The use of insulin should always be considered
carefully especially when used with other anti-
| September 2015 | 15
DIABETES
diabetic medications with an emphasis on ‘situation-
specic’ decisions. Despite the obvious concern
of hypoglycaemia, it must be stressed that when
indicated, insulin therapy should not be delayed.24
Elderly people are at higher risk of visual impairment
as well as more likely to have joint disease37 which
can inuence specic insulin delivery devices making
these elements of care requiring utmost attention.
Other important factors
Older people with diabetes are more likely to suffer
with cognitive impairment than those without the
condition.38 Cognitive impairment in turn makes
the management of both hyper and hypoglycaemia
more challenging. Depression is also more common
in people with diabetes.39 Diabetes is an important
cause of physical disability and the effects of this
are further translated into ill consequences of both
physical and mental health. People with diabetes are
also more likely to require hospital admission with
longer hospital stays even if the admission was not
primarily linked to the diabetes itself.40
Conclusion
Diabetes in the over 50 age group is denitely a
challenging condition to manage. There are many
different components of the disease itself and its
treatment that require a comprehensive assessment.
The role of shared decision making with full
involvement of patients and their carers cannot be
stressed enough and more importantly, care should
be personalised for each individual. There should
also be a focus on multidisciplinary team working as
this unique patient group provides a challenge that
requires a holistic approach.
Conict of interest: xx
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