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* Corresponding author: University of Oran 1- Ahmed Ben-Bella, Department of Internal Medicine at the University Hospital
, Oran 31000, Algeria. Tel: +213 661 416 353 E-mail: docteur_chami@yahoo.fr
Nor. Afr. J. Food Nutr. Res. 2022; 6(13): 9-21
https://doi.org/10.51745/najfnr.6.13.9-21
https://www.najfnr.com
REVIEW ARTICLE
Epidemiology, diagnosis, and assessment of diabetes mellitus in the elderly
population: a purposive review
Mohammed Amine Chami 1,2 *, Meghit Boumediene Khaled 3
1 Grand Hôpital de l’Est Francilien (GHEF), Site de Meaux, Court séjour gériatrique, France.
2 University of Oran 1- Ahmed Benbella, Department of Internal Medicine at the University Hospital , Oran 31000, Algeria.
3 Faculty of Life and Natural Science, Depart ment of Biology, Djillali Liabes University of Sidi-Bel-Abbes. Laboratoire de Nutrition, Pathologie, Agro-Biotechnologie et Santé (Lab-
NuPABS), Sidi-Bel-Abbes, 22000, Algeria
1 Diabetes mellitus
Several studies have shown that the prevalence of diabetes
mellitus increases with advancing age 1-5. The elderly and/or
those with multiple co-morbidities have often been excluded
from randomized controlled trials of treatments for diabetes and
its associated conditions 6. The management of this chronic
disease in the elderly suffers from a great insufficiency, especially
in countries where the specialty of geriatrics is not taught and
where structures dedicated to this age group are non-existent.
The aim of the current purposive review article is to provide, on
the one hand, an update on the epidemiology of diabetes mellitus
in the elderly, on the other hand, to shed the light on the
specificities of this pathology in the elderly people in terms of
diagnosis, of diabetes evaluation considering macro- and
microangiopathic complications. As well as the evaluation of the
elderly person as a whole with an emphasis on the geriatric
evaluation being an essential prerequisite for the management of
the elderly diabetic patients by looking for geriatric syndromes.
The geriatric assessment will classify the elderly as robust
(healthy), fragile, and at the end of their life and the treatment
objectives will be according to this categorization 7. The search
strategy was developed using the following keywords: “Elderly”,
“Diabetes Mellitus”, Epidemiology”, Geriatric assessment”,
“Geriatric syndrome”. To retrieve relevant articles to the research
question of this review, databases of PubMed/Medline, Scopus,
were searched in English and French with no time restriction.
The grey literature was also searched (Google, Google Scholar).
2 Diabetes mellitus epidemiology in the
elderly
According to the International Diabetes Federation (IDF), the
diabetes mellitus pandemic is dramatically arising worldwide. In
2019, the number of diabetes mellitus patients reached 463
million and will be 578 million in 2030 and 700 million in
2045 8. Several epidemiological studies have shown that the
prevalence of diabetes mellitus increases with advancing age.
According to the IDF, the number of diabetic people among those
65 and over has reached 136 million (19.3%). The projections are
more alarming since they will be 195.2 million and 276.2 million
respectively in 2030 and 2045 8.
As summarized in Table 1, the prevalence of diabetes mellitus in
the elderly by continent is as follows: In Europe 20.1%, in North
America 27%, in Middle East and North Africa (MENA) 24.2%,
in Central and South America 22.7%, in western pacific 18.9%,
in Africa 8.4% and in Southeast Asia: 13.6% 9. In the United
States, a third of people aged 65 and over are diabetic and half
suffer from prediabetes 10. In our region (North Africa), two
prevalence studies were carried out, one in Tunisia which found a
prevalence of 27.4% 11 and the other in Algeria and which found
26.7% in subjects aged 65 and over 12. What should be noted is
that the prevalence of diabetes mellitus decreases after the age of
75, this is explained by the high mortality linked to diabetes
mellitus but also to the weight loss after 75 years which decreases
the incidence of diabetes mellitus 13.
Abstract
The elderly population with diabetes mellitus is rapidly growing worldwide and has become a major social burden with significant impact on health and
economics. This social category requires considerations that are not traditionally associated with diabetes mellitus management. Several epidemiological
studies have shown that the prevalence of diabetes mellitus increases with advancing age. According to the recent International Diabetes Federation (IDF)
published data, the number of people with diabetes mellitus among those 65 and over has reached 136 million (19.3%) with more frequent diabetes mellitus
complications and co-morbidities compared to the young counterparts. Cardiovascular complications are the leading cause of death and the quality of life
is strongly impacted by geriatric syndromes such as poor vision, dementia and functional dependence. The elderly diabetic population is classified into three
categories; the robust, the fragile and the patient at the end of life. In practical terms, they can also be classified into two categories: the autonomous patients
and the dependent patients, requiring support and assistance.
Keywords:
diabetes mellitus, elderly, epidemiology, geriatric syndromes, geriatric evaluation.
Received
: July 24, 2021 /
Accepted
: December 31, 2021 /
Published
: January 03, 2022
Chami & Khaled Diabetes mellitus in the elderly
Nor. Afr. J. Food Nutr. Res. 2022; 6 (13): 9-21
10
Table 1: Diabetes mellitus prevalence in people older than 65 years by IDF Region in 2017, 2019, 2030 and 2045, ranked by 2019 prevalence estimates 2
Rank
IDF
Region
2017 2019 2030 2045
Prevalence
(%)
Number of
people with
diabetes
(millions)
Prevalence
(%)
Number of
people with
diabetes
(millions)
Prevalence
(%)
Number of
people with
diabetes
(millions)
Prevalence
(%)
Number of people
with diabetes
(millions)
World
18.8
(15.4
–23.4) i
122.8
(100.2
–152.3)
19.3
(15.3
–24.2)
135.6
(107.6
–170.6)
19.6
(15.5
–24.8)
195.2
(154.7
–247.1)
19.6
(15.2
–25.4)
276.2
(214.8
–358.9)
1 NAC
26.3
(23.4–29.4)
17.7
(15.7–19.7)
27.0
(22.2–32.6)
19.2
(15.7–23.1)
27.3
(22.4–33.0)
26. 9
(22.0–32.5)
27.5
(21.9–33.9)
34.0
(27.1–42.0)
2 MENA
20.4
(12.6–29.0)
6.5
(4.0–9.3)
24.2
(13.2–34.0)
8.4
(4.6–11.8)
24.7
(13.7–34.6)
13.7
(7.6–19.2)
25.2
(13.9–35.6)
25.2
(13.9–35.6)
3 SACA
19.0
(15.1–24.4)
7.9
(6.3–10.2)
22.7
(18.3–29.3)
10.3
(8.3–13.2)
23.1
(18.7–29.7)
15.7
(12.7–20.2)
23.1
(18.5–30.1)
24.0
(19.2–31.2)
4 EUR
19.4
(14.9–25.0)
28.5
(21.9–36.7)
20.1
(15.3–25.8)
31.0
(23.5–39.8)
20.2
(15.2–26.1)
38.8
(29.2–50.0)
20.5
(15.2–26.8)
46.3
(34.5–60.8)
5 WP
20.0
(17.8
–23.0)
48.1
(42.7
–55.2)
18.9
(16.7
–22.1)
50.3
(44.4
–58.9)
19.6
(17.2
–23.1)
75.4
(66.4
–89.1)
19.8
(17.3
–23.9)
107.3
(93.5
–129.6)
6 SEA
13.5
(9.5–18.6)
12.5
(8.7–17.1)
13.6
(10.1–18.6)
13.6
(10.1–18.6)
13.9
(10.3–19.1)
20.5
(15.3–28.2)
14.0
(10.4–19.7)
32.2
(24.0–45.1)
7 AFR
5.2
(2.8–12.8)
1.6
(0.9–4.0)
8.4
(3.0–15.5)
2.8
(1.0–5.1)
8.7
(3.1–16.2)
4.2
(1.5–7.8)
8.4
(3.1–16.8)
7.3
(2.7–14.6)
IDF: International Diabetes Federation; AFR: Africa; EUR: Europe; MENA: Middle East and North Africa; NAC: North America and Caribbean; SACA: South and Central
America; SEA: South-East Asia; WP: Western Pacific.
i:
95% confidence intervals are reported in brackets.
Chami & Khaled Diabetes mellitus in the elderly
11
Nor. Afr. J. Food Nutr. Res. 2022; 6 (13): 9-21
3 Diagnosis of diabetes mellitus in the
elderly and circumstances of discovery
The diagnostic criteria for diabetes mellitus in the elderly are
identical as in the young population. Glycated hemoglobin
(HbA1c) is also a parameter used for the diagnosis of diabetes
mellitus, but it is often distorted by comorbidities, in particular
anemia in the elderly 14. The most frequent circumstances of
discovery are a fortuitous diagnosis either during a check-up
routine, either on the occasion of a cardiovascular complication,
an infection (most often urinary) or a lesion of the foot 15.
In emergencies, diabetes mellitus can be revealed mainly by a
hyperosmolar coma or precoma where the elderly subject do not
feel thirsty. This complication is encountered during the hot
seasons, in the event of diarrhea, vomiting, fever or medication
(diuretics or laxatives), or when taking corticosteroids 16.
A distinction must be considered between recent diabetes
mellitus occurring at an advanced age and aged diabetes, this
distinction is crucial since the clinical data are not identical.
Diabetes mellitus occurring at an advanced age requires the use
of insulin less often, it presents less microvascular complications,
in particular less diabetic retinopathy, however there is no
difference in the prevalence of neuropathy or other
complications mainly the cardiovascular ones 17.
In most cases, aged type 2 diabetes mellitus (T2DM) does not
constitute a major issue of classification, this type of diabetes
mellitus requires insulin therapy after a certain period of
development, the distinction then between insulin-treated
T2DM and type 1 diabetes mellitus is important to take into
consideration 17.
T2DM is generally asymptomatic, so the seniority cannot be
specified, and the search for complications that have gone
unnoticed must be systematic, in particular, by performing an
ophthalmological examination (fundus) in search of retinopathy,
which can inform us about the duration of diabetes mellitus 18.
Diabetes mellitus poses a real concern of diagnosis and
classification when transient hyperglycemia must be eliminated,
at this age, during stress (cardiovascular complication,
inflammation, hyperthyroidism) 19. Pancreatic disease should
also be diagnosed.
4 Assessment of the elderly diabetic
4.1 Search for microangiopathic complications
Diabetic retinopathy should be sought systematically by
performing a fundus. Retinopathy is considered as the fourth
cause of poor vision in the elderly 20. However, diabetic
nephropathy is sought by performing an ACR (Albumin-to-
creatinine ratio) on a fresh urine sample. This nephropathy may
be of diabetes mellitus, vascular origin, or secondary to other
etiologies 21. The assessment of glomerular filtration rate (GFR)
must use the Modification of Diet in Renal Disease (MDRD)
formula or the Chronic Kidney Disease Epidemiology
Collaboration (CKD-EPI) formula 22.
4.2 Search for macroangiopathic complications
The practice of an electrocardiogram (ECG) is systematic in the
search of a cardiac complication such as cardiac ischemia or an
unnoticed myocardial infarction or further abnormalities, such as
left ventricular hypertrophy (LVH), atrial fibrillation (AF), etc. 23.
Peripheral arterial disease is sought by using a pocket vascular
Doppler. The Ankle Brachial Index (ABI) is calculated while
keeping in mind that it is often faulted by the arterial stiffness
being frequent in the elderly and therefore it is often necessary to
supplement by a vascular echo Doppler, even an angiography of
the arteries of the lower limbs 24.
The search for a plaque or carotid artery stenosis is also
recommended by the practice of an echo Doppler of the supra
aortic trunks 23.
Finally, the search for heart failure must be part of the
assessment of the elderly diabetes mellitus patients because of its
high prevalence and its seriousness. It is frequently a heart failure
with preserved ejection fraction and an echocardiography should
be performed in the event of any symptom leading to heart
failure such as dyspnea, cough on exertion, an abnormality on
the ECG 25.
4.3 Diabetic neuropathy (DN)
DN is frequent in the elderly but it is always necessary to look
for further cause of neuropathy such as vitamin B12 deficiencies,
especially in patients on metformin. Painful neuropathy is
diagnosed using
Douleur Neuropathique en 4 Questions
(DN4),
one of the questionnaires that can be useful in diagnosing
neuropathic pain. The painful neuropathy affects quality of life
and must be treated 25.
4.4 Diabetic foot
Foot lesions are particularly frequent in the elderly due to the
presence of several risk factors such as peripheral neuropathy, foot
deformities, arterial disease of the lower limbs, vision disorders,
balance disorders, and reduced mobility. The risk of amputation
increases with age. The prevention of foot ulcerations is based on
the estimation of the podiatry risk, on the implementation of
preventive measures and on therapeutic education. It is essential
to avoid bad footwear, barefoot walking, exposure to heat sources
(hammam, radiator), henna, dry feet after ablutions or a bath 26.
Obliterating arterial disease of the lower limbs is a major cause of
amputation; their prevention is based on the correction of
cardiovascular risk factors by insisting on smoking cessation 27.
The treatment of foot ulcers is based on ulcer area off-loading,
being crucial for the healing of plantar ulcers, including also
debridement of the wounds, and treatment of infection and
ischemia 26.
4.5 Geriatric assessment
The overall geriatric assessment is at the heart of all care decisions
and will identify the different geriatric syndromes, and determine
the functional, clinical and social profile of the elderly 28, 29.
Chami & Khaled Diabetes mellitus in the elderly
Nor. Afr. J. Food Nutr. Res. 2022; 6 (13): 9-21
12
4.5.1 Social assessment
It would be primordial to determine the lifestyle of the elderly
population, their marital status, living alone or with their family,
the type of accommodation, the presence of a caregiver or not,
income, health insurance, their autonomy for activities of daily
living. All these would help to identify the needs of the elderly and
possibly provide the necessary home assistance and support 26.
4.5.2 Cognitive disorders
Diabetes mellitus accelerates cognitive decline in the elderly,
several studies showed that diabetics have impaired cognitive
functions compared to the non-diabetic population 30-33. Studies
have also shown that the risk of vascular dementia and dementia
Alzheimer's is multiplied by 1.5 to 2.5 34, 35.
The mechanisms of cognitive decline are not elucidated and
would be explained by the reduction of extracellular glucose in
the hippocampus that limits the memorization process. Another
explanation would be the prolonged and repeated hypoglycemia
in patients on hypoglycemic agents or insulin-therapy 28, 29.
Cognitive decline has a negative impact on the management of
diabetes mellitus and therefore diabetes mellitus patients no
longer recognize hypoglycemia. This could aggravate cognitive
decline. As a consequence, patients cannot or no longer want to
self-monitor, and reaching glycemic objectives is difficult.
Therefore, an early diagnosis and management of cognitive and
diabetes mellitus impairment should help prevent or at least
delay the progression of a Mild Cognitive Impairment (MCI) to
severe dementia 36.
The involvement of healthcare professionals as well as the family
and primary caregiver plays a crucial role in improving the
adherence and persistence of the diabetic patient to the
treatment 37.
Hypoglycemia must be avoided, for this it would be better to
provide drugs with a low risk of hypoglycemia, to avoid the use of
HbA1c as the unique measure of glycemic monitoring. Capillary
blood glucose levels or even better the continuous glucose
monitoring (CGM) are more accurate. A simplified diagram and
patient education when possible and/or that of caregivers and
family is imperative 36-38.
To assess cognition, several tests are available, three are particularly
useful and rapid to perform, the Mini-Mental State Examination
(MMSE), the Montreal Cognitive Assessment (MoCA) and the
Mini-Cog 39.
Elderly diabetic patients with cognitive impairment are generally
not included in therapeutic education and disease self-
management programs. This situation can lead to the
institutionalization of the patient or to total care by the
caregivers 40.
4.5.3 Thymic disorders
Diabetes mellitus increases the risk of developing or recurring
depression, similarly, a history of depression increases the risk of
developing diabetes mellitus 41. In elderly diabetics, the presence
of undiagnosed, untreated or insufficiently treated depression
negatively impacts the management of diabetes mellitus, as
consequence, patients show low adherence to the treatment 42.
The coexistence of depression and diabetes mellitus can
accelerate cognitive decline, hence the importance of treatment
for both depression and diabetes mellitus. Depression is often
masked and it is necessary to know how to look for signs such as
sleep disturbances, changes in appetite, asthenia, reduced
motivation and a lack of interest in participating in care. Several
treatment approaches are available, pharmaceutical,
psychotherapeutic, behavioral, lifestyle interventions, and
combination therapies. The elderly may feel desperate in the face
of prescribed treatments 43.
Symptoms of depression in the elderly are unfortunately often
attributed to natural aging, bereavement, illness or dementia, thus
delaying diagnosis and the initiation of beneficial treatment 44. In
the elderly diabetes mellitus population, depressive symptoms
may be mistaken for symptoms due to diabetes mellitus or other
illnesses. Many of the symptoms of depression such as asthenia,
loss of appetite and trouble sleeping are also found in diabetes
mellitus. It can therefore be difficult to differentiate symptoms
related to diabetes mellitus from those associated to depression 45.
The majority of older people with clinically significant depressive
symptoms do not meet the standard diagnostic criteria for major
depression 46, 47. Furthermore, these patients have a high risk of
developing major depression afterwards and may also develop
suicidal thoughts 48-50. Depressed patients with diabetes mellitus
are at greater risk of developing chronic depression or making less
complete recovery 51.
Depression is frequent, difficult to diagnose, it must be
mentioned in the face of a wide variety of symptoms. The
treatment of depression has a favorable impact on adherence to
diabetes mellitus treatment and therefore allows for better
glycemic control 36.
4.5.4 Functional profile
Functional disability refers to the presence of "limitation in the
performance of socially defined roles and tasks in a socio-cultural
environment due to physical impairment" 52. Frailty and
sarcopenia are two risk factors for the development of disability.
Frailty being a clinical entity, is characterized by a decrease in
reserve and resistance to stressors (unsuitability to stress) resulting
from the physiological decline of numerous systems 53. Sarcopenia
is an important cause of frailty in the elderly. It is defined as a
decrease in muscle mass associated with a decrease in muscle
function (strength or performance) 54. People with diabetes
mellitus present a high risk of developing sarcopenia. Sarcopenia
is thought to be an intermediate stage in the development of frailty
and disability in elderly people with diabetes mellitus 55.
It is important to identify the risk factors, especially when they
are modifiable, for the development of sarcopenia in elderly
people with diabetes mellitus. Several studies have shown that
elderly people with diabetes mellitus have an increased risk of
functional disability, and show more impairment in simple and
complex activities of daily living than people without diabetes
Chami & Khaled Diabetes mellitus in the elderly
13
Nor. Afr. J. Food Nutr. Res. 2022; 6 (13): 9-21
mellitus 56, 57. Moreover, they also have a higher risk of falls and
fractures 58.
According to Wong et al., diabetes mellitus increases the risk of
loss of mobility by 1.5, the risk of instrumental daily living
disability (IADL) by 1.6, and the risk of disability in activities of
daily living (ADL) by 1.8 57.
There are several causes of disability in adults with diabetes
mellitus, such as visual impairment, cardiovascular morbidity,
peripheral neuropathy and kidney failure. The frailty of the elderly
is most often sought by two tools, the Fried criteria and the
Rockwood criteria 53, 59.
The two most widely used tools to assess functional disability are
activities of daily living (ADL) [60], and IADL 61.
4.5.5 Risk of falling
Falls are a leading cause of fractures in the elderly population 62,
affecting a third of adults 65 years and over in the United
States 63. Falls are associated with the risk of fractures and
hospitalization. Diabetes mellitus is associated with a high risk of
recurrent falls and fractures in people with or without pre-existing
functional disability; this risk is particularly high in diabetics after
a long period of development.
According to some studies, the risk factors are female sex, reduced
mobility, postural hypotension, high body mass index (BMI) and
poor diabetes mellitus control, but not hypoglycemia 64-66. In
contrast, a systematic review and a meta-analysis revealed that
older people with diabetes mellitus have a higher risk of falls
compared to non-diabetics. The same authors found that
hypoglycemia is a risk factor for falls, especially in patients treated
with insulin and peripheral neuropathy and retinopathy, induced
by poor blood sugar control, can also increase the risk of falls 67.
Other risk factors, associated with diabetes mellitus, include visual
impairment, peripheral neuropathy, foot deformities (including
previous amputation), and polypharmacy 68.
Despite the fact that bone density is high in type 2 diabetics due
to obesity, there is an increase in fractures in this population 69. In
the Study of Osteoporotic Fractures, diabetic women had a high
risk of hip fracture, proximal humerus, but no vertebral fractures,
after adjusting for age, BMI, bone density, and other factors 70.
The Health ABC Study also found an increased risk of fractures
in diabetic patients (relative risk 1.64) after adjusting for bone
mineral density and other fracture risk factors 71. Two simple and
widely used tools to diagnose the risk of falls are the get up and go
and the monopodal support 72, 73.
4.5.6 Malnutrition
Protein-energy malnutrition results from an imbalance between
the body's intake and needs. This imbalance leads to tissue loss,
especially muscle loss, which has deleterious consequences 74.
According to the Haute Autorité de Santé (HAS) or French
National Authority for Health, the prevalence of protein-energy
malnutrition is 4 to 10% of elderly people living at home, 15 to
38% of those living in retirement homes and 30 to 70% of those
who are hospitalized 74. In the 2007 HAS recommendations 75,
the diagnosis of undernutrition in a person aged 70 or over is
based on the presence of one or more of the following criteria.
To diagnose undernutrition at least one phenotypic criterion
should be present with no etiologic criterion 76.
a. Undernutrition criteria:
- Body weight loss: ≥ 5% in 1 month, or ≥ 10% in 6
months;
- BMI <21 kg/m2;
- Albuminemia <35 g / L
- Global mini nutritional assessment (MNA)<17
b. Severe undernutrition:
- Body weight loss: ≥ 10% in 1 month or ≥ 15% in 6
months
- BMI <18 kg/m2
- Albuminemia <30 g / L
The factors favoring undernutrition in the elderly diabetic are:
retinopathy, vision disorders, reduced mobility, swallowing
disorders, intestinal absorption disorders, financial resources,
depression and loneliness, cognition, decreased intestinal motility,
frequent hospitalizations. Undernutrition is associated with risks
of infection, falls, functional disability, sarcopenia, frailty, delayed
wound healing, prolonged hospital stays, cognitive impairment,
depression and mortality 76.
Malnutrition screening tools
The diagnosis and management of undernutrition must be
systematic to preserve the quality of life, autonomy and survival in
the elderly. The five main criteria for diagnosing undernutrition
are: body weight loss, low BMI, reduced muscle mass, decreased
food intake or absorption, and coexistence of disease and / or
inflammation 75.
The MNA is the best validated and most widely used nutritional
assessment tool 77-79. A score comprised between 17 and 23 is
considered at risk of undernutrition and a score of less than 17 is
in favor of protein-energy undernutrition. The major advantage
of this test is that it does not require any laboratory testing. A short
version of the MNA has been developed and validated 80.
Determining BMI in the elderly is often difficult, and therefore a
new revised version of the Mini Nutritional Assessment Short-
Form (MNA-SF) has been developed, showing that calf
circumference can replace BMI 81. When the MNA identifies
people at risk of undernutrition, they are often identified as fragile
because the different items of the MNA-SF explore the
components of frailty such as body weight loss, low food intake
and muscle strength (mobility and girth calf) 82-84.
Nutrition Management and Intervention
It is essential to consider that the elderly with diabetes mellitus
constitute a diverse population with various care needs requiring
individualized management and dietary treatment and therefore
should be involved in this management. To minimize the
incidence of frailty and mortality in elderly people, sufficient
energy intake is recommended. The European Society of Clinical
Nutrition and Metabolism guidelines on clinical nutrition and
Chami & Khaled Diabetes mellitus in the elderly
Nor. Afr. J. Food Nutr. Res. 2022; 6 (13): 9-21
14
hydration in geriatrics recommend an energy intake of
approximately 30 kcal/kg body weight/day, based on the
nutritional status, physical activity level, disease status, and
tolerance 85. According to some authors, decreased energy intake
in older patients with diabetes mellitus might lead to a lower
BMI, cognitive impairment, and higher prevalence of sarcopenia,
which might be associated with an increased risk for frailty and
mortality 86, 87.
According to the 2019 Japan Diabetes Society guidelines, the total
energy intake requirement in older adults should be calculated
using age-dependent target body weight (kg)= (22–25 kg/m2 ×
height [m]2) multiplied by coefficients of physical activity [88].
An appropriate protein intake could reduce the incidence of frailty
or mortality in older individuals. A minimum of protein intake of
1.2–1.5 g/kg body weight/day is recommended by the European
Society of Clinical Nutrition and Metabolism guidelines for older
subjects with acute or chronic illness 89. Together with sufficient
vitamin D intake can ameliorate cognitive function, reduce risks
of sarcopenia 90, 91 and might play a protective role in Alzheimer’s
disease 92. Concerning fatty acids, consumption of
polyunsaturated fatty acids (PUFA) and ω-3 fatty acids was
associated with lower risk of mortality in diabetes mellitus patients
aged over50 years 93 and reduced cognitive decline 94. The authors
of the Nurses' Health Study conducted on 1,486 female
participants aged ≥70 years, with diabetes mellitus type 2 showed
that higher intakes of saturated and trans fat and lower
polyunsaturated to saturated fat ratio, were each highly associated
with worse cognitive decline 95.
The Mediterranean diet (MD) being widely considered as a
healthy diet, is rich in vegetables, fish, and olive oil and known to
reduce the risk of cardiovascular events 96. Meta-analysis of
observational studies showed that high adherence to the MD with
higher intake of vegetables, fruits, and whole grains was associated
with lower risk of frailty and functional disability in the elderly
population 97, 98.
4.5.7 Pain
Pain, in the elderly, is frequent. According to an American study,
52.8% of people aged 65 and over suffer from pain. In diabetes
mellitus elderly population, pain reaches 61.5% 99 and is
dominated by pain of rheumatic and of neuropathic origin.
- Rheumatic origin: concerns joint stiffness syndrome,
Dupuytren's disease, tenosynovitis, carpal tunnel syndrome,
shoulder capsulitis / periarthritis, osteoarthritis 100, 101.
- Neuropathic origin: the prevalence of neuropathic pain, in
people with diabetes mellitus, is difficult to estimate because
definitions, populations studied, and methodologies vary
across studies.
Pain regardless of its etiology has a negative impact on the quality
of life 102. A Finnish study showed that the pain in elderly people
with diabetes mellitus was neither more frequent nor more intense
than in non-diabetics. The pain is due to depression and other
comorbidities more than to diabetes mellitus 103. It is imperative
to assess and treat pain to improve quality of life.
4.5.8 Vision disturbances
Diabetes mellitus increases the risk of poor vision and blindness
in elderly people with diabetes mellitus compared to the healthy
population by a factor of 1.5 according to Sinclair
et al.
104.
Diabetic retinopathy represents the fourth leading cause of
blindness in elderly diabetes mellitus patients after age-related
macular degeneration (AMD), cataracts and glaucoma. Unlike the
population under 60, in whom diabetes mellitus is the leading
cause of blindness 105, vision disturbances in the elderly are
associated with functional disability and poor quality of life.
Most older people relate poor vision to a physiological process of
aging and therefore do not seek medical attention, even though
many conditions require effective treatment 106. In patients with
diabetic retinopathy, the main cause of poor vision is macular
edema and not proliferative diabetic retinopathy 107. Poor vision
worsens other geriatric syndromes such as falls, inability to
function, undernutrition, depression and cognitive impairment.
Therefore, a complete eye exam is required in any elderly diabetic
to determine the cause of poor vision and to suggest adequate
treatment.
4.5.9 Hearing problems
Aging is the most frequent cause of sensorineural hearing loss in
adults. Deafness seriously affects the quality of life of patients who
no longer communicate, resulting in social isolation leading to an
increased risk of depression, anxiety and cognitive impairment 108.
More than 35% of people over 60 and 50% of those over 70 have
difficulty in activities of daily living due to hearing loss 109. A study
that included 37,773 subjects, conducted from 2009 to 2012
aimed to assess the presence of hearing disorders according to age,
to the presence of hypertension and/or diabetes mellitus, showed
that aging and diabetes mellitus were correlated with hearing loss
(p<0.05). There was no statistically significant association
between hearing loss and hypertension after adjusting for age and
diabetes mellitus 110.
4.5.10 Polypharmacy
The use of multiple drugs, often termed polypharmacy is
commonly defined as using from 5 to 10 prescription drugs.
Among seniors living at home in the United States, 57% of
women and 59% of men report using 5 or more medications, and
almost 20% report taking 10 or more medications 111.
Older people with diabetes mellitus are more likely to take
multiple medications than those without diabetes mellitus 112.
Polypharmacy is associated with increased risks of drug
nonadherence 113, drug interactions 114 and adverse events 115. The
presence of polypharmacy is also associated with cascading
prescriptions, in which adverse drug events are interpreted as new
pathologies, leading to the prescription of new drugs to treat these
pathologies 116.
4.5.11 Urinary incontinence
Urinary incontinence (UI) is frequent in the elderly and is
associated with significant morbidity and mortality. Diabetes
Chami & Khaled Diabetes mellitus in the elderly
15
Nor. Afr. J. Food Nutr. Res. 2022; 6 (13): 9-21
mellitus is a potent risk factor for UI, increasing both the
prevalence and severity of UI. 117, 118. UI dramatically decreases
quality of life, increasing the risk of social isolation, depression,
falls, fractures, hospitalization and mortality 119-122. UI is little
sought after by caregivers, yet studies show that its presence affects
the prognosis. The UI diagnosis is based on questioning the
patient or family, and its management involves several therapies.
5 Conclusion
Studies and epidemiological projections conclude that with a
significant increase in the prevalence of diabetes mellitus in the
elderly, it will undoubtedly constitute a major public health
concern.
Diabetes mellitus management in the elderly is based on:
- a clinical assessment with eliminating transient
hyperglycemia and distinguish aged type 2 diabetes mellitus
patients with insulin treatment from type 1 diabetes ones,
know how to look for secondary diabetes, mainly
pancreatitis;
- diabetes assessment with looking for macroangiopathic,
microangiopathic, neuropathic complications, and
podiatry evaluation;
- and a global geriatric assessment with an emphasis on the
cognitive and functional status of the elderly individuals.
At the end of this evaluation, the treatment goals will be defined
according to the recommendations of the ADA (American
Diabetes Association).
Older adults who are otherwise healthy with less coexisting
chronic diseases and preserved cognitive function and functional
status should present lower glycemic goals (such as HbA1c, 7.5%
[58 mmol / mol]), while those presenting multiple coexisting
chronic diseases, cognitive impairment, or functional dependence
should have less-stringent glycemic goals (such as HbA1c, 8.0–
8.5% [64–69 mmol / mol]) 123.
For some older adults, blood glucose targets car reasonably be
relaxed as part of individualized care. However, hyperglycemia
leading to symptoms or risk of developing acute hyperglycemia
complications should be avoided in overall patients 123.
Abbr ev i ations
- ABI: Ankle Brachial Index
- ADA (American Diabetes Association)
- ADL: activities of daily living
- AF: Atrial fibrillation
- AMD: age-related macular degeneration
- BMI: body mass index
- CGM: continuous glucose monitoring
- CKD-EPI (Chronic Kidney Disease Epidemiology
Collaboration)
- DN : Diabetic neuropathy
- DN4 :
Douleur Neuropathique en 4 Questions
- HAS :
Haute Autorité de Santé
- HbA1c: Glycated hemoglobin
- IADL: instrumental activities of daily living
- IDF: International Diabetes Federation
- LVH: left ventricular hypertrophy
- MD: Mediterranean diet
- MDRD (Modification of Diet in Renal Disease)
- MENA: Middle East and North Africa
- MMSE: mental state examination
- MNA: mini nutritional assessment
- MNA-SF: mini nutritional assessment short-form)
- MoCA: Montreal Cognitive Assessment
- T2DM: Type 2 diabetes mellitus
- UI: Urinary incontinence
Acknowledgments: None.
Author contribution: A.C. conceived and designed the study. C.A. and
M.B.K. undertook the literature research. C.A. and M.B.K. prepared, drafted
and reviewed the manuscript. All authors approved the final version before
submission. All authors have read and agreed to the published version of the
manuscript.
Funding: None.
Conflict of interest: The authors declare that they have no conflict of interest.
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Cite this article as: Chami A., & Khaled M.B. (2022). Epidemiology, diagnosis, and assessment of diabetes mellitus in the elderly population: a purposive review.
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