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July/August 2013
Older Diabetes Patients Present Unique ChallengesBy Jill Weisenberger, MS, RD, CDE Rather than the classic diabetes symptoms, patients may present with dehydration, dry eyes, dry mouth, confusion, incontinence, and complications such as neuropathy or nephropathy. Jean, 78, has been experiencing urinary incontinence and showing signs of confusion. Her physician also notices she’s slightly dehydrated. When he suggests screening Jean for type 2 diabetes, she believes that’s a waste of time. After all, she isn’t experiencing frequent urination or excessive thirst, which she knows are telltale symptoms of the disease. But the truth is Jean’s symptoms are typical in older patients newly diagnosed with type 2 diabetes. Older patients often present with different signs and symptoms of diabetes, so it’s important to recognize them and help patients stabilize blood glucose levels by referring them to a physician who specializes in geriatric diabetes care or a registered dietitian for nutritional recommendations. Signs and Symptoms Because of age-related physiological changes, older patients may not present with classic symptoms of hyperglycemia. The renal threshold for glucose increases with age, and older people often have impaired thirst mechanisms. Thus, polyuria and polydipsia may be absent. Common presenting symptoms are dehydration, dry eyes, dry mouth, confusion, incontinence, and diabetes complications such as neuropathy or nephropathy.2 Hypertension and dyslipidemia frequently coexist with diabetes, but in older patients with diabetes so do dementia, depression, and functional decline.3 In general, individuals with type 2 diabetes have twice the risk of developing dementia.4 In one study of older adults with diabetes, one-third of those over the age of 70 showed cognitive dysfunction associated with poor diabetes control.3 Moreover, older diabetes patients have higher rates of premature death.5 They have greater physical and mobility limitations compared with individuals without diabetes, even when controlled for hypertension, cerebrovascular disease, chronic obstructive pulmonary disease, cancer, dementia, and osteoarthritis.6 They’re also more likely to use a wheelchair, cane, or other mobility aid. These problems put elder diabetes patients at a high risk of falls, which can have life-threatening consequences. Barriers to Care “Dental status is also a very important and underrated issue since this automatically limits many food choices,” explains Janice Baker, MBA, RD, CDE, CNSC, BC-ADM, a private practitioner in San Diego. Furthermore, limited dexterity and poor eyesight may affect this age group’s ability to monitor their blood glucose levels and inject insulin. Glycemic Targets The glycemic goals for older patients who don’t fit this criteria should be less stringent, using individual criteria to avoid episodes of hypoglycemia.5 The European Diabetes Working Party for Older People recommends an A1c target of 7% to 7.5% for older adults with type 2 diabetes who don’t have major comorbidities. For frail or elderly patients, the organization recommends an A1c range of 7.6% to 8.5%. When deciding on blood glucose targets, health care professionals and patients must weigh the risk of hypoglycemia against the benefits of tighter glycemic control. Intensive glycemic control is associated with significantly reduced rates of microvascular and neuropathic complications. However, those with a short life expectancy may have too few years of life remaining to reap the benefits. For these patients, avoiding hypoglycemia is most critical because even mild hypoglycemia can lead to dizziness or weakness that increases the risk of falls and serious injury. Age appears to affect counterregulatory responses to hypoglycemia, even in people without diabetes. Thus, the likelihood of hypoglycemic unawareness is greater among the elder population. During a small hypoglycemic clamp study in people with type 2 diabetes, one-half of the middle-aged participants correctly identified low blood glucose, but only about 8% of the older participants recognized it.1 That’s because hypoglycemia often presents differently in older adults with diabetes. Therefore, it’s important to teach older diabetes patients to look for symptoms such as dizziness, weakness, delirium, and confusion in addition to sweating and tremors. “Often, the low glucose will cause them to fall, resulting in a head injury and death,” Hill warns. And Baker had an older patient with erratic eating who suffered a hypoglycemic event in her home and fractured her jaw when she fell. Avoiding high blood glucose levels is equally important. At a minimum, glycemic goals must prevent acute complications of hyperglycemia, which include dehydration, poor wound healing, urinary incontinence, and hyperglycemic hyperosmolar coma. Medical Nutrition Therapy To help patients prevent hypoglycemia, remind them to eat during regular meal times and include snacks that contain adequate amounts of carbohydrates. If patients tend to forget to eat or take their medications, have them set alarms on their watches or cell phones to remind them. Additionally, explain the importance of older patients discussing changes in appetite, eating habits, and weight with their health care team because each of these will influence the risk of hypoglycemia. Encourage older adults with diabetes to wear medical ID bracelets or necklaces and always carry appropriate treatment for hypoglycemia, such as glucose tablets, glucose gel, and juice boxes. Keep in mind that older adults are at higher risk of inadequate protein, calorie, fluid, calcium, vitamin D, and vitamin B12 intake, among other nutrients. Making a Connection To educate older adults with diabetes, discuss only one or two topics per visit, making the information specific. Write out instructions in large print. If you use handouts, be sure the font is large enough for patients to read. Assess patient understanding by having them reiterate the information you’ve shared with them and repeat key information. Hill finds she has greater success when a patient’s family becomes involved in diabetes education and care. The area Council on Aging or senior center in the local community may be helpful resources when a family cannot assist a patient. Such organizations can provide diabetes support groups and home-delivered meals in addition to other services. Baker encourages older patients with diabetes to attend support group meetings. “They really benefit from the socialization with others. They really bond and are stimulated to learn more from conversation and interaction than handouts,” she says. — Jill Weisenberger, MS, RD, CDE, is a freelance writer, nutrition consultant, and diabetes educator in southeast Virginia and the author of Diabetes Weight Loss — Week by Week.
Protecting Diabetes Patients From Hypoglycemia Hypoglycemia occurs when patients who have diabetes experience low blood glucose concentrations that put them at risk of injury or death. Acute hypoglycemia can cause confusion, loss of consciousness, and seizures. Endocrine Society member Elizabeth Seaquist, MD, of the University of Minnesota, led a group of experts from the two organizations in developing the consensus statement. They noted that episodes of hypoglycemia can occur even when test results are not available to confirm the symptoms or a blood test shows glucose levels in the normal range. The consensus statement includes classifications for these two events, known as probable symptomatic hypoglycemia and pseudohypoglycemia, respectively. They also emphasized the importance of using hypoglycemic risk as one of the key factors in individualizing a patient’s glycemic target. Improved understanding of hypoglycemia in patients with type 2 diabetes is, in part, the result of three large clinical trials: Action to Control Cardiovascular Risk in Diabetes (ACCORD), Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation (ADVANCE), and Veterans Affairs Diabetes Trial (VADT), conducted during the past decade. A total of 24,000 people with diabetes participated in the trials. “Through these clinical trials, researchers discovered that patients who had hypoglycemia were at greater risk for subsequent mortality regardless of whether they were assigned to the intensive or standard therapy group,” says Robert A. Vigersky, MD, past president of The Endocrine Society and coauthor of the consensus statement. “Whether a person has type 1 or type 2 diabetes, it is crucial to minimize the number of hypoglycemic episodes because patients gradually become desensitized to the symptoms, become less likely to recognize and address hypoglycemia, and thereby have a greater risk of confusion, loss of consciousness, seizure, coma, and death.” The consensus statement incorporates research findings that have emerged since the issue of The Endocrine Society’s 2009 Evolution & Management of Adult Hypoglycemic Disorders clinical practice guidelines and the American Diabetes Association’s 2005 report on hypoglycemia. Since then, researchers have found that older adults who have type 2 diabetes, children with type 1 diabetes, and hospitalized patients with diabetes are particularly vulnerable to hypoglycemia. “We recognize that patient education and health care provider surveillance plays a key role in averting hypoglycemic episodes,” Vigersky says. “The consensus statement provides new informational resources for both patients and health care providers, including a patient hypoglycemia questionnaire, a provider checklist, and a table listing key strategies for restoring the patient’s awareness during a hypoglycemic episode.” — Source: Endocrine Society
Resources • large-print educational materials; • blood glucose meter with a backlight or audio; • blood glucose meter with a drum of preloaded test strips, eliminating the need to insert a test strip each time; • lancing devices with a drum containing multiple lancets; • insulin pens that combine insulin and a syringe in a single device; and • syringe magnifier, a clear device that slips over or clips to a syringe to magnify its markings. Additional resources may be available through the Academy of Nutrition and Dietetics’ Diabetes Care and Education Dietetic Practice Group (www.dce.org). — JW
References 2. Abbatecola AM, Paolisso G. Diabetes care targets in older persons. Diabetes Res Clin Pract. 2009;86 Suppl 1:S35-S40. 3. Munshi M, Grande L, Hayes M, et al. Cognitive dysfunction is associated with poor diabetes control in older adults. Diabetes Care. 2006;29(8):1794-1799. 4. Strachan MW, Reynolds RM, Marioni RE, Price JF. Cognitive function, dementia and type 2 diabetes mellitus in the elderly. Nat Rev Endocrinol. 2011;7(2):108-114. 5. American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care. 2012;35 Suppl 1:S11-S63. 6. Sinclair AJ, Conroy SP, Bayer AJ. Impact of diabetes on physical function in older people. Diabetes Care. 2008;31(2):233-235.
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