David K McCulloch, MD
Medha Munshi, MD
Rury R Holman, FRCP
Kenneth E Schmader, MD
Jean E Mulder, MD
Last literature review version 18.1: enero 2010 | This topic last updated: junio 4, 2009 (More)
INTRODUCTION — The prevalence of diabetes continues to increase steadily as more people live longer andgrow heavier. The overall prevalence of diagnosed cases of type 2 diabetes rises from 1.4 percent between the ages 25 of 44 years to 3.6 percent between the ages of 45 and 54 years, 7.8 percent between the ages of 55 and 64 years, and over 10 percent over the age of 65 years . The prevalence may be well over 20 percent among frail elderly people living in nursing homes . There are probablysimilar numbers of undiagnosed patients at all ages.
The prevalence of known cases of type 2 diabetes is likely to increase further with the adoption of new diagnostic criteria and the recommendation to screen all adults over age 45 years at least once every three years by measuring fasting blood glucose . (See "Diagnosis of diabetes mellitus" and "Screening for diabetes mellitus".)
Olderadults with diabetes are at risk of developing macrovascular and microvascular complications similar to their younger counterparts with diabetes and as a result, suffer excess morbidity and mortality compared with elderly individuals without diabetes . In addition, they are at higher risk for polypharmacy, functional disabilities and common geriatric syndromes that include cognitive impairment,depression, urinary incontinence, falls and persistent pain . This topic will review diabetes management in elderly patients and how management priorities and treatment choices may differ between elderly and younger patients.
INDIVIDUALIZING MANAGEMENT — Older adults with diabetes are a heterogeneous population that includes persons residing independently in communities, in assisted carefacilities or nursing homes. Thus older adults with diabetes can be fit and healthy or frail with many co-morbidities and functional disabilities.
The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycemia and risk factors. However, in frail elderly patients with diabetes, avoidance of hypoglycemia, hypotension and druginteractions due to polypharmacy are of major concern. In addition, management of coexisting medical conditions is important as it influences their ability to perform self-management.
Glycemic goals — Hyperglycemia increases dehydration, impairs vision and cognition , all of which contribute to functional decline and an increased risk of falling in elderly diabetic patients. On the other hand,side effects of diabetes treatment, most notably hypoglycemia, can result in poor outcomes, such as traumatic falls and exacerbation of co-morbid conditions. Goals for glycemic control as well as risk factor management should be based upon the individual's overall health. The appropriate target for hemoglobin A1C (HbA1c) in fit elderly patients who have a life expectancy of over five years, should be7.0 to 8.0 percent. The goal may be somewhat higher in those whose life expectancy is less or in those with multiple medical and functional co-morbidities. (See "Glycemic control and vascular complications in type 2 diabetes mellitus".)
Avoiding hypoglycemia — The risk of hypoglycemia, which may lead to impaired cognition and function, is substantially increased in the elderly. In addition,older adults may have more neuroglycopenic manifestations of hypoglycemia (dizziness, weakness, delirium, confusion) compared with adrenergic manifestations (tremors, sweating). These symptoms may be missed or misconstrued as primary neurological disease (such as a transient ischemic attack), leading to inappropriate reporting of hypoglycemic episodes by the patients.
Hypoglycemic episodes in...