Diabetes in the Elderly
Glucose tolerance deteriorates with age. Diabetes is quite common in the elderly, since the incidence of diabetes increases with age. With the introduction of insulin and antibiotics, many diabetics live well upto an old age. Besides, the life expectancy of the general population is increasing all over the world. Diabetes which develops for the first time in old age is usually type 2, but other types of diabetes may also develop in old age.
The leak point of the kidneys for glucose (renal threshold for glucose) is often increased in the elderly. This means that an old person may have a high blood glucose level without there being any glucose in the urine.
Features
Type 2 diabetes develops insidiously and is often detected in investigation for some other disease. The disease may be suspected because of vague complaints like apathy, slow recovery from infections or stroke, poor wound healing, weight loss or incontinence of urine. Coronary and peripheral arterial disease, high blood pressure, neuropathy, foot problems,cataracts and erectile dysfunction are commonly present. Infections precipitate hyperglycaemia and ketoacidosis. Mortality of these acute complications is higher in the elderly than in the young.
Aims of treatment
These are similar to those in young diabetics. Hypoglycaemia should be avoided.
Diet
The elderly are less active than the young and hence they need less kcals that young adults. After forty, the kcal requirement of an individual falls by 5 per cent, after fifty by 10 per cent, after sixty by 15 per cent. The diet has to be balanced.
Financial constraints, shopping difficulties because of lack of transport or physical disability, poor culinary skills (especially in the case of widowers), ingrained dietary habits and aversion to change, poor memory are some of the factors that come in the way of following dietary instructions by the elderly diabetics. Many elderly people living alone often subsist on beverages and bread and avoid cooking a regular meal.
Many elderly persons are constipated. They should be encouraged to take more fibre in the diet and to take more liquids in order to stimulate bowel movement. The liquids should be taken during the early part of the day. Many elderly males have to get up at night to pass urine, due to an enlarged prostate. They should consume smaller amounts of fluids after 4 p.m. Since an excess of body weight puts a strain on the weight bearing joints like knee, hip and back and the heart and lungs, elderly diabetics should maintain normal body weight
Insulin
Self-administration of insulin may be difficult in the elderly due to poor vision or unsteady hands. Special insulin syringes are available for the visually handicapped. Many elderly diabetics find difficulty in mixing insulins. Premixed insulins come handy for them. Some responsible member of the family should administer insulin if the elderly diabetic is unable to inject himself/herself for any reason; for instance, poor vision, stiff or unsteady hands or confusion. It can cause hypoglycaemia.
Oral agents
Many elderly persons with diabetes can be treated with oral drugs. In the elderly, hypoglycaemia can give rise to confusion, loss of speech. Hypoglycaemia may be mistaken for a transient stoke. Severe hypoglycaemia in the elderly may be very dangerous, especially if they are living alone. A long-acting Sulphonylurea like chlorpropamide is best avoided in the elderly as hypoglycaemia due to this drug is recurrent and prolonged. A short-acting drug like gliclazide is preferred. Metformin may be hazardous especially if the individual is lean and has poor appetite.
Metformin, thiazodilediones and acarbose can be given subject to their indications and contraindications. ( Ch. 11 )
Other drugs
High blood pressure and abnormal blood lipids should be treated by suitable drugs. Aspirin 75 mg, once after meals, is given to prevent clotting of blood. Clopidogrel 75 mg once a day is given if aspirin is not tolerated.
Hypoglycaemia
Poor food intake, consumption of alcohol and an impaired kidney function can contribute to hypoglycaemia. The capacity to correct hypoglycaemia is often defective in the elderly diabetics. Many elderly diabetics are not able to make out the early signs hypoglycaemia.
Poor eyesight
Poor vision should not be attributed to old age per se. Apart from a regular examination of the eyes, a diabetic should consult doctor if his/her eyesight is failing. Poor vision in the elderly is often due to cataract or lens opacities. A cataract operation can be performed and a lens can be implanted in the elderly, if diabetes is controlled.
Teeth
Stumps of teeth, bad teeth, ill fitting dentures or absence of teeth make chewing food difficult and lead to malnutrition. An elderly diabetic should see a dentist if there are any problems of teeth.
Care of the feet
The blood supply to the legs becomes poor in old age due to narrowing and hardening of the arteries. This process is especially common in diabetics. Moreover, the sensations of the feet become dull in old age, even in the absence of diabetes. This combination of poor blood supply to the feet and benumbed feet can be very dangerous in elderly diabetics. The care of the feet is therefore of special importance in elderly diabetics.
Other common problems
Complaints like deafness, erectile dysfunction should not be attributed automatically to old age. The cause should be investigated and treated.
Exercise
Regular and gentle exercise is advisable in the elderly diabetics. They should avoid strenuous and unaccustomed exertion and sudden back and neck bending.
Prevention of accidents
Accidents and falls can be very dangerous in the elderly. Highly polished floors, slippery bathrooms, poorly illuminated staircases can be very dangerous. An elderly individual should avoid a sudden turning of the head and neck, as this may produce giddiness.
Infections
Infections in an elderly diabetic should not be taken lightly.
The outward signs of infections like fever are often inconspicuous in the elderly. A doctor should be consulted if an infection does not clear up quickly in an elderly person.
Homes for elderly diabetics
In some countries, there are homes for elderly diabetics, where they can stay for varying length of time. These homes are very helpful, since they provide a change for the elderly diabetics as well as the members of their families. So far, no home for the elderly diabetics has been started in India.