Diabetes

DIABETES IN THE ELDERLY

ED
Brenda Capaldi

A
s the world population continues to age and the proportion of the elderly suffering from
Diabetes Specialist Nurse,
diabetes increases compared to other age groups, the health burden of diabetes in the
Gartnavel Diabetes Centre, Glasgow

D IT
elderly is set to continue to rise. Practices need to be prepared to cope with a near

TE M
doubling of the number of elderly people with diabetes over the next twenty years. In
this article, we review the particular challenges of managing diabetes in the older patient.

BI LI
The International Diabetes Federation reported in 2003 CLINICAL MANAGEMENT OF ELDERLY

HI S
O IBB
that about 45% of all adults with diabetes (about 88 million
globally) were in the 40-59 year age group and that this
number will rise to 146 million by 2025, with a further
PATIENTS WITH DIABETES
Managing diabetes in elderly people is complicated by the
physiological changes and comorbidities that are the

PR G 147 million people with diabetes aged 60 or older. natural result of the ageing process. Elderly people with
N E
In the UK, the majority of elderly people with diabetes are diabetes therefore require careful monitoring to ensure that
IO RN
treated at their local GPs surgery. The projected increase in they, and their condition, are being managed effectively.
the number of cases of diabetes in the elderly suggests that Despite this, the goals of treatment are essentially the
CT BO

the primary care sector needs to ensure that it is sufficiently well same as for younger people. These should include the
staffed and trained to cope with what has been predicted to management of cardiovascular risk and hypertension,
DU ER

be a near doubling of the elderly diabetic population. stopping smoking, regular exercise and reducing obesity.
With the additional complications due to the patients
O SH

Projection of diabetes prevalence age, it is essential that any management strategy takes
into account functional and cognitive status, life
PR T

Developed countries expectancy, comorbidities and the individuals willingness

RE GH

2000
Estimated number of people with diabetes (millions)

and ability to follow treatment regimens. We need to

2030
50 consider the impact of treatment on the patients quality of
Source: Wild S, Roglic G, Green A et al. Diabetes Care 2004; 27: 1047-1053
RI

life and emphasise the achievement of functional goals

over strict glycaemic targets, while avoiding therapies
PY

40
which may cause excess worry and loss of independence
CO

30 or which may themselves result in the development of

complications in elderly patients.
20
TREATMENT OPTIONS
A full assessment of the patient, performed before any
10
treatment decisions are made, will help to identify any
0
potential problems with long-term treatment and highlight
20-44 45-64 65+ any anxieties the patient may have about diabetes or its
Age group (years) treatment. Management decisions can then be made
based on the individual patients needs and issues.

c By educating elderly patients, we can ensure that they

understand why treatment is needed, what antidiabetic drugs do,
and why concordance with therapy is so importantd
128
 Diet and exercise, which are the usual initial
starting therapies for type 2 diabetes, may be
difficult or impossible for some frail or partially
disabled elderly patients to comply with and putting
these into a treatment regimen without being sure
that they are achievable can lead to worry and a
deterioration in health. For those individuals who do
embark on these lifestyle modifications, the support
of the practice nurse will be invaluable.

ED
Education of elderly patients is another essential

D IT
role of the practice nurse. By educating elderly
patients, we can ensure that they understand why

TE M
treatment is needed, what antidiabetic drugs do,

BI LI
and why concordance with therapy is so important.
Nursing staff can also be on hand to give support

HI S
and advice on injection and technique.

O IBB
If oral medical therapy is needed, consideration
should be given to age-specific side-effects before

PR G
prescribing any of the following oral agents:
N E
As with younger patients, if lifestyle changes plus
IO RN
oral agents are not enough to control glycaemia,
then insulin therapy should be considered. Initiating

Alamy Images
CT BO

insulin treatment in elderly people with diabetes is a

potential source of great anxiety and many elderly
DU ER

people are reluctant to take this step. Practice

nurses can again play an important role at this
O SH

point, through completion of geriatric assessments, Agent Considerations for use in the elderly
patient education and by being available to talk to
Alpha-glucosidase inhibitors May cause bowel problems, so should not be given to elderly patients with
PR T

and reassure patients about insulin therapy.

inflammatory bowel disease or other intestinal disorders. Useful, because they dont
RE GH

INSULIN THERAPY IN THE ELDERLY cause hypoglycaemia when used alone.

SPECIAL CONSIDERATIONS Metformin May cause lactic acidosis where there is renal insufficiency (glomerular filtration rate
RI

Nurses and other healthcare professionals dealing (GFR) <30 ml/min/1.73m2). Order a 24-hour urine sample for creatinine clearance
PY

with elderly people with diabetes need to be aware for patients over 70.
of a number of specific challenges associated with
Sulphonylureas Avoid as their long half-life may cause hypoglycaemia in the elderly.
CO

insulin therapy in elderly patients. Reduced manual

dexterity and visual acuity make measuring and
administering the correct dose of insulin a problem
for many elderly patients. The type of injection
device to be used needs to be chosen with these
difficulties in mind, as handling some devices may
be problematic.
If visual or dexterity limitations prevent accurate
injection, then use of a device that allows the dose
to be preset by nursing staff should be considered.
If drawing up the correct dose or performing the
injection itself are too difficult, either because of
physical disability or lack of injection sites, it may be
possible to get a friend or local relative of the
patient to perform this task. However, daily visits by
the district nurse may be the only viable option in
(e.g. chlorpropamide)
Thiazolidinediones Not indicated in elderly patients with heart failure or liver disease. Otherwise, may be
(glitazones) useful, as do not cause hypos.
cases where the patient is unable to carry out the Nurses in charge of elderly people with
injection routine. diabetes have an important role in spotting the
Some elderly patients with reduced cognitive signs which suggest poor glycaemic control,
function may also forget to take insulin doses or including tiredness, weight loss, an increase in
may take additional doses because they cannot infections and a decrease in strength and
remember what they have taken, leading to hyper- mobility. Where side-effects are reducing quality
or hypoglycaemia. Nutrition difficulties can also lead of life, the treatment regimen should be altered
to an increased risk of hypos, especially where to emphasise simplicity, improvement of
there is functional disability that makes preparing symptoms, safety and convenience, perhaps by
meals a problem, so that there is a tendency to switching to medications with better side-effect
miss meals. profiles.

129
Diabetes

Diabetes in the elderly BENEFITS OF BASAL INSULIN ANALOGUES

The number of elderly people with diabetes is predicted to nearly
double by 2030.
The elderly present specific clinical management issues and careful
monitoring and follow-up in this group is crucial in order to limit
long-term diabetic complications.
In the last few years, rapid- and long-acting insulin analogues have been
developed that better simulate aspects of physiological insulin secretion. These
analogues have significantly improved the treatment of diabetes, providing
greater convenience and a lower risk of hypoglycaemia.
Rapid-acting insulin analogues should be used with caution in elderly patients
because of their increased likelihood to cause hypos in this age group. However,

ED
basal insulin analogues, such as insulin detemir and insulin glargine, are useful
The practice nurse is increasingly responsible for the day-to-day agents for managing glycaemia in the elderly because they provide a relatively

D IT
management of elderly people with diabetes.
constant concentration profile, with no pronounced activity peak and a duration

TE M
Practice nurses need to be aware of the specific problems which anti- of action of up to 24 hours.
diabetic drugs may pose for the elderly and to be alert for adverse effects.

BI LI
The pharmacological characteristics of insulin glargine make it a particularly
Basal and rapid-acting insulin analogues are useful for managing useful drug in the elderly. Clinical trials comparing the efficacy and safety of

HI S
diabetes in elderly people and may reduce the incidence of insulin glargine and NPH insulin (which has been the most frequently used

O IBB
hypoglycaemias, a side-effect which is a worry for many elderly people basal insulin), demonstrated similar improvements in glycaemic control but a
taking antidiabetic medication. reduced risk of nocturnal hypoglycaemia with insulin glargine given at bedtime.

PR G
N E
IO RN
CT BO
DU ER
O SH
PR T
RE GH
RI
PY
CO
These characteristics mean that a single daily dose of insulin glargine provides
the basal insulin requirements, while reducing the risk of hypoglycaemia
compared with intermediate- and long-acting insulin preparations, which exhibit
unpredictable peaks. There are no comparable trials of once daily insulin
detemir versus NPH. In two trials of twice daily detemir vs NPH there were
contradictory results in respect to nocturnal hypoglycaemia. Piebar and
colleagues reported no difference in the incidence of nocturnal hypoglycaemia
when comparing twice daily detemir with twice daily NPH, however Home and
colleagues reported a 53% reduction in hypoglycaemia with twice daily detemir
compared with twice daily NPH during the last 12 weeks of a 16-week open-
label study.
In addition to its good efficacy and safety profiles, insulin glargine, like
insulin detemir, is formulated as a solution. Use of pre-dissolved insulins is
better structuring of the district nurses' day. Insulin detemir is also flexible, in
that the later dose can be given either in the evening or at bedtime, however
the fact that it may require twice-daily injections in some patients on basal
bolus regimens means extra work for the nurse and may tell against the use
of this agent.
Diabetes UK. www.diabetes.org.uk
http://diabetes.niddk.nih.gov/dm/pubs/control/
www.dtu.ox.ac.uk/index.php?maindoc=/ukpds/
www.nhs.uk/England/AboutTheNhs/Nsf/Diabetes.cmsx
Wild S, Roglic G, Green A, et al. Global prevalence of diabetes: estimates

ED
advantageous because there is no need for mixing that could affect dosing for the year 2000 and projections for 2030. Diabetes Care 2004; 27:
accuracy and cause day-to-day variability of effect. This may be of particular 1047-1053.

D IT
importance in elderly people, where manual and visual difficulties may make Piebar TR, Draegar E, Kristensen A, et al. Comparison of three multiple

TE M
mixing difficult. injections regimens for type 1 diabetes: morning plus dinner or bedtime

BI LI
For the district nurse who may have to administer insulin injections, insulin administration of insulin detemir vs morning plus bedtime bedtime NPH
glargine has another important benefit it can be administered at any time of insulin. Diab Med 2005; 22(7): 850-7.

HI S
the day as long as it is around the same time each day. Use of glargine in this Home P, Bartley P, Russell-Jones D, et al. Insulin detemir offers improved

O IBB
way may mean fewer logistical problems for nurses in ensuring that all elderly glycaemic control compared with NPH insulin in people with type 1
patients get their injections at the correct time relative to meals and facilitates diabetes: a randomized clinical trial. Diabetes Care 2004; 27(5): 1081-7.

PR G
N E
IO RN
CT BO
DU ER
O SH
PR T
RE GH
RI
PY
CO