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 PATIENTS WITH DIABETES
globally) were in the 40-59 year age group and that this Managing diabetes in elderly people is complicated by the
number will rise to 146 million by 2025, with a further 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
2000
Estimated number of people with diabetes (millions)
40
which may cause excess worry and loss of independence
CO
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
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
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
129
Diabetes
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 better structuring of the district nurses' day. Insulin detemir is also flexible, in
the basal insulin requirements, while reducing the risk of hypoglycaemia that the later dose can be given either in the evening or at bedtime, however
compared with intermediate- and long-acting insulin preparations, which exhibit the fact that it may require twice-daily injections in some patients on basal
unpredictable peaks. There are no comparable trials of once daily insulin bolus regimens means extra work for the nurse and may tell against the use
detemir versus NPH. In two trials of twice daily detemir vs NPH there were of this agent.
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 Diabetes UK. www.diabetes.org.uk
compared with twice daily NPH during the last 12 weeks of a 16-week open- http://diabetes.niddk.nih.gov/dm/pubs/control/
label study. www.dtu.ox.ac.uk/index.php?maindoc=/ukpds/
In addition to its good efficacy and safety profiles, insulin glargine, like www.nhs.uk/England/AboutTheNhs/Nsf/Diabetes.cmsx
insulin detemir, is formulated as a solution. Use of pre-dissolved insulins is 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