Managing type 2 diabetes in the elderly

In general, the diagnosis and management of type 2 diabetes in elderly people is the same of other adults who have the disease. (The term ‘elderly’ generally refers to people who are over 65 years of age.) However, there are some distinct differences, which we’ll review in this article.

Symptoms of type 2 diabetes in the elderly

Some of the most common symptoms of type 2 diabetes in the general population include increased thirst, frequent urination, weight loss and blurred vision. However, elderly people who have diabetes may not have any of these symptoms. Rather, the most common symptoms of diabetes in elderly people are dehydration (a harmful reduction in the amount of water in the body), dry eyes and mouth, and confusion.

Diagnosis of type 2 diabetes in the elderly

Four different tests are generally used to diagnose diabetes:

1. A1C test
2. Casual blood glucose test
3. Fasting blood glucose test
4. Oral glucose tolerance test

However, in elderly people, an A1C test is not appropriate, as the normal process of aging is associated with a progressive increase in A1C levels. That’s why elderly people should be diagnosed using one of the other tests.

Blood glucose targets in the elderly

Generally, blood glucose targets in the elderly are the same as other adults with diabetes:

• A1C: less than 7.0%
• Fasting blood glucose (before eating a meal): 4.0 to 7.0 mmol/L
• Blood glucose two hours after eating a meal: 5.0 to 10.0 mmol/L

However, in elderly people who are described as ‘frail,’ their blood glucose targets are different from the general population with diabetes. Frail elderly people are described as those who suffer from three or more of the following conditions:

1. Unintentional weight loss of more than 4.5 kilograms (10 pounds) in the past year
2. Exhaustion
3. Weakness
4. Slow walking speed
5. Low levels of physical activity

In the frail elderly, blood glucose levels two hours before eating a meal are a better gauge of diabetes control than A1C or post-meal blood glucose levels. The recommended fasting blood glucose for the frail elderly is 5.0 to 12.0 mmol/L.

For more information about blood glucose, click here.

How is type 2 diabetes managed in the elderly?

Lifestyle

As with anyone who has diabetes, eating healthy foods and getting regular exercise are very important in helping you manage your diabetes. Your healthcare team can help you determine a diet that works for your nutritional needs. They can also help you develop an exercise program that is safe for you.

Medications

Metformin is the most common drug used to manage type 2 diabetes, and it is an effective medication in elderly people with type 2 diabetes.

Sulphonylureas, another common class of drugs, are often prescribed for people with type 2 diabetes, but should be used with caution in elderly people with type 2 diabetes. This is because can greatly increase the risk of hypoglycemia in the elderly. The Diabetes Canada clinical practice guidelines recommend that if elderly adults with type 2 diabetes are prescribed a sulphonylurea, it should be started at half the dose used for younger people, and the dose should be increased (‘titrated’) more slowly.

Insulin

For elderly adults who are prescribed insulin, Lantus® (insulin glargine) or Levemir® (insulin detemir) are recommended instead of NPH insulin, as NPH insulin may cause hypoglycemia in elderly people. Premixed insulins and prefilled insulin pens are also preferred over insulins that need to be mixed, as they reduce the risk of dosing errors.

For more information about medications for type 2 diabetes, click here.

Hypoglycemia in the elderly

Hypoglycemia is an important issue regarding diabetes management in elderly people, for two important reasons:

1. Elderly people are at higher risk for hypoglycemia.
2. When elderly people do have an episode of hypoglycemia, it tends to be more severe than in younger people.

While some symptoms of hypoglycemia in older people are the same as in younger people (e.g. trembling, sweating and nausea), hypoglycemia can present differently in older adults with diabetes. Symptoms specific to elderly people include dizziness, weakness and confusion. It’s important for elderly people to recognize these symptoms, as they could cause them to have a fall, which could result in a head or limb injury.

Some of the more common reasons for hypoglycemia in the elderly include:

• Numerous prescription medications (i.e. more than five)
• Chronic kidney problems
• Poor food intake
• Having other illnesses or conditions

For more information about hypoglycemia, click here.