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Diabetes in the Elderly

Diabetes in the Elderly

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Introduction

Diabetes becomes increasingly common with advancing age.

A screening study in Melton Mowbray in 1990 suggests that the prevalence may be 10.5% in 70 year olds, and as high as 13.8 % in 85 year olds. Current levels are likely to be significantly higher.

Morbidity from diabetes in elderly people is high and the prevalence of cardiovascular disease, hypertension, overweight, neurological and vascular disease is higher in elderly diabetic patients than non-diabetics. Elderly individuals are particularly susceptible to hypoglycaemia and hypothermia. They have poor performance on a variety of cognitive tasks, higher incidence of depression and are more likely to be housebound compared to individuals without diabetes.

The overall approach to care of an elderly patient with diabetes is similar to that of a younger person, however some issues need to be considered specifically for the elderly diabetic patient and also for certain individuals.

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Aims of Care

Safety is paramount – targets for diabetes and other metabolic parameters should be the same as for young patients but coexisting factors may indicate a need for a different approach.

Avoid symptomatic hyperglycaemia and aim for best level of glycaemic control whilst preventing hypoglycaemia.

Manage coexisting diseases, reduce functional disability, and improve quality of life.

Engender a positive attitude to patients’ condition.

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Diagnostic Issues

A normal fasting blood glucose does not exclude the diagnosis of diabetes in a frail elderly person. If a high index of suspicion exists, then a two hour blood glucose taken after a 75g oral glucose load would be required.

Stress induced hyperglycaemia (eg: acute infection) is common and needs to be treated. However, if hyperglycaemia appears to settle after resolution of the acute illness the diagnosis needs to be confirmed: repeat blood glucose after 4 – 6 weeks.

Screen for diabetes:

 

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during the over 75 annual health check

 

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in patients with vascular diseases (hypertension, IHD, cerebrovascular disease)

 

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in all admissions

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Special Management Issues

Identify the principal carer with regard to diabetes

Set realistic goals: overzealous application of clinical targets may compromise quality of life.

Consider limitations imposed by other factors:

 

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Activities of daily living

 

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Mobility

 

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Mental state

 

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Social support – carers, meals on wheels, etc.

Current medication – compliance, use of aids i.e. a monitored dosage system (MDS)

May need to involve other agencies eg social services.

Review above issues on ongoing basis

Treatment:

Choice of Oral Hypoglycaemic Agents (OHA) – avoid long acting OHA e.g Glibenclamide

Metformin

- avoid if creatinine >150mm/l or eGFR <35 ml/min.

 

- avoid if in severe heart failure

Pioglitazone  - low risk of hypoglycaemia but carry risk of precipitating or worsening heart failure and risk of fractures with prolonged use.

Insulin can be used safely in elderly people

DPP4 inhibitors are safe in the elderly and have a low risk of hypoglycaemia

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Special Needs of Patients who are Housebound or in Care Homes

Such patients are a highly vulnerable and often neglected group, with a high prevalence of complications and a marked susceptibility to infections. There is an increased risk of hospitalisation compared to ambulatory patients, and high levels of physical disability and cognitive impairment. Access to conventional services is often difficult and their care may be compromised.

It is recommended that individual Care Plans are used for those with diabetes living in cared environments.

Improving care of patients who are housebound and in Care Homes

Clinical:

Individualised care plan to be agreed between the patient, healthcare professionals and carers.

Each patient with diabetes should be reviewed by either their family doctor or a diabetologist at least once a year.

Ensure appropriate access to other specialist health professionals eg podiatry and dietetics.

Ensure that patients with diabetes in residential and nursing homes are included in audits of diabetic care and in service planning.

Nutritional issues (See - Dietary Recommendations Guideline. Avoid strict dietary regimens: ensure adequate calorie intake and be proactive in treating hyperglycaemia arising from enhanced nutritional support

Support:

The complexity of the care of this group often requires increased support in the community from experienced health professionals such as specialist diabetes nurses and dietitians

Education and Training:

Staff (nursing, personal carers and catering) working in residential and nursing homes require regular and ongoing diabetes educational and training programmes.

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Useful External Links & Resources
PDF File

Diabetes UK | Good Clinical Practice Guidelines for Care Home Residents with Diabetes - 2010

View 'National Patient Safety Suite - Safe anagement of people with diabetes, dementia, depression and severe mental illness - e-learning module'
PDF File
Care Plan for a Person with Type 1 Diabetes in a Cared Environment
PDF File

Care Plan for a Person with Type 2 Diabetes in a Cared Environment

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