Diabetes Complications

Diabetes in Older People

Diabetes mellitus, or diabetes, is a disease affecting the regulation of blood glucose (sugar) levels. An organ called the pancreas creates the hormone insulin, which helps keep blood sugar levels in a healthy range.

With diabetes, the pancreas either doesn’t make enough insulin, or the body doesn’t respond to it well. Without proper insulin function, blood sugar levels rise and can lead to health problems if left untreated.

Diabetes is becoming more prevalent worldwide. As of 2015, 30.3 million people in the United States, or about 9.4 percent of the population, had diabetes. Unfortunately, more than one in four people with diabetes don’t know they have it. Having undiagnosed diabetes increases the risk of complications from lack of prompt treatment.

Many people also have prediabetes, a condition where blood sugars are slightly elevated but not high enough to be considered diabetes. Having prediabetes is a major risk factor for eventually developing type 2 diabetes. The U.S. Centers for Disease Control (CDC) estimates that up to 30% of people with prediabetes will develop type 2 diabetes within five years of their prediabetes diagnosis.

The majority of people with diabetes have type 2 diabetes, which usually results from insulin resistance and a combination of several risk factors. Some of the most common risk factors for type 2 diabetes include:

  • Weight: People who are considered overweight or obese according to their body mass index (BMI).

  • Age: people 45 and older are at increased risk.

  • Family history of diabetes

  • Race/ethnicity: diabetes tends to affect certain races more than others. At-risk races include African American, Alaska Native, American Indian, Asian American, Hispanic/Latino, Native Hawaiian, or Pacific Islander.

  • High blood pressure: if your blood pressure is higher than 120/80, you may be at increased risk.

  • Altered lipid levels: low levels of HDL “good” cholesterol and high levels of LDL “bad” cholesterol are risk factors, as well as high triglycerides (blood fat).

  • Pregnancy history: women with a history of gestational diabetes (GDM) or who gave birth to a baby 9 pounds or heavier are at increased risk.

  • Physical activity: People who aren’t regularly active or who have a sedentary lifestyle are at increased risk.

  • Smoking status: Smokers are 30-40% more likely to develop type 2 diabetes than nonsmokers.

  • Health history: those with a history of heart attack or stroke have a higher likelihood of developing type 2 diabetes.

  • PCOS: Polycystic Ovarian Syndrome in women is a risk factor, as it usually is associated with insulin resistance.

  • Acanthosis nigricans: dark, velvety patches of skin are a sign of insulin resistance and are a risk factor for developing diabetes. These patches of skin usually occur around the neck or armpits.

Type 1 diabetes is an autoimmune condition and is more rare than type 2 diabetes. Type 1 diabetes results from the body attacking the cells in the pancreas responsible for producing insulin. People with type 1 diabetes need to take insulin to manage their diabetes, whereas people with type 2 diabetes don’t always have to take insulin.

The risk factors for type 1 diabetes aren’t as well-understood as type 2 diabetes because of its nature as an autoimmune disease. Some of the known risk factors for developing type 1 diabetes include:

  • Family history: people with a parent or sibling with type 1 diabetes are more likely to develop it than people without a family history.

  • Genetics: certain genes tend to indicate an increased risk of type 1 diabetes.

  • Geography: incidence of type 1 diabetes tends to increase as the distance from the equator increases.

  • Age: the first peak of diagnosis tends to occur between ages 4-7 and again between ages 10-14. This is one of the reasons type 1 diabetes is often referred to as juvenile-onset diabetes.

Type 2 diabetes usually impacts people at an older age; being 45 years and above is a risk factor in itself. Over 25% of people above the age of 65 have diabetes, impacting over 14 million seniors. Managing diabetes in older people has its own unique considerations compared to younger people.

Some of the symptoms of diabetes and its related complications include:

  • Increased hunger

  • Increased thirst

  • Excessive urination

  • Slow-healing sores or cuts

  • Unexplained weight loss

  • Itchy skin (usually around the vaginal or groin area)

  • Frequent yeast infections

  • Velvety, dark skin changes of the neck, armpit, and groin

  • Numbness and tingling of the hands and feet

  • Vision changes

Diabetes in elderly people

People over the age of 65 have the highest prevalence of diabetes of any age group. Older people are more at risk of developing diabetes because of increased insulin resistance and declining insulin production in the pancreas. 

One of the considerations when treating a senior with diabetes is choosing how aggressively to manage diabetes based on other health conditions, life expectancy, and quality of life. A 95-year-old person with multiple health conditions will likely have less stringent blood sugar goals than a healthy and active 70-year-old.

HypoglycemiaElderly patients are more likely to experience severe hypoglycemia (low blood sugar), which occurs when blood glucose levels fall below 70 mg/dL. Symptoms of hypoglycemia include:

  • Shakiness

  • Dizziness

  • Sweating

  • Hunger

  • Fast heartbeat

  • Inability to concentrate

  • Confusion

  • Irritability or moodiness

  • Anxiety or nervousness

  • Headache

Incidences of hypoglycemia are usually more dangerous in older people since they are already at higher risk of falls and can have underlying balance issues. Older people can also have hypoglycemia unawareness, meaning they don’t identify symptoms of low blood sugar as well as they should.

Hypoglycemia unawareness can worsen the longer someone has diabetes; if a senior has had diabetes for a while, they might develop hypoglycemia unawareness in their older years. Repeated hypoglycemia worsens hypoglycemia unawareness, further complicating the cycle. Repeated hypoglycemic events can deteriorate an older person’s general health and lead to frailty, disability, and negative outcomes. 

Older people tend to eat fewer calories due to many physical changes of aging. Inconsistent or insufficient food intake, especially when taking blood sugar-lowering medications, further increases hypoglycemia risk.

Many older patients take medication for high blood pressure. High blood pressure is considered the “silent killer” of older people, so it’s usually a top priority to manage. Blood pressure medications can cause dizziness or lightheadedness, which can further increase the likelihood of a fall from dizziness associated with hypoglycemia.

Urinary tract infections: Having high blood sugar increases the likelihood of developing a urinary tract infection or UTI. The body tries to rid itself of the extra sugar through urination, leading to higher sugar levels in the urine. Bacteria feed off this sugar, which increases the risk of the UTI.

UTIs tend to become more prevalent with age, regardless of whether or not the person has diabetes. Elderly patients don’t always exhibit the telltale symptoms of a UTI, which can make it more challenging to spot. Some of the symptoms of a UTI in the elderly include agitation, lethargy falls, and decreased appetite. Elderly patients with diabetes are therefore at an even greater risk of developing urinary tract infections.

Blood sugar targets. Healthcare providers typically have less strict goals for blood sugar levels in elderly patients. Part of the reason is to lessen the likelihood of hypoglycemia. Fasting blood sugar targets for older people generally fall in the range of 90-150 mg/dL with an A1c goal of less than 7.5%. As comorbidities increase and life expectancy decreases, those goals tend to become higher, with a target of an A1c less than 8.5% in people where the benefit of controlling blood glucose is likely, not worth the potential risks associated with lowering blood sugar.

Kidney function. Kidney function tends to decline with age, and diabetes can cause kidney disease and further kidney function decline. Many diabetes medications are prescribed based on glomerular filtration rate, which is a measure of how quickly the kidney filters blood. Seniors with a reduced GFR may not take certain diabetes medications that require a certain level of kidney clearance.

Diabetes and Alzheimer’s

Alzheimer’s is a type of dementia that severely impacts memory, cognition, and behavior. It is the most common form of dementia and accounts for 60-80% of all dementia cases. Being age 65 and older is the greatest risk factor for developing Alzheimer’s, but it’s not a normal part of aging. Alzheimer’s is a progressive disease, meaning it gets worse over time, and there is no cure.

There is such a correlation between diabetes and Alzheimer’s that Alzheimer’s is referred to as “type 3 diabetes“. While the reason behind the correlation isn’t quite clear, people with diabetes do tend to be at greater risk of developing Alzheimer’s disease. One of the main reasons diabetes may increase the chances of developing Alzheimer’s is through vascular changes in the brain.

Diabetes can cause damage to blood vessels from having high blood sugar over a long period of time. When blood vessels to the brain become blocked or damaged, a condition called vascular dementia can result. People with diabetes often show changes in the brain indicative of both vascular dementia and Alzheimer’s.

Alzheimer’s may also be associated with diabetes because of the inflammation high blood sugar can cause, therefore damaging brain cells. Researchers also believe that insulin resistance may play a role in changing the brain to make it more susceptible to developing Alzheimer’s.

Insulin resistance is a term for the body not responding to insulin as well as it should. Insulin is a hormone that helps reduce blood sugar levels by allowing the sugar to be taken in by cells to use as energy. Without enough insulin, blood sugar builds up in the bloodstream, unable to enter the cells where it’s needed. Chronic insulin resistance is a major risk factor and cause of developing type 2 diabetes mellitus.

Caring for a senior with diabetes

Due to the increasing life expectancy and other factors, many people will find themselves caring for a senior with diabetes. Some things caregivers can do to help include:

Encourage balanced eating habits. Seniors may not eat as well as they should and often suffer from a reduced appetite. Caregivers should encourage a balanced diet consisting of protein, a carbohydrate or starch source, and a vegetable, similar to the Plate M

https://www.cdc.gov/diabetes/managing/eat-well/meal-plan-method.htmlethod

Elderly people often lose muscle mass as they age, which can cause weakness and loss of strength, both contributing to more falls. Ensuring they eat enough protein is important to help support lean muscle mass. Foods rich in protein include:

  • Meat (beef, poultry, fish, etc.)

  • Eggs

  • Dairy products

  • Nuts

  • Seeds

  • Soy products

  • Beans and lentils

Seniors taking blood sugar-lowering medications should consume a consistent amount of carbohydrates throughout the day to help prevent low blood glucose levels. This is especially true for any seniors on insulin. There should be carbohydrates consumed with meals and snacks, consisting of foods like:

  • Grains (bread, cereal, pasta, rice, crackers, etc.)

  • Fruit

  • Starchy vegetables such as beans/legumes and potatoes

  • Milk & yogurt

If an older person lives alone and doesn’t eat well on their own, programs such as Meals on Wheels or meals offered at local senior centers are good ways for seniors to get good nutrition and prevent weight loss.

Know how to treat low blood sugar

Hypoglycemia is a potentially serious health condition and increases the likelihood of falls. 

If blood sugar is below 70 mg/dL, it should be treated by consuming a food or beverage containing 15 grams of carbohydrates. Sugary drinks and hard candies are preferred as they are rapidly absorbed into the bloodstream. It doesn’t take much juice to get to 15 grams of carbohydrates; about one-half cup is enough.

Glucose tablets are a popular treatment for low blood sugar because they’re easy to have on hand in different situations. They dissolve quickly and provide pure glucose, so they are rapidly absorbed into the bloodstream as glucose. Each tablet contains 4 grams of carbohydrates, so in the case of low blood sugars, 3-4 tablets should be used in order to provide 12-16 grams of carbohydrates. A common brand of glucose tablet is Dex4, but other brands make similar products. They are available over the counter without a prescription.

After taking some carbohydrates, blood sugar should be rechecked in 15 minutes. If blood sugar levels are still below 70 mg/dL, the treatment should be repeated and blood sugar retested in another 15 minutes. That process should be repeated until blood sugar is above 70 mg/dL; if it’s not working, a healthcare provider should be notified.

If blood sugar levels don’t rise despite treatment or are dangerously low and/or the senior is unresponsive, a glucagon emergency kit may be used. A medical professional must prescribe glucagon, and it’s in the form of an injection. Glucagon is a hormone that helps convert the body’s stored sugar (glycogen) into blood sugar. Glucagon is helpful when the person with the hypo is too unresponsive to be able to take in food or drink since it is injected under the skin and done by another person.

Encourage regular physical activity

Staying active not only helps promote healthy blood sugar levels but can help seniors maintain lean muscle mass and promote the strength needed to stay mobile, and reduce fall risk. Walking on a level surface, doing water aerobics or swimming, using light resistance bands or weights, practicing yoga, and participating in exercise classes specifically for seniors are all great options. 

30 minutes of physical activity most days of the week is the recommended amount of exercise for people to stay healthy, and older people are no exception.

Make sure medications are being taken properly

Older people, especially those suffering from cognitive impairment or dementia, may become confused about their medication regimen. They may skip doses of their medications, which can result in high blood sugar and diabetes-related complications. They may also take too much diabetes medication, which can result in low blood glucose.

Other than insulin therapy , other medications that can cause hypoglycemia include:

  • Sulfonylureas, such as glipizide, glyburide, and glimepiride. 

  • Meglitinides, such as Prandin and Starlix.

  • Exenatide (Byetta) can cause hypoglycemia if it’s also taken with a sulfonylurea; it usually doesn’t cause hypoglycemia on its own.

Conclusion

Diabetes impacts people 65 years and older more than any other age group. Blood sugar goals for older people tend to be less strict as age increases, along with comorbidities, life expectancy, and other factors. The benefit of blood sugar control must be weighed with the risks of potential low blood sugar, which can cause more diabetes complications in elderly patients.

People with diabetes are more likely to develop Alzheimer’s, the most common form of dementia. The link between diabetes and Alzheimer’s is so strong that it’s often referred to as “type 3 diabetes”. Vascular changes and insulin resistance are thought to be potential causes for the correlation.

Older patients with diabetes should be encouraged to eat a balanced, consistent diet, take medications as prescribed, and stay as active as possible to maintain good health and promote longevity. 

Sources

https://www.alz.org/national/documents/latino_brochure_diabetes.pdf
https://www.cdc.gov/diabetes/managing/eat-well/meal-plan-method.html
https://care.diabetesjournals.org/content/35/12/2650

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