With increasing life expectancy, the number of elderly people is also increasing and so is the prevalence of diseases associated with aging such as type 2 diabetes, heart disease, dementia, osteoarthritis etc. The geriatric age group has its own set of unique challenges.

Cognitive impairment including dementia is common in the elderly and poorly controlled diabetes further adversely affects cognition creating a vicious cycle. Besides pancreas, insulin is also synthesised and released in the brain. Insulin resistance and insulin deficiency in the brain have been proposed as the pathogenic mechanism of the neurogenerative changes in Alzheimer’s disease. The term type 3 diabetes was coined for Alzheimer’s disease, which is the most common form of dementia among the elderly. Cognition affects acceptance of and compliance to treatment modalities. Chronic diseases such as heart disease, hypertension frequently coexist with type 2 diabetes as well as other conditiosn such as cataract, arthritis.

Another major concern in geriatric diabetes is the acute complication of hypoglycemia, which is precipitated by multiple risk factors. Management of hypoglycemia is of importance not only medically because of the associated risk of falls and head injury or other injuries, it has social implications too as many elderly people stay alone as their children have migrated outside the country for work or education. Therefore, it’s important to teach them to recognise the signs of hypoglycemia.

Compared to fasting blood glucose, which increases by 1-2mg% every decade, the rise in postprandial glucose is faster at 15mg% per decade. Hence, using fasting glucose alone may miss a large number of the elderly with diabetes. Opportunistic screening, when other routine blood tests are done or as part of investigation for any other illness, must be the recommended approach.

Geriatric diabetes requires a patient-centered approach for treatment, rather than the algorithmic approach as there are several barriers to care.

Treatment planning must take into account their social circumstances as many of the elderly patients stay alone or rely upon their family members to take them to the doctor and other medical needs. These situations may further compound their anxiety, stress and loneliness. The psychosocial and financial factors influence compliance to treatment. These factors must be taken into consideration in treatment planning.

Non-pharmacological therapy includes therapeutic patient education and lifestyle modification, with regard to diet, physical activity and stress management. It is also important to educate them about hypoglycemia, foot care and stress management. The following ‘8 As’ must be kept in mind when prescribing diet for the diabetes patient: Accurate, Appropriate, Available/accessible, Acceptable, Attractive, Achievable, Affordable and Absorbable/digestible. The exercise regimen, which includes isotonic exercises like walking, should be individualized taking into account the disabilities and physical limitations. It should be carried out in familiar and relaxed surroundings. It is very important to instil a sense of self-confidence in them. This can be done by making them equal partners in clinical decision making and empowering them to manage their disease.

The choice of antidiabetic drug depends on the characteristics of individual drugs as well as the presence of comorbidities. Metformin is the first-line drug, in the absence of any contraindication or intolerance to the drug. Being a calorie-restriction mimetic, it should be avoided in frail, underweight or malnourished individuals. Watch out for GI symptoms, B12 deficiency, rise in creatinine and lactic acidosis with metformin. Sulfonylureas (SUs) are best avoided as hypoglycemia is a very common side effect. Hence, SUs should be avoided in patients who are poor eaters. The dipeptidyl dipeptidase (DPP)-4 inhibitors (sitagliptin, vildagliptin and linagliptin) can be used. Alpha-glucosidase inhibitors (acarbose and voglibose) are also considered safe in the elderly.

Insulin is a cost-effective treatment. Several formulations are available such as rapid acting analogues (aspart, lispro and glulisine), premixed insulin, basal insulin, Basal-Bolus Insulin, Premixed analogues such as aspart 30:70, aspart 50:50, lispro 25:75 and lispro 50:50. However, caution should be exercised because of the risk of attendant hypoglycemia.

It is also important to avoid hyperglycemia and its complications such as impaired wound healing, dehydration, urinary incontinence. More than tight glycemic control, controlling the risk factors for heart disease may reduce morbidity and mortality to a greater extent, in the elderly diabetic population.

Geriatrics is still an evolving specialty in India and is yet to come up on its own strength as a separate and independent specialty. The healthcare needs of the elderly differ from the younger population. Polypharmacy is common because of other comorbid conditions as well as diabetes-related chronic conditions. Their immunity is low. Their living conditions and functional capacity may not be optimum. The social and emotional aspect also influence management of elderly.

The pathophysiology, diagnosis and management of diabetes differ between the elderly and their younger counterparts. It is important for physicians to be aware of these differences, however subtle, and manage their geriatric patients accordingly with a safe and effective treatment plan.

Suggested reading

1. Kalra S. Geriatric diabetes. J Pak Med Assoc. 2013;63(3):403-5.
2. Bradley D, et al. Type 2 diabetes in the elderly: challenges in a unique patient population. J Geriatr Med Gerontol. 2016;2(2):14.
3. Weisenberger J. Older diabetes patients present unique challenges. Today’s Geriatric Medicine. 2013;6(4):24.