Indian Write-Ups

Management

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Profile of Diabetes Mellitus in the Elderly

Dr Yogini V Meisheri

Professor of Medicine,Seth G S Medical College, K E M Hospital, Mumbai

Generation "O"

Globally the total population of individuals aged 60 years or more, is 629 million. United Nations has projected, that from the present ratio of one individual being 60 years or older for every 10 persons, the ratio will increase to one of every five persons.

In India, the elderly population above 60 years at the turn of 2nd century was 75 million & is projected to reach a figure of 326 million by 2050. This projected escalation is steep and a cause of constant concern in the next 50 years to come. Diabetes mellitus (DM) is a disease associated with ageing. In our country, it is of foremost concern due to large number of diabetic elderly surviving beyond the seventh decade. Disease-associated morbidity, difficult metabolic control, co-existent diseases such as hypertension, ischaemic heart disease and dyslipidemia that affect multiple organ functions, and life threatening complications in the frail older persons with poor homeostatic reserve, compound the problem further.

Decrease in circulating insulin, and, decrease in insulin sensitivity results in minimal increase in fasting serum or blood glucose concentrations with normal ageing. The physiologic changes that accompany the ageing process primarily manifest as an elevation in the postprandial blood glucose levels, which may increase as much as 15 mg/dl per decade after the age of 30. Age-related changes in fasting blood glucose levels are small, perhaps 1-2 mg/dL per decade after 30.

Regardless of age, subjects with fasting serum-glucose levels of >140 mg/dl are classified as diabetic. Diabetes seen in the elderly for the first time tends to have a milder course. Prevalence of Type 2 in subjects over age 65 years is 7-9%. Occasionally Type-I DM occurs in the elderly. The long-term microvascular and macrovascular, renal and neuropathic complications of DM occur with similar frequency in young and older diabetic patients given comparable duration of the disease. The prevalence reported from our country varies from 3% to 16.5%, being three times higher in the urban population.

A study conducted by us (1992-94) found a prevalence of 8.9%, and an incidence of 3.1% to 2.3% of our patients were asymptomatic and 15% had complications at the time of detection.

Coronary artery disease-47%,
Peripheral sensory neuropathy-34%,
Autonomic neuropathy-15%,
Persistent macroalbuminuria-28%,
Cerebrovascular accidents-11%,
Retinopahy-7%,
Peripheral vascular disease-3%

Also 26% of the diabetics were obese (women-50%, men-14.7%). The mean glycated hemoglobin was 8.45% + 2.01. Hypertension was associated in 43% of the patients. Longer duration of DM was associated with Peripheral neuropathy and uncontrolled DM caused Stroke, autonomic neuropathy and multiple complications.

Clinical Pattern:

Begins in middle age or beyond
The risk of significant ketosis or acidosis is low, However some Type-2 patients may develop mild starvation ketosis without acidosis when their blood sugar is poorly controlled.
Glycosuria may predispose older individuals to volume depletion and risks of secondary problems related to hypotension and poor tissue perfusion.
Hyperosmolar non-ketotic diabetic stupor and coma leads to high mortality.
Type 2 may be iatrogenic, as is seen with use of either, high dose steroids or chronic thiazide diuretic.
Patients with concomitant hyperlipidemia & microvascular disease should be monitored to detect large vessel disease, retinopathy, neuropathy & nephropathy.
Complications related to treatement: Hypoglycemia, hyperosmolar non-ketotic diabetic coma, infections-necrotising fascitis, malignant otitis externa, sudden death & dehydration.
Chronic infections such as tuberculosis, candidiasis, and mucormycosis can occur.

Principles of management:

The priorities and therapeutic strategies need to be cautiously individualized. Euglycemia is the GOAL. The objectives of treatment are to improve glycaemic control in a stepwise approach that involves nonpharmacological methods including diet and exercise, and pharmacological therapy including mixtures of oral antihyperglycaemic agents alone or in combination with insulin. All older adults with DM should receive minimum care program that meets minimum standards, regardless of treatment goals.

Aggressive care: This aims to prevent long-term complications.
"Tight control": Importance of normoglycemia has been emphasized in most of the trials including DCCT (Diabetes Control and Complications Trial) to reduce the risk of complications of diabetes. Fasting blood glucose should be maintained below 160 mg/dl.
Avoid substantiative hyperglycemia (i.e.blood glucose levels>250mg/dl)
Total daily caloric intake should not exceed 800-1000 kcal with conventional dietary habits. Use of dietary fiber to decrease dietary carbohydrate absorption postprandially is also advocated.
Self-monitoring of glucose at home is encouraged. With satisfactory home control the physician can monitor glycohemoglobin level as an index of accumulated glycemic experience in the preceding 3-6 weeks.
Short acting sulfonyureas are preferred.
Metformin can be used as monotherapy or can be combined with other oral hypoglycemic agents (OHA) and insulin. Acarbose is an oral alpha-glucosidase inhibitor should not be used with metformin as it reduces the bioavailability of metformin.
Combination therapy with evening insulin and a long-acting sulphonylurea, is an effective strategy to improve hyperglycaemia in the elderly patient with Type 2 diabetes in whom polypharmacy with oral agents is unsuccessful.
Insulin: A single bedtime dose of neutral protamine Hagedorn (NPH) insulin, with or without continuation of daytime oral agents, may control fasting blood glucose. A pre-mix combination of NPH and Regular insulin such as 70/30 or 50/50 may be used pre-meal.
Avoid long-medium acting sulfonylureas.
Besides glucocorticoids and diuretics, estrogens, phenytoin, tricyclic antidepressants, niacin and sympathomimetics can exacerbate glucose intolerance.
Stress states such as myocardial infarction, infection, burns and surgery can worsen glucose tolerance and precipitate fasting hyperglycemia.
Cautiously use drugs like aspirin, NSAIDS, sulfonamides, oral anticoagulants, tricyclic antidepressants & ß-blockers.

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