Challenges in Treatment of Diabetes in Geriatric Population

– Dr. Atulya Saurabh, Geriatrician, Bhopal

Geriatric age group is the group of persons aged 60 years or older. Geriatrics or geriatric medicine is a specialty that focuses on health care of elderly people which aims to promote health by preventing and treating diseases and disabilities in older adults and geriatrician or geriatric physician is a physician who specializes in the care of elderly people.

This specialised training is needed as :

1. The decline in physiological reserve in organs makes the elderly develop some kinds of diseases and are more prone to complications from diseases (such as dehydration from a mild gastroenteritis). Multiple problems may compound. A mild fever in elderly persons may cause confusion, which may lead to a fall and to a fracture of the neck of the femur (“broken hip”).
2. Elderly people require specific attention to medications as they are subjected to poly-pharmacy (taking multiple medications). Elderly people often have multiple medical disorders and are under care of multiple specialists and hence this is very common in them. They also undertake self-prescribed herbal medications (Ayurvedic Medicines containing Bhasma / Heavy Metals) and over-the-counter drugs. This poly-pharmacy may increase the risk of drug interactions or adverse drug reactions.
3. Drugs metabolites are excreted mostly by the kidneys or the liver, which may be impaired in the elderly or even compromised by the use of multiple medications and non propitiatory medicines, necessitating medication and dose adjustment. Also their renal and hepatic profile may warrant stringent drug dosing.
4. The presentation of disease in elderly persons may be vague and non-specific or it may include delirium or falls. Some elderly people may find it hard to describe their symptoms in words, especially if the disease is causing confusion, or if they have cognitive impairment. Many of these problems are treatable, if the root cause can be discovered.
   With age elderly people begin to fail and impairements appear in the form of the so-called geriatric giants. These include immobility, instability, incontinence and impaired intellect / memory.

Diabetes Mellitus:

Diabetes Mellitus is the most common chronic disease among the geriatric population. It is present in up to 18% of people older than 65 years. The geriatric population has to spend four times more on health annually as compared to non diabetics. The diagnosis and treatment of Diabetes in the geriatric population has its own challenges. Due to the physiological changes occurring as a result of aging process, the elderly people may not present with classical symptoms.
This group (geriatric population) is also different in many other ways –

1. Prevalence of complications in of diabetes in elderly population is much more;
2. Older people have an increased prevalence of functional disability & co-morbid illnesses that contribute to the complexity of managing diabetes;
3. Special evaluation and goals of treatment need to be devised for the aged population to avoid treatment complications;
4. They have multiple co-morbidities and the rate increases as the age advances;
5. As the age advances, the metabolic activity of the person also decreases which results in delayed or poor metabolism of the drugs so the excretion of the drugs is also delayed or hampered;
6. The aged patients also rely heavily on the alternative pathies of medicines like Homeopathy / Ayurvedic / etc. Most of the Ayurvedic medicines, which is prescribed by non trained persons, contain bhasmas of heavy metals that can lead to renal failure and other complications. Also as the older people are fed up with increased number of medicines and social misconception that the allopathic medicines are dangerous.
7. The aged population has problem in diet, many a times due to the loss of tooth / dentition. This results in improper nutrition and digestion and will in turn result in difficulty in diabetes control;
8. The geriatric population needs to be given extensive dietary advice as they have their own preconceived notions about food and diet. Fasting is also one of the hurdles in proper control of their diabetes.

The overall health conditions of the individual dictates the Diabetes management goals. The development of an individualized management plan that fits the goals and health status of each person is an essential part of diabetics care in the elderly.

Assessment of the Geriatric Diabetic Patient :

1. Comprehensive assessment of the health status;
2. Assessment of the signs and symptoms related to hyper glycaemia and diabetic complications;
3. Evaluation of hyper-lipidaemia, hypertension, and other risk factors associated;
4. Evaluation of the patient’s medications, dietary and exercise habits, nutritional, functional, & cognitive status, social and economic status.
5. Complete & comprehensive assessment is essential in every Geriatric Diabetic patient. It should also assess for problems with but not limited to ophthalmic, neurological, podiatric, renal and other bodily functions.
6. Complete and detailed assessment is crucial as certain disease conditions and medications can lead to hyper-glycaemia in the Geriatric Population.

Management:

The treatment of diabetics in older people needs not only attention to the common diabetic complications but also to the other co-morbid conditions (such as cognitive impairment, falls and impaired body functions). The management of diabetes in elderly creates a double challenge of combining the principles of Geriatric Medicine with the Diabetes management for the geriatrician.
Goals of diabetes management in elderly are more or less similar to the goals of any other diabetic. The main goals are:

1. Alleviation of hyper-glycaemia;
2. Treatment of risk factors for atherosclerosis;
3. Identification and treatment of diabetic complications associated with Insulin or Oral Hypoglycaemic agents;
4. Diabetic self management education;
5. Prevention of development or worsening of diabetic complications;
6. Avoidance of Hypoglycaemic episodes;
7. Improvement of general health status.

Treatment of Hyperglycaemia Symptoms:

First and foremost is to control the hyperglycemia symptoms. Many a times, the symptoms can be atypical and can include cognitive changes, delirium, anorexia, falls and incontinence.

Prevention and Treatment of Diabetic Complications :

In older persons, the most significant morbidity & mortality is attributable to the atherosclerotic disease.
Smoking is one risk factor that scores over all the other risks tenfold. Stopping smoking improves the morbidity and mortality risks in elderly to a great extent.
Blood pressure management helps in lowering the risk of atherosclerosis in aged people. It also reduces the chances of coronary artery disease and stroke.
A large number of older diabetic people have Dyslipidaemia and they should be regularly screened and treated.
Concomitant treatment of other endocrine problems like hyper/hypo-thyroidism also needs to be taken care of.
Diet, exercise and good glycaemic control are the corner stone of treatment for Diabetes.
Especially important is the need of regular exercise and walking to be emphasized upon the geriatric population. It is the duty of the geriatrician and the care-giver to see that the aged person has access to proper IDLs like walking sticks / walkers / walking shoes etc. They should also be protected from excessive heat & cold environment so that the body is not subjected to unnecessary metabolic stress. Excessive meta-bolic stress leads deranged blood sugar levels which in turn makes diabetes control difficult.