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In conversation: Geriatrician Dr Nur Farhan on diabetes management in the elderly

Asykin Ismail, 27 Apr 2017
One of the reasons that diabetes is underdiagnosed in older people is that the classic symptoms of diabetes do not often present themselves in the elderly. The wellknown symptoms of diabetes, such as urinating excessively and feeling thirsty all the time, are not as obvious in the elderly as in young people.

In addition, symptoms of type 2 diabetes, such as feeling tired and lethargic, can often be misinterpreted as just part of the normal ageing process. As a result, older people with diabetes may be relatively free of symptoms and may remain undiagnosed until damage has been done.

If left unchecked, the accumulation of glucose in the blood can cause enormous damage to nearly every major organ in the body, including kidney damage; artery damage, which increases the risk of stroke and heart attack; eye damage, leading to vision loss; erectile dysfunction (impotence) in men; and nerve damage, which can lead to traumatic injury and infection, possibly leading to limb amputation.

Nutrition, exercise and management

To stabilise diabetes complications, administering medical nutrition therapy (MNT) is imperative. The goals of MNT include the management of blood glucose, lipids, and blood pressure while optimising overall well-being and quality of life. Elderly with diabetes may experience less morbidity and mortality from the control of these other cardiovascular risk factors than from tight glycemic control.

To help patients prevent hypoglycaemia, geriatricians and dietitians should remind them to eat during regular meal times and include snacks that contain adequate amounts of carbohydrates. In addition, these patients should always carry appropriate treatment for hypoglycaemia, such as glucose tablets, glucose gel, and juice boxes. It is also useful to note that older adults are at higher risk of inadequate protein, calorie, fluid, calcium, vitamin D, and vitamin B12 intake, among other nutrients.

Elderly with diabetes, who are otherwise healthy, should be encouraged to engage in physical activity and exercise in moderation. Exercise improves insulin sensitivity and can improve a person’s response to blood glucose medications. Balancing, posture and strengthening exercises are essential to maintain function and prevent falls. By regularly participating in strength-building exercise, however, muscle tissue and strength can be restored. “What’s more, exercise also makes it easier for these older individuals to maintain their strength, balance, flexibility and endurance – all of which are important for staying healthy and independent,” she said.

Diabetes can be easily managed with appropriate diet and exercise modifications, along with proper pharmacological therapies. Some aspects of treating diabetes in younger and older patients are similar, but knowing where it can differ will help health care professionals provide better treatment and improve patients’ quality of life, Dr Farhan explained.

As in younger patients with type 2 diabetes, insulin can also be considered as initial therapy in the elderly. However, injectable forms may be dangerous for older patients with declined motor and visual skills. Therefore, assessment of these skills, along with cognitive function, before initiating insulin is important. The use of sliding-scale insulin in elderly patients is not recommended due to increased risk for hypoglycaemia. Additionally, it is also important to screen for microvascular complications like retinopathy, neuropathy, and foot ulcers in all patients with diabetes. Yearly eye exams by an ophthalmologist and foot exams by a podiatrist are recommended for younger and older diabetes patients alike.

Tapping on resources

When counselling the elderly with diabetes, it is critical for geriatricians and dietitians to consider their limitations with regard to dexterity, hearing and vision. “The method to teach elderly with diabetes will be critical to their understanding and involvement in their healthcare and the best approach is to keep it simple,” said Dr Farhan.

Some of the ways, she highlighted, was to ensure the information given out to elderly diabetic patients is specific; and they may include writing out instructions in large print to make it easy for them to read; assessing their understanding by having them reiterate the information you’ve shared with them and repeating key information.

Greater success can also be achieved by involving the patient’s family in the diabetes education. “Elderly patients are also encouraged to attend support groups as they are able to benefit from the socialisation with others. Through such sessions, they really can bond with others and are stimulated to learn more from conversation and interaction than handouts,” she noted. Elderly patients can also benefit from using user-friendly diabetes care devices such as a blood glucose meter with a drum of preloaded test strips (eliminating the need to insert a test strip each time) or even insulin pens that combine insulin and a syringe in a single device. The elderly may also benefit from additional care resources which may also be available through the Diabetic Society of Singapore, concluded Dr Farhan. MIMS

Read more:

War on diabetes: Preventing the onset of diabetes
Specialist Spotlight: Geriatricians