March 2013 Issue

Elder Diabetes Patients — Know the Signs and Symptoms of Type 2 Diabetes in This Population to Improve Care
By Jill Weisenberger, MS, RD, CDE
Today’s Dietitian
Vol. 15 No. 3 P. 20

Jean, 78, has been experiencing urinary incontinence and showing signs of confusion. Her physician also notices she’s slightly dehydrated. When he suggests screening Jean for type 2 diabetes, she thinks this is a waste of time. After all, she isn’t experiencing frequent urination or excessive thirst, which she knows are telltale symptoms of the disease. But the truth is Jean’s symptoms are typical in elder patients newly diagnosed with type 2 diabetes.

Elder patients often present with different signs and symptoms of diabetes, so it’s important for RDs to know what these are so they can help this patient population stabilize blood glucose levels with proper nutrition or refer them to a physician who specializes in geriatric diabetes care.

Different Signs and Symptoms
More than one-quarter of the US population aged 65 and older has diabetes,1 including type 1 and 2, and approximately one-half of older adults have prediabetes. In this population, age-related insulin resistance and impaired pancreatic islet function increase the risk of developing the disease.

Because of these age-related physiological changes, elder patients may not present with classic symptoms of hyperglycemia. The renal threshold for glucose increases with age, and older people often have impaired thirst mechanisms. Thus, polyuria and polydipsia may be absent. Common presenting symptoms are dehydration, dry eyes, dry mouth, confusion, incontinence, and diabetes complications, such as neuropathy or nephropathy.2

Hypertension and dyslipidemia frequently coexist with diabetes, but in elder diabetes patients so do dementia, depression, and functional decline.3 In general, individuals with type 2 diabetes have twice the risk of dementia.4 In one study of elder adults with diabetes, one-third of those over the age of 70 showed cognitive dysfunction associated with poor diabetes control.3

Moreover, elder diabetes patients have higher rates of premature death.5 They have greater physical and mobility limitations compared with those without diabetes even when controlled for hypertension, cerebrovascular disease, chronic obstructive pulmonary disease, cancer, dementia, and osteoarthritis.6 They’re also more likely to use a wheelchair, cane, or other mobility aid. These problems put elder diabetes patients at a high risk of falls, which can have life-threatening consequences.

Barriers to Care
In addition to their many physical challenges, elder diabetes patients often are socially isolated and have financial problems that negatively affect their care, says Joan Hill, RD, CDE, LDN, a consulting dietitian and diabetes educator with the Council on Aging in Natick, Massachusetts. They may forget to eat, be unable to afford medications or quality food, or skip medication doses to extend a prescription. They also may experience changes in taste and a lack of interest and ability to shop for food and prepare meals at home.

“Dental status is also a very important and underrated issue since this automatically limits many food choices,” explains Janice Baker, MBA, RD, CDE, CNSC, BC-ADM, a private practitioner in San Diego. Furthermore, limited dexterity and poor eyesight may affect this age group’s ability to monitor their blood glucose levels and inject insulin.

Glycemic Targets
Blood glucose targets vary depending on a patient’s health status and life expectancy. According to the American Diabetes Association (ADA), older adults who are functional, cognitively intact, and have a significant life expectancy should have the same blood glucose targets as younger adults with diabetes. This means they should have a hemoglobin A1c below 7%.5

The glycemic goals for elder patients who don’t fit this criteria should be less stringent, using individual criteria to avoid episodes of hypoglycemia.5 The European Diabetes Working Party for Older People recommends an A1c target of 7% to 7.5% for elders with type 2 diabetes who don’t have major comorbidities. For frail (or elderly) patients, they recommend an A1c range of 7.6% to 8.5%.

When deciding on blood glucose targets, healthcare professionals and patients must weigh the risk of hypoglycemia with the benefits of tighter glycemic control. Intensive glycemic control is associated with significantly reduced rates of microvascular and neuropathic complications. However, those with a short life expectancy may have too few years of life remaining to reap the benefits. For these patients, avoiding hypoglycemia is most critical because even mild hypoglycemia can lead to dizziness or weakness that increases the risk of falls and serious injury.

Age appears to affect counterregulatory responses to hypoglycemia, even in people without diabetes. Thus, the likelihood of hypoglycemic unawareness is greater among the elder population. During a small hypoglycemic clamp study in people with type 2 diabetes, one-half of the middle-aged participants correctly identified low blood glucose, but only about 8% of the older participants recognized it.1 The reason is because hypoglycemia often presents differently in older adults with diabetes. Instead of or in addition to sweating and tremors, elder diabetes patients should be taught to look for symptoms such as dizziness, weakness, delirium, and confusion. “Often, the low glucose will cause them to fall, resulting in a head injury and death,” Hill warns. Baker had an elder patient with erratic eating who suffered a hypoglycemic event in her home and fractured her jaw when she fell.

Of equal importance is avoiding high blood glucose levels. At a minimum, glycemic goals must prevent acute complications of hyperglycemia, which include dehydration, poor wound healing, urinary incontinence, and hyperglycemic hyperosmolar coma.

Medical Nutrition Therapy
To stabilize diabetes complications, administering medical nutrition therapy (MNT) is imperative. The goals of MNT include the management of blood glucose, lipids, and blood pressure while optimizing overall well-being and quality of life. According to the ADA, elders 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 hypoglycemia, RDs should remind them to eat during regular meal times and include snacks that contain adequate amounts of carbohydrates. If dietitians have patients who forget to eat or take their medications, have them set alarms on their watches or cell phones to remind them. Baker also suggests RDs explain the importance of elder patients discussing changes in appetite, eating habits, and weight with their healthcare team, as each of these influence the risk of hypoglycemia.

In addition, dietitians should encourage these patients to wear medical ID bracelets or necklaces and always carry appropriate treatment for hypoglycemia, such as glucose tablets, glucose gel, and juice boxes. RDs also should keep in mind that older adults are at higher risk of inadequate protein, calorie, fluid, calcium, vitamin D, and vitamin B12 intake, among other nutrients.

Delivering Your Message
The method dietitians choose to teach elders with diabetes will be critical to their understanding and involvement in their healthcare. Usually, simple is best, Hill says. Memory lapses, cognitive problems, poor hearing, or poor eyesight may hinder their learning ability. For these reasons, a food group meal planning technique may be more appropriate than carbohydrate counting.

To begin treating such patients, discuss only one or two topics per visit, making the information specific; write out instructions in large print; if using handouts, be sure the font is large enough for them to read; assess their understanding by having them reiterate the information you’ve shared with them; and repeat key information.

Hill says she has greater success when a patient’s family is involved in the diabetes education and care. If the family can’t assist the patient, recommend that the patient gets in touch with the Council on Aging or a senior center in his or her community, Hill says. Organizations such as these may provide diabetes support groups and home-delivered meals in addition to other services.

Baker encourages her older patients with diabetes to attend support groups. “They really benefit from the socialization with others. They really bond and are stimulated to learn more from conversation and interaction than handouts,” she says.

— Jill Weisenberger, MS, RD, CDE, is a freelance writer, nutrition consultant, and diabetes educator in southeast Virginia and the author of Diabetes Weight Loss — Week by Week.

 

Resources
When counseling older adults with diabetes, consider their limitations with regard to dexterity, hearing, and vision when choosing or recommending diabetes care devices. The following products may be helpful:

• Large-print educational materials

• Blood glucose meter with a backlight or audio

• Blood glucose meter with a drum of preloaded test strips, eliminating the need to insert a test strip each time

• Lancing devices with a drum containing multiple lancets

• Insulin pens that combine insulin and a syringe in a single device

• Syringe magnifier, a clear device that slips over or clips to a syringe to magnify its markings

Additional resources may be available through the Academy of Nutrition and Dietetics’ Diabetes Care and Education Dietetic Practice Group (www.dce.org).

— JW

 

References
1. Sue Kirkman M, Briscoe VJ, Clark N, et al. Diabetes in older adults: a consensus report. J Am Geriatr Soc. 2012;69(12):2342-2356.

2. Abbatecola AM, Paolisso G. Diabetes care targets in older persons. Diabetes Res Clin Pract. 2009;86 Suppl 1:S35-S40.

3. Munshi M, Grande L, Hayes M, et al. Cognitive dysfunction is associated with poor diabetes control in older adults. Diabetes Care. 2006;29(8):1794-1799.

4. Strachan MW, Reynolds RM, Marioni RE, Price JF. Cognitive dysfunction, dementia and type 2 diabetes mellitus in the elderly. Nat Rev Endocrinol. 2011;7(2):108-114.

5. American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care. 2012;35 Suppl 1:S11-S63.

6. Sinclair AJ, Conroy SP, Bayer AJ. Impact of diabetes on physical function in older people. Diabetes Care. 2008;31(2):233-235.

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