Dr Aidin Rawshani

Elderly with diabetes


How to treat diabetes among the elderly

Population studies have evaluated the incidence and incidence of type 2 diabetes in the elderly, studies from different Western countries show that more than 20% of the population develops type 2 diabetes after 75 years of age. A large percentage of these are unaware that they have the disease. The prevalence of diabetes is much higher in some ethnic groups. The risk of developing diabetes increases the older one gets, at the same time the life expectancy increases, which means that more people will live with diabetes in the future. Diabetes is likely to require enormous medical resources in the future.

Having diabetes increases your chances of developing several serious age-related complications such as heart attack, stroke, heart failure, dementia and specific cancers. There is much you can do to lower the risk of future complications, or at least postpone your illness by controlling your diabetes. Individuals with diabetes should focus on several factors, first you need to ensure that blood sugar levels are well controlled, follow your treatment plan, take your medicines as prescribed, control what you eat and try to be more physically active. All these steps will help you live a longer and healthier life.

The research world is increasingly interested in studying the relationship between diabetes and biological aging. Several studies suggest that diabetes in leads to accelerated biological aging, the difference between biological age and chronological age tends to increase over the years. The cause of diabetes in the elderly is most likely a lack of insulin-producing cells and low insulin levels in the body.

Diabetes and kidney function in the elderly

Renal function deteriorates with increasing age. Renal function can be calculated using several different methods, some methods are quite complex and are mainly used to investigate kidney function for major interventions such as kidney transplantation or cancer investigation. In clinical practice, usually, measure kidney function with a blood test, the measurement method is called the glomerular filtration rate (EGFR, unit: ml/min/1.73 m2). Renal function is usually 90 ml/min/1.73 m2 in healthy individuals, but the renal function is impaired on average by 1 ml/min/year from the age of 50 years. People who are 80 years of age or older have usually lost half of the kidney function compared to 50 years of age.

Common risk factors for cardiovascular disease contribute to even impaired renal function, these factors have a synergistic effect with age. Risk factors for cardiovascular disease, such as high blood pressure, obesity, high blood lipids and smoking, also contribute to poor kidney function. In Western countries, diabetes and hypertension (hypertension) are the cause of most cases of impaired renal function and diabetic renal failure (nephropathy).

Table 1. Chronic renal failure (five stages)  
StageDescriptioneGFR (ml/min/1.73 m2)
1.Normal renal function>90
2.Slight renal impairment 60-89
3.Moderate renal impairment 30-59
4.Severe renal impairment 15-29
5.Terminal renal failure<15

The creatine value is another blood test that reflects both muscle mass and kidney function, therefore this is not a good blood test for older individuals because they have low muscle mass.

The relationship between diabetes and impaired renal function is known for a long time. High blood sugar levels significantly contribute to impaired renal filtration capacity. Renal impairment is also a major risk factor for cardiovascular diseases such as myocardial infarction and heart failure. The choice of drug therapy in diabetes usually depends on kidney function in individuals with diabetes, several drugs are contraindicated or require dose reduction in case of moderate or pronounced renal impairment. Therefore, it is important to check your kidney function regularly with your family doctor to detect early damage to your kidneys and whether you need to adjust your medicines.

Metformin in the elderly with diabetes and poor kidney function

Metformin is the first choice in type 2 diabetes. The drug exhibits a range of beneficial effects, but the scientific documentation for use in people with diabetes over 80 years of age is inadequate. Elderly individuals with diabetes and metformin therapy should check their kidney function regularly, for example, every 3-6 months. As a rule, treatment with metformin is stopped when renal function is lower than 30 ml/min/1.73 m2 in EGFR.

The risk of the unusual but potentially life-threatening complication lactic acidosis is important to be aware of. However, metformin poisoning is probably not the most common cause of lactic acidosis, new findings show that serious illnesses such as cardiogenic shock (excessive blood loss), severe trauma, bacterial sepsis (sepsis) and excessive fluid loss are usually the cause of lactic acidosis.

It is important that the physician and the patient make an assessment of possible risk factors that may contribute to complications during metformin treatment. Such risk factors include, for example, several antihypertensive drugs (ACE inhibitors or ARB inhibitors), anti-inflammatory drugs, high risk of fluid deficiency and people with an ongoing infection (febrile condition, stomach sickness, diarrhea). In these conditions, treatment with metformin should be a pause in the elderly.

Elderly people with diabetes usually have more cardiovascular diseases and other conditions that complicate the treatment of high blood sugar. Elderly people eventually develop cognitive impairment that may affect diabetes treatment.

In the case of cognitive impairment, the medication should be reviewed and treatment simplified to reduce the risk of sudden blood sugar falls (hypoglycemia). Severe blood sugar falls cause greater damage than slightly elevated blood sugar levels in elderly individuals.

Doctor’s visit

Elderly people with diabetes should see a doctor 1-3 times a year for long-term blood sugar sampling (HbA1c) and drawing up an individual care plan with a diabetic nurse. For patients in the home care system who cannot visit the health care center, consideration may be given to checking HbA1c 2-5 times/year.

Drug treatment for various pathological conditions in the elderly with diabetes

Treating high blood sugar, blood pressure and cholesterol levels reduce the risk of cardiovascular diseases in people with diabetes. However, the usefulness of intensive pharmacological treatment against various pathological conditions is not as safe in elderly people with diabetes.

The risk relationship for long-term blood sugar (HbA1c) and diabetes-related complications is a little complicated. In addition, the risk relationship differs in different age groups. For older individuals with diabetes, the risk of complications and death increases if long-term blood sugar drops too low, but the risk does not increase as strong if HbA1C levels are slightly elevated. This is because very low blood sugar levels are more dangerous in the short term than slightly elevated blood sugar levels. Severe hypoglycemia can cause rhythm disturbances in the heart (arrhythmias), coma and sudden death.

Control blood sugar in the elderly with diabetes

Increased blood sugar levels can lead to classic diabetes symptoms such as increased thirst, feeling tired and increased urine output. These symptoms cause unnecessary suffering and occur at blood sugar levels 10 — 12 mmol/L, and the kidneys are unable to filter out enough blood sugar, resulting in diabetes symptoms.

Blood glucose values should be 15 mmol/l to avoid symptoms, temporarily high values 25 mmol/l without symptoms do not require urgent action but need to be discussed with doctors if blood sugar levels do not decrease. However, individuals with type 1 diabetes who have blood sugar 15 mmol/l should seek medical advice immediately because of the risk of ketoacidosis.

Blood sugar fall (hypoglycemia)

Blood sugar drops can cause various symptoms, such as trembling, palpitations, irritation, increased aggressiveness and fatigue. Elderly people with diabetes exhibit nonspecific symptoms of blood sugar fall and may, in addition to the above, experience symptoms such as confusion and increased risk of fall.

How to treat hypoglycemia?

A person with a blood sugar drop who is conscious should get 4 glucose tablets, usually something more such as 2 cups milk or 1 cup juice may be needed.

An unconscious person with hypoglycemia needs emergency care and is given 50 ml of 30% glucose (sugar) in the arm (intravenously) or an injection of 1 mg glucagon, which is a hormone that stimulates the liver to produce and release more sugar (glucose).

Blood pressure in the elderly

High blood pressure rarely gives symptoms, unless the person does not have very high levels, blood pressure is an important risk factor, especially for serious complications such as heart attack, stroke, kidney failure, and heart failure. To treat hypertension in people older people with diabetes is usually difficult. Elderly individuals with diabetes usually have rigid blood vessels, which complicates the treatment of high blood pressure. Elderly individuals, most often those with cardiovascular disease, usually have an increased risk of a sudden drop in blood pressure when changing body position, this is called postural hypotension in medical language.

In elderly people with diabetes, cardiovascular diseases of the heart and kidneys are most often manifested, these factors complicate the choice of drug therapy. When treating cardiovascular risk factors, a doctor should take into account the risk of side effects of treatment, the benefit of cardiovascular prevention and the quality of life. Therefore, a holistic approach should prevail when choosing treatment targets in elderly multiple-sick people with diabetes. A reasonable target is blood pressure lower than 140/85 mmHg.

Lipids in blood

People with diabetes and elevated lipids receive treatment with blood-lowering treatment. Older subjects with diabetes, elevated blood lipids and short life expectancy should not be treated with blood-lowering treatment (statins). The risk of complications such as muscle pain and kidney damage increases with statins.

Physical activity in the elderly with diabetes

Older people also need to exercise and stay active. Physical activity improves sensitivity to insulin and can lead to better blood sugar and reduce the need for antidiabetic medicines.

Common complications in the elderly with diabetes

Eye problems

Aging and diabetes can lead to certain eye diseases. These include:

  • Cataract – cloudy areas of the eye lens
  • Glaucoma – increased pressure in your eye
  • Retinopathy – damaged blood vessels in the fundus

Each of these can cause serious vision problems and blindness.

Gingival disease

Elderly people often develop an inflammation of the gums and diabetes even affects the blood vessels in the mouth, which can lead to more problems in the oral cavity. Gingival disease (periodontitis) affects people with diabetes more compared to people without diabetes. Untreated gum disease can lead to periodontal disease.

Increased risk of falling

There are several reasons for the increased risk of falls in people with diabetes. Poor vision, drugs and balance problems can lead to people with diabetes falling and beating.

Sexual function in the elderly

Older people with diabetes usually develop sexual dysfunction either as a result of erectile dysfunction or retrograde ejaculation while women develop discomfort or pain during intercourse, minor sex drive or vaginal dryness.

Contact your doctor if you experience any problems during intercourse. It may be strange to talk about it, but these problems are common and treatable. They range from medicines and lubricants to counseling and exercises that strengthen muscles used during sexual intercourse.

Influenza and pneumonia

Diabetes increases the risk of serious complications such as influenza and pneumonia. This is because both diabetes and rising age weaken your immune system, which allows you not to fight infections. In severe cases, complications can lead to hospitalization and even death.

Influenza may also affect your diabetes disease, usually, your blood sugar levels rise during the flu. The flu can also affect your appetite, and when you do not eat enough, your blood sugar drops. The best way to stay healthy is by vaccination.

Dementia and Alzheimer’s disease

Recent research shows that dementia-related diseases are linked to age and diabetes. High blood sugar can affect many organs, including the brain. Remember that the primary source of energy of the brain is sugar (glucose). Several other risk factors for cardiovascular disease such as high blood pressure and high blood lipids also contribute to an increased risk of dementia.

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