Growing Older and Staying Healthy with Diabetes
Medha Munshi, M.D.
Director, Geriatrics Clinic, Joslin Diabetes Center; Director, Outpatient Geriatric Program at Beth Israel Deaconess Medical Center; Instructor in Medicine, Harvard Medical School
Chances are that you or someone you know has diabetes. One out of every five people over age 60 has diabetes. It is a complicated disease to manage, but for older adults with many other health issues, it can be overwhelming.
Diabetes care is necessarily left in the hands of the person with diabetes, who “self-manages” by monitoring blood glucose, taking medications and/or insulin, following diet plans and getting more physical activity. Goals for diabetes care for older adults and the plan for how to achieve them should take into account their unique challenges. We don’t treat a 10-year-old child with diabetes as we would a 40 year-old adult and we should not treat an 80-year-old the same way either.
Our overall goal is for older adults with diabetes to have the best quality of life possible. And that can’t happen if they are having trouble following through with care instructions due to undiagnosed depression, memory problems or other medical conditions.
Who Is Old?
There is something to be said for the saying “You are as young as you feel.” Medicare sets 65 as the age for eligibility, but that by no means answers the question: “Who is old?” Many people with diabetes over age 65 are managing quite well—they eat in moderation, are physically active and have a positive outlook on life.
But then there are some older adults who may have just been diagnosed and are having trouble coping with the required changes in routine. Or, they may have had diabetes for years, but they’ve had a stroke or heart attack or lost significant vision, and their blood glucose control has suddenly deteriorated. With major changes such as these, their diabetes management goals need to be reassessed.
Unique Challenges
Several conditions occur more commonly in older adults with diabetes. A major reason why some older adults have a difficult time is that they are experiencing “cognitive dysfunction,” abnormalities in brain function that make it hard to problem-solve, plan and organize and be attentive. Depression is also highly prevalent in older patients, as are vision and hearing impairments, leading to difficulty coping with daily activities. Diabetes should be seen in the context of these and other medical conditions.
We are good at identifying vision and hearing impairments, and screening for cardiovascular problems. But cognitive dysfunction and depression often go undiagnosed. Our recently published research shows that one-third of our patients in the Joslin Geriatrics Clinic have cognitive problems, associated with poor diabetes control.
People with diabetes are about twice as likely to be depressed than those without diabetes. In our study of patients older than 70, we also found that more than one-third have symptoms of depression. Once identified, we can treat cognitive dysfunction or depression, which can improve quality of life and probably diabetes control as well.
Family members are most likely to see subtle changes of cognitive dysfunction or depression in their loved ones. Signs that an older adult with diabetes should be screened for these conditions include:
• blood glucose control that is suddenly worse
• subtle changes in mental status, i.e., more forgetful about monitoring or taking medications; making more mistakes
• sudden difficulty coping, or acting more stressed
• less socially active or showing other signs of depression, such as sadness or hopelessness or isolation from friends and family
Many Meds
Another important aspect to caring for older adults with diabetes is to re-evaluate their medications. For example, for those on insulin, there are now once-a-day insulins. Insulin pens with pre-measured amounts can help those who face difficulties because of arthritis, impaired vision or cognitive problems. Oral medications may need to be changed or monitored more closely for side effects (such as risk of hypoglycemia) that particularly affect older adults.
Drug interactions are a big problem for anyone on multiple medicines. It is important to bring a list of all one’s medications to every medical visit. It is common to find that one medicine causes a side effect, which is being treated by another medication. It becomes a chain effect. But it might be possible to find an alternative to the medication that started the chain, making other medications unnecessary.
Simplify, Simplify, Simplify
Goals for diabetes care aim to keep blood glucose levels as near normal as possible to avoid diabetes complications that can develop over time—eye, kidney and nerve disease, heart attacks and stroke. Blood glucose control is important no matter what one’s age. But for older adults, quality of life and safety become most important.
One side effect that occurs in the quest to maintain tight control of blood glucose is hypoglycemia—glucose levels falling too low. This is much more dangerous in the elderly. They may be more severely affected and become confused, delirious, dizzy or weak. A frail person using a cane or a walker who is even mildly hypoglycemic may get dizzy and fall, ending up in a nursing home.
We try to simplify the care plan so that an elderly person with diabetes can follow the plan without feeling stressed. Our goal is to achieve the best diabetes control possible without any episodes of hypoglycemia. Keeping quality of life in mind, the short-term goal of avoiding these episodes becomes more important than a long-term goal of reducing the risk of complications, for which an occasional episode of hypoglycemia is expected.
The Best Possible Life
An overall objective in the care of older adults is to maintain good quality of life and functional independence. We’ve seen people with diabetes who had to go to a nursing home because they couldn’t manage injections of insulin four times a day or were having too many low blood glucose reactions that could not be managed at home. It was not the disease that put them there—it was the treatment. We can avoid this from happening. By keeping their unique needs in mind and treating them differently, we can keep older adults healthier and happier longer.
This article appeared in the Special Diabetes Insert of the November 13, 2006 issue of TIME Magazine.
