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Diabetes Spectrum
Volume 12 Number 2, 1999, Pages 70 – 77

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Feature/Diabetes Care for Older Adults
Mooradian and Associates

Diabetes Care for Older Adults


Arshag D. Mooradian, MD, Sue McLaughlin, RD, CDE, Cecilia Casey Boyer, RN, MSN, CDE, and Jewel Winter, BSN, GNP


Abstract

Diabetes is a common problem in older adults. Approximately 20% of individuals over 65 years of age have diabetes mellitus, and almost half of these individuals have not been diagnosed. However, there are widespread misconceptions about possible consequences of uncontrolled hyperglycemia, the rate at which diabetic complications develop, and the role of multidisciplinary management.

Overall, management strategies for diabetes in older adults are no different from those of diabetes in younger groups, with some exceptions. Unlike younger people with type 2 diabetes, who are often overweight, obesity is not that common among older diabetes patients. In nursing homes, the problem of being underweight is as common as that of being overweight. Thus, nutritional management should focus on weight gain for underweight elderly patients as much as it is focused on weight loss for obese patients.

In addition to diet and exercise, pharmacological therapy is often required for optimizing blood glucose control. Target blood glucose ranges should be individualized. In frail patients, fasting plasma glucose levels should range from 100 to 140 mg/dl, and postprandial values should be <200 mg/dl. Older subjects may require extra educational support to become proficient in self-monitoring of blood glucose.

The discovery of several classes of oral antidiabetic agents has increased the prospects of achieving better control of hyperglycemia with reduced risk of severe adverse events. Some of these agents, such as acarbose, miglitol, metformin, and troglitazone, do not cause hypoglycemia when used as monotherapy. As such, they are safer agents. On the other hand, the low cost of some sulfonylurea agents and a once- or twice-daily administration schedule make them an attractive option. Metformin appears to be especially useful in obese insulin-resistant patients. The available data on safety and efficacy of troglitazone in the elderly is insufficient. In addition, the cost of this agent is prohibitive for most patients with limited financial resources.

The use of a combination of two or three oral antidiabetic agents to delay the need for insulin therapy is now possible. The long-term effects of this approach are not known, and the cost of polypharmacy is of concern.


The recent data from the U.S. Census Bureau clearly show that older Americans are becoming for 1 last update 30 May 2020 an increasingly larger segment of the population.1 In 1994, one of eight Americans was over the age of 65, and it is estimated that by 2020, one in every six Americans will be over the age of 65.1 The recent data from the U.S. Census Bureau clearly show that older Americans are becoming an increasingly larger segment of the population.1 In 1994, one of eight Americans was over the age of 65, and it is estimated that by 2020, one in every six Americans will be over the age of 65.1

Increasing age is a major risk factor for the development of type 2 diabetes. The Third National Health and Nutrition Examination Survey (NHANES III) indicated that 18.5% of people aged 65Β­74 years have diabetes.2 One-half of this group had not been previously diagnosed as having diabetes by their health care providers.2 When subjects with impaired glucose tolerance (IGT) are also included, approximately 40% of the older population has some degree of carbohydrate intolerance.2

In certain ethnic groups, such as Mexican Americans and to a lesser extent African Americans, the prevalence of diabetes is more than twice as high as for Caucasians. Pima Indians have the highest incidence of diabetes, with the prevalence of the disease in older adults of this population exceeding 50%.

The economic implications of this highly prevalent disease are enormous. It is estimated that the annual cost of diabetes care of older adults exceeds $5 billion.3 Despite the magnitude of the problem and its economic, social, and health implications, diabetes in older adults is often unrecognized and undertreated.

Table 1. Common Misconceptions About Diabetes in Older Adults
   1. The high prevalence of diabetes in older adults is inevitable.
   2. Hyperglycemia in the older adult population is usually a benign condition.
   3. Reduced life expectancy makes the consequences of chronic hyperglycemia
       irrelevant.
    4. The majority of older adults with type 2 diabetes are obese and need to lose weight.

    5. Older patients are less capable of self-monitoring of blood glucose.

Widespread misconceptions among both health care providers and the public are a major barrier to the optimal management of diabetes in older adults.4 Some of these misconceptions are summarized in Table 1. We will attempt here to address these misconceptions. In addition, we will discuss current management strategies involving the interdisciplinary team.

Pathogenesis of Diabetes in Older Adults
The widespread recognition that aging is a major risk factor for the development of diabetes has led some to believe that glucose intolerance is an inevitable outcome of aging. However, there appear to be large differences in the prevalence of this disease among different communities. In some areas of the world, although the prevalence of diabetes increases with age, it does not exceed 3.5%.5

This observation suggests that much of the diabetes in older adults in the United States is essentially preventable. The three most important risk factors in the pathogenesis of this disease in older adults—sedentary lifestyle, poor dietary habits, and changes in body composition—are essentially modifiable risks.

Other pathogenetic factors are more difficult to circumvent. These include coexisting diseases, the use of medications with known adverse effects on carbohydrate (CHO) tolerance, and age-related changes in insulin secretion for 1 last update 30 May 2020 or action reported in various animal models and human subjects.6-9 Other pathogenetic factors are more difficult to circumvent. These include coexisting diseases, the use of medications with known adverse effects on carbohydrate (CHO) tolerance, and age-related changes in insulin secretion or action reported in various animal models and human subjects.6-9

The precise mechanisms of age-related changes in insulin secretory reserve or insulin action at target sites remain unknown. It is noteworthy that, although the majority of older adults with diabetes have type 2 diabetes, some may present with type 1 diabetes or may progress over time from a non-insulin-dependent state to an insulin-requiring state.

This time-dependent deterioration of CHO intolerance, irrespective of the antidiabetic regimen used, was well demonstrated in the recently published data from the United Kingdom Prospective Diabetes Study (UKPDS).10 This change appears to be at least partly related to the gradual depletion of pancreatic insulin secretory capacity. Studies in animal models indicate that aging is associated with altered insulin secretory activity along with alterations in gene expression within the pancreatic islet cells.8,9 In addition, clinical studies confirm the reduced insulin activity in aged subjects.6,7

Overall, it appears that although an age-dependent increase in CHO intolerance is common, much of the diabetes in the elderly is potentially preventable.

Diabetic Complications in Older Adults
Another common misconception about diabetes in the elderly is that mild hyperglycemia is usually innocuous or that reduced life expectancy makes the consequences of chronic hyperglycemia irrelevant. This presumption fails to acknowledge that diabetes continues to be a major cause of morbidity and mortality in the elderly. Several epidemiological studies have indicated that, even when the onset of diabetes is in the sixth or seventh decade of life, survival of the individual is reduced.11 In addition, mortality associated with acute diabetic complications, such as ketoacidosis or hyperosmolar coma, increases with age.12 Furthermore, the outcomes of strokes13 and myocardial infarctions (MIs)14 are worse in patients who are hyperglycemic. Finally, poor glycemic control as evidenced by high HbA1c levels is a predictor of cardiovascular mortality in elderly subjects.15 High HbA1c is also a predictor of strokes,16 retinopathy,17,18 and development of microalbuminuria.19

In addition to the increased mortality risk associated with diabetes, there is significant morbidity associated with this disease. Increased urination can be a cause of urinary incontinence, interferes with sleep, causes dehydration, and increases the risk of falls. Poor vision secondary to hyperglycemia-associated changes in the lens may also increase the risk of falls. The fear of falling will force these patients to reduce their mobility. Hyperglycemia also increases platelet adhesiveness, which may increase the risk of stroke, MI, intermittent claudication, and impotence.20,21 Hyper-glycemia also decreases pain tolerance,22 which may lead to increased use of analgesics. Several studies have shown that hyperglycemia is associated with cognitive changes that would interfere with compliance.23-25 These cognitive changes improve with better glycemic control.24,25 Hyperglycemia can also interfere with immune system function and may increase the potential risk of infections and interfere with wound healing.

Older patients may be more vulnerable to most of the diabetes-related complications since these complications can develop in elderly subjects at an accelerated rate.26 This may be the result of the age-related homeostenosis whereby defense mechanisms against glucotoxicity are reduced. Alternatively, the apparent increase in susceptibility of elderly subjects to the ravages of uncontrolled hyperglycemia may be secondary to having diabetes undiagnosed for years before presentation with a complication.

The prevalence rate of retinopathy in diabetic subjects over 74 years of age ranges between 25 and 70%.27 Age itself is a predictor of retinopathy in older diabetic patients.27 Cataracts and glaucoma are also common complications in elderly diabetic subjects. Older people may be at increased risk of nephropathy as a result of increased use of nephrotoxic agents, such as non-steroidal antiinflammatory drugs (NSAIDs), in addition to the known age-related decline in renal function.

Painful peripheral neuropathy is also common in this age group. In one study over a 1-year period, 76.8% of diabetic subjects aged 60Β­70 years complained of lower extremity pain compared to only 38.7% of control subjects.27 In addition, painful diabetic amyotrophy and diabetic neuropathic cachexia usually occurs in older patients with diabetes.27

MI, cerebrovascular accidents, and the increased incidence of amputations in older patients with diabetes are major causes of morbidity and the 1 last update 30 May 2020 mortality.27-29 The emergence of these complications also appears to be accelerated in the older patients.29 MI, cerebrovascular accidents, and the increased incidence of amputations in older patients with diabetes are major causes of morbidity and mortality.27-29 The emergence of these complications also appears to be accelerated in the older patients.29

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Management of Diabetes
The management of diabetes in the elderly poses a unique challenge. Several factors, including limited financial resources and coexisting diseases, complicate diabetes management.31,32 The first prerequisite of management is a comprehensive assessment.

Assessment of older patients
In general, individuals with known risk factors for diabetes or those with symptoms of possible complications of diabetes are targets for screening programs.33 Since diabetes is very common in elderly subjects and is associated with significant mortality and morbidity if left untreated, we recommend that all individuals over the age of 45 years should be considered as candidates for screening. A fasting plasma glucose >125 mg/dl or random plasma glucose >200 mg/dl would necessitate further evaluation. Otherwise, retesting in 3 years is satisfactory.33

It should be kept in mind that symptoms of diabetes in the elderly can be atypical. Anorexia and weight loss, rather than the typical polyphagia, can be the presenting symptoms.34 Other atypical presentations include incontinence, falls, cognitive or behavioral changes, and pain intolerance. Many patients, however, may have no preceding symptoms and are admitted to the hospital with an acute diabetes emergency, such as hyperosmolar coma.

In addition to history, physical examination, and diagnostic testing, a comprehensive geriatric assessment should include evaluation of nutritional status, review of the individual'' evaluation. A commonly employed tool is evaluation of the activities of daily living (ADL), as well as instrumental activities of daily living (IADL), which include more complex and demanding activities than ADLs, such as answering the telephone, traveling, and managing money.35 The psychosocial evaluation should include at a minimum the Mini Mental Status Examination (MMSE)35 and a depression scale, such as the Geriatric Depression Scale (GDS).35 In addition, patients''s functional capabilities and level of dependency should also be taken into account when management goals are set. Indeed, for patients with high levels of dependency, the risks of hypoglycemia outweigh the benefits of tight glycemic control. Unrealistic expectations for an older individual who has poor vision, poor dexterity, and no social support system are counterproductive.

All of these factors should be kept in mind. However, age per se should not be an excuse for denying optimal glycemic control to older subjects with diabetes.

Medical nutrition therapy
The four-step model of medical nutrition therapy starts with assessment, followed by goal-setting, institution of an intervention and, finally, evaluation and problem-solving.37

reverses diabetes type 2 cramping (πŸ”΄ jardiance) | reverses diabetes type 2 oliveshow to reverses diabetes type 2 for A nutrition assessment includes evaluation of medical diagnosis, measurements of anthropometric parameters and biochemical indices, and review of medications.38 A thorough nutrition history would include evaluation of the patient''s knowledge base pertaining to diabetes and nutrition, as well as the patient''s age. Diabetes education should be recognized as a lifelong commitment, for both patients/families and the interdisciplinary diabetes team.

Effective education starts with an assessment of educational needs and readiness to learn. Just as diabetes treatment needs to be individualized, so do educational needs. Many people with diabetes have had no for 1 last update 30 May 2020 formal diabetes education, often despite years of living with diabetes. There may be many misconceptions, fears, and/or myths that need to be explored or acknowledged. Health beliefs, culture, and religious beliefs may also influence adherence to diabetes treatment and management plans. Effective education starts with an assessment of educational needs and readiness to learn. Just as diabetes treatment needs to be individualized, so do educational needs. Many people with diabetes have had no formal diabetes education, often despite years of living with diabetes. There may be many misconceptions, fears, and/or myths that need to be explored or acknowledged. Health beliefs, culture, and religious beliefs may also influence adherence to diabetes treatment and management plans.

It is important to utilize principles of adult learning when providing education to older adults with diabetes. These principles include recognizing previous experiences, using a variety of teaching methods, adapting teaching materials to accommodate learning (i.e., large print, additional time for practicing skills), using a variety of teaching materials, making the education relevant, and actively including the person in the learning process.

Breaking more complicated skills/information into smaller, simpler steps may assist with retention and mastery. Providing opportunities to practice skills and ask questions, as well as providing positive feedback, are all important.

One-on-one and group classes can provide needed socialization and support for older adults. Other factors that may influence learning include the aging process, other medical conditions/medications, and emotions. Including the family/caregivers in the assessment and education process is essential since they may be providing the care as well as reinforcing education/monitoring practices. Utilization of community resources (i.e., Meals on Wheels, Red Cross for transportation, local diabetes organizations for education and support groups, home care nurses/aides) is also important.

Follow-up is important to clarify questions and concerns, as well as to encourage and motivate patients. Phone follow-up may be more realistic due to transportation problems and can be helpful in providing education in conjunction with regular follow-up appointments or in using community resources.

Appropriate tools or aids should be provided to circumvent some of the limitations associated with poor vision and poor dexterity. The glucose meters provided should be easy to use, have large display screens, require no cleaning, and have memory capabilities.

Older adults with diabetes are often incorrectly stereotyped as being slow and unmotivated in managing their diabetes. In fact, many older adults with diabetes are enthusiastic, motivated learners actively involved in all aspects of their diabetes treatment plan. When older patients are appropriately educated, they are capable of carrying out self-monitoring of blood glucose as accurately as do younger people.53 The frequency of monitoring should be individualized based on the type of diabetes treatment and frequency of dose adjustment and financial resources of the individual.

Conclusions
Diabetes in older adults is often undiagnosed and undertreated. Prevalent myths and misconceptions have interfered with optimal management. Achieving individualized glycemic goals is an important quality-of-life issue.

The older diabetes population is a highly heterogeneous group. Nutritional, psychosocial issues, and coexisting medical problems further complicate diabetes management. Therefore, management should begin with a comprehensive assessment and should be individualized.

reverses diabetes type 2 is caused by (πŸ‘ olives) | reverses diabetes type 2 in young childrenhow to reverses diabetes type 2 for With the availability of new antihyperglycemic agents, it is now possible to control blood glucose levels without the risk of hypoglycemia. More studies as to the cost-benefit ratio of each pharmacological agent would be helpful.

Given the complexity of the disease itself and the multiple complicating factors, an interdisciplinary team working in conjunction with community resources is needed for optimal management of diabetes in older patients.


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reverses diabetes type 2 term (πŸ”΄ with diet) | reverses diabetes type 2 treatshow to reverses diabetes type 2 for 29Connell FA, Shaw C, Will J: Lower extremity amputations among people with the 1 last update 30 May 2020 diabetes: Washington state. Olympia, Wash., State Department of Health Diabetes Control Program MMWR 40:737-39, 1991. 29Connell FA, Shaw C, Will J: Lower extremity amputations among people with diabetes: Washington state. Olympia, Wash., State Department of Health Diabetes Control Program MMWR 40:737-39, 1991.

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reverses diabetes type 2 hacks (⭐️ meds) | reverses diabetes type 2 life expectancyhow to reverses diabetes type 2 for 42Skipper A (ed.): Dietician's Handbook of Enteral and Parenteral Nutrition. Rockville, Md, Aspen Publications, Inc., 1988, p. 107-17.

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reverses diabetes type 2 genetics nature (πŸ”΄ urine) | reverses diabetes type 2 drugshow to reverses diabetes type 2 for 50Mooradian AD: Drug therapy of non-insulin dependent diabetes mellitus in the elderly. Drugs 51:931-41, 1996.

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52Coscelli C, Bistoni S, Calabrese G, Lapolla A, Fedele D, Maurl MG, Pisu E, Rossi A, Calderini C, Zapella A: Use of premixed insulin for 1 last update 30 May 2020 among the elderly: reduction of errors in patient preparation of mixtures. Diabetes Care 15:1628-30, 1992. 52Coscelli C, Bistoni S, Calabrese G, Lapolla A, Fedele D, Maurl MG, Pisu E, Rossi A, Calderini C, Zapella A: Use of premixed insulin among the elderly: reduction of errors in patient preparation of mixtures. Diabetes Care 15:1628-30, 1992.

53Bernbaum M, Albert SG, McGinnis J, Brusca for 1 last update 30 May 2020 S, Mooradian AD: The reliability of self blood glucose monitoring in elderly diabetic patients. J Am Geriatr Soc 42:779-81, 1994. 53Bernbaum M, Albert SG, McGinnis J, Brusca S, Mooradian AD: The reliability of self blood glucose monitoring in elderly diabetic patients. J Am Geriatr Soc 42:779-81, 1994.


Acknowledgments

The authors would like to thank Linda Cann and Phyllis Barrier of the American Diabetes Association for their helpful suggestions. The authors also thank Abbott Laboratories, Ross Products Division, for their financial support.


Arshag D. Mooradian, MD, is a professor of internal medicine and director of the Division of Endocrinology, Diabetes, and Metabolism at St. Louis University in St. Louis, MO. Sue McLaughlin, RD, CDE, is a consultant nutritionist in Omaha, Neb. Cecilia Casey Boyer, RN, MSN, CDE, is a diabetes clinical nurse specialist at Ohio State University in Columbus. Jewel Winter, BSN, GNP, was the 1994-95 president of the National Conference of Gerontological Nurse Practitioners in Denver, Colo. All of the authors are members of the American Diabetes Association Task Force for Developing a Continuing Education Program on Diabetes in Older Adults.

reverses diabetes type 2 journal pdf (πŸ‘ high blood sugar symptoms) | reverses diabetes type 2 rashhow to reverses diabetes type 2 for Note of disclosure. Dr. Mooradian has received honoraria and grant research support from Bristol-Myers Squibb, Bayer Corp., Eli Lilly, and Pfizer; Ms. McLaughlin has received consulting fees from Lifescan Corp; and Ms. Boyer has received honoraria from Eli Lilly and Parke-Davis. All of these companies manufacture or market products for the treatment or management of diabetes in the elderly.


Address correspondence and reprint requests to: Arshag D. Mooradian, MD, Division of Endocrinology, St. Louis University, 1402 S. Grand Blvd., St. Louis, MO 63104.


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