Stut RW Management
l Diabetes
THE MANAGEMENT OF DIABETES
Professor Robert W. Stout, MD FRCP
Department of Geriatric Medicine
The Queen' S University of Belfast
Whitla Medical Building
97 Lisburn Rood, Beflast BT9 7BL
Northern Irland
Summary
Diabetes becomesincreasingly common with advanc-
ing age and this particularly applies to non insulin de-
pendent disabetes. The mechanism for this appears to he
insulin resistance ata postreceptor level but there are also
deficits in insulin secretion and the sensitivity of the liver
to insulin. Elderly patients with diabetes often present with
non specific symptoms and may only present when they
develop complications. It is important that a correct diag-
nosis is made as both false positivefalse
and negative diag-
nosesmay have adverseeffects. Diabetes is diagnosed
when when
thefasting venous plasma glucose is more than 7.8 mmol/l
on two or more occasions. Treatment should aim to keep
the patient symptom free and avoid the complications of
diabetes. General health advice. modification of cardio-
vascular riskfactors and dietary treatment are primary
methods. If drugs have to he used, short-acting
sulphonylureas are preferable and insulin is not often
needed. Elderly din diabeticpatients, like
other elderly patients,
may have problems with the use of drugs in old age. Treat-
ment should be monitored but attention paid to the whole
of the patient's lifestyle.
Diabetes, particularly non insulin dependent diabetes.
becomes increasingly common with advancing age and im-
paired glucose tolerance is also common in older people1.
Diabetes is a serious condition in older people and the mor-
tality and morbidity from conditions such as neurological
and visual disease and cardiovascular disease is higher in
elderly diabetic subjects than in non diabetic people of the
same age2.. This may be related to a high frequency of un-
diagnosed diabetes in older people3. Severe uncontrolled
diabetes in older people also has a high mortality, often
because it tends to present for medical attention rather late4.
Possible mechanisms for glucose intolerance in eld-
erly people include decreased insulin secretion, peripheral
insulin insensitivity, either at the cell membrane insulin
receptor or at a postreceptor level, and changes in other
hormones. Insulin resistance at the postreceptor level is
the major mechanism of glucose intolerance in older peo-
pl5’. There is also inappropriate insulin secretion and de-
creased hepatic sensitivity to insulin6. Other factors which
may adversely influence glucose tolerance in older people
of in oldAge
IN OLD AGE
are increasing body weight, decreased physical activity, im-
paired renal function and the ingestion of drugs which cause
hyperglycaemia. most commonly diuretic drugs7. In the
management of diabetes in older people. avoidance of these
factors is the first approach.
Characteristics of Elderly Diabetic Patients
Old age and diabetes interact to produce some char-
acteristic features. Diabetes is a disease with complications
in many organ systems so multiple pathology is common
in the diabetic subject. Elderly patients tend to have a de-
crease in their ability to maintain homeostasis and as a re-
sult hypoglycaemia. dehydration and confusion are more
common in elderly diabetic pstients. Drug treatment may
cause problems - the body’s handling of drugs may be im-
paired. particularly renal excretion; multiple prescribing may
result in drug interactions and side effects. while poor com-
pliance may make the management of drug treatment diffi-
cult. Self management is more difficult as the patient, be-
cause of impaired dexterity, eyesight or memory, may have
difficulty in managing treatment regimes or diet.
Symptoms and Signs Suggestive of Diabetes in
Older People
Diabetes may present in a number of ways. General
symptoms, including polydypsia, polyphagia, polyuria and
weight loss, may occur in older people although they are
more commonly absent. Elderly diabetic patients may have
recurrent infections, of which urinary tract infections are
the most common. They may also present with some of
the complications of diabetes, including neurological prob-
lems. such as parathesiae, muscle weakness and pain, iso-
lated nerve palsies or autonomic dysfunction which may
present as postural hypotension, diarrhoea or incontinence.
A common presentation of diabetes in older people is car-
diovascular disease. Microangiopathy causing either retinal
disease and visual impairment or renal disease is a less com-
mon presentation in older people and skin lesions specific
to diabetes are not often present. Many elderly diabetic
subjects are obese and they may also have abnormalities in
their circulating lipids. There may be a family history of
diabetes. Frequently, however, there may be no specific
presenting features of diabetes in older people and the dis-
ease is diagnosed as a result of routine testing.
I 9 I
Risks in Misdiagnosing Diabetes in Older People
It is important that the diagnosis of diabetes in old age
is made correctly as there are problems if the wrong diag-
nosis is made.
IF a diagnosis of diabetes is made when it is not present,
there may be inappropriate treatment with hypoplycaemic
agents with a potential for side effects. Unnecessary re-
strictions on behaviour. affecting, for example, alcohol in-
take, food choices, stressful situations, fasting and prolonged
exercise may occur. There will be an increased cost of un-
necessary medical treatment and insurance may be diffi-
cult to obtain or expensive. There may be a false assump-
tion of a family history of diabetes.
Not diagnosing diabetes n-hen it is present may result in
inadequate preparation or alteration of therapy at the time
of stressful events. such as surgery. infections, trauma or
serious illness. There n-ill be a lack of awareness of the
importance of reducing body weight if obesity is present
and there will be a lack of knowledge among family mem-
bers of the fact that they may he at increased risk.
Diagnosis of Diabetes in Old Age
The diagnostic classification of diabetes adopted by
the World Health Organisation in recent years is not age
specific but is conservative enough to accommodate dia-
betes in older people’. The glucose tolerance test is un-
necessary and the diagnosis is made if the fasting venous
plasma glucose is more than 7.8 mmol/1 on two or more
occasions.
Treatment of Diabetes in Old Age
The aims of treatment of diabetes in older people are :
1To keep the patient symptom-free
2. To avoid the sequelae of diabetes
Management starts with general care. The patient
should be advised about the risks of diabetes and in par-
ticular the problems associated with oveweight and with
inadequate foot care. The importance ofadherence to treat-
ment regimes and attending for review as arranged is also
important.
Attention to cardiovascular risk factors is assuming in-
creasing importance in the management of diabetes. There
is little evidence that reduction of blood glucose will re-
duce cardiovascular disease. However, many cardiovascu-
lar risk factors are common among diabetic patients. Of
particular importance is hypertension and the treatment of
hypertension by the use of drugs, which do not themselves
increase blood glucose levels, is very important even in very
elderly diabetic subjects; suitable drugs would be calcium
antagonists and angiotensin converting enzyme inhibitors.
Avoidance of smoking are also of great importance. Treat-
ment of lipid disorders in older diabetic patients is more
problematic as none of the trials of lipid lowering to pre-
vent cardiovascular disease have studied people over the
age of 65 years (or indeed people with diabetes). Never-
theless. it is reasonable to assume that the beneficial effects
of treating hypercholesterolaemia, which have been found
in younger non diabetic people. will also occur in older
people with diabetes whose hyperlipidaemia is not con-
trolled by treatment of diabetes.
Diet is the first method of treating non insulin depend-
ent diabetes and as most of these subjects are overweight,
the aim is weight reduction. The calorie content of the diet
is. therefore. critical and the exact composition of the diet
being much less important. Weight loss will produce a rapid
decrease in blood glucose levels.
If diet is not sufficient, drugs may have to be used. Of
the drugs available. the sulphonylureas are preferable to
the biguanides as the latter may cause lactic acidosis, par-
ticular&~ in stressful situations such as might occur in eld-
erly diabetic patients. The short-acting sulphonylureas. such
as glipazide. are most useful as prolonged hypoglycaemia
is less of a problem. However. if the patient is well main-
tained on another drug regime which had been instituted
in the past. there is not necessarily any need to change. It
is only rarely that insulin is needed in an elderly diabetic
patient and in those circumstances a search should be un-
dertaken for pancreatic causes of the diabetes. As a gen-
eral rule. if the fasting blood glucose is more than 11 mmol/
l, the patient will require treatment with anti-diabetic drugs
at an early stage. If the fasting blood glucose is between 8
and 11 mmol/l, dietary treatment should be instituted with
the aim of weight reduction, If this is not effective, then
oral agents may be added.
Problems with Drug Treatment of Diabetes in Old Age
Drug treatment of diabetes in elderly patients may be
associated with a number of problems. These included in-
appropriate ingestion of drugs, multiple prescribing, poor
compliance. drug interactions and unwanted effects. The
side effects tend to be more common and of more serious
significance in older diabetic subjects and impaired renal
excretion is a particular problem for those drugs that are
excreted by the kidney. Certain drugs are liable to potentiate
hyperglycaemia, including steroids, oestrogens, thiazide
diuretics, sympathomimetic agents and nicotinic acid.
Other drugs can potentiate hypoglycaemia in patients tak-
ing insulin or oral anti-diabetic agents, and these include
alcohol. beta blockers, warfarin, salicylates and monoamine
oxidase inhibitors.
It is important that treatment is monitored but the pa-
tient should not have to make unduly frequent or long jour-
neys to a hospital diabetic clinic. Monitoring can take place
in the community or at a clinic which serves other purposes
as well, e.g. a geriatric clay hospital. The patient’s blood
glucose should be monitored. as should weight and car-
diovascular risk factors and there should be an annual in-
spection of the optic fundi. It is important that treatment is
aimed at controlling blood glucose levels but avoiding com-
plications. particularly hypoglycaemia as in the elderly dia-
betic patient hypoglycaemia is a particularly serious prob-
lem, often causing permanent brain damage as well as falls
and faints.

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n