Diabetes Mellitus in the Elderly: Managing the Complexities

Diabetes mellitus diagnoses are soaring in numbers, with the elderly population disproportionately affected. The American Diabetes Association indicates that up to half of affected individuals have poor disease control despite the growing assortment of drugs and biologics approved for diabetes. The APhA featured a case-based presentation at its 2015 annual meeting in San Diego, CA, that discussed diabetes management’s complexities in older adults.

A primary concern in older diabetics is altered symptomatic presentation. Up to half of patients with elevated blood sugars can be asymptomatic. Patients may interpret diabetes’ hallmark symptoms—general malaise, fatigue, or lethargy—as normal signs of aging. With age, patients’ renal threshold for glucose also increases. Subsequently, osmotic symptoms become less prominent, reducing the intensity of polyuria and impairing thirst sensation (making polydipsia much less noticeable). Thus, their first symptom may be an elevated glycated hemoglobin (A1C) found in routine blood work.

Comorbidities are common with age, creating challenges after diagnosis. Specific concerns are depression, urinary incontinence or infection, cardiovascular disease, renal impairment, weight gain/loss, and pain (especially when it restricts activity). Mental conditions—altered cognition, depression, and geriatric syndromes that marry cognitive and physical dysfunction to create frailty, increased risk of falls, and poor muscle tone—are also considerations, especially if self-care is expected or needed.

“We want to think about the common things you find in the elderly, and this includes cognitive function,” said Jennifer Trujillo, PharmD, BCPS, CDE, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, who presented at the session. She noted several factors for pharmacists to consider, including: “Are they taking their medications themselves? Can they see their syringe [when measuring medication]?”

It is important to ask these questions even if you have asked them recently, according to Dr. Trujillo. “Where they were 4 or 5 years ago may not be where they are today.”

Altered pharmacodynamic and pharmacokinetic parameters that accompany age means that therapy selection is more complex. Metformin, a cornerstone of therapy in younger adults, should be avoided in renally impaired or frail (low weight) patients. Similarly, those who suffer from dehydration, heart failure, or acute illnesses are at elevated risk of lactic acidosis. Long-acting sulphonylureas, another popular intervention in younger adults, should be avoided in this population.

Dr. Trujillo noted that the guidelines are not specific enough to know how low their goal should be, and research is lacking in this population. A1C targets should be slightly more permissive—around 7% as opposed to the 6.5% preferred in younger adults—to avoid hypoglycemic episodes. “The older population is a very, very heterogeneous group,” she said.

Elders who experience repeat bouts of hypoglycemia need medication adjustments. Those who suffer from recurrent hypoglycemia often do better on the α-glucosidase inhibitors (acarbose or miglitol).

The SGLT-2 inhibitors (canagliflozin, dapagliflozin, empagliflozin) create heavy glucosuria, decreasing blood sugar. Individuals who should avoid these drugs include frail elderly with weight loss, those who are at risk for or likely to be incapacitated by urinary tract infections or candidiasis, patients who cannot hydrate adequately, and those with hypotension.

Finally, insulin is an option when oral and subcutaneous agents do not work. Patients, often reluctant to move from oral drugs to insulin, often need coaching and encouragement. Discussing the newer formulations (insulin glargine or detemir), the possibility of once-daily dosing, and their long-term benefits can help persuade older individuals to try insulin products. With insulin (or any injectable), patients may need a family member or caregiver to help with injection.