Diabetes Treatment Considerations for Older Adults

About 30.3 million people in the United States, 9.4 percent of the population, have type 2 diabetes (hereafter diabetes). The disease affects seniors more than any other age group. “About 38 percent of people over the age of 65 are living with diabetes, almost double the amount compared to just 15 years ago,” says endocrinologist Deepashree Gupta, MD, UCLA Medical Center.

Age-related changes, as well as other existing conditions, should be incorporated into diabetes management. An older person with several chronic conditions requires different care than someone who has only one or two. Whether that older adult is you or someone you love, Dr. Gupta says it’s important to consider cognitive health, individualized blood sugar goals, and the potential need for medication simplification.

Depression, Diabetes and Cognition

Studies have shown that people with diabetes are twice as likely to be depressed as those without the disease. However, that relationship also is “bidirectional,” meaning that having diabetes can lead to depression, and conversely, depression can lead to diabetes. For example, a person who is depressed may not eat well or exercise, thus gaining weight and triggering diabetes. A person with diabetes may become depressed about having the condition. A substantial body of literature also suggests that clinical depression is associated with diminished cognitive ability, dementia, and Alzheimer’s disease. For anyone over age 65, memory problems and depression become relevant in diabetes management. Thus, experts recommend yearly screening for early detection of mild memory loss and depression for older adults with diabetes.

“Poor glucose control for a long time is associated with worsening memory function,” says Dr. Gupta. “For those who screen positive for memory impairment, our goal is to simplify medication regimens and involve caregivers in all aspects of care.”

For example, she recommends that caregivers keep well-organized lists of diabetes medications, accompany the patient to doctor’s visits so that everyone is aware of any medication changes, and if a person is taking non-insulin medications, check blood sugars once or twice per day and notify the physician when blood glucose levels are that less than 70 milligrams per deciliter (mg/dl).

Beware of Low Blood Sugar

Diabetes medications help lower blood sugar levels. But there is such a thing as too low. Hypoglycemia, also known as low blood sugar, can cause confusion, dizziness, fatigue, and irregular heartbeat. It can also lead to personality changes, such as irritability, nervousness, and becoming argumentative or combative. Severe hypoglycemia has been linked to increased dementia risk.

“In our practice, if we see consistent blood sugars less than 100 mg/dl, we start backing off medications,” says Dr. Gupta. “Repeated low blood sugar episodes (below 70 mg/dl) can make it difficult for people to detect further low blood sugars. Usually they get sweaty, dizzy, or lightheaded, and people can feel that. But repeated low blood sugar episodes can make it difficult to feel symptoms. It also makes it difficult to sense abnormal cardiac rhythms, which can lead to sudden cardiac arrest.”

Metformin is typically recommended as a first-line treatment and rarely causes low glucose levels. On the other hand, sulfonylureas are associated with hypoglycemia and should be used with caution. In June of this year, the FDA issued an alert about excessive levels of N-Nitrosodimethylamine (NDMA) in several batches of extended-release metformin formulations. If you or a loved is taking this medication, consult with your pharmacist to see if the manufacturer of your metformin has been affected by the recall. Excessive exposure to NDMA has been linked to jaundice, nausea, fever, dizziness, and several types of cancer.

Broadly by the Numbers

In general, Dr. Gupta recommends that if an older person is relatively healthy and active, with intact cognition and three or fewer chronic illnesses, A1C less than 7.5 is the goal. Those with three or more serious conditions that require medications, have mild cognitive issues, are weak/frail, and have difficulty managing treatment, 8 to 8.5% A1C may be acceptable. As A1C is an average over three months, keeping an eye on daily blood sugars is best. Before a meal the reading should be in the 80-130 mg/dl range. Two hours after a meal, blood sugar should be lower than 80. However, don’t check too soon, as the numbers will be too high. For more information on diabetes and older adults, see Dr. Gupta’s excellent UCLA MD Chat video online at http://tiny.cc/ogg1rz.

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