More than 25% of US population aged 65 and older have diabetes. Management of diabetes in elderly can become challenging, especially if they have uncontrolled diabetes. Older adults with diabetes are at an increased risk for developing complications. People over 65 are often excluded from clinical trials and therefore we do not have enough evidence based trials to come up with a standards or guidelines for managing diabetes in elderly population. This is further complicated by the physiological changes associated with aging as well as the comorbidities and functional impairment that is often present in older people. Older adults have a high risk of having heart attacks, visual impairments, kidney disease, and lower extremity amputations. Clinical characteristics of diabetes in those diagnosed before age 65 and those after 65 differs in number of ways period. While those diagnosed under age 65 are at high risk of complications as they age, elderly patients diagnosed with diabetes after age 65 have relatively milder diabetes, less complications, lower Hba1c and lower likelihood of requiring insulin.
Risk of hypoglycemia,
Risk of hypoglycemia is much elderly population compared to younger population. There are several reasons for it.
1-The counter regulatory mechanisms which helps to prevent hypoglycemia and produces symptoms are diminished in elderly population.
2-Elderly often have other comorbidities such as heart disease or impaired kidney function, which results in decreased clearance of medication from the body.
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3-Appetite in elderly can vary from day to day. Most elderly patients don't have regular meals which can lead to hypoglycemia.
4-Sometimes access to food is an issue. If elderly does not have easy access to food, they may not eat.
5-Older people can also get forgetful and end up having double dosing of the medication.
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6-Presence of conditions like Alzheimer's and dementia makes it worse, 7-Elderly also have visual problems and may not be able to see or read the dosing correctly.
Tips to prevent hypoglycemia in Elderly
Simplify their medication regime. talk to your doctor to see how this can be done.
Medications like glyburide or other sulfonylureas can linger on in the body for a longer time period. Use of sulfonylureas is discouraged elderly patients, specially in those with complications.
There are many alternate medications like DPP four inhibitors or GLP-1 agents that can be safely used in elderly with relatively lower risk of hypoglycemia.
Elderly should be encouraged to have regular meals as skipping meals is often a common problem that leads to hypoglycemia.
Elderly with vision problems should consider using a talking glucose monitor.Talking monitors a specifically designed for patients with visual impairment when they can, where they can hear the glucose reading as well as in addition to seeing it on the screen.
Use pillboxes helps to keep track of medications.
Medication dispensing systems can also be used which not only dispense a controlled amounts of medication at a given time but also can send messages to the loved ones if the patient has taken medication or not. -Elderly also encouraged to take other precautions of hypoglycemia, like avoiding delaying meal and keeping a glucose tablet or hard candy with them all the time for emergency treatment of hypoglycemia,
Setting up a medical alert system is also highly recommended for specially for those who live alone to get immediate help.
Glucose Targets in Elderly
Based on American diabetes association guidelines. Older adults who do not have cognitive issues and have normally functional status can use the same guidelines for glucose targets as normal population, which is hemoglobin A1c less than 7. For patients with cognitive problems and other comorbidities, like heart disease, kidney disease, decreased functional status, less stringent diabetes goal is advised You can discuss with your doctor what Hba1c goal is appropriate for you. Hba1c by itself is sometimes not reliable in elderly individuals, especially if they have chronic kidney disease, which causes anemia. This can make the hemoglobin A1C falsely low. Other means of monitoring such as fasting glucose levels and Accucheck readings have to be used and these patients for monitoring and medication dose adjustments. . Monitoring and glucose targets are set on individual basis for patients with advanced complications and life expectancy less than five years, For these patients it is suggested to have more relaxed Hba1c goal preferably between 8-9.
How often should you test
How frequently one should check blood glucose levels varies from person to person depending on how well controlled your diabetes is and what medications you are taking. People who have uncontrolled diabetes and those who are on multiple doses insulin regime may have to test much more frequently than those on oral medications and other injectable medications compared to those who are relatively well controlled. Typically for uncontrolled diabetics it is recommended to check before meals and two hours after meals. And most other cases it is recommended to check before each meal and bedtime. If you are on oral medications and have well controlled diabetes checking twice a day might be enough.
One should also be checking glucose if there is a change in routine, like sudden plans to walk or exercise a delayed meal if you are having signs and symptoms of hypoglycemia, if you are sick or recovering from illness. If you are on antibiotics or steroid medications as these medications may increase or decrease blood glucose levels. Target glucose goals for blood glucose also vary from person to person depending on the extent or the control of diabetes and presence and absence of complications and comorbidities.Based on ADA guidelines, it is recommended that premeal glucose should be between 80 to one 130 and two hours’ post-meal local should be less than 180. Glucose goals can be tighter or less stringent in some cases. For example, in a younger person without any complications or co-morbidities. Glucose goal is stricter for tighter control of diabetes and preventing complications. On the other hand, an elderly person with co-morbidities like heart disease and renal failure and hypoglycemia may need a much less stringent goal. Exactly what is an appropriate target glucose for you is a discussion you must have with your healthcare team.
GLUCOSE MONITORING: Choosing a glucose monitor
There are several different glucose monitors available. Each monitor uses specific kind of strips and has an expiration date. Some monitors may require charging while others are operated on battery. You must do some research before you buy a glucose monitor. Sometimes your doctor’s office might be able to give you glucose monitor free of cost however you will still need to buy the test stripes. Before you invest in a meter, you must find out the cost of the strips and insurance coverage if applicable, to make sure it is affordable for you for long term use. There are special meters available with bigger screen and display for people with poor vision. There are also special glucose monitors available called the talking meters for those who are legally blind. Also meters have settings for pre meal and post meal glucose. Try to learn your meter and adjust those settings based on your meal times. Some meters have the capability of downloading the information which you can print and take it to your doctor’s office.
Most meters will only take one to two minutes to check the glucose, others will give you the results within few seconds.
How do you use the glucose meter
Before using a glucose meter, one must wash their hands with soap and water. An alcohol swab may be used however; the hands must be dried completely after using alcohol swab as the alcohol might interfere with blood glucose reading. Using a glucose meter is very easy process and takes only a couple of minutes.
First you use a Lancet to pick your finger.
Gently Squeeze your finger to bring a small drop of blood. It is advisable to discard the first drop of blood and use the second drop of blood for testing.
Take the test strip close to the drop of blood. Most test stripes have the capability to suck the blood in. some may require putting the drop of blood on the test stripes.
Insert the test strips into the meter. The meter then displays your blood glucose reading. Some meters may require inserting the test strip first before you put the drop of blood on it.
Read the instructions carefully before you start testing.
Your reading usually is stored in the meter.
If you see an unexpectedly high or low readings, repeat testing. wash your hands and test again.
Make sure the test strips are not expired.
Alternate site testing.
Some glucose meters are FDA approved to be tested on sites other than your fingertips like thigh calf upper arm and forearm. Sites other than your fingers can only be used if your glucose is stable as this may not be very accurate. You must check your glucose using fingertips if your glucose is low or higher than expected.
Continuous glucose monitors ( CGM )
A continuous glucose monitor is a device that attaches to your body to check glucose continuously throughout the day and night. Several different types of continuous glucose monitors are available and each has a specific sensor, a transmitter and receiver that displays and stores the readings. Most continuous glucose monitors can be downloaded and printed for review. Continuous glucose monitors help you see how glucose levels are affected by certain types of foods and activities. It will also keep track of your glucose while you are sleeping. It helps to keep a check of hyperglycemia or hypoglycemia. Most continuous glucose monitors have programmable alerts. If your glucose is going too low or too high. Most people find CGM very helpful as it prevents from picking yourself multiple times. Some of the commonly used continuous glucose monitors are Freestyle libre, Dexcom, and Metronics sensors. Continuous glucose monitors are becoming more and more popular and more insurance companies are providing coverage for them.
What to do with the high and low values.
Hyperglycemia, high blood glucose is one of the signs of uncontrolled diabetes.
Persistently elevated blood glucose can lead to complications. If you check your glucose and it is unusually higher than normal, then you may need to take some action. Firstly, you want to think why your glucose reading is high. Perhaps you've had something to in your meal which spiked up your glucose, or you may have had a snack after a meal. Did you forget to take your medications or you may be sick or stressed or in pain. Unfortunately, a single high glucose reading does not give you any symptoms. Talk to the doctor on how you want to manage the high glucose readings. In most cases, as long as the glucose is not very high, you may want to watch your diet and monitor closely for next 24 hours. If high readings persist, you may want to call your doctor with the readings to get further instructions. If you are on insulin, your doctor might have given you instructions on taking extra insulin when your glucose is high. If you already know you've had something in your meal that spiked up your glucose levels like a piece of cake or dessert, then you may want to just wait and be careful until your next meal, what you're eating. However, if your glucose is very high, usually over 400 you must call your provider and may need to go to emergency to get evaluated for diabetic ketoacidosis. Ketoacidosis will be discussed in detail at a later section.
Why does my blood glucose go high even when I am not eating?
Sipping meal can potentially raise your glucose higher. When you don’t eat for several hours or when you are sleeping your body fuels itself on glucose released from the liver. Skipping meals can also lead to overeating which can cause weight gain.
What to do if you get sudden low reading.
If you have low blood glucose, you need to treat it right away as low glucose can be life threatening. If glucose gets too low, it can lead to seizures and coma. Hypoglycemia is defined as glucose under 70 however, some people may have symptoms of hypoglycemia at the higher glucose levels, especially if they have been running high most of the time. Most people have some symptoms if glucose is dropping. Symptoms of Hypoglycemia may vary in different individuals and not everyone gets all the symptoms. The only way of knowing exactly is checking your blood glucose level. Sometimes when symptoms are severe you may need to get some sugar in first before you can check the glucose to prevent yourself from passing out specially if you are alone.
Signs and Symptoms of Hypoglycemia
Sweating
Headache
Irritability
Confusion
Cold clammy skin
Blurred vision
Weakness
Fatigue
Hunger
Nausea
Lightheadedness
Seizures
Loss of consciousness
Coma
Treatment of Hypoglycemia
It has been emphasized how important it is to treat hypoglycemia right away. For treatment we follow the rule of 15
Rule of 15 for treatment of Hypoglycemia
By following the 15 gram rule you don’t overshoot. Most people will get very panicked when they have signs and symptoms of hypoglycemia and will end up eating a lot of sugar, which then results in a hyperglycemic spike later on.
Once you have treated the hypoglycemic episode step back and think why it happened. In 95% of the cases there is an obvious reason when a person gets low sugar reaction. You may have skipped a meal or your meal might be delayed. You may be unusually active or working in a yard, mowing a lawn, snow shoveling, or going shopping or walking. Sometimes it might be too much medication. You may be sick and taking some medication that’s affecting your glucose. Certain antibiotics also lower the blood glucose levels.
List of things that can be taken for treatment of hypoglycemia following the 15 grand rule
Glucose tablet 3 (each tablet is 5 grams)
Glucose gel or paste
Hard candy
Four-ounce Apple juice
Four-ounce orange juice
Two tablespoon of raisins.
White sugar
Four ounces of soda.
Chocolate milk, chocolate, crackers or sandwiches are not good choices to treat acute hypoglycemia. Sometimes if your sugar suddenly drops and it's not treated right away, you may pass out in which condition someone else may have to take care of you. When glucose is very low and if you pass out a glucagon injection can be given by a family member or a friend. Glucagon is a hormone that will raise your blood glucose up right away. It is a lifesaving drug. It is a good idea to have a family member or a friend know about it so they can give it to you if needed. Glucagon is available in the form of a kit with prefilled pen. Glucagon is now also available inhalation form, which makes it much easier for a family member to give it to you. You must ask your doctor about emergency glucagon prescription when you are on multiple diabetes medications specially insulin.
(Insert pics of glucagon kits pen and inhalation device)
Hypoglycemic unawareness.
Some people with diabetes may not feel any signs and symptoms when the glucose is dropping. This is called hypoglycemic unawareness. This is a complication of Diabetes that occurs due to damage to the nerve endings. In this condition the low blood sugar fails to trigger the secretion of epinephrine which generates the characteristic symptoms of hypoglycemia such as sweating, palpitations, etc. which serves as the warning signs for the person. Frequent monitoring is the only way to know if you are dropping. Using a continuous glucose monitor is also very helpful in this situation.