Friday, January 22, 2021

Diabetes Care in the Elderly: A pragmatic approach

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Care of Diabetes in the elderly can have its own challenges and these need to be considered whilst planning the treatment of Diabetes in the elderly.

It is true that prevalence of Diabetes increases with age. About a quarter of the population aged more than 65 years have Diabetes, as per one estimate. Some of them have multiple comorbidities such as kidney problems, heart disease, which have to be factored in, whilst planning treatment. Moreover, some of the elderly are dependent, living with the help of assistance, physical or financial, from others.

Add to the above, polypharmacy is a concern as many elderly are on multiple medications for various ailments apart from Diabetes, which raises compliance issues, cost concerns and also complex drug interactions. Functional disabilities and memory issues do not help the problem either.

In view of all the above, the Diabetes health care providers need to factor in the individual’s overall health, risk for low blood sugar, affordability and projected period of survival, while prescribing medication and while devising individual care pathways. This also helps in devising simplistic medication regimens that can be easily followed by patients and their carers.

Screening for dementia and depression can be done during the clinic visits of the elderly to Diabetes clinics as it aids detection of these, appropriate referrals, and management. Hypoglycaemia or low blood glucose should be avoided, recognized and treated appropriately. This can be achieved through proper education of the patients and training of the carers. Setting realistic glucose targets and usage of medication with low risk of low blood glucose, is of paramount importance.

Blood glucose target values for the elderly might have to be relaxed without being overambitious for very strict tight glucose control. Target HbA1c value, i.e., 3 months sugar average test ‘target value’ may need to be relaxed. Simultaneously, it is important to educate regarding the avoidance of dehydration, and the need to prevent and treat huge spikes of blood sugar which may lead to dangerous complication of Hyperglycaemic Coma.

As management of Diabetes involves periodic screening of complications such as Neuropathy, Nephropathy, Retinopathy and Heart disease, these ought to be taken care of. Hypertension and high Cholesterol need to be treated appropriately with the right blood pressure lowering medication and statins. A baby Aspirin for prevention of heart attacks, brain strokes may be indicated wherever appropriate.

Foot care is usually a neglected area in most elderly Diabetics leading to foot ulcers and sometimes even amputations. Again, education, prevention of foot problems and screening for the same, is very important. Simple measures like, not walking bare-footed, taking care of heel cracks can help a lot.

As Old Age Homes have become the norm even in India, it is essential to train the staff in such institutions about the basics of Diabetes care such as recognition and treatment of low blood sugar, administration of Insulin to those elderly Diabetics with dexterity problems or memory issues. Using simple, practical dosing regimens with modern Insulins with low risk of low blood sugar, certainly aids in this process.

Palliative care or care of the terminally ill with Diabetes needs modification of regular treatment. Strict BP and glucose control is not appropriate in such a scenario. Lipid lowering medications need to be withdrawn and overall withdrawl of therapy may be appropriate in some circumstances. Overall comfort, prevention of distressing symptoms, and preservation of quality of life and dignity should be the primary goals.

Elderly, especially those with Diabetes are at high risk of succumbing to the complications of Covid. Telemedicine portals may help taking care of Diabetics who are elderly during these Covid times.

To summarize, the challenges of Diabetes care in the elderly can be overcome using simple strategies of blending common sense, realism and compassion to medical science and educating the patients as well as their carers regarding the same.

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