Q & A: Aging and Diabetes
NOVEMBER 01, 2012
One out of every four people over age 65 has diabetes. Medha Munshi, MD, Director of the Geriatrics Clinic at Joslin Diabetes Center and Director of the Outpatient Geriatric Program at Beth Israel Deaconess Medical Center, answers your questions about aging well with diabetes.
First of all, who are we talking about when we say "older adults?"
Dr. Medha Munshi: That's a good question. I actually do not like using the term "seniors" because that now includes people 50 and over! Medicare sets the age of eligibility at 65, but there is something to be said for "You are as young as you feel." In my clinic, the ages range from 65 to 101.
But, it is important to understand that more and more older adults (over 65 years) are highly functional individuals and are treated in similar fashion as the younger adults. On the other hand, some patients in their 70s, 80s and 90s tend to have difficulty performing self-care - these are the people we are talking about.
How does diabetes care change when someone gets older, or is diagnosed at an older age?
Dr. Medha Munshi: Although there are no separate guidelines for older adults with diabetes, there are several factors unique to older age that can complicate diabetes treatment in these patients.
The most important difference between young adults and older adults is that the older adults have many co-existing medical conditions. These conditions can act as barriers to a patient's ability to do self-care, an essential component for achieving good diabetes control. For example, heart disease, stroke, vision problems and hearing problems are some of the common conditions seen in elderly patients.
Another challenge in caring for older adults with diabetes is to make sure that the treatment is suitable for their environment. Some older adults live alone and we have to be careful to prescribe treatment that is safe and easy for them to take.
Lastly, the main goal for treatment of diabetes is to prevent complications in the future. On the other hand, hypoglycemia (low blood sugar) is a risk of the treatment of diabetes that can be dangerous to elderly patients. We try to avoid any episodes of hypoglycemia, particularly in those who are frail and use a cane or walker where falling is a risk.
What is cognitive dysfunction and how does it impact diabetes management in older adults?
Dr. Medha Munshi: We have noticed that elderly patients with diabetes suffer not so much from memory loss, but from difficulties with problem solving, planning and organizing. They also often have difficulty being attentive, starting a new behavior or stopping old behavior.
Since much of diabetes care involves these skills and behaviors, managing diabetes can become very difficult. For example, someone with cognitive dysfunction could have trouble monitoring blood glucose, taking medication, following diet plans and getting more physical activity. It is a major reason why older adults experience problems managing their disease.
How much of a problem is depression in older adults with diabetes?
Dr. Medha Munshi: People with diabetes are about twice as likely to be depressed as those without diabetes, and the rate increases with age. In our study at the Joslin Geriatric Diabetes Clinic, we found that approximately one-third of our patients had symptoms of depression.
When patients with diabetes have depression, they are at a higher risk of poor diabetes control. They have trouble following medication and diet regimens, and they often experience a reduction in quality of life, as well as an increase in healthcare costs. Recent studies have shown that if we treat depression successfully, we can improve blood glucose control in these patients.
Are there any signs of cognitive dysfunction or depression that family members can look out for?
Dr. Medha Munshi: Yes, there are some subtle changes that should raise concern:
- Blood glucose control is suddenly worse in an individual who has done fairly well on his/her own.
- Subtle changes in mental status; for example, being more forgetful about monitoring or taking medications, making mistakes in doses of insulin or even forgetting to eat a meal.
- Difficulty coping with multiple medical conditions or medications and seeming stressed or overwhelmed by it.
- Gradually becoming less socially active, dropping activities that they used to enjoy, or showing other signs of depression, such as sadness or hopelessness or isolation from friends and family.
An older adult displaying any of these behaviors should be screened for cognitive dysfunction and depression.
How are the goals different when treating an older adult than someone who is younger?
Dr. Medha Munshi: A major goal of treating elderly patients with diabetes is not just to improve their blood glucose, but also encourage higher functional status and improved quality of life. These goals are achieved by different strategies in individual patients. Here at Joslin, our goal is to achieve best possible blood glucose control, while maintaining acceptable quality of life for an individual. We avoid management plans that overwhelm patients physically, emotionally or financially. Safety remains our primary concern.
Do you have any parting advice for older adults with diabetes, or their loved ones?
Dr. Medha Munshi: I think one of the most important aspects of improving overall health, not just blood glucose, is physical activity. Physical activity can also improve blood pressure, cholesterol levels, and heart and lung function. It helps us feel energetic instead of tired all the time. We lose muscle mass as we age. For this reason, it is important to keep our existing muscle mass toned. This can be achieved by resistance training - about twice a week with light weights or bands. Aerobic exercise, which increases the heart rate, such as walking, stationary bicycling, and swimming is also important for improving diabetes control and heart and lung health.
Some of the amazing individuals who have aged well in their 90s tell me that their secret is "to eat moderately, stay physically active and keep a positive attitude in life." I think that is the best advice I can pass on to my patients.
Posted November 2012
Joslin Diabetes Center
A Clinical Partner of BIDMC
One Joslin Place
Boston, MA 02215