Complete Nurse's Guide to Diabetes Care, 3rd Edition

Chapter 29:

Diabetes in Older Adults

Geralyn Spollett, MSN, C-ANP, CDE,1 Marjorie Cypress, PhD, MSN, RN, C-ANP, CDE,2 and Sandra Drozdz Burke, PhD, APRN, FAAN3

1Spollett is an adult nurse practitioner at Yale Diabetes Center, New Haven, CT. 2Cypress is an adult nurse practitioner and certified diabetes educator in Albuquerque, NM. 3Burke is the academic chair for Upper Division Programs and a professor of nursing with the Goldfarb School of Nursing at Barnes–Jewish College in St. Louis, MO.

As increasingly larger numbers of people began living into their seventies, eighties, and beyond, gerontologists subdivided the categories of aging into the young-old, the middle-old, and the old-old. The youngest oldsters are those individuals between the ages of 60 and 70 years. The category of middle-old includes those from 71 through 84 years, and the oldest of the old are those elders who are ≥85 years of age. By 2050, the global population of those >65 years of age will triple. In the U.S., the number of adults will more than double: from 41 million in 2010 to 86 million in 2050.1 The fastest-growing segment of the older adult population will be among the oldest old (i.e., ≥85 years). The prevalence of diabetes among older adults has increased significantly, and 2014 data indicate a rate of 21.5% diagnosed diabetes in those ≥65–74 years of age, and 19.2% in those ≥75 years of age.2This information is of great importance to nurses who will be caring for these older adults.

No “typical” aging process exists. Function and levels of capability vary greatly in the older adult; therefore, in this population, the assessment of each person with diabetes takes on added importance. For some older adults, diabetes will be a new health problem requiring an adaptation and change in lifestyle that may or may not be difficult depending on their current state of health. In others who have diabetes of long duration with or without associated medical complications, aging may add to the increasing complexity of self-care. The combination of age-related changes and long-duration diabetes may affect daily function, cognition, hearing, and vision. It also can cause or increase depression, dementia, and other psychosocial problems. All of these factors make assessment and planning individual diabetes care in this age-group a challenge.

DIABETES IN OLDER ADULTS

In early 2012, an American Diabetes Association (the Association) consensus panel reviewed the scientific literature specific to diabetes in the older adult population. Their report, published simultaneously in Diabetes Care and theJournal of the American Geriatrics Society, summarized the evidence, recognized the complexity of caring for this heterogeneous population, and provided a framework aimed at helping clinicians to develop treatment goals for their older adult patients (see Table 29.1).3,4

Table 29.1–Framework for Treatment Goals in Older Adults with Diabetes

Table 29.1—Framework for Treatment Goals in Older Adults with Diabetes

This represents a consensus framework for considering treatment goals for glycemia, blood pressure, and dyslipidemia in older adults with diabetes. The patient characteristic categories are general concepts. Not every patient will clearly fall into a particular category. Consideration of patient and caregiver preferences is an important aspect of treatment individualization. Additionally, a patient’s health status and preferences may change over time. ADL, activities of daily living.

A lower A1C goal may be set for an individual if achievable without recurrent or severe hypoglycemia or undue treatment burden.

*Coexisting chronic illnesses are conditions serious enough to require medications or lifestyle management and may include arthritis, cancer, congestive heart failure, depression, emphysema, falls, hypertension, incontinence, stage 3 or worse chronic kidney disease, myocardial infarction, and stroke. By “multiple,” we mean at least three, but many patients may have five or more.6

**The presence of a single end-stage chronic illness, such as stage 3–4 congestive heart failure or oxygen-dependent lung disease, chronic kidney disease requiring dialysis, or uncontrolled metastatic cancer, may cause significant symptoms or impairment of functional status and significantly reduce life expectancy.

AlC of 8.5% equates to an estimated average glucose of ~200 mg/dL. Looser glycemic targets than this may expose patients to acute risks from glycosuria, dehydration, hyperglycemic hyperosmolar syndrome, and poor wound healing.

Source: American Diabetes Association.5

The consensus document made a number of important points about diabetes management in the older adult population. Perhaps the most important point is that evidence to guide clinical decision-making remains scarce despite the recognition that diabetes management in the aging population is complex. The lack of research in this population is problematic given the remarkable dissimilarity among elders with diabetes. The older adult may have incipient or longstanding diabetes. Most will have type 2 diabetes (T2D), but increasingly larger numbers of older adults have type 1 diabetes (T1D).6 Misconceptions linking type of diabetes with age of onset may cause T1D in the older population to be mistakenly diagnosed as T2D. This misdiagnosis can have dire consequences as refraining from insulin use in the individual with T1D can result in diabetic ketoacidosis (DKA) or even death.

The nursing assessment, intervention, and goal-setting process for diabetes management must include the individual’s functional level as well as the current living environment. The elder may be living independently, in an assisted living environment, or in a skilled nursing facility. All of these situations have a bearing on the breadth and depth of self-care management as well as the possible support needed to achieve favorable outcomes. In addition, diabetes of considerable duration is more likely to be complicated by cardiac, renal, neuropathic, and ophthalmic conditions, creating a more complex plan of care.

Regardless of type or duration of diabetes, clinical management decisions for the older adult must be individualized and guided by principles of safety and the preservation of function. All individuals with diabetes should aim to achieve optimal glycemic control to maintain quality of life. The definition of optimal can vary, however. In the older adult, the target A1C level must be fluid, changing with the individual’s age, duration of diabetes, severity of complications, and overall health status. Specifically, the impact of diabetes needs to be considered in terms of functional status, frailty, geriatric syndromes, and life span.3,4,7,8

Aging and its Effects on Diabetes

Aging invariably leads to physiologic changes.9,10 The amount or color of hair and the overall elasticity of the skin have obvious changes. Sarcopenia, an age-related and progressive decline in lean muscle mass, develops over time. Thermoregulation and pain sensitivity changes. The amount of fluid volume, including total body water, reduces overall. This, combined with a reduction in thirst sensitivity, increases the older adult’s risk of dehydration. Visual changes, such as presbyopia, begin in the fourth decade. Other age-related visual changes, including glaucoma, cataracts, and macular degeneration are more likely to occur later in life and occur more often and at a younger age with diabetes. Hearing acuity often declines. Changes in the gastrointestinal (GI) system include an altered taste sensation, reduction in the amount of saliva, achalasia, achlorhydria, and a delay in transit time through the gut. Combined with a high risk for periodontal disease and a potential for poorly fitting dentures, it is not difficult to understand why the older adult might have alterations in appetite or nutritional intake. Other changes in organs, such as a smaller and less dense liver; reduction in renal blood flow leading to a decline in glomerular filtration; thyroid gland atrophy; and a decline in pancreatic β-cell mass, which can lead to a reduction in glucose-stimulated insulin release, can affect glucose control, drug metabolism, and excretion. Each one of these physical changes can affect or is affected by diabetes.

For example, older adults with diabetes are at increased risk for chronic kidney disease than their counterparts without diabetes. Renal disease can reduce physical and cognitive function and can lead to frailty and disability. Diabetic retinopathy is increasing in the older population with diabetes, and the risk of cataracts and glaucoma is greater in those >65 years old than in the general population. Diabetes hastens the process of atherosclerosis and increases the risk of cardiovascular disease (CVD). Data gathered in 2010 estimated that 40% of those with diabetes in the U.S. between 65 and 74 years old had CVD. Of those ≥75 years, 55% had CVD.11

Individualization of Treatment

Individualizing treatment is especially important in the older adult with diabetes. The variety of physical, emotional, and psychosocial issues that some older adults face has major implications for clinical decision-making and treatment. The older age-group has a wide range of functional ability. Some will be able to live independently and handle health-care needs with limited outside support, while others will need extensive support from family, community agencies, and medical/nursing services to remain in the home setting. Myriad factors influence self-care abilities. During the assessment, the nurse must be alert for both cognitive and physical changes that can impair self-care management. Functional impairment encompasses a variety of difficulties with activities of daily living (ADLs). Although authors of recent studies note some variability in the specific conditions they discuss, they seem to have reached the general consensus that malnutrition, functional impairment, urinary incontinence, polypharmacy, falls, cognitive impairment, and frailty should be included in the list of implications.12–17 Older adults with diabetes tend to exhibit greater levels of dependency at earlier ages.

Given that multimorbidity is common in older adults, the use of multiple medications is common in this population. The greater the number of medications prescribed, however, the higher the risk for adverse drug reactions and drug-to-drug interactions. Polypharmacy, which generally refers to the use of five or more prescription medications, some of which may be inappropriate or medically unnecessary, complicates care for the patient or caregiver, and can result in poorer outcomes. For example, some medications, including those with either a potential for hypoglycemia or that mask the symptoms of hypoglycemia, lead to an increased risk of falls. Ongoing medication reconciliation becomes an especially important nursing action when individuals with diabetes are seeing multiple providers and taking many medications.

One in every three older adults falls.18 Dizziness and syncope, often implicated in falls, can be related to specific medications, environmental factors, or to chronic conditions such as idiopathic orthostatic hypotension. Falls are more common in the oldest old as they often are the most frail. The concept of frailty does not simply reflect a loss of mobility, function, or inability to perform ADLs. Frailty is associated with reduced activity levels, weight loss, weakness, feelings of exhaustion, and functional decline.19 Overall, as aging progresses, the individual with multiple morbidities has a tendency to become increasingly frail. Denoted as a geriatric syndrome commonly associated with poor outcomes, frailty may be present in as much as 25% of the older adult population.20 Diabetes is one of the chronic conditions commonly associated with frailty. The treatment of diabetes depends heavily on the physical and cognitive abilities necessary for self-care (e.g., diet and physical activity, proper medication administration) and becomes increasingly difficult to manage in the frail individual.

Diabetes is a significant risk factor for cognitive impairment and the acceleration of cognitive decline. Cognitive decline significantly contributes to the complexities of aging. Some, but not all, aspects of cognitive functioning decline with age. Specifically, older adults experience a gradual decline in the ability to remember tasks without a list, the specific source of information, and what may need to be done in the future.21 Integrating diabetes self-care management routine into the life of an older adult struggling with cognitive decline requires that the care provider understand the assistive and supportive components necessary to achieve important tasks. Taking these age-related changes into account, treatment plans must focus on safety. Individual goals for treatment, nutrition, physical activity, and specific medications must be prescribed with the safety of the person in mind and with the understanding of whether the patient will be able to carry out the plan independently or will need assistance. In these situations, it is vital that family members or other caregivers are included in the creation and implementation of the plan of care.

Table 29.1 considers the clinical and functional heterogeneity of individuals. Some older adults have long-duration diabetes with multiple complications that may limit specific treatments, yet others may be healthy with little to no impairments.

Nutrition and Physical Activity

Nutrition and physical activity are integral parts of diabetes care regardless of age. Malnutrition, however, can be a problem in the older population because of anorexia, restrictive diets, decreased sensation of taste and smell, deficiencies in macro- and micronutrients and other vitamins, swallowing difficulties, dental problems, difficulty feeding oneself or lack of assistance with feeding, depression, social isolation, and cognitive or other functional impairments. Optimally, every patient with diabetes should be assessed and referred to a registered dietitian for an individual plan, and the older adult who is at particular risk for malnutrition must be evaluated. At that time, the dietitian can make recommendations for assistance and referrals to community resources such as Meals on Wheels or other senior community services.3 Nurses and diabetes educators also can promote healthy nutrition options as well as identify and refer the individual and caregivers to community resources.

Although fitness and strength may be reduced as people age, physical activity can improve functional status.3 Before an exercise program is initiated, cardiac status should be monitored, a treadmill test should be performed, and any symptoms suggestive of cardiac decompensation must be assessed. A periodic assessment is conducted thereafter and is particularly warranted should any new symptoms appear. Balance must be assessed and care must be taken to avoid falls. All individuals, particularly those with insensate feet, should engage in balance-training exercises, combined with some lower body and core strength training, to lower falls risk Exercise participation can prevent further loss of muscle strength and flexibility. Even light-intensity physical activity has been associated with higher self-rated physical and psychosocial well-being.22

The Selection of Medications

Before analyzing options and selecting an appropriate medication, the patient and health-care provider need to discuss the goals of therapy based on the patient’s current state of health and quality of life. Determining a glucose target or A1C goal varies from person to person depending on age, duration of disease, comorbidities, and psychosocial factors. The primary outcomes always should be to preserve function and safety.

Some medications have higher risks of hypoglycemia, and hypoglycemia-induced falls are unfortunately common in the elderly with diabetes.23

In patients with long-standing T1D who have used intensive insulin therapy, whether multiple daily insulin or insulin pump, the goal of therapy was to achieve an A1C level of ≤7%. In 1993, the findings of the Diabetes Control and Complications Trial resulted in a recommendation for tighter glucose control to help avoid the occurrence or lessen the progression of diabetes complications.24 As A1C goals lowered, the rates of hypoglycemia rose. Yet in the older adult, the risk of hypoglycemia and all its attendant sequelae, must be avoided. Although past A1C goals may no longer be appropriate, it may be challenging to help the person with T1D who has struggled for years to achieve near-normal glycemic goals to consider raising them. Overtreatment by maintaining stringent glycemic goals, however, is detrimental and can result in severe hypoglycemia and even death. For these patients, the best treatment plan may be to simplify the insulin regimen to meet a more appropriate A1C level. It is important to discuss the reasons for changes in glycemic goals with the patient.

In T2D, the choice of antidiabetes medication in an elderly individual depends on several factors, including renal and liver function and the ability to purchase medications and adhere to the regimen, as well as the risk of hypoglycemia with specific medications (also see Chapter 7, Therapy for Type 2 Diabetes). In general, medications should be started at the lowest dose and titrated gradually until blood glucose goals are achieved. Table 29.2 lists and compares the different classes of glucose-lowering medications for older adults based on reductions in A1C, adverse effects, as well as cautions, safety, and cost. The fewest medications should be used to reach the A1C goal selected and should be mutually agreed on by the patient and health-care provider. Side-effects and drug-to-drug interactions should be minimized.

Table 29.2—Different Classes of Glucose-Lowering Medications for Older Adultsa

Table 29.2—Different Classes of Glucose-Lowering Medications for Older Adults

Table 29.2—Different Classes of Glucose-Lowering Medications for Older Adults, continued

Abbreviations: DPP, dipeptidyl peptidase; eGFR, estimated glomerular filtration rate; GLP, glucagon-like peptide; HbA1c, hemoglobin A1c; SGLT2, sodium-glucose cotransporter.2

SI conversion: To convert HbA1c in percentage to mmol/mol, subtract 2.152 and then multiply by 10.93.35

aInformation about these medications that can be used in the shared decision-making process with patients is available at http://shareddecisions.mayoclinic.org/decision-aid-information/decision-aids-for-chronic-disease/diabetes-medication-management.

bCosts are the wholesale acquisition cost of a 30-day supply of the initial dose of each medication.

Source: Lipska et al.25

Because of the rising costs of diabetes medications, some desired or preferred medications may not be feasible. It is important to discuss medication adherence, barriers, and problem-solving tactics with patients.

Hypoglycemia

Avoiding hypoglycemia in any treatment program is always important; it is particularly important in this age-group. In an older adult population, a fall subsequent to hypoglycemia can result in a fracture and sequelae.26Hypoglycemia is also associated with a higher risk for dementia, cardiovascular events, poor health-related quality of life, and increased mortality.27,28 Commonly, hypoglycemia is associated with a blood glucose level <70 mg/dL.29 Hypoglycemia is associated with the use of insulin secretagogues (sulfonylureas and glinides) and any form of insulin; however, in the older adult, the highest risk of hypoglycemia occurs with the use of chlorpropamide, glyburide, or sliding-scale insulin.30 Acknowledging the inherent risk of hypoglycemia, insulin use still should be considered in an older adult who is unable to take other agents or has a glycated hemoglobin A1c (A1C) level above the individual’s target. In general, A1C levels >9% indicate the need for insulin. In the older adult, however, a risk–benefit analysis also should be used to determine whether insulin use is a safe therapeutic choice for the patient. Use of insulin requires good visual and motor skills, and the ability to learn and perform accurate and safe administration, or the availability of a caregiver to support self-care. Using a basal insulin (such as detemir) once or twice a day or glargine and deguldec once daily can simplify the insulin regimen, can lower glucose levels to an acceptable range, and has a reduced risk of hypoglycemia. If the patient is on a set schedule, then a premixed insulin of rapid or short-acting insulin with an NPH-like intermediate-acting insulin such as a 75/25 or 70/30 may be an option. For this to be a safe option, the individual must be eating consistent meals that correlate with the peak action of the insulin. In some cases, lean patients or those with T2D for many years may be insulin deficient and have glucose variability similar to those with T1D. While the best treatment for these patients may be basal-bolus therapy that offers flexibility in meal coverage and glucose correction, assistance by a caregiver may be necessary to use this therapy safely.

Practical Points for Reducing Risk of Hypoglycemia in Older Adults

Increase A1C targets

Consider avoiding sulfonylureas in those >65 years old, those with renal insufficiency, or those on basal insulin

Assess environmental risks

If possible, minimize medication list

Source: Adapted from Malabu et al.23

Self-Monitoring of Blood Glucose

In general, self-monitoring of blood glucose (SMBG) is a useful tool in diabetes self-care management, but in the older person with diabetes, it is essential for safe and effective care. The vulnerability of the elderly to severe hypoglycemia may be partially related to a progressive age-related decrease in β-adrenergic receptor function. Age-related impairment in counterregulatory hormone responses has been described in elderly patients with diabetes, especially with respect to glucagon and growth hormone resulting in hypoglycemic unawareness.27 This hypoglycemia unawareness places the patient in a precarious position because without symptoms, the patient must rely on blood glucose testing results to determine the presence of hypoglycemia. Depending on the glucose-lowering treatment prescribed, the older adult with diabetes may need to self-monitor blood glucose for medication adjustment and to prevent hypoglycemia. In addition, the more complicated the medication or insulin regimen, the higher the risk for hypoglycemia, and the greater the need for self-monitoring. If the medication regimen uses drugs associated with a low risk of hypoglycemia, then glucose monitoring is not imperative but may be necessary to assess the effect of behavior changes, such as diet and physical activity.

In the older adult with diabetes, the two distinct issues pertaining to SMBG are 1) cost and 2) the use of the monitoring device. The manual dexterity and visual capabilities necessary to use a monitoring device can be significant barriers. In some cases, the manufacturers’ drive to make glucose monitors smaller, more discreet, and portable also makes use more difficult for those with arthritis, sensory and motor neuropathies, or visual impairment. Tiny test strips, small grey-tone display screens, lancing devices, and lancets all pose challenges to the user. In addition, the cost of test strips and the number of strips allowed per day can vary depending on the insurer’s coverage. This can be determined by the type of diabetes, the use of insulin versus oral medications, and the preferred meter brand.

Medicare has an established benefit to cover diabetes supplies and services, including diabetes self-management education (DSME).31 Unfortunately, <2% of Medicare beneficiaries take advantage of this latter benefit.32Considering the heterogeneity of this population and the often gradual physiologic changes affecting glucose control in the elderly, early initial and ongoing DSME are vitally important. Nurses not only are in an optimal position to inform older adult patients about this important Medicare benefit but also can refer patients to qualified diabetes education programs.

DSME

A lack of access to and awareness of programs available are only two of the barriers to DSME. Although the physiologic changes can affect diabetes management and the attainment of glucose control, they also may influence the format, style, and delivery of diabetes education. Hearing impairment, visual changes, and manual and tactile decline call for adaptation of learning materials. In turn, this may alter the way in which the nurse presents information and teaches skills. A recent systematic review of the literature of patients with T2D indicated that age and duration of diabetes were associated with a significantly higher incidence of hearing loss than in those without diabetes.33 This predominance of hearing loss indicates the need for routine hearing tests. Cognitive changes may impair learning abilities. For example, attention span can be shortened or memory issues can limit the use of more complex or multistep processes. Executive function, such as decision-making or applying learned principles to a situation, may be impaired. Learning styles, including preferred language, literacy, and numeracy skills, also may differ. Therefore, just as in any other age-group, diabetes education must be tailored to the individual to be relevant and meaningful. For many adults, group education offers the opportunity to learn from others and to experience a sense of support.

Alzheimer’s disease has been associated with diabetes. A meta-analysis of 28 observational studies on this topic found a 73% increased risk of all types of dementia, a 56% increase in Alzheimer’s dementia, and a 127% increase in vascular dementias in patients with history of diabetes as compared with people without diabetes.34 This is but another reason that makes it particularly critical to assess the patient’s understanding of the treatment regimen and ability to perform diabetes self-care activities. The “teach-back method” in which the patient is asked to repeat instructions back to the nurse educator is an effective way to ensure understanding. If the older adult is impaired, this teach-back method can be used with the primary caregiver.

Practical Points and Nursing Considerations in the Elderly

• Medication reconciliation: check for polypharmacy and adherence

• Control of hyperglycemia and its symptoms

• Prevention and treatment of hypoglycemia

• Prevention, screening, evaluation, and treatment of macro- and microvascular complications

• Self-management through education of patient, family, and caregivers

• Maintenance or improvement of general health status

• Assessment of patient’s understanding using teach-back method

DIABETES COMPLICATIONS

All diabetes-related conditions and complications should be assessed routinely. Frequent changes may be required for patient safety as age or condition-related problems progress. Table 29.3 includes nursing considerations for some of these complications.

Table 29.3—Nursing Considerations for the Elderly with Diabetes

Table 29.3—Nursing Considerations for the Elderly with Diabetes

CHF, coronary heart failure; SOB, shortness of breath; UTI, urinary tract infection.

Acute Complications

Hypoglycemia risks were discussed in earlier sections of this chapter. Prevention of hypoglycemia is the goal of care. If the individual is on medication that places them at risk for hypoglycemia, the individual should know appropriate treatment guidelines (i.e., 15 g carbohydrate, wait 15 min, and recheck the blood glucose). Reviewing treatment options with the individual or caregiver is important. If patients live alone, they should be instructed to always keep treatment options at the bedside or near them so they do not have to get up to find appropriate hypoglycemia treatment, such as glucose tabs, 8-ounce bottles of regular soda, or 6-ounce cans of juice.

Severe hyperglycemia in the older adult also presents numerous negative consequences and should be avoided. Glucose levels above the renal threshold (180–200 mg/dL) cause glycosuria, leading to polyuria. If severe hyperglycemia persists, it leads to dehydration. Because the sensation of thirst is diminished in older patients, low levels of dehydration can continue undetected. If illness or other stressors further increase hyperglycemia and the dehydration becomes more profound, hyperosmolar hyperglycemic nonketotic syndrome, a hyperglycemic emergency, can occur. This is a life-threatening state demanding emergency care, usually in the form of intravenous rehydration and monitoring. A lesser but still important problem also can result from dehydration: alterations in skin integrity. Dry skin is more prone to breakdown and infection, which will be further compounded by the reduction in healing caused by hyperglycemia. The occurrence of skin lesions in the lower extremities may place the patient at increased risk for ulceration, osteoporosis, sepsis, or gangrene, depending on the status of the circulatory system and its ability to heal. In addition, glycosuria can lead to urinary tract infection (UTI) and other deleterious sequelae.

Glycosuria from poorly controlled diabetes may result in the loss of calories and important electrolytes. Weight loss contributes to frailty and decreased strength. Hyperglycemia also retards gastric motility and can increase constipation. For patients who use diuretics, the occurrence of severe hyperglycemia can cause hypovolemia and hypotension, making the patient more prone to falls.

In the patient with T1D, increased levels of hyperglycemia, particularly those associated with illness or insulin deficit can be dangerous. DKA can result. Insulin should never be withheld in patients with T1D during illness and sick day rules must be reinforced with both patients and caregivers.

Chronic Complications

Autonomic neuropathy can cause orthostatic hypotension, which can lead to falls, and importantly, this neuropathy also can lead to a patient’s inability to recognize symptoms of hypoglycemia (see Chapter 16, Peripheral and Autonomic Neuropathy). Neurogenic bladder causing urinary retention can lead to UTI. In many cases, the UTI will be asymptomatic or present with general malaise, increased glucose levels, and sometimes fever. Urinalysis and urine culture should be ordered to assist in making the proper diagnosis.

Other forms of autonomic neuropathy can affect the GI tract. Esophageal dysmotility and gastroparesis make it more difficult to swallow and digest foods. To avoid the sensation of choking, nausea, or bloating, the patient may restrict certain foods such as meat and other proteins, fresh fruits, and vegetables, and instead select soft carbohydrate-rich foods, such as mashed potato, applesauce, or cooked cereals causing a rise in glucose levels. Additional aging issues affecting vitamin and nutrient consumption may further affect nutritional status. In these cases, a referral for medical nutrition therapy dietary counseling is beneficial.

Peripheral sensory neuropathy can present as increased pain, numbness, or decreased pain sensation, causing the patient to limit activity. Decreased proprioception and issues with gait and balance increase the risk for falls. It is important to assess the need for assistive walking devices, such as a quad cane, and to check shoes for proper fit and support. Peripheral neuropathy also increases the risk of foot ulcers. The individual or caregiver should perform a thorough exam of the feet daily especially if decreased pain sensation is present. It is critical to instruct the individual to not go barefoot, even in the house, and to physically check the inside of one’s shoes before wearing them. A common cause of foot ulcers is pressure from an object in the shoe that was not known by the individual because of the lack of sensation in the lower extremities.

Diabetic retinopathy may cause impaired vision particularly in those with macular edema. Patients may need assistance with diabetes self-management, such as glucose monitoring and medication administration. The use of an insulin pen instead of a vial and syringe can make insulin easier to administer, improve accuracy, and improve adherence.35

CLINICAL PRACTICE GUIDELINES

Because older adults are confronted with multiple morbidities, no single disease-specific guideline of care sufficiently addresses the complexities faced by these individuals. More than a decade ago, the California Healthcare Foundation and the American Geriatrics Society (AGS) Panel on improving care for older people with diabetes introduced novel guidelines for the older adult.36 Since then, clinical practice guidelines began to include tailored recommendations for the older adult with diabetes, but even within these guidelines, inconsistencies exist.37–40 Recognizing the high risk for fragmented care, coupled with the importance of addressing the unique needs of the older adult with diabetes, in 2013, the International Diabetes Federation (IDF) released the first global guideline specific to this population.39 Of note, although aspects can be applied to all older adults with diabetes, the IDF guideline was developed to guide management of T2D in the population ≥70 years old. In late 2013, the AGS released updated guidelines for care of older adults with diabetes,7,41 and the Association addresses issues specific to the older adult in its annual Standards of Medical Care in Diabetes.37

These guidelines have a number of similarities. In particular, each set of guidelines identifies the need to individualize therapy according the elder’s age, levels of functional and cognitive status, overall health status, and life expectancy. The leading cause of death in the older adult population is heart disease.42 All guidelines address the importance of reducing cardiovascular risks and some suggest that a focus on cardiovascular risk factors is more likely to yield benefit in this population. Glycemic control targets are fluid in older adults. Healthy elders—that is, those who are cognitively intact, have few comorbid conditions, and are free from functional limitations—can strive to achieve more stringent glucose targets. On the other end of the spectrum are the elders who are frail, possibly cognitively impaired, need assistance with ADLs, and have a limited life expectancy. In this group, glucose targets should be more relaxed so as to protect the individual from glucose extremes of hypoglycemia and hyperglycemia. Although not specific to diabetes, an important guideline to consider in the medication management of older adults is the AGS Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.30 Initially released in 1991, and updated in 2015, the Beers Criteria are designed to improve pharmacologic safety by guiding clinical decision-making.

SUMMARY

Caring for the older adult with diabetes is challenging for the entire health-care team. Nurses play a pivotal role in advocating for the elderly. Effective diabetes education gives patients the knowledge and skills needed to manage their diabetes successfully. The capacity to learn and integrate new information remains intact throughout the life cycle, although age-related changes can affect this process. Nurses must be attentive to the health-related changes among some older adults with diabetes so preventive strategies can be implemented to keep elders in their optimal state of health.

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