Aging in the Know - Diabetes

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Aging in the Know - Diabetes
AGS

Published: 3/28/2005

Glucose is a simple sugar that provides energy to the cells of the body. In diabetes mellitus, glucose (sugar) levels in the blood get too high. Diabetes is one of the most common chronic diseases of aging, developing in up to one in five older adults. People 65 years and older now account for more than 40% of all people with diabetes in the United States, and this percentage is expected to increase. Diabetes is more common among black Americans and Hispanic Americans than among white Americans. Black Americans also suffer from complications of diabetes at much higher rates than white Americans.

There is another type of diabetes, called diabetes insipidus, that causes some of the same symptoms (ie, increased thirst and urination) as diabetes mellitus. However, diabetes insipidus is caused by the inability of the kidneys to conserve water, not a problem with blood glucose. This type of diabetes is uncommon, and the rest of this discussion refers only to diabetes mellitus.

* Causes
* Consequences of Diabetes
* Diagnosis and Evaluation
o Blood glucose testing
o Complications of diabetes
* Treatment and Management
o Lifestyle changes
o Oral drugs
o Insulin
o Your role in treatment
* Diabetic Coma from High Blood Glucose
* Low Blood Glucose



Causes

A hormone called insulin, which is produced by the pancreas, controls how glucose is used by the body. There are two types of diabetes mellitus. In type 1 diabetes, the pancreas is not producing enough insulin. In type 2 diabetes, the body cannot use the insulin that is there. Type 2 diabetes is by far the most common type in older adults, accounting for about 90% of cases.

The underlying causes of diabetes in older adults are not fully known. However, lifestyle, aging, and genetics all seem to play a part. Being overweight and not getting much exercise are both common among older adults, and can both contribute to developing diabetes. Some of the changes that come about as all people age, such as developing more fat in the middle of the body, may also play a role. Diabetes also tends to run in families. Other possible factors include stress, inflammation, and certain medications. The effect of each of these various factors likely varies from person to person.

Consequences of Diabetes

Diabetes is a serious condition associated with both many complications and earlier death. These complications include blocked arteries, nerve damage, loss of vision, and kidney disease. The rates of heart attack, stroke, kidney failure, and blindness are up to twice as high in older adults with diabetes.

Older adults with diabetes are also at higher risk of incontinence, falls, frailty, decrease in mental function, and depression. Functional loss and disability is also more common in older adults with diabetes than in those of similar age without diabetes. Older adults with diabetes are 2-3 times more likely to have trouble getting around, and 1.5 times more likely to have trouble performing activities of daily living, compared with older adults without diabetes. When diabetes is poorly controlled in older adults, high blood glucose alone can cause fatigue, weight loss, muscle weakness, and a loss of function.

Of course, not all older adults with diabetes experience these complications and problems. The key to staying healthy and independent for as long as possible is early diagnosis and proper management. You can take control of your diabetes and strongly reduce the chances of developing any complications.

Diagnosis and Evaluation

Possible symptoms of diabetes include the following:

* increased thirst
* increased urination
* weight loss
* fatigue
* loss of vitality
* wounds that heal slowly
* foot sores
* numbness or tingling in the feet
* confusion
* depression

Not everyone with diabetes shows these symptoms, and some people with diabetes go for years without any obvious symptoms. This is especially true for older adults, who often do not have the increased thirst and urination that is common younger people with diabetes. In fact, it is estimated that up to one-third of older adults with diabetes are unaware of their condition. Unfortunately, asymptomatic diabetes (diabetes without showing symptoms) is still associated with increased risk for many serious illnesses. This is why blood glucose tests are so important. They are the only way to know for sure whether or not you have diabetes.

Blood glucose testing

Blood glucose is measured in units called mg/dL. The normal level of blood glucose is around 100 mg/dL. To check for diabetes, blood glucose levels are usually measured after an 8-hour fast (ie, no food for 8 hours). If two fasting blood glucose measurements are at or above 126 mg/dL, diabetes is diagnosed. Diabetes can also be diagnosed if you are showing symptoms along with having a random (not fasted) blood glucose level at or above 200 mg/dL. Sometimes, more sophisticated tests (eg, glucose tolerance test) are needed to confirm a diagnosis of diabetes.

Drug reactions can sometimes cause high blood glucose or lead to complications, so it is a good idea to give your health care providers a complete list of all medications that you are taking. It helps to put all of your medications (including over-the-counter drugs) in a bag and take it to your doctorÌs appointment. This "brown bag" inventory allows your physician to see all the drugs you are taking, and to remove medications that you no longer need or are inappropriate for any reason (eg, expired drug). (See also Health Assessment.)

Complications of diabetes

Symptoms or signs of serious health conditions that are often caused by diabetes include the following:

* heart disease
* blood vessel problems (eg, narrowed arteries)
* nerve problems
* foot problems
* eye problems (including blindness)
* kidney problems

Because heart problems are so common with diabetes, your healthcare provider will likely ask about and check for other conditions that can also cause heart trouble, such as smoking, high blood pressure, high cholesterol, and family history.

The blood vessel and circulation problems associated with diabetes can result in serious foot problems that, unfortunately, can possibly lead to the need for amputation. Your feet should be examined by your health care provider at least once a year, and you should examine your feet every day and report any changes or any signs of damage, including any type of sores or discolored toes. Careful, frequent examination to find any changes as soon as they develop can decrease the risk of amputation from foot damage related to diabetes. Good care of your toenails is also very important to prevent foot infections. Your healthcare provider may recommend that you see a foot doctor (podiatrist) regularly.

The blood vessel and circulation problems associated with diabetes can also affect your eyes, and you should also have a thorough eye examination by an ophthalmologist every 1Û2 years.

Treatment and Management

Although there is no cure for diabetes, it is very manageable. There are three main goals of diabetes management among older adults:

* control high blood glucose and its symptoms

* prevent the complications caused by diabetes (eg, kidney disease, heart disease, eye problems, etc)
* identify and treat any complications

Lifestyle changes

Diabetes can be treated with insulin, but daily insulin injections may not be necessary. Several things can be tried first, before resorting to the pain, expense, inconvenience, and risk associated with daily insulin injections. The first thing to do is examine your daily diet and make some changes. If you are overweight, losing 10Û15 pounds may improve your level of blood glucose significantly. As a general rule, about half of your total daily calories should come from complex carbohydrates, such as cereals, grains, pasta, and breads. Less than 30% of your total daily calories should come from fat (primarily polyunsaturated fats), and the rest from protein. Your diet should also be high in fiber and rich in appropriate vitamins and minerals. Your healthcare provider will be able to give you more specific information about a healthy diet that can help you control your diabetes or may refer you to a dietician for advice.

Diet alone can control diabetes in about 10Û20% of older adults with the disease. Many more older adults can improve substantially by adding an exercise program. For example, walking for about 20Û30 minutes three times a week significantly improves the bodyÌs ability to use glucose. Proper diet and exercise can also improve your overall health and decrease your risk of common complications of diabetes, such as stroke and heart disease. Diet and exercise programs should be modified for each individual, depending on other illnesses or disabilities.

Complications of diabetes can also be decreased by controlling other risk factors, such as smoking, high blood pressure, and high cholesterol. Preventing and managing risk factors for heart disease in older adults with diabetes is especially important. These include the following:

* Maintain appropriate weight
* Increase physical activity
* Stop smoking
* Limit fat and carbohydrate intake
* Consider drug therapy to treat high blood pressure, prevent heart attack, or treat high cholesterol or blood lipids

Other chronic conditions that affect your ability either to eat a healthy diet or to exercise, such as arthritis, vision problems, and poor teeth, need to be addressed and treated. Your physician may also recommend changing some medications that might be increasing your blood glucose (eg, certain diuretics ["water pills"] or certain steroid medications for asthma or arthritis).

Oral drugs

If diet and exercise cannot control high glucose levels, then oral medications (pills) can be tried. These drugs work by increasing the amount of insulin produced by the body or by increasing the bodyÌs ability to respond to insulin. Several types of oral drugs are available, and each type has advantages and possible side effects. Depending on the drug, side effects can include stomach upset, liver damage, or blood glucose dropping too much. The latter is the most serious complication of all medications for diabetes. Your physician or pharmacist can tell you about the characteristics of the specific drugs you are taking.

Insulin

If diet, exercise, and oral medications do not adequately control the diabetes, your physician will likely suggest insulin treatment. Insulin may also be the initial treatment if your blood glucose levels are very high. Many types of insulin are available. Usually the initial dose of insulin is low (about 15 units of an intermediate-acting insulin), given as a once-a-day injection before breakfast. Your health care providers will show you how to monitor yourself and change the dosage of insulin as needed.

The greatest risk of insulin therapy is lowering the level of blood glucose too much, especially in frail older adults. Older adults often do not show early symptoms of low blood glucose. Because of this, blood glucose levels are initially checked on an empty stomach, after eating, and at bedtime to be sure that the level does not drop suddenly in any of these situations. People with diabetes and their caregivers should learn how to use a simple machine to check blood glucose. Blood glucose should be checked at least every week, even if the levels have stabilized, or more frequently if medications are being changed or you feel sick.

People with diabetes need to keep foods high in glucose (eg, honey and fruit juice) handy in case of an episode of dangerously low blood glucose. If episodes of low blood glucose are frequent or severe, the management plan, including medications, should be reevaluated. In some cases, all that is needed is a better understanding of what needs to be done to control blood glucose levels. Some people may need more frequent contact with their healthcare providers or even referral to specialists in diabetes care. Sometimes, other factors make diabetes management at home difficult, such as disability or lack of caregiver support.

Intensive management of all conditions associated with diabetes may not be practical or reasonable for everyone. For some older adults with diabetes, aggressive management may not improve the situation and may even result in harm. This is especially true for people who have other severe illnesses, disabilities, or a limited life expectancy. In these situations, your health care provider will help you and your caregivers choose the appropriate level of treatment. Management must be designed to fit your situation, taking into consideration your preferences and quality of life.

Your role in treatment

Ideally, you (and your caregivers) can manage your diabetes day-to-day on your own by understanding how the disease works and by learning what needs to be done and how to do it. Ask your health care provider as many questions as often as needed until you feel comfortable that you understand what you need to do. Monitoring your blood glucose levels is extremely important, and your health care provider will show you how to use the tools to do so. You should keep track of your blood glucose results, noting the time of day and when you last ate and took medication, and bring this record with you to each visit with your health care provider. You may want to ask your health care provider to check your technique periodically to make sure you are managing your blood glucose correctly.

It is also important to know the consequences of low and high blood glucose, including triggers, prevention, symptoms, monitoring, and treatment, as well as situations when you should notify your health care provider. You also need to know the reason for every drug you are taking, how to take it, and its common side effects. In addition, you should learn about proper foot care and the risk factors for foot ulcers and amputation.

Your health care provider will likely provide you with some written information about diabetes that you can use for reference. If you need additional training, you may visit a diabetes educator for one-on-one counseling or go to group training classes. Training programs in diabetes self-management are covered under Medicare Part B and can be repeated every year.

Caregivers should also receive training and become involved in your diabetes self-management program. Caregivers may need to take over the self-management program if the older person with diabetes begins to have mental difficulties or becomes significantly disabled.

Diabetic Coma from High Blood Glucose

Coma caused by very high blood glucose (ie, hyperglycemic coma) is a complication of diabetes that is seen almost exclusively in older adults. Blood glucose levels rise because of a decreased ability to both remove glucose into the urine and feel thirst. The body loses more and more fluid, causing the blood to thicken. The thick blood does not move easily into the blood vessels of the brain, resulting in a loss of consciousness. In other words, the affected person may pass out. This situation may be triggered by a sudden illness, particularly an infection, or by certain medications. Before the coma, people often show signs of physical weakness, lack of energy, agitation, or a sudden confusion. Changes in the nerves can be obvious, and even possibly mimic a stroke. Kidney failure is also often present.

Almost one-third of people who suffer a hyperglycemic coma do not even know they had a problem with blood glucose. This is another reason to screen for diabetes often so that it can be diagnosed early. It is also important to keep up your fluid intake, even if you donÌt feel thirsty (see Nutrition).

The most important part of treating very high glucose that causes coma is to give back enough fluids to the body. Usually, intravenous fluids are given for about 2 days. Very small amounts of insulin may also be given. During this initial treatment, your health care provider will try to determine the underlying trigger leading up to the coma, such as pneumonia or a heart attack. Although the dehydration and blood thickness usually improve in 1Û2 days with treatment, the changes in mental function, including confusion and agitation, may continue for several weeks. Ongoing insulin treatment may not be needed after discharge from the hospital, but people who have had a diabetic coma are at risk of high blood glucose levels and should be monitored carefully.

High blood glucose that is not high enough to cause coma often is not even noticed by a person. Occasionally, high blood glucose can make someone feel tired, or make them thirsty or urinate a lot. High blood glucose can be managed by taking in extra fluids and being sure not to miss any dosages of medications. If the problem continues, your healthcare provider may need to adjust the dosages of your medications.

Low Blood Glucose

Blood glucose that is much too low can also cause coma. The first symptoms a person may notice as the glucose levels become low is feeling nervous, shaky, or sweaty, or sometimes the person may just feel confused. If the glucose level continues to go lower, the person can become even sweatier and more confused, and can possibly go into a coma. Low blood glucose is seen most commonly when someone takes too much diabetes medication, develops kidney problems, or skips a meal either intentionally or because of sickness. Infections can also either raise or lower blood glucose.

Most people with diabetes keep some form of sugar on hand in case they feel their blood glucose is getting low. Usually eating a piece of candy or drinking a glass of juice quickly fixes the problem. When the blood glucose level is dangerously low and can result in coma, the person needs to be hospitalized and often needs glucose given through an intravenous (IV) line.

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