Category: Diet

Hypoglycemia in elderly individuals

Hypoglycemia in elderly individuals

Standards of medical individuaks in diabetes — Diabetes Care 1 April ; 39 4 : — There is also the possibility of survivor bias.

Hypoglycemia in elderly individuals -

Monitoring recommendations for older patients with diabetes are similar to those in younger patients table 3. In particular, complications that impair functional capacity eg, retinopathy, foot problems should be identified and treated promptly [ 12 ]. Retinopathy — The prevalence of retinopathy increases progressively with increasing duration of diabetes figure 2.

See "Diabetic retinopathy: Classification and clinical features". Regular eye examinations are extremely important for older patients with diabetes because poor vision can lead to social isolation, an increased risk of accidents, and impaired ability to measure blood glucose and draw up insulin doses.

A complete ophthalmologic examination should be performed by a qualified ophthalmologist or optometrist at the time of diagnosis and at least yearly thereafter. The purpose is to screen not only for diabetic retinopathy, but also for cataracts and glaucoma, which are approximately twice as common in older individuals with diabetes compared with those without diabetes [ 55,56 ].

See "Diabetic retinopathy: Screening". Nephropathy — The availability of effective therapy for diabetic nephropathy with angiotensin-converting enzyme ACE inhibitors, angiotensin receptor blockade agents ARBs , mineralocorticoid receptor antagonists, and sodium-glucose co-transport 2 SGLT2 inhibitors has led to the recommendation that all patients with diabetes be screened for increased urinary albumin excretion annually.

See "Moderately increased albuminuria microalbuminuria in type 1 diabetes mellitus" and "Moderately increased albuminuria microalbuminuria in type 2 diabetes mellitus". However, the prevalence of increased urinary albumin excretion increases in the older population for reasons unrelated to diabetic nephropathy.

For older patients who are already taking an ACE inhibitor or ARB and have progressive decline in glomerular filtration rate GFR or increase in albuminuria, referral to a nephrologist for further evaluation and treatment is warranted.

Foot problems — Foot problems are an important cause of morbidity in patients with diabetes, and risk is much higher in older patients. Both vascular and neurologic disease contribute to foot lesions. See "Management of diabetic neuropathy". In addition to the increasing prevalence of neuropathy with age, more than 30 percent of older patients with diabetes cannot see or reach their feet, and they may therefore be unable to perform routine foot inspections.

We recommend that older patients with diabetes have their feet examined at every visit; this examination should include an assessment of the patient's ability to see and reach his or her feet and inquiry about other family members or friends who could be trained to do routine foot inspections.

Visits to a podiatrist on a regular basis should also be considered if feasible. A detailed neurologic examination and assessment for peripheral artery disease should be performed at least yearly. It is also important that prophylactic advice on foot care be given to any patient whose feet are at high risk.

See "Evaluation of the diabetic foot". In addition, they are at high risk for polypharmacy, functional disabilities, and other common geriatric syndromes that include cognitive impairment, depression, urinary incontinence, mobility impairment, falls, and persistent pain [ 1 ].

See "Comprehensive geriatric assessment". All older adults should undergo screening for mild cognitive impairment or dementia at initial evaluation and, thereafter, annually or as appropriate for the individual patient [ 12 ].

Despite limited treatment options, identification of underlying cognitive impairment is critical for assessing a patient's capacity to self-manage diabetes treatment and care.

In particular, cognitive function and the possibility of depression should be assessed in older patients with diabetes when any of the following are present see "Evaluation of cognitive impairment and dementia" and "Screening for depression in adults" :.

Nursing home patients — Few studies have focused on management of older adults with diabetes residing in nursing homes [ 4 ]. Life expectancy, quality of life, severe functional disabilities, and other coexisting conditions affect goal setting and management plans.

See 'Controlling hyperglycemia' above and 'Avoiding hypoglycemia' above. Treatment regimens should be chosen with a focus on avoidance of hypoglycemia and control of hyperglycemic symptoms [ 17 ].

For patients requiring insulin, metformin combined with once-daily basal insulin is an effective, relatively simple regimen. If prandial insulin is necessary, it can be administered immediately after a meal to better match the meal size and minimize hypoglycemia.

Sliding scale insulin should not be used as a sole means of providing insulin. If a patient is temporarily managed with sliding scale insulin to determine the requisite dose s of insulin therapy, a more physiologic glucose control strategy should be implemented within a few days table 4.

End-of-life care — Management of patients with diabetes at the end of life must be tailored to individual needs and the severity of the illness. In general, the risks and consequences of hypoglycemia are greater than those of hyperglycemia in patients at the end of life.

The goal is to avoid extreme hyperglycemia and dehydration as well as excessive treatment burdens such as multiple insulin injections or intensive monitoring. For patients with type 2 diabetes who are no longer taking anything by mouth, discontinuation of diabetes medications is reasonable [ 59 ].

This is in contrast to patients with type 1 diabetes, in whom continuing a small amount of basal insulin is required to prevent iatrogenic acute hyperglycemia and ketoacidosis.

See "Palliative care: The last hours and days of life", section on 'Eliminating non-essential medications' and "Deprescribing", section on 'Glucose-lowering medications'. SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately.

See "Society guideline links: Diabetes mellitus in adults". Older adults with diabetes are a heterogeneous population that includes persons residing independently in communities, in assisted care facilities, or in nursing homes.

They can be fit and healthy, or frail with many comorbidities and functional disabilities. Therefore, older adults in particular require individualized goals for diabetes management, keeping in mind their limited life expectancy and comorbidities.

See 'Goals' above. Thus, avoidance of hypoglycemia is an important consideration in establishing goals and choosing therapeutic agents in older adults. See 'Avoiding hypoglycemia' above and "Hypoglycemia in adults with diabetes mellitus", section on 'Strategies to manage hypoglycemia'.

See 'Cardiovascular risk reduction' above. The nutrition prescription is tailored for older people with diabetes based upon medical, lifestyle, and personal factors.

Exercise is beneficial to help maintain physical function, reduce cardiac risk, and improve body composition and insulin sensitivity in older patients with diabetes. See 'Lifestyle modification' above. Because of concern for hypoglycemia, some clinicians use insulin only for a short time to ameliorate glucose toxicity.

Once insulin secretion and sensitivity are improved, it may be possible to lower the dose or replace insulin with metformin or another oral hypoglycemic agent with lower risk of hypoglycemia. See 'Choice of initial drug' above.

Metformin will likely reduce glycemia safely at any level of hyperglycemia and further may reduce progression of hyperglycemia or the risk of developing diabetes-related complications.

See 'Metformin' above. An alternative option for patients who present with A1C near their medication-treated target and who prefer to avoid medication is a three- to six-month trial of lifestyle modification before initiating metformin.

The approach to choosing alternative therapy in metformin-intolerant patients is similar in older and younger adults. See 'Contraindications to metformin' above and "Initial management of hyperglycemia in adults with type 2 diabetes mellitus", section on 'Contraindications to or intolerance of metformin'.

The therapeutic options for patients who do not reach glycemic goals with lifestyle intervention and metformin are similar in older and younger patients.

All of the medications have advantages and disadvantages table 2. The choice of a second agent should be individualized based upon efficacy, risk of hypoglycemia, the patient's underlying comorbidities, the impact on weight, side effects, and cost figure 1.

See 'Persistent hyperglycemia' above and "Management of persistent hyperglycemia in type 2 diabetes mellitus". Another option is two oral agents and a glucagon-like peptide 1 GLP-1 receptor agonist. See 'Dual agent failure' above. In particular, complications that impair functional capacity eg, retinopathy, foot problems should be identified and treated promptly.

See 'Screening for microvascular complications' above. Cognitive function should be assessed routinely in older adults with diabetes. Unexplained deterioration in glycemia or nonadherence to diabetes care may reflect underlying depression.

See 'Common geriatric syndromes associated with diabetes' above. Why UpToDate? Product Editorial Subscription Options Subscribe Sign in. Learn how UpToDate can help you. Select the option that best describes you. View Topic.

Font Size Small Normal Large. Treatment of type 2 diabetes mellitus in the older patient. Formulary drug information for this topic. No drug references linked in this topic. Find in topic Formulary Print Share. View in. Language Chinese English. Author: Medha Munshi, MD Section Editors: David M Nathan, MD Kenneth E Schmader, MD Deputy Editors: Katya Rubinow, MD Jane Givens, MD, MSCE Contributor Disclosures.

All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Jan This topic last updated: Jan 04, Diabetes in older adults: a consensus report.

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Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med ; Riddle MC, Ambrosius WT, Brillon DJ, et al. Epidemiologic relationships between A1C and all-cause mortality during a median 3.

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Matyka K, Evans M, Lomas J, et al. Altered hierarchy of protective responses against severe hypoglycemia in normal aging in healthy men. Geller AI, Shehab N, Lovegrove MC, et al. National estimates of insulin-related hypoglycemia and errors leading to emergency department visits and hospitalizations.

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When and how to deintensify type 2 diabetes care. Apr 26, 5 min read. What are the symptoms of diabetes in older adults? Increased thirst and urination: Diabetes causes a buildup of excess glucose in your blood, which sends your kidneys into overdrive.

As the kidneys work to filter out this glucose, excess glucose is excreted into your urine, drawing fluids from your body along with it. This can leave you feeling more thirsty than normal polydipsia , which causes you to drink more liquid and urinate more frequently polyuria.

Excessive fatigue: Are you feeling more sluggish than usual lately? Another symptom of diabetes in older adults is extreme tiredness. Another reason for fatigue could be diabetes-related dehydration.

Wounds that heal more slowly: Some older adults with diabetes notice that cuts and bruises seem to heal at a slower pace than usual. Women who have diabetes may also experience more frequent bladder infections and vaginal yeast infections.

Hypoglycemia is defined as a blood sugar level below 70 mg. When blood glucose levels plummet, it can cause weakness, dizziness, shakiness, confusion, and even fainting. People with diabetes can elevate their blood sugar quickly by drinking fruit juice or eating glucose tablets.

Headaches: Our brain requires consistent delivery of glucose to function properly, which is not always compatible with the blood sugar dips and spikes associated with diabetes. It's no surprise, then, that headaches are a common symptom of diabetes in older adults.

Tingling sensations in hands and feet: Roughly half of people with diabetes have nerve damage, especially those who have been diabetic for many years. Blurry vision: High blood glucose levels can draw fluid out of the lenses of the eyes, making it difficult for them to focus.

When not properly treated, this diabetes symptom can cause the creation of new blood vessels behind your retina, damaging existing vessels. Eventually, it can lead to partial or complete vision loss. Gum problems: Another symptom of diabetes in older adults is red, swollen, painful gums.

This is because diabetes can compromise your body's immune system, increasing the likelihood of infection in your gums and in the bones that anchor your teeth. Some warning signs to look out for in addition to inflamed gums include loose teeth, sores, and pus-filled pockets in your gums.

Increased appetite: Have you noticed an unusual bump in your appetite, particularly when it comes to sugary foods? Another warning sign of diabetes in seniors is being hungrier than usual—a condition called polyphagia.

This condition can trigger a frustrating cycle of eating more, which leads to higher blood sugar, which further increases your sugar cravings. Dry mouth: Also known as xerostomia, dry mouth is another sign of diabetes in older adults.

Often accompanied by dry, cracked lips and a rough-feeling tongue, this uncomfortable sensation occurs when your mouth is unable to produce enough saliva. This diabetes symptom may come and go with fluctuations in your blood sugar.

What should I do if I have symptoms of diabetes? They will likely use one or more of the following tests to screen you for diabetes: A1C test: This test measures the average of your blood glucose levels over the course of two or three months.

Oral glucose tolerance test: With this diabetes test, your blood glucose is measured both before and two hours after you drink a glucose-containing liquid. The objective is to see how your body responds to the glucose. Fasting plasma glucose test: For this blood test, you must refrain from eating for at least 8 hours.

Another version of this test is the random plasma glucose test, which can be given at any time of day without the need for fasting. Sources 1. pdf 2. Was this helpful? Yes No. More Ways to Manage Your Health Get information on prevention and how to manage ongoing health conditions focused on physical and mental health.

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There Hy;oglycemia much to be learned from indiviiduals who have Hypoglycrmia the unintended effects Hypoglycemia in elderly individuals medication therapy. Individuzls this knowledge base Hypoglycdmia, it is important to seek systematic reviews and meta-analyses of these effects and to rely on the idividuals these studies provide in Hypoglycemia in elderly individuals to slderly serve patients through appropriate medication Enhancing nutrient bioavailability levels and Nutrient-dense eating medication-therapy management MTM services. In light of the fact that advancing age is a risk factor for drug-induced DI hypoglycemia TABLE 1this brief discussion will provide nuanced guidance and additional resources to help pharmacists better individualize pharmaceutical care to this vulnerable patient population. Before implicating a drug as the cause of DI hypoglycemia TABLE 3other possible etiologies e. For those patients receiving medications known to cause hypoglycemia, providing education regarding the associated signs and symptoms, the importance of follow-up testing, and the need for careful management and close medical supervision is imperative. While an organic imbalance between plasma glucose and insulin concentration can result in hyperglycemia or hypoglycemia, drugs may also induce hyperglycemia or hypoglycemia via mechanisms as varied as 4 :. Hypoglycemia in elderly individuals

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