|
Introduction
Six percent of our population is over the age of 60 years. With the improvement in health
care system and also with effective implementation of fertility control, population of aged is bound to increase. Hence there is a real need to understand Diabetes in Geriatrics age Group.
Who is an elderly diabetic?
When the diabetes for the first time is detected in a patient aged 60 years or above then
he is considered as a elderly diabetics.
How diabetes presents clinically in elderly? About 25% of elderly diabetic patients have
asymptomatic onset. Diabetes is discovered in the above group accidentally because of preoperative check up or routine check up. In the remaining onset is symptomatic.
Table :- Modes of clinical presentation of diabetes in geriatric age-group
1. With the classical symptoms
2. Hyper Osmolar non ketotic coma.
3. Diabetic ketoacidosis
4. With chronic complications like:
A) Neuropathy
B) Coronary artery disease
C) Peripheral Vascular disease
D) Infections-Common being foot infection and pulmonary tuberculosis.
What are the diagnostic problems in diabetes in the aged
There is hyperglycemia without glycosuria. Urine sugar is often negative and misleading.
This is because renal threshold for glucose raises with age. Hence control of therapy based on urine analysis alone is inadequate and often misleading.
Elderly patients may have urinary incontinence this will cause difficulties in obtaining
specimens of urine and diabetic state cannot be assessed by urine examination alone from time to time.
Blood sugar estimation
With advance of age there is a gradual tendency for the level of blood sugar to raise.
Whether this is aging process or increase frequency of diabetes is still controversial.
It is said that to the extent of 50% or more over the age 70 years would be suspected of
being diabetic if criteria developed for younger people are used. It is customary to add 10 mgm. percent for each decade over age 50 years for the one hour postprandial sugar values 5,6,7. The diagnosis of diabetes in the elderly should be made on fasting glucose level, only if the values are over 140 mgm% on more than one occasion.
Management of diabetes in elderly
I-Diet
Majority of diabetics are controlled with diet alone. Old have difficulty in following
complicated diet sheets. Simplicity of dietary regieme is essential for compliance. Ideal diet for the elderly may be difficult to achieve for many reasons. Dietary instruction should take into account all the preceding factors.
Factors to be considered in old diabetics before prescribing diet
1. Socio economic factors.
2. Difficulty in understanding the instruction.
3. Patient may live alone with no one to look after.
4. Absent Teeth and Faulty Denture.
Caloric restriction sufficient to correct any excess weight, avoidance of refined sugar,
nutrionally adequate food and often small in between meal and bed time feeding are recommended.
II Exercise
No new unaccustomed exercise is advised to elderly diabetics. He can participate in mild
forms of exercise.
II-Oral hypoglycemic drugs
If drug therapy is deemed necessary use short acting suplhonylurea like Tolbutamide
rather than long acting chlorpropamide because Chlorpropamide has the risk of inducing hypoglycemia in elderly. 60% of the drug is excreted unchanged in urine. It has a prolong half life of 36 hours. Hence with renal impairment severe prolonged hypoglycemia can occur. While tolbutamide has short half life and transformed in liver to inactive metabolites which has no hypoglycemic effect and hence with renal impairment no danger of hypoglycemia is there.
Hypoglycemic effect may be potentiated by starvation, ethanol, Salicylates, Monoamine
oxidase inhibitors, sulfonamides, bishydroxy coumarin and phenylbutazone.
Oral hypoglycemic agents must be used with great caution in patients who have renal and
hepatic disorders where the drug metabolism and excretion are deranged.
Insulin
In a relatively small but very definite percentage of elderly patients treatment with insulin is
necessary for control of diabetes. Rarely such patients go in for diabetic ketoacidosis which carries high mortality. 12 When elderly patients present with complications of diabetes particularly foot problem, infections and/or gangrene then insulin therapy is the only choice. It is better to give slightly less amount of insulin rather than tight control of hyperglycemia as hypoglycemia in elderly carry greater risk. With hypoglycemia, there is concommitant release of catecholamines which may lead to fatal cardiac arrythmias in elderly. Further more elderly diabetic patients with some degree of pre- existing arteriosclerosis 'may have more profound central nervous system symptoms associated with hypoglycemia. In addition to classic signs of hypoglycemia in these patients confusional state is seen or occasionally hemiplegia may also occur.
If insulin is required at home and should impairment of vision render the patient unable to
measure or administer insulin with safety then a responsible relative must be trained in its administration.
B-Renal failure in elderly diabetics
In elderly diabetics when renal failure occur in addition to diabetic glornerulosclerosis
other causes like hypertensive nephrosclerosis, chronic pyelonephritis, obstructive uropathy due to stone, senile enlarged prostate and neuropathic bladder are to be considered.
Diabetics show abnormal urodynamics. Bladder becomes greatly distended due to autonomic neuropathy and uretral orifice incompetence occur which results in uretral reflux, this is turn predisposes to infection and hydronephrosis.
C-The diabetic foot
Elderly diabetic is prone to get foot lesion because of poor circulation, neuropathy,
infection and uncontrolled diabetes. All factors aggravate and can lead to life threatening gangreane.
D- Cancer and diabetes
Pancreatic carcinomalS is three times greater in diabetics as compared to non diabetics.
Endometrial carcinomalS is more commoner in diabetic women as compared to non-diabetics.
E-Hypertension and diabetes
Incidence of hypertension increases with age of the patient and the duration of his
diabetes. In a juvenile onset (type-I) diabetes the etiology of hypertension is renal secondary to diabetic glomerulosclerosis or chronic pyelonephritis whereas elderly diabetics, hypertension is essential. Quite often they may have systolic hypertension only without any elevation of diastolic pressure. The systolic hypertension is related to accelerated atherosclerosis.
Conclusion
Old age itself leads to change in carbohydrate metabolism and diabetes. Micro & Macro
angiopathy affect mainly heart, eye, peripheral vascular system and nerves. The last two complications lead to foot lesions, which are dangerous can lead to gangrene and amputation. Diabetic hypertensive patients show low plasma renin and the therapy is complex and difficult. The main therapy for the elderly diabetic patient is a planned diet, which is tailored to an individual in terms of socio-economic status.
If oral hypoglycemic agents are to be used short acting drugs like tolbutamide is preferred.
A small percentage may need insulin for control of diabetes. In these patients it is better to give under dosage because of risk of hypoglycemia and associated danger.
REFERENCES
1. Central Bureau of Health Intelligence. Pocket Book of Health Statistics of India.
D.G.H.S., Ministry of Health and Family Welfare, Govt. of India, New Delhi 1977.
2. P.G. Raman, S.K. Khanijo, Tiwari, A.K. and B.N. Bisariya Jr.: Diabetic Ass. India Vol.
XVI, July 1976.
3. Spence et al. : Some observation on sugar tolerance with special reference to
variations found at different ages Quarterly Journal of Medicine 14:314; 1921.
4. Cowdry's : The care of Geriatric patient page 135, Edited by Steinberg 1978.
5. Grobin, W.:Diabetes in the aged under diagnosis and over treatment, Canada Med.
Ass.Jour.105: 915-23; 1970.
6. Reubin: Effect of age in interpretation of Glucose and Tolbutamide tolerance test.
Diabetes Mellitus. Diagnosis a treatment chapter XX page 115 published by Amer.
Diab. Association 1971.
7. Streeton, D.H.P. et al: Reduced glucose tolerance in elderly human subjects.
Diabetes 14: 579-83; 1965.
8. O'Sullivan, J.B, Mahan, C.E, Frudlender, A.E, and William, R.F.: Effect of age on CHO
metabolism Jr. Clinical Endocrinology and Metabolism 33: 619; 1971.
9. Duck Worth and Kitabchi, A.E. : Effect of age, obesity and degree of carbohydrate in
tolerance on proinsulin response to oral glucose diabetes (21) supplementl:356,1972.
10. Unger, R.H., Madison, L.C. and Muller W.A. ; Abnormal alphacell function in diabetes
and response to insulin. Diabetes 21: 301; 1972.
11. Brodows, R.G. and Cambell, R.: Effects of age on post heparin lipase activity/New
England journal of Medicine 287: 469; 1972.
12. Barnett, D.M., Willax, D.S, and Marble, A.: Diabetic Coma in persons over 60 years.
Geriatrics 17, 327,1962.
13. Non Ketotic diabetic Coma in Schwartz T.B.(Ed) yr. Book of Endocrinology P.165;
1965-1966.
14. Buck and Coworker C.U., Reed. P.I. et al. : The diabetic bladder Proc. Royal society
Med. 67-81; 1974.
15. Alexander Marble, Priscilla White, R.F., Bradley and L.P. Krall: The pathology of
Diabetes mellitus Page 183, Joslin Diabetes Mellitus. llth Ed. 1971 Lea and Febiger
Philadelphia.
16. Locke, S,, Lawrence, D G. and Legg, M.A.:Diabetic amyotrophy. Amer.J. Med. 34,
775; 1963.
|
