SAN FRANCISCO — Managing blood sugar, lipids, and blood pressure levels in elderly patients with diabetes is important, but don't forget to address their quality of life, Dr. Hermes Florez said at a meeting sponsored by the American Diabetes Association.
Be aware of common geriatric syndromes that affect quality of life as well as morbidity and mortality rates in people with diabetes, urged Dr. Florez, an endocrinologist at the University of Miami and the Miami Veterans Affairs Medical Center.
Screen for and treat the following geriatric syndromes as part of your routine care, he suggested.
Cognitive decline. People with diabetes have an increased risk for vascular dementia or Alzheimer's dementia, compared with people who don't have diabetes. One large study found nearly a doubling in age-adjusted risk for dementia if diabetes is present. Separate data suggest that factors that may contribute to the increased risk include chronic hyperglycemia, repeated episodes of hypoglycemia, polypharmacy, and microvascular or macrovascular complications of diabetes. There seems to be a trend toward greater likelihood of dementia with longer duration of diabetes.
Do at least a quick test for cognitive decline, such as asking the patient to draw a clock face, Dr. Florez said. If you have more time, do a more formal evaluation such as the Mini-Mental State Examination.
Polypharmacy. Although polypharmacy commonly is described as the use of five or more medications, Dr. Florez prefers to think of it as any prescription for a medication that may interact with a medication being used or with a disease it was not intended to treat. Certain antimicrobial medications interact with sulfonylureas, for example. If a patient on an ACE inhibitor for hypertension is prescribed a nonsteroidal anti-inflammatory drug for complaints of pain and stays on the latter for a year or two, a drug-drug interaction can occur that will worsen their hypertension, Dr. Florez said.
One cohort study of 418 elderly patients in Los Angeles found that 13% were taking 5 drugs and 14% were taking 10 or more drugs. Trying to intensify therapy for control of blood sugar, lipids, or blood pressure in these patients is a challenge. “Patients will be struggling to follow your instructions for additional medications,” he said, and some patients will not be able to afford all these medications.
Depression. A common syndrome in older patients with diabetes, depression of even minimal severity increases the risk for microvascular complications, disability, and mortality, compared with nondepressed patients with diabetes. Diabetes patients with depression of any severity are more likely to have poor glycemic control (hemoglobin A1c levels of 8% or higher), compared with nondepressed diabetes patients. “It's important always to ask about mood” and to assess with instruments such as the Geriatric Depression Scale, if indicated, he said.
Falls. It's also important to ask older patients about injurious falls. Frequent falls suggest that a diabetes patient is either having frequent hypoglycemic events or may have significant hyperglycemia and nocturia, increasing night-time wakening and the risk for falls on the way to the bathroom.
Look for reversible treatable causes of falls such as retinopathy, cataracts, and use of medications that can cause orthostatic hypotension, including thiazide diuretics for hypertension or α-2 blockers to treat benign prostatic hypertrophy. Ask about environmental factors in the home that may contribute to falls.
A quick, easy way to assess someone's risk for falling is to ask the patient to stand up from a chair without the use of arms. If you have more time, assessing gait and balance will provide more information.
Urinary incontinence. Poor glycemic control, heart failure, and some medications each can increase the risk of urinary incontinence. Behavioral modification can be helpful in some cases, Dr. Florez said. Poor eating habits and insufficient water intake may cause constipation that leads to urinary incontinence, which can be treated by increased intake of water and fiber.
Dr. Florez has received research funding from Merck & Co., which makes medications for diabetes.