running head: DIABETES MELLITUS II IN THE ELDERLY 1

Diabetes Mellitus II in The Elderly

Sammie Bowmaster

James Madison University

DIABETES MELLITUS II IN THE ELDERLY 2

Abstract

This paper discusses Diabetes Mellitus II (DMII) in the elderly including diagnosis, treatment,

and complications. A diagnosis of DMII can be very debilitating to an aging adult. DMII

requires a complete lifestyle change; diet and exercise are mandatory, and medication may be

necessary. Oral and injectable medication, as well as diet compliance is vital in order to prevent

complications. According to Chentli, Azzoug, & Mahgoun (2015), advancements in medication

technology are allowing easier administration, therefore make more treatment options available.

Collaboration is necessary between the patient, family members and healthcare team members to

provide the best quality of life possible.

DIABETES MELLITUS II IN THE ELDERLY 3

Diabetes Mellitus II in The Elderly

Diabetes Mellitus II (DMII) is the seventh leading cause of death in elderly adults

(Eliopoulos, 2018). It is estimated that around twenty percent of older adults 65 to 74 years of

age have been diagnosed with DMII (Eliopoulos, 2018). The incidence of diabetes is expected

to double in the next twenty years (Yakaryilmaz & Ozturk, 2017). Aging adults face many

challenges with a diagnosis of DMII. Navigation of a new way of life after being diagnosed with

DMII would be undoubtedly difficult for anyone, especially for the aging population.

Management of new medications and their side effects, change in diet, financial burdens,

complications, and ways to cope are some of the obstacles they must overcome. The goal of this

paper is to discuss Diabetes Mellitus II, its treatments and complications.

Hyperglycemia and insulin resistance largely contribute to Diabetes Mellitus II in the

elderly (Chentli, Azzoug, & Mahgoun, 2015). Inadequate amounts of insulin in circulation,

disrupted glucose metabolism, beta-cell insufficiency, and diminished tissue sensitivity are all

physiological factors that impact hyperglycemia in the elderly. (Mordarska & Godziejewska-

Zawada, 2017). Longer life expectancy, genetic disposition, and obesity also contribute to a

higher prevalence of DMII in the elderly.

Aging can cause difficulties when diagnosing DMII. Classic symptoms of DMII such as

frequent urination and excessive thirst may not be present (Sommers & Fannin, 2015). Atypical

symptoms such as incontinence, cognitive impairment, neuropathy, and depression may initially

be attributed to aging or other medical conditions (Chentli, Azzoug, & Mahgoun, 2015). In fact,

symptoms of advanced dehydration usually are the first to point to a possible diagnosis of DMII.

The diagnosis of DM II in the elderly may require multiple glucose intolerance tests to ensure

positive results.
DIABETES MELLITUS II IN THE ELDERLY 4

The American Diabetes Association (2016) states that the diagnosis of diabetes should be

established based on one of the four criteria listed: symptoms and a random blood glucose level

of greater than 200 mg/dL, HbA1c of greater than or equal to 6.5%, an 8 hour fasting blood

glucose concentration of greater than or equal to 126mg/dL, and finally, a blood glucose

concentration two hours after oral glucose intake of greater than or equal to 200mg/dL.

However, HbA1c is not a recommended criterion for the elderly because the test can have

increased variation based upon red blood cells (Kalra & Sharma, 2018). Conditions affecting the

HbA1c include anemias, recent blood transfusions, acute illness/hospitalization and chronic liver

disease (Chentli, Azzoug, & Mahgoun, 2015). Due to the complex nature of diagnosing DMII, it

is recommended persons 45 years or older begin fasting blood sugar tests every three years

(Eliopoulos, 2018). Screening in the elderly should be performed annually however, glucose

should be checked anytime laboratory specimens are collected (Kalra & Sharma, 2018).

Aging adults with a diagnosis of DMII are likely to have co-morbidities such as high

blood pressure, dyslipidemia, obesity, chronic pulmonary diseases, sarcopenia, kidney

insufficiencies and etc. (Chentli, Azzoug, & Mahgoun, 2015). They are also more at risk for

complications such as cardiovascular disease, functional disability, cognitive impairment and

depression (Chentli, Azzoug & Mahgoun, 2015). Neuropathy, retinopathy and accelerated

atherosclerosis are typically seen in this population (Chentli, Azzoug, & Mahgoun, 2015).

Neuropathies in the foot can prevent or slow wound healing (Chentil, Azzoug, & Mahgoun,

2015). Therefore, providing foot care is paramount to diabetics any wound unattended could

lead to amputation. Medication compliance is important to prevent unnecessary medical

complications.
DIABETES MELLITUS II IN THE ELDERLY 5

The goal of treatment of diabetes in the elderly is to provide the best quality of life

possible while avoiding complications. Treatment plans can vary based on the patient's status,

the patient may independent, require limited assistance, or totally dependent. According to

Chentli, Azzoug & Mahgoun (2015), individualized treatment is key. Glycemic targets also vary

based on cognitive level and physical activity. If a patient is physically active and cognitively

independent, they should maintain an HbA1c of 7% or below (Chentli, Azzoug, & Mahgoun,

2015).

Management of Diabetes Mellitus includes non-pharmacological methods such as diet

and exercise and pharmacological treatment such as injectable and oral medications. Lifestyle

modifications such as physical activity and diet are necessary steps in the successful treatment of

DMII. Physical activity promotion is important as it will provide an opportunity to increase

muscle strength and assist in weight loss. Prevention of obesity is ideal as it is a major risk

factor in the development of DMII in the elderly due to its association with insulin resistance

(Chentli, Azzoug, & Mahgoun, 2015).

Promotion of new eating habits and food counseling are necessary when creating a

treatment plan. Discussion of the glycemic index and carbohydrate intake is a critical part of the

diabetic diet (American Diabetes Association, n.d). According to Kalra (2013), it is beneficial to

use the eight A's of dietary prescription: accurate, appropriate, accessible, acceptable, attractive,

achievable, affordable, and absorbable/digestible during the creation of a dietary plan.

Restriction of calories should only be considered in obese elderly patients (Chentli, Azzoug &

Mahgoun, 2015). It is essential to aid the patient in building confidence in their abilities to

change their lifestyle, empowerment will promote their success (Kalra, 2013).
DIABETES MELLITUS II IN THE ELDERLY 6

Medications used to treat DMII can be split into two categories, oral and injectable. Oral

medications include Metformin, sulfonylureas (glimepiride), and, Thiazolidinediones

(pioglitazone) (Chentli, Azzoug, & Mahgoun, 2015). Other oral medications exist but some have

not been widely used with elderly patients and some are contraindicated in elderly patients due to

nephrotoxicity, such as sodium-glucose co-transporter type 2 inhibitors (canagliflozin)(Chentli,

Azzoug, & Mahgoun, 2015).

Metformin is commonly chosen as the first line treatment because of its low risk for

hypoglycemic events and low cost to the patient (Yakaryilmaz & Ozturk, 2017). Metformin

works by decreasing hepatic glucose release and increases insulin sensitivity (Chentli, Azzoug,

& Mahgoun, 2015). Metformin should not be prescribed to patients with a history of cardiac

insufficiency, stroke, myocardial infarction, or kidney insufficiency (Chentli, Azzoug, &

Mahgoun, 2015). In fact, metformin should not be given to elderly patients with a glomerular

filtration rate of 30ml/min or less (Chentli, Azzoug, & Mahgoun, 2015). When taking

metformin, it is important to educate the patient to stop taking the medication before any surgery

or any procedure involving contrast dye and to stay hydrated to avoid renal impairment (Chentli,

Azzoug, & Mahgoun, 2015).

Sulfonylureas such as glimepiride work by limiting hepatic glucose. Sulfonylureas are

commonly used when metformin is not tolerated or contraindicated. These drugs have the

potential to cause hypoglycemia and should be avoided in patients with renal insufficiency,

dementia, and/or heart failure (Yakaryilmaz & Ozturk, 2017). Short-acting sulfonylureas, such

as meglitinides are preferred in the elderly because there is a lower risk of hypoglycemia

(Chentli, Azzoug, & Mahgoun, 2015). It is important to educate the patient not to skip meals
DIABETES MELLITUS II IN THE ELDERLY 7

while taking this medication and that this class of drug may cause weight gain and fluid retention

(Yakaryilmaz & Ozturk, 2017).

Thiazolidinediones, such as pioglitazone, improve glucose response as they affect insulin

sensitivity in peripheral tissues and skeletal muscle (Yakaryilmaz & Ozturk, 2017). This class of

drug has a low risk of hypoglycemia and can be taken in conjunction with metformin

(Yakaryilmaz & Ozturk, 2017). These drugs are tolerated well in the elderly population but

should not be prescribed to patients with a history of congestive heart failure as fluid retention is

the main side effect of these drugs (Chentli, Azzoug, & Mahgoun, 2015). This class of

medication is not widely available or accessible due to its high cost in comparison to other

medications on the market (Chentli, Azzoug, & Mahgoun, 2015).

Insulin may be used in patients who have an HbA1c level of greater than 9%, a random

glucose level of greater than 300mg/dL, or patients with ketones present in urine (Yakaryilmaz

& Ozturk, 2017). Before the use of insulin, it is essential to assess the patient's cognitive

abilities. Patients using insulin will be required to use a glucometer to assess their blood glucose

level, calculate their insulin dosage and be able to draw their own insulin with a syringe or using

an insulin pen. Some patients will need the assistance of their family members or caregivers to

administer their insulin. Studies have shown that insulin therapy in the elderly has led to a better

quality of life (Chentli, Azzoug, & Mahgoun, 2015). New technologies such as insulin pens and

glucometers have allowed more independence in the elderly population. It is important to

educate patients not to skip meals and if meals are skipped or no carbohydrates are consumed,

insulin level should be held or adjusted as needed (Yakaryilmaz & Ozturk, 2017). Insulin is not

advised for use in patients with chronic renal insufficiency or patients with a glomerular filtration

rate of 50ml/min (Chentli, Azzoug, & Mahgoun, 2015).

DIABETES MELLITUS II IN THE ELDERLY 8

There are many challenges of medication therapy in the elderly, nutrition and hydration

may be impaired due to physiological changes such as difficulty chewing and swallowing,

gastric upset, impaired thirst mechanisms and change in bowel habits (Yakaryilmaz & Ozturk,

2017). All of these physiological changes can cause complications with diabetic medications.

This population should be educated about the physiological changes occurring in their body and

the importance of staying hydrated and ingesting carbohydrates at meal times (Chentli, Azzoug,

& Mahgoun, 2015).

Compliance of lifestyle modifications and medication regimens are vital in maintaining

control of DMII in the elderly. However, compliance has become increasingly difficult for

elderly patients who are experiencing the financial burden related to the cost of their conditions

and medications. According to Choi et al. (2017), elderly adults diagnosed with diabetes take on

average eight medications per day and the cost of their prescriptions are almost five times higher

than those younger than 65 years of age. Elderly individuals with chronic conditions are more

likely to experience the Medicare gap and maintain poor adherence to medications. Poor

compliance with diabetes medications can lead to increased hospital admissions. More than one-

third of all patients hospitalized over the age of 65 suffer from DMII (Yakaryilmaz & Ozturk,

2017). Medication compliance is key in preventing unnecessary complications.

This paper has outlined essential information regarding Diabetes Mellitus II. In

conclusion, the collaboration between the healthcare team, family, and the patient is important

for successful management of DMII. It is important to ensure that the patient is coping

positively. It is easy for patients to sink into a depression with unwanted change.

Encouragement can assist in promoting the necessary lifestyle modifications and treatment plan.

Treatment plans are very individualized for this population. It is necessary to take into account
DIABETES MELLITUS II IN THE ELDERLY 9

the vascular age over the numerical age when creating the treatment plan Chentli, Azzoug, and

Mahgoun, 2015). Medications should be started at a low dose and moved slowly to prevent

hypoglycemia or any other medication complication (Chentli, Azzoug, and Mahgoun, 2015). It

is important that the treatment plan provides the best quality of life possible. Many advances in

insulin medication management have made administering insulin easier, therefore, prompting

providers to utilize it more (Chentli, Azzoug, & Mahgoun, 2015). Patient education is vital with

this disease. Misunderstanding any piece of information could have major consequences.

Compliance issues with medication may occur due to insurance lapse and financial burden.

However, non-compliance of diet, exercise, and medications can lead to a variety of

complications including blindness, amputation, and micro and macrovascular accidents

(Yakaryilmaz & Ozturk, 2017). The healthcare team should remain up-to-date on new research,

technology, and treatments that will assist in providing a better quality of life to elderly patients

suffering from Diabetes Mellitus II.

DIABETES MELLITUS II IN THE ELDERLY 10

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American Diabetes Association. (2016, November 21). Diagnosing Diabetes and Learning
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