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Some individuals who take calcium supplements might experience gastrointestinal side effects including gas, bloating, constipation, or a combination of these symptoms. TLR-induced local metabolism of vitamin D3 plays an important role in the diversification of adaptive immune responses. This training includes diabetes detection and institutional quality assessment. The best way to prevent trichinellosis is to cook meat to safe temperatures…Do not sample meat until it is cooked. Older adults with diabetes should be carefully screened and monitored for cognitive impairment 3. Low finger-stick blood glucose values should be confirmed by laboratory glucose measurement.
Hearing loss may contribute to a patient's inability to fully understand instructions from providers. Hearing and vision impairment can also limit social interaction and independence and have untoward psychosocial effects e. Such impairments should be identified and addressed during diabetes education and training, and management plans should be modified as needed.
Older adults with multiple comorbidities, including geriatric syndromes, may experience a failure-to-thrive pattern of decline. Coexisting chronic medical conditions such as hypertension, chronic kidney disease, heart failure, chronic lung disease, musculoskeletal conditions, cancer, and history of stroke require particular attention.
These comorbidities can have profound impacts on functional status and quality of life 20 , 21 and affect insulin requirements and self-care abilities. Older adults with type 1 diabetes may require frequent adjustments in insulin dosing, especially during acute illnesses, to decrease the likelihood of dehydration, DKA, hypoglycemia, and poor wound healing. Incontinence is common in older women with type 1 diabetes and has a greater prevalence than neuropathy, retinopathy, and nephropathy. Because hyperglycemia worsens incontinence, bladder infections, and vaginal candidiasis, achieving satisfactory glycemic control to avoid glucose-induced polyuria and nocturia is recommended.
Polypharmacy, which is common in diabetes, predisposes older adults to drug-to-drug interactions and adverse drug effects caused by altered drug disposition from age-related changes in drug metabolism. Careful selection of medications that have a strong benefit-to-risk ratio, prescription of the lowest doses possible, consideration of renal function, and discontinuation of medications that are no longer needed or are causing undue adverse events are all important.
Medical nutrition therapy is an essential component of diabetes care. Mealtime insulin dosing is designed primarily to match the carbohydrate content of meals, but inconsistent food intake is common in older adults, and numeracy skills are often lacking. This can be responsible for wide glycemic fluctuations. Older adults with diabetes can also develop micronutrient deficiencies from declining caloric intake with aging.
Tooth loss and dental disease, inability to shop for groceries or prepare or consume meals, depression, swallowing difficulties, and polypharmacy can lead to undernutrition. Weight loss, whether intentional or unintentional, may contribute to nutritional deficits, worsen sarcopenia, and reduce bone health.
Dietary counseling is recommended. Fortified foods and nutritional supplements can be used. Older adults may find community resources such as Meals on Wheels or meals served at local senior centers beneficial. In the presence of poor and unpredictable food intake, consideration should be given to administering rapid-acting insulin immediately after meals instead of before so lower doses can be given if less food is consumed.
Unlike other chronic conditions, diabetes management involves performing multiple complex self-care tasks, including frequent SMBG and appropriate adjustment and self-administration of insulin multiple times daily. Cognitive dysfunction, which can vary in magnitude from subtle deficits to overt dementia, affects the ability of older adults with type 1 diabetes to self-manage their disease.
Although vascular disease in type 1 diabetes has been associated with brain damage, glycemic control also appears to play a role in cognitive performance.
When impaired cognition becomes evident, screening for alcohol use, thyroid dysfunction, and vitamin B 12 deficiency should be considered. Older adults may not display typical signs and symptoms of hypothyroidism, and there is an increased risk of autoimmune thyroid disease in type 1 diabetes.
Recognition of cognitive deficits, assistance from family members or caretakers, simplification of treatment regimens, and use of cognitive aids can all be helpful for older patients with type 1 diabetes.
Physical disabilities are common in older adults with diabetes and predict future decline in health status and reduction in quality of life. These conditions can interfere with the ability to keep medical appointments and perform activities of daily living. Physical activity is an important component of diabetes care. Even light-intensity physical activity has been associated with self-reported improvements in physical health and psychosocial well-being. Supervised home- and community-based exercise programs should be encouraged.
To avoid hypoglycemia during or after increased physical activity, insulin dosing at the previous meal should be reduced or omitted or a carbohydrate snack should be given just before exercise. Basal insulin dosing may need to be lowered with regular daily physical activity.
Fall risk should be assessed periodically in older adults. Fall prevention should be reviewed with all older adults with type 1 diabetes. Daily calcium intake diet plus supplements should be 1,—1, mg, and vitamin D intake should be —1, IU. Adults with diabetes have a high prevalence of depression. Untreated depression not only negatively affects self-care, medication adherence, and lifestyle choices, but also can be responsible for anorexia, nausea, constipation, and loss of appetite. Alterations in food intake can contribute to fluctuations in glucose levels and increase the risk of hypo- and hyperglycemia.
Depression screening at regular intervals can help identify older adults who may benefit from antidepression treatment. In older adults with a long duration of type 1 diabetes, acute and chronic complications, as well as other causes of stress, are common.
Effective coping and social support can help improve adherence, glycemic control, and quality of life. There has been little research examining the best treatment approaches for older adults with type 1 diabetes.
The American Diabetes Association ADA and the American Geriatrics Society AGS recommend a collaborative and integrated team approach to treating older patients with diabetes, using a variety of strategies to assess and address age-specific barriers and provide individualized treatment plans and education to patients and their partners or caretakers.
In the absence of guidelines specifically for older individuals with type 1 diabetes, these general principles are used. A framework is provided for consideration of glycemic goals Table 2 and treatment goals for blood pressure and dyslipidemia Table 3 in older adults based on health status and comorbidities.
Healthy, independently functioning older adults should be treated more aggressively than those who are frail or who have multiple comorbid conditions and disabilities associated with a limited life expectancy.
Frailty is defined as the presence of three of five of the following: Lower goals can be considered in the absence of hypoglycemia and if they can be achieved without undue burden. Older adults with complex or intermediate health status have multiple chronic illnesses; have mild to moderate cognitive impairment or dependency in more than two instrumental activities of daily living; and are susceptible to hypoglycemia.
Complex insulin regimens may become difficult for them to follow. Frequent SMBG is important to guide insulin therapy and detect and avoid hypoglycemia. Insulin regimens should be simplified according to patients' preferences. The need for diabetes education should be periodically assessed.
Family members and caretakers should participate in education, training, and follow-up. They should be reminded that basal insulin should not be discontinued during inter-current illness or during periods of poor oral intake because this could lead to DKA.
With serious hyperglycemia, attention is needed in monitoring hydration and electrolyte status, and abnormalities should be carefully treated. Physical activity should be encouraged to help maintain functionality, and regular screening for barriers to adequate management of type 1 diabetes should be followed with appropriate intervention. Continued surveillance of diabetes-related disabilities should be a priority, along with interventions to reduce disability.
Periodic comprehensive geriatric assessments should be carried out to identify functional and cognitive decline, as well as psychosocial concerns. Frequent communication with the diabetes care team and use of community resources can be helpful.
Insulin therapy is required in type 1 diabetes to prevent serious hyperglycemia and DKA. Insulin treatment strategies and delivery approaches must be individualized and will differ between healthy older adults and those with frailty and limited life expectancy. Multiple daily injection MDI insulin regimen.
The basal insulin is commonly once-daily insulin glargine or once- or twice-daily insulin detemir. Insulin detemir, particularly in low doses, may not be effective for 24 hours and may need to be given twice daily. Insulin detemir may be associated with less hypoglycemia than insulin glargine. To achieve good glycemic control, prandial insulin dosing should take into account the premeal blood glucose level and anticipated carbohydrate intake and activity.
If food intake is uncertain, rapid-acting prandial insulin can be given immediately after the meal so the dose can be adjusted based on actual intake. Many healthy adults use insulin-to-carbohydrate ratios and correction factors to calculate their mealtime doses. This approach becomes more difficult with aging and the development of geriatric syndromes. Older individuals with these syndromes may require the assistance of their partner or caretaker.
An alternative approach relies on fixed meal dosing and an eating plan that provides consistent carbohydrates at each meal and consistent timing of meals.
To avoid hypoglycemia, correction dosing should be prescribed with great caution in the presence of frailty and used only to correct for serious hyperglycemia. Frail individuals also have a high risk of acute illness and hospitalization and may require frequent insulin dose adjustments with changes in their overall health status.
Periodically, a diabetes educator should evaluate the ability of older individuals or their caretaker to perform the necessary tasks to properly administer insulin. Some older patients use NPH insulin twice daily and regular insulin before breakfast and dinner and at lunch if the morning NPH effect is insufficient to cover lunch because the cost of these insulin formulations is less than that of insulin analogs.
Because of the increased risk for hypoglycemia with these insulin preparations, snacks may be needed mid-morning, mid-afternoon, and at bedtime to avoid hypoglycemia. Glucose levels should be checked in the middle of the night to rule out nocturnal hypoglycemia.
Administering NPH insulin at bedtime instead of before dinner can be helpful in reducing nighttime hypoglycemia. Continuous subcutaneous insulin infusion CSII. Insulin pump therapy is commonly used in adults with type 1 diabetes and has been associated with less hypoglycemia and better quality of life than MDI regimens.
With aging, the use of CSII may become difficult. Pump therapy can be continued as long as individuals are capable of properly using a pump or their partner or caretaker is capable and willing to take over this responsibility.
Pump therapy has the advantage of being able to provide more than one basal rate, permit the use of reduced temporary basal rate for increased activity, provide an insulin bolus calculator incorporated in the pump to calculate bolus dosing based on glucose level, carbohydrate intake, and sensitivity factor , and permit the use of extended or dual boluses for patients with gastroparesis.
The memory and vibration features may be helpful in the elderly population. As with MDI regimens, postmeal administration of prandial insulin via the insulin pump may be advisable to avoid hypoglycemia in individuals with unpredictable food intake. The use of CGM-augmented pump therapy has not been well studied in older adults. Hypoglycemia was reduced without deterioration in A1C levels. Premixed insulins are rarely used in type 1 diabetes because of their nonphysiological profiles. In specific circumstances when other regimens are not possible, twice-daily dosing before breakfast and dinner can be considered.
Snacks may be needed mid-morning, mid-afternoon, and at bedtime to avoid hypoglycemia. Glucose levels should be checked in the middle of the night to rule out hypoglycemia. Diabetes is a well-recognized risk factor for admission to long-term care LTC facilities. All of these factors make this population particularly vulnerable to wide glycemic excursions, with unrecognized hypo- and hyperglycemia.
Meals of fixed composition should be given with consideration to the residents' food preferences to avoid unintentional weight loss and malnutrition. Administration of fixed prandial insulin doses immediately postmeal if intake is uncertain is desirable to enhance patient safety.
Older adults with type 1 diabetes who are unable to ingest meals require basal insulin to avoid DKA. Premixed insulins should be used rarely because of the high risk of hypoglycemia given the variable dietary habits and poor ability to recognize and communicate about hypoglycemia in this vulnerable population. More frequent blood glucose monitoring is indicated during acute illnesses, when food intake is changing, and when adjusting insulin doses for hyper- or hypoglycemia.
Most older adults in LTC facilities are dependent on facility staff to perform self-care tasks. The staff should have diabetes education and training, understand the importance of glucose monitoring in type 1 diabetes, and be alert for possible hypoglycemia and serious hyperglycemia. Glucose monitoring results should be regularly reviewed, with modification of insulin dosing and diet as needed when hypoglycemia or severe hyperglycemia is detected.
Results from a pilot study suggest that telemedicine consultations may be of benefit in reducing hypoglycemia and severe hyperglycemic events for insulin-treated residents in skilled nursing facilities.
The risk of cardiovascular disease CVD is 7. Blood pressure should be lowered gradually to reduce the risk of hypotensive symptoms, especially in the frail elderly. Renal function and serum potassium should be monitored within 1—2 weeks of initiation of therapy for those taking ACE inhibitors or angiotensin receptor blockers and at least yearly thereafter. If diuretics are used to treat hypertension, electrolytes should be monitored within 1—2 weeks of initiation of therapy and periodically thereafter.
The ADA recommends annual monitoring of the fasting lipid profile. Statin therapy is indicated in healthy older adults and frail older adults with complex health status to reduce CVD morbidity and mortality, unless contraindicated or not tolerated. In older adults with poor health status and those residing in LTC facilities, life expectancy should be considered when determining the benefit of statin therapy.
The use of other lipid-lowering medications alone or in combination has not been shown to be of benefit in older adults with type 1 diabetes. The role of aspirin for primary prevention of CVD in older adults with type 1 diabetes is unclear.
Aspirin is also used in patients with known CVD for secondary prevention. The potential benefits of aspirin therapy should be weighed against the risk of bleeding in these individuals, especially in older adults with multiple medical conditions, severe cognitive impairment, or a high risk for falls. Older adults with type 1 diabetes are a heterogeneous group and have not been well studied. With long-duration diabetes, hypoglycemia is common, regardless of A1C level. Individualized treatment plans using more complex insulin regimens and lower glycemic goals with frequent SMBG are recommended in healthy older adults.
For individuals with poor health status and frailty, modifications are suggested. Older adults should be assessed for hypo- and hyperglycemia; hypertension; physical disabilities; vision, hearing, and cognitive impairments; pain; social support; urinary incontinence; polypharmacy; depression; nutritional deficits; fall risk; and the need for social services.
The treatment plan should focus on minimizing hypoglycemia and serious hyperglycemia and should address identified physical, emotional, and social challenges to enhance safety and quality of life.
In the future, new insulin preparations and technological advances are expected to contribute to better therapeutic approaches for this growing population. Weinstock has participated in multicenter trials funded by AstraZeneca, Biodel, Eli Lilly, GlaxoSmithKline, Medtronic, and Sanofi, all of which develop or sell products for the treatment of diabetes. We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail.
We do not capture any email address. Skip to main content. Weinstock , MD, PhD. Diabetes Spectrum Feb; 27 1: Abstract In Brief Older adults with type 1 diabetes are at high risk for severe hypoglycemia and may have serious comorbid conditions. Challenges in the Management of Type 1 Diabetes in Older Adults There is a paucity of data related to glycemic management and control of type 1 diabetes later in life. Hypoglycemia risk Hypoglycemia is a major barrier to achieving optimal glycemic control.
Chronic pain Chronic pain can lead to difficulty with self-care in older adults and can contribute to glycemic variability. Vision and hearing impairment Visual and auditory impairments affect the ability to perform self-care tasks and are related to aging, as well as vascular and neurological damage from diabetes.
Comorbid medical conditions Older adults with multiple comorbidities, including geriatric syndromes, may experience a failure-to-thrive pattern of decline.
View inline View popup Download powerpoint. Urinary incontinence Incontinence is common in older women with type 1 diabetes and has a greater prevalence than neuropathy, retinopathy, and nephropathy. Polypharmacy issues Polypharmacy, which is common in diabetes, predisposes older adults to drug-to-drug interactions and adverse drug effects caused by altered drug disposition from age-related changes in drug metabolism.
Nutrition concerns Medical nutrition therapy is an essential component of diabetes care. Cognitive impairment Unlike other chronic conditions, diabetes management involves performing multiple complex self-care tasks, including frequent SMBG and appropriate adjustment and self-administration of insulin multiple times daily.
Physical disability Physical disabilities are common in older adults with diabetes and predict future decline in health status and reduction in quality of life.
Physical inactivity Physical activity is an important component of diabetes care. Falls and fractures Fall risk should be assessed periodically in older adults. Depression risk Adults with diabetes have a high prevalence of depression. Diabetes-related distress In older adults with a long duration of type 1 diabetes, acute and chronic complications, as well as other causes of stress, are common.
Guidelines for Managing Type 1 Diabetes in Older Adults There has been little research examining the best treatment approaches for older adults with type 1 diabetes. Insulin therapy Insulin therapy is required in type 1 diabetes to prevent serious hyperglycemia and DKA.
Residents of long-term care facilities Diabetes is a well-recognized risk factor for admission to long-term care LTC facilities. Management of cardiovascular risk factors The risk of cardiovascular disease CVD is 7. Conclusion Older adults with type 1 diabetes are a heterogeneous group and have not been well studied.
Incidence and trends of childhood type 1 diabetes worldwide — Incidence trends for childhood type 1 diabetes in Europe during — and predicted new cases — Brussels, Belgium , International Diabetes Federation , The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus.
N Engl J Med Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. Prolonged effect of intensive therapy on the risk of retinopathy complications in patients with type 1 diabetes mellitus: Guidelines for improving the care of the older person with diabetes mellitus. J Am Geriatr Soc 51 5 Suppl. This content does not have an English version.
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