Geriatricians face a lot of challenges when providing diabetes care, and the challenges really stem from the fact that most older adults don’t just have diabetes. They’re likely to have hypertension, many of them may have chronic renal disease, but they also may have things that aren’t directly related to their diabetes, such as osteoarthritis, chronic pain from other problems.
I think the biggest challenges are really about setting priorities and making sure that you keep things as simple as you can, but at the same time, making sure that you’re offering the therapies that reduce morbidity and lengthen life and improve quality of life for patients.
Another big challenge with caring for older adults with diabetes is that it is a very heterogeneous population. Now when you think about it, if somebody is 68 or 69, they could be a person who’s had type 2 diabetes for 30 years, and it could be well controlled. But you can also have somebody at the same age who may have already had a stroke, who may have found out a year ago that they have type 2 diabetes. So, we can’t just go with age. We have to really think about life expectancy. We have to think about what are the other chronic conditions that the person has under treatment. We also have to think about their functional status, and we have to think a lot about their cognitive status and family support.
We know that older adults with type 2 diabetes are much more likely to get a group of conditions that we call the geriatric syndromes than people who are of a similar age and don’t have diabetes.
These geriatric syndromes include gait problems and falls, cognitive impairment, higher rates of depression, higher rates of chronic pain, urinary continence, and challenges with what we call polypharmacy.
Medicare beneficiaries, oftentimes people over 65, will be on six or more prescription drugs. And when you think about how hard it is to just take one antibiotic correctly when you get sick, you can imagine what it must be like to try to take all of these pills correctly every day.
The probability of drug-drug interactions, creating yet a third symptom, happens quite frequently. And as medical regimens get more complex and more medications are added, adherence goes down.
So, in addition to taking care of the diabetes, these conditions really need to be screened for because many of them are treatable.
And I have to mention that particularly depression travels a lot with diabetes, and we have a growing evidence base that, if you don’t treat the depression, it’s very hard, not only for older adults but for all adults, to take care of their diabetes.
You really have to take a very holistic approach to the person you’re treating and, as much as possible, you need to engage them in shared decision-making. So, with patients with type 2 diabetes who are older, the frail ones and the people with impaired cognition, there are a lot of family meetings in these decision-making sessions. And we really, as a group, have to decide what’s going to be the most feasible and practical care plan to keep someone’s quality of life as high as possible, for as long as possible, and to keep the burden of our treatments as low as possible.
The Guiding Principles have a lot of very useful information for taking care of older adults. And the document that came out of this process has 10 guiding principles.
They’re very practical. And for all of us who care for older adults with type 2 diabetes, it provides a very efficient place to find that information. So, I would encourage you to look at it and incorporate some of the suggestions into your practice. I think you’ll find it helpful.