Diabetes in the Elderly

Diabetes in the Elderly was written by Jennifer Spindola, NDTR, CDM, CFPP & reviewed/edited by Katie Dodd, MS, RDN, CSG, LD, FAND.

Americans are living longer than ever.

The U.S. Census reports that approximately 49 million Americans are 65 years of age or older. Even with these life expectancy gains, age itself is a risk factor for chronic conditions. For example, insulin residence, which can lead to diabetes. Diabetes is a condition that causes your blood sugar (AKA glucose) levels to be too high.

This article is for those experiencing pre-diabetes and diabetes and/or their caregivers. It dives deep into how to maintain glycemic control, medications affecting blood sugar, and effective (yet cost-efficient) meal/snack ideas. Scroll down to learn more!

Age and Insulin Resistance

Insulin is a hormone in the pancreas that helps our body regulate blood sugars. It helps us use food for energy and to be healthy and active. Insulin resistance (when your body doesn’t respond well to insulin) is the precursor to type 2 diabetes.

It occurs when the cells in our body do not respond to insulin and cannot use glucose from the blood for energy. This makes the pancreas go into overdrive. It tries to make more insulin and this causes blood sugar levels to go up.

Elderly persons are susceptible to insulin resistance if they are obese, lead a sedentary lifestyle, and/or have a family history of diabetes.

One study found that walking at a moderate pace just 15 minutes after each meal can help reduce blood sugar during a 24 hour period in older persons.

Who is More Susceptible to Diabetes?

The American Diabetes Association reports 26.8% of Americans (14.3 million) are living with the disease (diagnosed and undiagnosed).

Genetics plays in a big role in who may develop diabetes. American Indian/Alaskan Native, Asian, or African-American are noted to be at a higher risk of developing diabetes. However, genes aren’t everything. The Journal of the American Medical Association (JAMA) in 2017 found the primary biological reason is obesity, which affects all races and ethnic groups.

Signs, Symptoms, and Complications of Diabetes in the Elderly

Some older Americans dismiss the symptoms of type 2 diabetes as “getting old.”

If you recognize the warning signs in yourself or a loved one – frequent urination, fatigue, unintended weight loss, blurred vision, and/or increased hunger and thirst – make an appointment to see a doctor right away.

For those seniors living with uncontrolled diabetes, complications can arise. Common complications include eye problems (e.g. cataracts, glaucoma), kidney disease, heart disease, nerve damage, (e.g. neuropathy), and red and swollen gums. Unfortunately, uncontrolled diabetes can take a toll on every organ in the body.

Common Lab Tests for Diabetes

The following blood tests are regularly used by physicians to either diagnose or monitor the progression of the disease. NOTE: Please consult with your doctor to determine appropriate lab values for you based on your age, medical conditions, and overall health status. These are commonly used lab levels, but are not intended to be used for everyone.

Random Plasma Glucose Test:

Blood is drawn at a lab or during outpatient visits. A random plasma glucose test gives us an immediate snapshot of how well diabetes is being managed. Acceptable range for elderly persons – <300mg/dL. This acceptable range may seem quite high, but keep in mind the test is taken at random. Someone may have just eaten a meal and we would expect this number to be higher.
Fasting Plasma Glucose Test (FBG):

Instead of being random, this test is intentional to make sure you haven’t eaten for a while. This way we know it’s not a recent meal causing a high blood sugar.

A fasting plasma glucose test measures blood glucose after fasting for eight hours. The test is usually done in the morning. It is used to either help diagnose diabetes or during routine medical examinations. Aim for a fasting glucose of between 160-170mg/dL (medication-dependent older adults) or <200mg/dL (frail persons with ADLs).

Oral Glucose Tolerance Test (OGTT):

Similar to FBG, the patient is fasting for eight hours and then again after two hours following ingestion of a sugary drink (two blood tests in one day). This test is a screening tool to diagnose diabetes. If test results are >200 mg/dL, a HgbA1C test will be performed to confirm diabetes diagnosis.

Hemoglobin A1C Test (HgbA1C):

The “gold standard” of clinical management of diabetes. It can be conducted at any time of the day, and captures one’s average glucose level over a three-month time span. Of note, if someone has a sickle-cell trait, this is an unreliable test due to the shortened life span of red blood cells (RBCs). See below for recommended values for older adults.

Glycemic Control in the Elderly

The most convenient test for to determine how well diabetes is being controlled is the HgbA1C. Where as other tests look at a blood sugar reading on single day, this test tells us how well blood sugars are being controlled over a longer time period (3 months).

It is important to note that there are different HgbA1C cutoffs for different age groups. In general, the guidelines recommend HgbA1C targets of 6.5-7% for adults 18 years of age and older. However, for persons over the age of 65, these targets may be higher.

The table below outlines the HbgA1c goals for older adults based on their health status. It includes the rationale as to why these targets are higher when compared to younger adults.

HbgA1c Goals in Older Adults with Diabetes
Health Status	Rationale	Goal
Healthy (few chronic diseases, functionally & cognitively intact)	Longer life expectancy	<7.5%
Complex/Intermediate (multiple chronic diseases, 2+ iADLs, mild-moderate cognitive impairment)	Intermediate life expectancyHigh treatment burden Hypoglycemia vulnerability Fall risk	<8.0%
Very Complex/ Poor Health (long-term care, end-stage chronic disease, moderate-severe cognitive impairment, 2+ ADLs)	Limited remaining life expectancyBenefit uncertain	<8.5%

Sue Kirkman, M., et al. “Diabetes in older adults: a consensus report.” J American Geriatrics Society 60.12 (2012): 2342-2356

Be sure to remember that HgbA1C values for younger adults are not the same for older persons.

Hypoglycemia in Older Adults

Hypoglycemia (low blood sugar) is a common occurrence in diabetic older adults. It can occurs in the elderly for a variety of reasons. It can be from not eating enough, altered kidney function which impacts how medication are used, other medications, and other medical conditions.

Hypoglycemia is not always easy to recognize by the patient or those who treat them. Some symptoms to monitor include shakiness, sweating, slurred speech, behavior changes, visual disturbances, poor appetite, or increased hunger.

Hypoglycemia also causes periods of confusion, dizziness, and/or loss of consciousness, which may lead to falls and fall-related injuries.

How about Hyperglycemia?

While hypoglycemia is the dominant complication in older adults with diabetes, high glucose levels are harmful, too. With hyperglycemia, it causes urinary incontinence, affects vision and cognition, as well as increases infection risk and dehydration.

Did you know frequent dehydration can lead to kidney damage? Thus, it is important to see a physician regularly to monitor diabetic treatment plans.

Some Glycemic Control is Important

Some glycemic control is absolutely important! It can be the key to providing optimum diabetes care. It is important to recognize symptoms, meet nutritional needs, eat around the same time each day (spaced ~4 hours apart), follow a medication schedule, monitor blood sugars, and stay active.

Work with your provider on your individual situation. If you feel comfortable with an HgbA1C at 8%, work with your provider on maintaining what is right for you. Quality of life is very important. The goals for all chronic diseases (not just diabetes) is to individualize care and be adapt with the changing circumstances that are attributed to the aging process.

Medications that Affect Blood Sugar

There is a greater incidence of polypharmacy in elderly patients with diabetes. Polypharmacy is the use of multiple drugs to treat various medical conditions on a given day.

Some medications – listed below – affect blood sugar, so be sure to discuss any adverse reactions with medical professionals.

Corticosteroids (Steroids):

Used to treat a variety of inflammatory conditions including inflammatory bowel diseases (Crohn’s Disease, Ulcerative Colitis), Rheumatoid Arthritis, Asthma, and Lupus. A side effect of these oral steroids is an increase of blood glucose levels.

Over-the-Counter Cold Medications:

While one might think a cough syrup is harmless to take during flu season, think again. Many oral decongestants can raise blood sugar. Look for either a sugar-free version (read labels) or consider a saline nasal spray.

Beta Blockers:

They are used to lower blood pressure. Not only do they affect blood sugar, but they also can mask an elevate heart rate which is often associated with hypoglycemia.

Antibiotics:

A specific class of antibiotics called fluoroquinolones – used to treat UTIs and pneumonia – may also increase or decrease blood sugar.

Best Diabetes Medications for the Elderly

Older adults with diabetes should take medicines as prescribed. Medication adherence is important to control the condition. Your doctor will work with you to decide the best medications for your situation.

Metformin

Metformin is often a first-line oral drug for elderly persons with diabetes. It is low-cost with minimal side effects.

Sulfonylurea

If one develops an intolerance to Metformin, short-acting oral sulfonylurea (glipizide) is also well tolerated.

DDP-4

Another oral medication, dipeptidyl peptidase-4 inhibitor (DPP-4 – Januvia), is also a good option for elderly persons. One study found it significantly decreased HgbA1C levels in one year without an increased risk for hypoglycemia.

Basal Insulin

If possible, insulin injections should be avoided (or limited) in elderly persons, as it puts them at greater risk of developing low blood sugar. However, if glycemic goals are not being met via oral therapies, basal insulin can be combined with the non-insulin agent.

Consider Working with a Dietitian

Older adults with diabetes should consider working with a dietitian on a regular basis. These nutrition professionals can help improve successful management of diabetes.

Dietitians are a great resource for meal planning, carbohydrate counting, and weight management, and they decrease the need for medications.

Click here to find a dietitian near you.

Weight Management in Diabetes

Studies have found older adults with diabetes have a higher fat percentage as well as larger abdominal fat deposits. They are also susceptible to accelerated loss of lean body mass – no matter what they weigh.

A healthy BMI for older adults (older than 65 years) is 23-30. For elderly diabetic patients who are obese, losing weight while preserving lean body mass (muscle) may improves their metabolic profile and reduces risk for future disease complications. They key is getting enough exercise and eating a healthy diet.

Underweight individuals with diabetes may require an intervention of high-calorie, low-glycemic foods (e.g. peanut butter). Ways to sustain lean muscle mass include consuming proteins with a high biological value (e.g. animal sources) and strength training.

For underweight individuals, check out our recent blog post on weight gain breakfast ideas here.

Overeating and Undereating in Diabetes

Some older adults with diabetes experience excessive hunger while others lose their appetite. A few things both groups should keep in mind to reduce diabetes complications include:

–Eat three meals at the same time per day (breakfast, lunch, and dinner). All food groups should be represented on meal plates.

–Monitor portions and keep a food log. A dietitian will provide meal planning based on body type. It is important to follow the recommendations.

–Get a Good Night’s Rest. Sleep plays a vital role in health. Older adults with diabetes who experience either insomnia (causes cravings) or hypersomnia (causes lack of appetite) both experience an increase in blood sugar levels. The National Sleep Foundation recommends that older Americans need between 7-8 hours of uninterrupted sleep nightly.

Healthy Eating Tips

For those living with diabetes, following a meal plan is important. As mentioned before, consider working with a Registered Dietitian (RDN). They can provide counseling on learning to create healthy menus, how to time meals and diabetes medication and more.

Note: Medicare Part B covers diabetes visits (confirmed diagnosis) with an RDN.

Diabetes Exchange List

One approach to healthy eating is the Diabetes Exchange list. This system for meal planning has six food groups – starchy foods, fruits, vegetables, dairy, meats and fat.

Within each group, there are foods that contain similar amounts of fat, protein and carbohydrates (“exchanges”). For example, rice, cereal and potatoes and bread are all starch exchanges, and meal plans will specify a certain amount of starch exchanges for a meal or snack. For each meal, there are exchanges in at least three to four food groups.

Work with a dietitian or Certified Diabetes Educator (CDE) to learn more about exchanges and diabetic diet.

Other Tips

Below are a few tips on eating healthfully with diabetes:

Carbohydrates, proteins and fats are the main components of food that provide energy the body needs.
Carbohydrate quantity and quality are important in diabetes management.
- Monitor food portion sizes
- Choose complex carbohydrates over simple ones (higher in fiber and digest more slowly)
- Carbohydrates should make up about 50% of the daily calories
Choose healthful fats – such as nuts, seeds and olive oil – to provide better blood sugar control.
Limit processed meats and choose chicken, poultry and finish or plant-based proteins such as tofu.
Enjoy favorite foods, but consider eating smaller portions or enjoying them less often.
- For those who are looking for sweet and satisfying snack that will NOT spike blood sugar levels, check out this free resource with recipes.
Consider the Diabetes Plate Method:
- Start with a 9-inch plate and fill:
- ½ of the plate with non-starchy vegetables
- ¼ of the plate with whole grain or starchy foods
- ¼ with lean proteins