Caring for Aging Patients with Diabetes

By Melissa Matteo, RD

As our nation’s population ages, it becomes more important to understand how diabetes impacts older adults. As people get older, insulin resistance increases and pancreatic islet cell functions decrease, placing them at greater risk for developing type 2 diabetes. Adults aged 65 and older are more likely to have diabetes than any other age group.

Nutrition plays a large role in diabetes management and requires some special considerations when working with an aging population. It is important to take an individualized approach to meal planning rather than base recommendations solely on age and to consider one’s overall physical and cognitive function, quality of life and preferences when developing a treatment plan for the older adult.

The American Diabetes Association (ADA) 2017 Standards of Medical Care in Diabetes recognizes the need for this individualized approach to diabetes management in the elderly. It recommends that healthcare practitioners develop individualized meal plans that include a wide variety of foods and beverages to avoid dehydration and unintentional weight loss instead of issuing restrictive “one size fits all” diets. Liberalizing the diet in this age group and utilizing medication therapy as needed for glycemic target can make eating more enjoyable for these patients.

Prevention of hypoglycemia (blood glucose < 70 mg/dl) should be the primary goal with older adults since they are at increased risk due to impaired renal function, variable appetite (due to poor dentition, changes in taste or smell, eating alone or depression), polypharmacy and slowed intestinal motility. Avoidance of medications that can cause low blood sugars is recommended when possible, as well as educating the patient, their family members and/or caregiver on the signs and symptoms of hypoglycemia, how to treat it and how to prevent it. Patients with poor appetite or weight loss may benefit from oral nutritional supplements to provide additional calories and protein.

About medications

Any forms of insulin or insulin secretagogues like sulfonylureas (i.e., glipizide, glyburide or glimepiride) may pose the risk of hypoglycemia. Other factors to consider when prescribing medications is cost and dexterity. Many elderly individuals may be on a fixed income and be taking many other prescription medications. Some of the injectable medications, including insulin, may be difficult to self-administer if one has diminished fine motor skills due to arthritis, deficits from a stroke or other debilitating chronic conditions more prevalent in advanced age.

Prevention of hyperglycemia should be managed next as persistent hyperglycemia can lead to dehydration, electrolyte imbalances, dizziness, falls, poor wound healing and even hyperglycemic hyperosmolar coma. Again taking an individualized meal planning approach utilizing simple nutrition concepts like the plate method for portion control (filling half of plate with non-starchy vegetables, one-quarter of plate with lean protein and one-quarter of plate with grains or other starchy foods), as well as avoiding sugar-containing beverages, can be beneficial.

For the active and healthy geriatric population (those with few coexisting chronic illnesses and intact cognitive and functional status), carbohydrate-controlled meal planning as well as education on healthy eating patterns like the Mediterranean diet, DASH diet or plant-based nutrition, may be of benefit to help maintain this status and avoid diabetes.

Ideal geriatric care requires a multidisciplinary approach that includes a registered dietitian, preferably one specializing in diabetes care. They can help patients develop a meal plan tailored to their culture, preferences and personal goals, which increases quality of life, satisfaction with meals and overall nutritional status.

About referrals

It is recommended that physicians refer patients for nutrition and diabetes education when first diagnosed, when glycemic targets are not being met, or when there has been a change in medical condition. An example is the diagnosis of chronic kidney disease, which may require additional diet and medication adjustments. Ideally, patients should be referred for education before they are diagnosed with type 2 diabetes, at the prediabetes stage (A1C of 5.7 percent to 6.4 percent). Unfortunately, many insurance plans do not cover diabetes education at this early stage. Many insurance plans do, however, cover a dietitian visit and diabetes prevention programs are offered at many YMCA locations.

Melissa Matteo, RD, is a diabetes educator at Cleveland Clinic’s Stephanie Tubbs Jones Health Center.