P R A C T I C A L
P O I N T E R S
Clinical Management of Diabetes in the Elderly
Diane Chau, MD, and Steven V. Edelman, MD
he population of the United States is aging. The elderly are increasingly comprising a larger proportion of newly diagnosed diabetic patients. In 1993, 41% of the 7.8 million people diagnosed with diabetes were over 65 years of age.1 Managing type 2 diabetes in the elderly population is difficult because of complex comorbid medical issues and the generally lower functional status of elderly patients. Nationally published guidelines often do not apply to geriatric care, and practitioners’ individualized approaches to therapy are highly variable. Understanding the special dynamics of geriatric patients will aid in the optimum management of their diabetes.
Physiology of Aging Many age-related changes affect the clinical presentation of diabetes. These changes can make the recognition and treatment of diabetes problematic. It is said that at least half of the diabetic elderly population do not even know they have the disease.2 Part of the problem is that, because of the normal physiological changes associated with aging, elderly diabetic patients rarely present with the typical symptoms of hyperglycemia.3 The renal threshold for glucose increases with advanced age, and glucosuria is not seen at usual levels.4 Polydipsia is usually absent because of decreased thirst associated with advanced age. Dehydration is often more common with hyperglycemia because of elderly patients’ altered thirst perception and delayed fluid supplementation. More often, changes such as confusion, incontinence, or complications relating to dia-
betes are the presenting symptoms. Alterations in carbohydrate metabolism in the elderly include the loss of first-phase insulin release.5 The initial surge in postprandial insulin does not occur in all elderly diabetic patients.6 In contrast to lean elderly and younger adults with diabetes, there is no...