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Graydon S. Meneilly
Graydon S. Meneilly, Room S 169, Vancouver Hospital and Health Sciences Centre, UBC Site 2211, Wesbrook Mall, Vancouver, BC V6T 2B5, Canada E-mail: [email protected].
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Daniel Tessier
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Daniel Tessier
The Journals of Gerontology: Series A, Volume 56, Issue 1, 1 January 2001, Pages M5–M13, https://doi.org/10.1093/gerona/56.1.M5
Published:
01 January 2001
Article history
Received:
30 June 2000
Accepted:
06 September 2000
Published:
01 January 2001
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Abstract

Diabetes is common in the elderly population. By the age of 75, approximately 20% of the population are afflicted with this illness. Diabetes in elderly adults is metabolically distinct from diabetes in younger patient populations, and the approach to therapy needs to be different in this age group. Diabetes is associated with substantial morbidity from macro- and microvascular complications. Several lines of evidence suggest that optimal glycemic control and risk factor modification can substantially reduce the risk of complications in elderly patients. In the past, treatment options were limited. However, recent studies have delineated several new and exciting therapeutic opportunities for elderly patients with diabetes.

Decision for 1 last update 09 Aug 2020 Editor: John E. Morley, MB, BChDecision Editor: John E. Morley, MB, BCh

Epidemiology

Numerous studies have evaluated the incidence and prevalence of type 2 diabetes in the elderly population. The most recent Health and Nutrition Survey, HANES III, suggests that approximately 20% of the population develop diabetes by the age of 75 (Fig. 1) (1). At least half of these patients are unaware they have the disease (2). The prevalence of diabetes is much higher in some ethnic groups, especially Native Americans, Hispanics, blacks, and Micronesians. Because elderly patients with diabetes are living longer and are likely to use increasing amounts of scarce health care resources in the next several decades, diabetes in aged adults may ultimately prove to be the most important epidemic of the 21st century.

Pathogenesis

There are several lines of evidence to suggest that type 2 diabetes in elderly adults has a strong genetic predisposition. Elderly patients with a family history of diabetes are more likely to develop the disease as they age (3). The prevalence of diabetes is increased in certain ethnic groups, implying that genetic factors play an important role. In elderly identical twins, the prevalence of diabetes is markedly increased in siblings of affected patients (4). In addition, in sibling pairs that are discordant for diabetes, nondiabetic siblings clearly have evidence of disordered glucose metabolism.

Several other factors contribute to the high prevalence of diabetes in the elderly population (5). There are a number of age-related changes in carbohydrate metabolism (such as alterations in glucose-induced insulin release and resistance to insulin-mediated glucose disposal) that interact with genetic background to explain the progressive increase in the incidence of diabetes with aging. Lifestyle factors are also important. Individuals who are obese (especially if the distribution of body fat is central), who consume diets that are high in saturated fat and low in complex carbohydrates, or who are inactive are more likely to develop diabetes as they age. Lower testosterone levels in men and higher values in women also appear to be risk factors for the development of diabetes in elderly persons, although the mechanistic significance of these abnormalities is uncertain.

control high blood sugar vomiting (⭐️ test kit) | control high blood sugar veganhow to control high blood sugar for A number of studies have carefully evaluated glucose metabolism in middle-aged patients with type 2 diabetes (6). These studies have shown that patients have several metabolic abnormalities, including increased fasting hepatic glucose production, altered glucose-induced insulin release, and marked resistance to insulin-mediated glucose disposal. Recently, investigators (7)(8)(9) have also carefully assessed the metabolic changes in lean or obese older subjects with type 2 diabetes. In contrast with younger patients, hepatic glucose production was within the normal range in elderly patients (Fig. 2). Lean older patients with type 2 diabetes had a marked impairment in glucose-reduced insulin secretion (Fig. 3), but relatively normal insulin-mediated glucose disposal (Fig. 4). It has recently been suggested that thin elderly diabetics have a syndrome intermediate between type 1 and 2 diabetes, which might properly be thought of as type 1 1/2 diabetes (10). In contrast, obese older patients have relatively normal glucose-induced insulin secretion (Fig. 3), but marked resistance to insulin-mediated glucose disposal (Fig. 4). Tumor necrosis factor α (TNF-α) is a cytokine produced by adipocytes that is believed to contribute to the insulin resistance seen in younger patients with diabetes. Of interest, there is a strong correlation between TNF-α levels and insulin resistance in obese elderly patients with diabetes (11), although the therapeutic relevance of this finding is unclear. The previously described data suggest that diabetes in elderly persons is metabolically distinct and may require a different therapeutic approach than is commonly applied to middle-aged patients.

Other metabolic defects have recently been defined in elderly patients with diabetes. Glucose uptake in men occurs by insulin-mediated and non-insulin–mediated mechanisms (12). In normal subjects, approximately 50% of glucose uptake after a meal occurs as a result of non-insulin–mediated glucose uptake (NIMGU). In younger subjects with insulin-resistant conditions, NIMGU may be responsible for an even greater proportion of postprandial glucose disposal. Studies that have evaluated non-insulin–mediated glucose uptake in middle-aged patients with diabetes have produced conflicting results (12). Recently, we demonstrated that non-insulin–mediated glucose uptake was significantly impaired in elderly patients with diabetes (13). Interventions that may enhance NIMGU are currently being tested in clinical trials, and these interventions may ultimately prove to have important therapeutic relevance to aged adults.

control high blood sugar yoga (👍 juice) | control high blood sugar breakfast recipeshow to control high blood sugar for It is well known that diseases characterized by insulin resistance (such as hypertension, obesity, and type 2 diabetes) are associated with endothelial dysfunction and an increased incidence of atherosclerosis (14). Insulin is known to stimulate blood flow by an endothelium-dependent mechanism. Insulin-mediated vasodilation may be impaired in younger subjects with diseases characterized by insulin resistance, although the data are controversial. It has also been implied that insulin-mediated blood flow may be an important component of insulin-mediated glucose uptake, although studies in normal subjects and younger patients with diseases characterized by insulin resistance have again produced conflicting results. Recently, we demonstrated that insulin-mediated blood flow is impaired with normal aging, and there is an even greater impairment in this parameter in elderly patients with diabetes (9)(15). Although the role of the alteration in insulin-mediated vasodilation in the insulin resistance that occurs with aging and diabetes is uncertain, it is clear that reduced insulin-mediated vasodilation is a marker of endothelial dysfunction in elderly patients with diabetes. Further studies are needed to determine whether enhancing insulin-mediated vasodilation will alter insulin resistance, improve endothelial function, or reduce the risk of atherosclerotic events in this population.

Autoimmune phenomena are an important contributing factor to the insulin deficiency that occurs in younger patients with type 1 diabetes (5). Autoimmune factors may also have a role to play in the insulin deficiency that occurs in lean elderly patients with diabetes, but the data are conflicting (5)(16)(17)(18). Further investigations are required to resolve this issue.

Molecular abnormalities that occur in for 1 last update 09 Aug 2020 elderly patients with diabetes have not been fully elucidated (5). The glucokinase gene is the glucose sensor of the β cell. Theoretically, alterations in this gene could explain defects in insulin secretion, but it is not clear whether the function of this gene is impaired in older people with diabetes. Insulin-receptor tyrosine kinase activity in skeletal muscle has been reported to be altered in elderly patients with diabetes and insulin resistance, but it is uncertain whether this is the cause or the result of the elevated glucose levels in these patients.Molecular abnormalities that occur in elderly patients with diabetes have not been fully elucidated (5). The glucokinase gene is the glucose sensor of the β cell. Theoretically, alterations in this gene could explain defects in insulin secretion, but it is not clear whether the function of this gene is impaired in older people with diabetes. Insulin-receptor tyrosine kinase activity in skeletal muscle has been reported to be altered in elderly patients with diabetes and insulin resistance, but it is uncertain whether this is the cause or the result of the elevated glucose levels in these patients.

Presentation and Clinical Features

One half of older persons with diabetes are unaware they have the illness, suggesting that symptoms of hyperglycemia are rarely present in this patient population (5). This may be because the renal threshold for glucose increases with age, so that no sugar is spilled into the urine until the glucose level is markedly elevated. In addition, because thirst is impaired with normal aging, polydipsia is unlikely in elderly patients with diabetes, even if they are hyperosmolar as a result of marked hyperglycemia. If symptoms do occur, they are generally nonspecific (confusion, failure to thrive, incontinence, etc.). Often, diabetes presents for the first time in an elderly person who is hospitalized with a complication that may be related to diabetes, such as a myocardial infarction or a stroke. In frail elderly nursing home patients, nonketotic hyperosmolar coma may be the first sign of diabetes.

Several unique syndromes occur in elderly patients with diabetes (5). Diabetic neuropathic cachexia presents with weight loss, depression, and painful peripheral neuropathy, and generally is resolved without specific treatment in a few months. Diabetic amyotrophy occurs almost exclusively in older men with diabetes. Malignant otitis externa, a necrotizing infection usually caused by pseudomonas, occurs primarily in elderly patients with diabetes. The papillary necrosis that can occur with pyelonephritis develops primarily in elderly patients with diabetes. Spontaneously resolving intradermal bullae of the feet and the painful limitation of shoulder movements occur more commonly in elderly patients with diabetes. Finally, diabetes in elderly persons has been associated with an increased risk of accidental hypothermia.

Community-dwelling elderly patients with diabetes are less obese and more likely to be hypertensive when compared with younger patients with this illness (5). When compared with community-dwelling elderly persons with diabetes, elderly nursing home patients with diabetes are more likely to be treated with diet, less obese, less likely to be treated with insulin, and have a higher incidence of macro- and microvascular complications and skin infections. Finally, when compared with nursing home residents without diabetes, elderly nursing home patients with diabetes have a higher incidence of infections and micro- and macrovascular complications.

Complications

Diabetes is the sixth most common cause of death among elderly adults. However, its role in mortality in the elderly population is probably understated, because when patients die of cardiovascular causes, diabetes is often not listed as a contributing cause of death (5)(19)(20). The principal cause of death in elderly patients with diabetes is cardiovascular disease, and these patients have nearly twice the mortality rate of age-matched controls without diabetes. It has been estimated that in patients who develop diabetes over the age of 65 years, life expectancy is shortened by at least 4 years (19). Mortality in elderly patients with diabetes is strongly correlated with long-term variability of plasma glucose and Hgb A1C values (5)(21)(22). People with diabetes have a poorer quality of life and a higher frequency of chronic disease than do age-matched controls without diabetes, and diabetes is one of the strongest predictors of functional decline in longitudinal studies (5)(23)(24)(25)(26). Finally, elderly patients with diabetes use almost twice as many inpatient and outpatient resources as elderly people without diabetes (5).

control high blood sugar treatment options (☑ normal) | control high blood sugar pathophyshow to control high blood sugar for The risk of macrovascular events (cardiovascular disease, cerebrovascular disease, and peripheral vascular disease) is doubled in elderly patients with diabetes when compared with controls (5). The risk of these events is related to duration of diabetes, Hgb A1C values, and the presence for 1 last update 09 Aug 2020 of traditional risk factors such as smoking, hypercholesterolemia, and hypertension (5). Although randomized trials are required to definitively address this issue, the data imply that risk-factor modification and improved glycemic control will result in improved outcome in elderly persons (5).The risk of macrovascular events (cardiovascular disease, cerebrovascular disease, and peripheral vascular disease) is doubled in elderly patients with diabetes when compared with controls (5). The risk of these events is related to duration of diabetes, Hgb A1C values, and the presence of traditional risk factors such as smoking, hypercholesterolemia, and hypertension (5). Although randomized trials are required to definitively address this issue, the data imply that risk-factor modification and improved glycemic control will result in improved outcome in elderly persons (5).

The risk of microvascular complications is also increased in elderly persons, and, again, there is a strong correlation between the risk of these complications and Hgb A1C, duration of diabetes, hypertension, and hyperlipidemia (5). Although no randomized controlled trials have been conducted in this regard, the previously described data again suggest that improved glycemic control and risk-factor modification may be of value.

The risk of severe or fatal hypoglycemia associated with the use of oral agents or insulin increases exponentially with age (5)(27). This increased risk of hypoglycemia in elderly persons is related, in part, to reduced responses of glucagon, the most important counter-regulatory hormone (Fig. 5). Because of this glucagon deficiency, elderly subjects are critically dependent on epinephrine to prevent hypoglycemia (28). Other contributing factors to the high prevalence of hypoglycemia include lack of knowledge of the warning symptoms of hypoglycemia and reduced awareness of autonomic warning symptoms, even when the patient has been educated regarding the nature of these symptoms (5). When elderly subjects do experience symptoms of hypoglycemia, the symptoms tend to be less intense and more nonspecific (29). It has been suggested that hypoglycemic awareness may be enhanced in older people treated with animal insulin rather than human insulin, but these data are controversial (30)(31).

Elderly patients with diabetes have a higher incidence of depression and impaired cognitive function when compared with age-matched controls without diabetes (5). Depression in elderly patients with diabetes is a strong predictor of hospitalization and death (32). The changes in cognitive and affective function are closely correlated with lipid, blood pressure, and Hgb A1C values, and recent studies suggest that improved glycemic control may enhance cognition and mood in this patient population (5). Diabetes in elderly persons is clearly a risk factor for vascular dementia and may also be a risk factor for Alzheimer''altmetric-embed''https://academic.oup.com/biomedgerontology/crossref-citedby/636729''s objective of excellence in research, scholarship, and education by publishing worldwide

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