ADA 2011: Overcoming Barriers to Deliver Smart Geriatric Diabetes Care

There are several challenges to effective diabetes care that are specific to geriatric patients.

There are many differences between young versus older adults with diabetes, explained Medha N. Munshi, MD, at the ADA 71st Annual Meeting in San Diego. “By young, I mean patients in their 50’s, 60’s, and 70’s. Those in their late 70s, 80s, and 90s are considered older.” Munshi described three areas of differences in the older diabetic population: they are more heterogeneous, have multiple comorbidities, and the goals of treatment are different. With regard to comorbidities, diabetes can increase problems and risks associated with cardiovascular diseases, cognitive dysfunction, depression, and polypharmacy. These, in turn, can result in decreased compliance, increased hypoglycemia, and decreased quality of life. Munshi emphasized how important it is to consider challenges specific to the older population when treating diabetes.

The first thing to do when managing diabetes in older populations is to look for barriers to effective treatment, she said. Physicians in her clinic assess several barriers: health literacy (what do they understand), cognition (via clock drawing test), depression, functional ability, social support, medication adherence and polypharmacy, nutrition, and exercise.

Physicians should examine the clinical, functional, and psychosocial barriers, then help patients overcome these when possible. For example, in patients who are socially isolated, physicians can provide resources and make suggestions to encourage more engagement. For barriers that are not easily reversed, such as cognitive dysfunction, physicians will need to revise their management plan.

Munshi illustrated the complications associated with diabetes in the older population by citing several studies. One study compared cognitive dysfunction in patients with and without diabetes; in patients over age 70, 34% of those with diabetes had cognitive dysfunction, compared to 18.5% in those without diabetes. Not surprisingly, A1c was much higher in patients with cognitive dysfunction than those without cognitive dysfunction.

In another study, depression was higher in those with diabetes compared to those without. In women living alone, glycemic control worsens as the number of medications increases. Functional impairment also increases with diabetes in older patients, with 48% experiencing hearing loss, 53% with vision problems, and 33% with a history of recent falls. “This just shows that when they look well, they have a significant amount of burden that’s going on,” said Munshi.

With regard to managing older diabetic patients, it is important to screen for comorbidities first, she explained, then assess medication and adherence, then perform a clinical assessment. She suggested continuous glucose monitoring and focused education specific to the patient’s needs at each visit. Because it is difficult to manage patients without a visit, her clinic utilizes a fair amount of remote telemonitoring. She has also found that phone communication between visits improves glycemic control and lowers diabetes-related distress in older adults.

A community educator who is cognizant of age-specific barriers may also improve patients’ glycemic control, according to Munshi.

Finally, she warned physicians not to believe everything their patients do or don’t tell them, because they may just say they are feeling fine. This is especially true when managing hypoglycemia. “Probe more to see if they have dizzy spells, weakness, or improvement in symptoms after eating,” she said. Even if patients are under excellent glycemic control, physicians need to be more proactive.

For all aspects of diabetes treatment and management, however, there needs to be a consideration for quality of life. In the older population with its heterogeneity and comorbidities, this poses a unique challenge for physicians.