Introduction

Managing diabetes in older adults is increasingly complex due to the combination of age-related health challenges and the growing number of elderly individuals affected: Approximately 40% of adult diabetics are over 65.¹ Insulin therapy, often necessary in these cases, presents additional difficulties, as older patients may struggle with factors like impaired vision, reduced mobility, manual dexterity, and memory issues.

These limitations, coupled with mental health concerns and the need for support in tasks such as meal planning, make maintaining stable blood sugar levels a challenge.² Despite these hurdles, proper management of insulin is essential to prevent complications like hypoglycaemia.³ 

This article examines the multifaceted nature of type 2 diabetes care in older adults, highlighting the importance of addressing coexisting conditions, cognitive and physical limitations, and the risk factors that complicate treatment.

What is insulin?

Insulin is a hormone produced by the pancreas that is essential for regulating blood sugar levels and converting glucose (sugar) into energy for the body. In individuals without diabetes, insulin is naturally released in response to rising blood sugar levels, helping cells absorb glucose for energy or storage. However, in people with diabetes, the body either doesn’t produce enough insulin or cannot use it properly, leading to elevated blood sugar levels.³

There are two main types of diabetes: in type 1 diabetes, the pancreas produces little to no insulin, while in type 2 diabetes, the body either resists the effects of insulin or doesn’t make enough of it. To manage these conditions, synthetic insulin is often prescribed.

This synthetic insulin mimics the action of natural insulin and can be administered through various methods, including injections, insulin pens, pumps, or as inhaled insulin powder.^2,3 By helping to regulate blood sugar, insulin therapy plays a crucial role in preventing complications like nerve damage, kidney disease, and cardiovascular issues.

Specific aspects to consider in elderly patients with type 2 diabetes

Many older adults with type 2 diabetes have additional health issues, with about 40% having at least three chronic conditions. Conditions like arthritis, emphysema (a lung disease), chronic pain, and mental health issues, including depression, call for extra vigilance because they could make it harder for patients to perform daily tasks.

Other significant health issues such as hypertension (high blood pressure) should be managed along with type 2 diabetes.³ Moreover, the American Diabetes Association suggests that addressing additional health issues may be more effective in reducing overall illness than solely focusing on blood sugar control. 

Physical and cognitive degeneration, common in advanced age, could make it more difficult for elders to manage diabetes. This can lead to mistakes with dosage, consequently leading to sugar level problems. Simplifying treatment plans, considering once-daily injections of basal insulin analogues (medications that are created to mimic the body’s natural pattern of insulin release), and promoting the use of insulin pens rather than vials and syringes can make it easier for people to follow and reduce the risk of hypoglycaemia (low blood sugar levels).

Social support, improved access to care, and trained healthcare professionals also help with challenges concerning daily tasks, especially in assisted living or long-term nursing homes. Such support is important to take into account when making a plan to manage diabetes.³

In addition, elders with type 2 diabetes who also have dementia are at high risk of illness (e.g., hypoglycaemia and its complications) and even death. A study found that the connection between dementia and low blood sugar goes both ways – people who had low blood sugar were more likely to develop dementia, and vice versa.⁴

What are the signs of hypoglycaemia?

In older adults, the warning signs of hypoglycaemia may become less noticeable or absent altogether, making it difficult for the individual to recognise a drop in blood sugar.⁵ Often, caregivers are the first to detect symptoms, which may include: 

• Difficulty concentrating
• Changes in personality
• Morning headaches
• Disrupted sleep

Undiagnosed or untreated hypoglycaemia can lead to more severe symptoms, such as:⁵

• Confusion
• Difficulties with speech and self-care
• Loss of appetite
• Aggressive behaviour
• Unsteadiness leading to falls
• Loss of consciousness 

In more extreme cases, it can result in cognitive dysfunction, heart attack, or stroke.⁵ Recognising these symptoms early is crucial to prevent further complications.

Risk of hypoglycaemia and its consequences

Hypoglycaemia occurs when blood glucose levels drop below 4 mmol/L.⁵ Older patients are particularly at risk due to several factors, including:

• Insulin or specific diabetes medications
• Chronic kidney disease
• Inadequate nutrition
• The presence of multiple health conditions

Managing blood glucose levels becomes increasingly difficult for older individuals, as their bodies may respond less effectively to low blood sugar, leaving many unaware of hypoglycaemic episodes.⁵

In older adults with diabetes, hypoglycaemia can lead to serious complications, including cardiovascular events, cognitive decline, and overall negative health outcomes.^5,6 Unnoticed episodes of low blood sugar can result in increased risks of falls, fractures, confusion, delirium, and symptoms like fatigue and dizziness, which significantly impact quality of life.

Early identification and proper management of hypoglycaemia are crucial for preventing these complications. Individualised care plans should focus on avoiding medications with a high risk of hypoglycaemia and closely monitoring blood glucose levels to ensure timely intervention.⁶

Insulin options and treatment approaches

Deciding to start insulin therapy should involve both patients and their caregivers. For older patients who rely on others for insulin administration, a once-daily long-acting insulin may be easier to manage, even if it doesn't control blood sugar as effectively as more complex insulin regimens.⁶

Newer long-acting insulins, such as Glargine and Detemir, help regulate blood sugar with a lower risk of hypoglycaemia, making it safer to aim for a Hemoglobin A1c (a measure of average blood glucose over two to three months) of less than 7%. The timing of long-acting insulin doses is flexible, allowing patients and community nurses to coordinate a convenient schedule.

If blood sugar isn't adequately controlled with long-acting insulin alone, short-acting insulin can be added. However, administering these at meal times can be challenging for frail patients who cannot manage their own injections. Newer short-acting insulins act more quickly, making them suitable for individuals with memory issues or irregular meal schedules, as they can still receive insulin even if administered right after eating.⁷

Summary

Managing diabetes in older adults requires a thoughtful approach that addresses their unique health and age-related challenges.

• High prevalence: Many people with diabetes are over 65, which means treatment plans need to be specifically tailored for this age group
• Insulin management: Age-related issues like poor vision, reduced mobility, and mental health challenges make insulin use more complicated for older individuals
• Hypoglycaemia risks: Older adults are more prone to low blood sugar, which can lead to serious consequences like falls, confusion, and cognitive decline
• Simplifying treatment: Long-acting insulins and newer insulin options can help stabilize blood sugar while minimizing the risk of hypoglycaemia, making treatment easier and safer
• Caregiver support: Involving caregivers and simplifying insulin regimens can improve diabetes management, particularly for those in assisted living or nursing homes

In conclusion, managing diabetes in older adults requires a personalised approach that balances their unique needs with effective and safe treatment options.