Diabetes management in the older or frail adult

Dr Rick Cutfield discusses diabetes management in the older or frail adult. Rick is the Clinical Director of the Endocrinology & Diabetes Division at Waitemata DHB and works privately at Mercy specialist group in Epsom. He is active in teaching, clinical research and all aspects of diabetes, endocrinology and general medicine.

Case Study

Mrs F is 84 and has type 2 diabetes for many years with excellent control HbA1c 49 mmol/min. She lives alone, and says she has no problems. She eats 3 meals per day. She walks daily.

Her exam reveals a slim woman with BMI 19 and no neuropathy with BP 120/78 and no postural drop. Visual acuity is 6/6 (R) and 6/9 (L).
However you notice she pushes up with both and to get out of the chair and is slow to move to the examination bed. You notice bruising on her knees and upper thigh and arm and she admits to a couple of falls going to the toilet.
Her medication list includes an ACE inhibitor, a statin, Glipizide 10 mg b.d., Metformin 850mm b.d. and also Isophane insulin 12u at bedtime.
She has an LDL cholesterol of 1.9 and an eGFR of 38 ml/min with urine microalbumin of 42 mmol/L.

Topics

Re-evaluating treatment goals in the frail and elderly. E.g. relaxing HBA1c goals, symptomatic treatment.
Careful pharmaceutical management. E.g. caution with sulphonureas and insulin.
Avoiding hypoglycaemia.
The importance of assessing cognitive impairment, nutrition, exercise, renal and cardiovascular status.
Social isolation, safety netting and safety.

Take home messages

The older/ frail diabetic patient needs are more through annual review.
Always ask about hypoglycaemia, fall and compliance.
It is appropriate to relax treatment goals.
Sulphonureas and insulin may no longer be the most appropriate medications to use in this age group.
Community initiatives such as falls prevention, diabetes NZ and others may be appropriate to get involved.