Dare to Disrupt Diabetes as You Age
By Dr. Medha Munshi
Aging can bring new challenges – and new opportunities – to diabetes management. Joslin Diabetes Center's Dr. Medha Munshi shares strategies for adapting your diabetes care plan or supporting loved ones with diabetes for better living.
With improvements in diabetes care over the past several decades, people with diabetes – both type 1 and type 2 – are living longer and healthier lives. However, aging brings its own challenges, and when those interact with the complexities of diabetes, self-care can become daunting.
The best way to successfully navigate this, either for yourself or for a loved one, is by understanding how aging may impact diabetes and how to avoid setbacks that can hinder aging well with diabetes.
Are you talking to me? Who is a senior?
A good question! Many cultures and countries have different ways to describe older adults. Some organizations may include people over age of 55 years as "seniors." Medicare sets the age of eligibility at 65 years. When thinking about age in the context of diabetes, I would like to avoid using a particular number as a guide. It does not matter how many years you’ve lived; rather, the focus should be on health issues related to aging, and how that interferes or interacts with diabetes.
One of the biggest privileges of being a geriatrician (a doctor specializing in the health of older people) is to meet with many people who age successfully and gracefully, while managing many medical conditions. What I learn from these fabulous people is to eat moderately, keep moving physically, and most of all, keep a positive attitude.
Why is age an important consideration in diabetes care?
There are two ways age can affect people with diabetes.
The older you are and the longer you’ve lived with diabetes, the more likely you are to develop diabetes-related health complications.
Older adults are also more likely to develop other medical conditions that may or may not be associated with diabetes.
Many of the conditions that can develop are well-known complications of diabetes. For example, people with diabetes have a high risk of heart disease, kidney disease, conditions affecting eyes, peripheral vascular disease, and neuropathy. Other conditions are generally associated with aging, such as some decline in vision, hearing, and physical endurance. Finally, there is a group of conditions known to be more common in older adults with diabetes, such as cognitive and physical decline, polypharmacy (the use of several different medications at once), risk for bone fractures, urinary incontinence, and chronic pain.
All of these conditions, alone or in combination, can interfere with glucose monitoring, insulin injections, or diet and exercise routines. Identify these barriers and develop strategies to maintain not only strong diabetes management but also high quality of life.
Does aging affect people with type 1 and type 2 diabetes differently?
Some of the bodily changes that occur with aging that affect diabetes include decreased muscle mass, increased insulin resistance, changes in insulin secretion and absorption, and higher risk of autonomic neuropathy that can affect normal body processes like food absorption or blood pressure management.
Although the overall impact of diabetes on the body’s organs, including health complications, is similar in those with type 1 and type 2 diabetes, age can affect diabetes self-care behaviors differently for each. For example, if you have type 1 diabetes, you typically require more frequent glucose monitoring or CGM and a higher number of insulin injections each day compared to people with type 2 diabetes. So, if you develop difficulty performing these diabetes management steps, this may pose more of a challenge if you have type 1 than type 2. On the other hand, if you were recently diagnosed with type 2 diabetes you may have a hard time learning the many new behaviors needed to manage your diabetes, such as use of blood glucose meters, injection techniques, or dietary changes. For these reasons, you may need different strategies depending on which type of diabetes you have.
Do strategies to manage diabetes change as you age?
The aging population with diabetes is diverse, and strategies to manage diabetes also need to vary to fit your strengths and challenges. That is why it is important to work with your healthcare team to develop a personal diabetes treatment strategy that takes into consideration your environment, other clinical health issues, your support system, and your personal choices and goals. The treatment strategy will need to be tweaked and adapted if and when other circumstances in your life change.
For example, if there are memory issues, the treatment strategy may need to be simplified. If there are other serious conditions such as heart disease or the need for hospitalization, diabetes treatment needs to be adjusted until overall health stabilizes. If the support structure changes – such as the death of a spouse – glucose monitoring and medication intake frequency and timing may need to change to fit a different type of caregiving. Many older adults live alone or with a spouse with other medical issues, and yet still strive to live independently.
Your healthcare team should make sure treatment strategies are safe and fit your ability to integrate and cope with them.
What should I consider when caring for a loved one with type 1 diabetes?
As a clinical provider for older adults with type 1 diabetes, I’ve learned to recognize that people do an amazing job learning to age with this difficult condition. It is also important for others to recognize that you know your own diabetes better than your family members or even your healthcare professionals. It is sometimes difficult for many with type 1 diabetes to let go of certain strict measures that you have gotten used to for many decades, including the need to maintain tight glycemic control or significant fear of high glucose levels. Many seniors tend to not worry about low glucose levels, which can result in falls, fractures, and worsening of cognitive function.
My strategy is to continue to educate those with type 1 diabetes on the change in risk that occurs with aging: the risks of high glucose remain in the future (further health complications) while the risks of low glucose can lead to dangerous outcomes in current time and undesirable situations such as living in supervised facilities. I encourage seniors to aim for careful glucose management while avoiding risk of hypoglycemia. It is important to recognize that you may find it difficult to give up control of glucose monitoring and insulin injections. Respectful but persistent discussion between you, you loved ones, and your healthcare team usually results in better and safer diabetes management strategies. This could include discussions around whether a CGM is something that could benefit you by alerting you when your glucose levels are too high or too low.
What should I consider when caring for a loved one with type 2 diabetes?
If you are an older adult with type 2 diabetes, especially if you were diagnosed at an older age, you may require help with diabetes management tasks, such as monitoring glucose levels or injecting insulin. If you take many medications daily, the risk of accidentally skipping a medication or taking double the dose increases and can result in harmful outcomes. Reminders, pillboxes, mail-order prescriptions, or helpful services like PillPack that automatically sort and deliver your medications can be useful to avoid these errors.
Changing dietary behaviors are not always easy. Instead of making major changes to eating habits, we recommend tweaking your routine dietary behavior around carbohydrates: avoid excessive carbohydrate intake at any single meal, but make sure that some carbohydrates are eaten at each meal. Lastly, encouraging and maintaining physical activity is important at every age.
What can you do if your loved one is having a hard time keeping up their diabetes management?
Recognize signs indicating that your loved one may need help caring for their diabetes, such as sudden worsening of diabetes management, frequent episodes of hypoglycemia, or feelings of stress when dealing with diabetes-related tasks.
Watch for symptoms and signs that you notice which could indicate low glucose episodes – and know that these may be different than at a younger age. For example, instead of sweating, shakiness, or palpitation, hypoglycemia in older adults can cause confusion, irritability, dizziness, weakness, feeling faint, or even a change of behavior. An older person with diabetes may not recognize this as hypoglycemia.
Identify which part of diabetes management is getting difficult. Is it taking medications as prescribed? Is it diet? Is it the ability to do physical activity? Help the person develop coping strategies once a barrier is identified. For example, filling pill boxes, setting alarms to remember insulin injections, helping with food preparation, or finding a safe place for exercise.
Make sure the person can care for themself when they’re sick. Are they taking their insulin on time? Are they eating? Watch out for very high or low blood glucose levels from illness, weight loss, dehydration or not enough food. Learn more about sick day plans here.
Check that your loved one is taking the correct doses of insulin and medication and is not skipping meals. If you notice challenges with this, it might indicate cognitive decline.
Notice if the person acts depressed. Depression is commonly missed when people try to hide their feelings. Notice if someone is withdrawing from activities they once enjoyed.
Identify if the treatment strategy seems too complicated, especially if your loved one has multiple health conditions. If so, ask their healthcare professional if treatment regimens can be simplified.
Dr. Munshi is an Associate Professor of Medicine at the Harvard Medical School. She is a geriatrician and an endocrinologist. She directs a unique Geriatric Diabetes Program that she developed at the Joslin Diabetes Center, and practices primary care geriatrics at the Beth Israel Deaconess Medical center. The primary focus of Dr. Munshi’s clinical research is to identify challenges faced by older individuals with diabetes, to develop strategies to overcome these barriers, and to improve clinical and functional outcomes, including quality of life.