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Insulin for the Elderly patient
As the care of people with diabetes improves, the number of people who have diabetes over the age of 70 years is steadily increasing. A significant proportion of these patients will require insulin treatment. This page will deal with special problems associated with insulin treatment in the elderly and is intended for elderly people planning to embark on insulin as well as their carers.
- Reluctance to embark on insulin therapy. This is very common and may be associated with considerable anxiety.
- Problems with dexterity – handling some injection devices may prove difficult
- Visual impairment – measurement of doses may prove difficult
- Elderly patients may forget doses or take additional doses due to problems with memory
- Poor appetite, problems with dentures or difficulty preparing food may lead to skipped meals which in turn leads to hypos. There is also a greater risk of hypoglycaemia due to poor kidney function or other medication and illness.
- Reduced warnings associated with hypos – awareness of palpitations, sweating or tremulousness may be reduced. If intellectual processes are also impaired this may seriously affect ones ability to recognise a hypo.
As for other patients who have type 2 diabetes, elderly people will require insulin should their control be sub-optimal on diet and oral hypoglycaemic tablets. Target HbA1c levels for elderly people should be determined individually by a doctor of diabetes specialist nurse. This decision will take into account other co-existing health problems and life expectancy. Poor control is associated with tiredness, weight loss and an increased risk of infections. This may lead to muscle loss, decreased strength and problems with mobility. These considerations need to be balanced against any risks asociated with treatment.
This would depend on the level of control required. As the emphasis in elederly people is often on control of symptoms, safety and convenience the minimum number of one or two injections is often adopted. Insulin types which have a lower risk of causing hypoglycaemia are usually selected.
All insulins currently available may be used in the elderly. Short acting insulin is sometimes avoided to minimise risk of hypoglycaemia. Where once daily supervised injections administered by a District Nurse are required, a long acting analogue may be considered.
There are various options for people with reduced dexterity. Certain injection devices such as the Innolet device may be easier for those with arthritis or visual impairment. Some devices have the facility to preset doses which can then be dialled-up easily. In some instances it may be appropriate to have the dose drawn up by someone else.
The target HbA1c for the elderly patient may be less stringent than for a younger person. The main aim for control may be improving qualtiy of life rather than prevention of complications. As in most instances the target is best determined on an individual basis.
Dr Nishan Wijenaike MD FRCP
Consultant Physician (Diabetes and Endocrinology)
West Suffolk Hospitals NHS Trust
Bury St Edmunds