Home / Resources / Clinical Gems / Handbook of Diabetes, 4th Ed., Excerpt #28: Diabetes in Old Age

Handbook of Diabetes, 4th Ed., Excerpt #28: Diabetes in Old Age

Jan 26, 2015

Rudy Bilous, MD, FRCP
Richard Donnelly, MD, PHD, FRCP, FRACP


There is a steep age-related increase in the prevalence of diabetes and impaired glucose tolerance which applies equally to both sexes. Overall, diabetes prevalence is higher in men, but there are more women with diabetes. In devel­oping countries, most people with diabetes are in the 45–64-year age band, whereas in developed countries the majority of people with diabetes are aged> 64 years (Figure 29.1 ). There is a particularly high frequency of type 2 diabetes in certain susceptible ethnic groups such as black Americans and Mexican Americans (about 30% of the elderly)….


By the year 2030, it is estimated that the number of people with diabetes over 64 years of age will be >82 million in developing countries and >48 million in developed coun­tries (Figure 29.2). In future years, a bigger proportion of the diabetes population will be elderly. This will have a number of effects on clinical practice. The presentation, management and outcomes of diabetes are different in older patients, especially if diabetes occurs in the context of other co-morbidities, frailty, physical and cognitive impairment and multiple drug therapies.

The presentation of diabetes in older people is often insid­ious and the diagnosis is often delayed. The symptoms can be non-specific and vague, such as fatigue, urinary inconti­nence or change in mental state (e.g. depression, confusion and apathy) (Box 29.1). Many cases are detected by finding incidental hyperglycaemia during the investigation of co-morbidities, such as a delayed recovery from specific ill­nesses, repeated infections or cardiovascular disease; the latter may present with atypical features, such as painless myocardial infarction, manifested as breathlessness, lassitude or falls. Acute metabolic disturbance is a further, rarer presentation: about 25% of cases of hyperosmolar nonketotic hyperglycemic coma (HONK, see Chapter 12) occur in people with previously undiagnosed type 2 diabetes. The tendency to hyperosmolarity may be worse in elderly people, who may not perceive thirst or drink enough to compensate for the osmotic diuresis of diabetes, and who are often taking diuretics.

Elderly patients with diabetes require treatment mainly to alleviate symptoms, to reduce the risk of hyperglycaemic crises, to prevent and manage vascular and other complica­tions and to achieve a normal life expectancy whenever possible (Box 29.2). Strict glycemic control may not always be appropriate. Diets rarely produce weight loss in the elderly and may be unjustifiably burdensome in the frail. Short-acting sulphonylureas such as gliclazide, or DPP-4 inhibitors, are preferred because of the likelihood in the elderly of impaired renal function, poor nutrition, impaired counterregulatory responses and cognition, and other factors that increase the risk of hypoglycaemia. Metformin is best avoided in many elderly subjects because of its increased tendency to cause lactic acidosis with renal impair­ment and hepatic or cardiac failure.

Simple insulin regimens are usually the most appropriate in diabetes of old age. Twice-daily injections of premixed insulins for type 1 diabetes or NPH insulin in type 2 patients are preferred. However, the practical difficulties of adminis­tration can limit their use in some patients and once-daily insulin, though unlikely to produce good control, may be more suitable for the very old and frail. The use of once- or twice-daily injections of the long-acting insulin analogues glargine or detemir may be advantageous and practical. The traditional multiple-dose, basal-bolus regimen for achieving near normoglycemia is probably only suitable for the com­paratively few well-motivated, mobile and mentally alert patients who are independent in self-care and have no other medical disorders.

For more information and to purchase this book, just follow this link:


Rudy Bilous MD, FRCP, Professor of Clinical Medicine, Newcastle University, Honorary Consultant Endocrinologist, South Tees Foundation Trust, Middlesbrough, UK

Richard Donnelly MD, PHD, FRCP, FRACP, Head, School of Graduate Entry Medicine and Health, University of Nottingham, Honorary Consultant Physician, Derby Hospitals NHS Foundation Trust, Derby, UK

A John Wiley & Sons, Ltd., Publication This edition first published 2010, © 2010 by Rudy Bilous and Richard Donnelly. Previous editions: 1992, 1999, 2004

Note: The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by physicians for any particular patient. The publisher and the authors make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organisation or website is referred to in this work as a citation and/or a potential source of further information does not mean that the authors or the publisher endorse the information the organisation or website may provide or recommendations it may make. Further, readers should be aware that Internet websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the authors shall be liable for any damages arising herefrom.