Diabetes is associated with increased risk of multiple coexisting medical conditions in older adults. In addition to the classic cardiovascular and microvascular diseases, a group of conditions termed geriatric syndromes, described below, also occur at higher frequency in older adults with diabetes and may affect self-care abilities and health outcomes including quality of life.
Cognitive dysfunction.
Alzheimer’s-type and multi-infarct dementia are approximately twice as likely to occur in those with diabetes compared with age-matched nondiabetic control subjects. The presentation of cognitive dysfunction can vary from subtle executive dysfunction to overt dementia and memory loss. In the ACCORD trial, for which referred participants were felt to be capable of adhering to a very complex protocol, 20% of those in the ancillary trial of cognition were found to have undiagnosed cognitive dysfunction at baseline (J. Williamson, personal communication) . In this trial, neither intensive glycemic control nor blood pressure control to a target SBP <120 mmHg was shown to prevent a decline in brain function . Cross-sectional studies have shown an association between hyperglycemia and cognitive dysfunction Hypoglycemia is linked to cognitive dysfunction in a bidirectional fashion: cognitive impairment increases the subsequent risk of hypoglycemia , and a history of severe hypoglycemia is linked to the incidence of dementia.
High rates of unidentified cognitive deficits in older adults suggest that it is important to periodically screen for cognitive dysfunction. Simple assessment tools can be accessed at Such dysfunction makes it difficult for patients to perform complex self-care tasks such as glucose monitoring, changing insulin doses, or appropriately maintaining timing and content of diet. In older patients with cognitive dysfunction, regimens should be simplified, caregivers involved, and the occurrence of hypoglycemia carefully assessed.
Functional impairment.
Aging and diabetes are both risk factors for functional impairment. After controlling for age, people with diabetes are less physically active and have more functional impairment than those without diabetes . The etiology of functional impairment in diabetes may include interaction between coexisting medical conditions, peripheral neuropathy, vision and hearing difficulty, and gait and balance problems. Peripheral neuropathy, present in 50–70% of older patients with diabetes, increases the risk of postural instability, balance problems, and muscle atrophy , limiting physical activity and increasing the risk of falls. Other medical conditions that commonly accompany diabetes such as coronary artery disease, obesity, degenerative joint disease, stroke, depression, and visual impairment also negatively impact physical activity and functionality.
Falls and fractures.
Normal aging and diabetes, and the conditions described above that impair functionality, are associated with the higher risk of falls and fractures . Women with diabetes have a higher risk of hip and proximal humeral fractures after adjustment for age, BMI, and bone density (71). It is important to assess fall risks and perform functional assessment periodically in older adults . Avoidance of severe hyperglycemia and hypoglycemia can decrease the risk of falls. Physical therapy should be encouraged in patients who are at high risk or who have experienced a recent fall. Medicare may cover physical therapy for a limited time in some of these situations.
Polypharmacy.
Older adults with diabetes are at high risk of polypharmacy, increasing the risk of drug side effects and drug-to-drug interactions. A challenge in treating type 2 diabetes is that polypharmacy may be intentional and necessary to control related comorbidities and reduce the risk of diabetes complications. In one study, polypharmacy (defined as the use of six or more prescription medications) was associated with an increased risk of falling in older people . The costs of multiple medications can be substantial, especially when older patients fall into the “doughnut hole” of Medicare Part D coverage. Medication reconciliation, ongoing assessment of the indications for each medication, and the assessment of medication adherence and barriers are needed at each visit.
Depression.
Diabetes is associated with a high prevalence of depression . Untreated depression can lead to difficulty with self-care and with implementing healthier lifestyle choices and is associated with a higher risk of mortality and dementia in patients with diabetes. In older adults, depression may remain undiagnosed if screening is not performed. Clinical tools such as the Geriatric Depression Scale can be used to periodically screen older patients with diabetes.
Vision and hearing impairment.
Sensory impairments should be considered when educating older adults and supporting their self-care. Nearly one in five older U.S. adults with diabetes report visual impairment . Hearing impairment involving both high- and low/mid-frequency sound is about twice as prevalent in people with diabetes, even after controlling for age and may be linked to both vascular disease and neuropathy .
Other commonly occurring medical conditions.
Persistent pain from neuropathy or other causes or its inadequate treatment is associated with adverse outcomes in older adults including functional impairment, falls, slow rehabilitation, depression and anxiety, decreased socialization, sleep and appetite disturbances, and higher health care costs and utilization (2). Pain should be assessed at every visit in older patients with the implementation of strategies for amelioration of pain. Urinary incontinence is common in older patients, especially women, with diabetes. In addition to standard assessments and treatments for incontinence, clinicians should remember that uncontrolled hyperglycemia can increase the amount and frequency of urination.
Unique nutrition issues
Nutrition is an integral part of diabetes care for all ages, but there are additional considerations for older adults with diabetes. Though energy needs decline with age, macronutrient needs are similar throughout adulthood. Meeting micronutrient needs with lower caloric intake is challenging; therefore older adults with diabetes are at higher risk for deficiencies. Older adults may be at risk for undernutrition due to anorexia, altered taste and smell, swallowing difficulties, oral/dental issues, and functional impairments leading to difficulties in preparing or consuming food. Overly restrictive eating patterns, either self-imposed or provider-directed, may contribute additional risk for older adults with diabetes. The Mini-Nutritional Assessment, specifically designed for older adults, is simple to perform and may help determine whether referral to a registered dietitian for medical nutrition therapy (MNT) is needed .
MNT has proven to be beneficial in older adults with diabetes . Recommendations should take into account the patient’s culture, preferences, and personal goals and abilities. When nutrition needs are not being met with usual intake, additional interventions may include encouraging smaller more frequent meals, fortifying usual foods, changing food texture, or adding liquid nutrition supplements (either regular or diabetes-specific formulas) between meals. For nutritionally vulnerable older adults, identifying community resources such as Meals on Wheels, senior centers, and the U.S. Department of Agriculture’s Older Americans Nutrition Program may help maintain independent living status.
Overweight and obesity are prevalent among older adults. BMI may not be an accurate predictor of the degree of adiposity in some older adults due to changes in body composition with aging . Sarcopenia may occur in both over- and underweight older adults. Obesity exacerbates decline in physical function due to aging and increases the risk of frailty . While unintentional weight loss is a known nutrition concern, intentional weight loss in overweight and obese older adults could potentially worsen sarcopenia, bone mineral density, and nutrition deficits . Strategies that combine physical activity with nutrition therapy to promote weight loss may result in improved physical performance and function and reduced cardiometabolic risk in older adults .
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