Second in a Series on Quality of Life
T2D is a heterogeneous condition, meaning that it has more than one specific, isolated cause, and it shows up in people who don’t share identical physical characteristics.
We do know, however, that there is a profile, solidly grounded in the medical evidence, of a person most likely to develop T2D. Someone at the greatest risk for T2D is clinically obese (body mass index of 30 or greater), has a diet high in carbohydrates and in particular in the salt and refined sugars in processed foods, and has reached age 45. But it is true that slim people can develop T2D, and that for some people T2D manifests itself first with insulin resistance in tissue and only later with the weakening of the pancreatic functions to deliver insulin and to signal the liver to hold or release stored glucose. There’s no magic to the number 45. There’s no magic to the number 65 either, really, although age 65 has served well as a point on the timeline when how we live has begun to change.
We also know this about life at 65:
First, even if diabetes isn’t in the picture or may never be, the aging process brings on its own set of health challenges. The odds of developing heart, nerve, joint, or kidney disease, or vision loss are known to be higher among people who have diabetes, but then these are chronic conditions that also have age-related causes unrelated to diabetes. Of course, a person already battling such a problem faces the likelihood that his or her treatment for it will change once a diagnosis of diabetes has been made.
Second, there is a steadily growing prevalence of T2D among our seniors. Beginning at age 65, the rate of new diagnoses does begin to level off, according to the current estimates published by the U.S. Centers for Disease Control and Prevention (CDC). Still, CDC’s estimates count 18% to 22% of people in the 65 and older segment of the population as having T2D (compared to about 8% to 10% of the entire U.S. population). As many as one in four seniors have prediabetes or T2D but don’t know it.
The good news? There is convincing research, begun begun in the 1980’s at the National Institutes of Health, that for aging people the lifestyle interventions of controlling weight and eliminating excess sugars from the diet will slow T2D onset or even prevent it. Even better news is that another NIH study from the 1980’s that ushered in the National Diabetes Prevention Program discovered that participants aged 60 and older seemed to benefit more from the lifestyle interventions than did younger participants.
In the first part of this series, we wrote about one of the underpinnings of the American Diabetes Association (ADA) professional care standards: that one size does not fit all when it comes to diabetes care, and that patients’ values and preferences must be considered and may lead to different targets and strategies. Most patients want to make their treatment choices in hopes of feeling better without adding at the same time to the burden of living with their medical problems. What can make T2D especially burdening for a senior, along with restricting diet and activities, is the expense and drudgery of testing blood glucose and keeping to a prescription regimen that may have to change unexpectedly.
Panelists at the American Association of Diabetes Educators conference in August 2017 described this as “diabetes burnout” in their patients having a rough go of it. Quality of life, the ultimate outcome, becomes elusive over time for them.
Here are some of the other things that do typically go on in the lives of older people who have T2D, and that go directly to quality of life:
- Adjusting to being retired from a career or changing how one works, likely involving the transition from employee health insurance to Medicare, or the individual coverage market, and the headaches of paying premiums and copayments and worrying about getting claims paid;
- Finding over-the-counter cold or flu relievers that won’t raise glucose or blood pressure;
- Frustration over blood glucose and A1c targets becoming harder to meet; and
- Forgetfulness, stress, and anxiety.
An easy way to see examples of how doctors modify treatments to best suit patients, and how their older patients can prepare themselves to stay engaged in self care, is to browse around the materials that ADA and nationally known diabetes clinics and research organizations publish on line. We don’t recommend any one over another, but here’s a sampling of measures suggested by Joslin Diabetes Center, Novo Nordisk, and others who are knowledgeable in ways that doctors and older patients can advance in the pursuit of quality of life.
Polypharmacy
This is the medical term for simultaneous use of a large number of medications — prescribed and over the counter — adding to the likelihood of forgotten doses, mistakes in dosing, and adverse drug interaction. Make a detailed list of all medications, strengths, and dosages, check its accuracy with your prescribers and your pharmacist, and keep it updated. Consult with your doctor to eliminate or reduce use of products that no longer offer a needed benefit or could reduce the effectiveness of your antidiabetic meds.
Exercise
People who develop problems with gait, balance, or loss of bone density are at heightened risk of injury of falling. Recumbent stationary bikes, lap pools, and water aerobics classes
offer exercise for people who need to be careful around gravity. Swimming offers low-impact highly aerobic exercise. Simply roaming around the pool offers gentle resistance for exercising legs and helps loosen stiff back muscles.
Nutrition
Some diabetes medications bring on loss of appetite and dulling of the sense of taste. If weight loss becomes a concern, consider with your diabetes educator or a nutritionist introducing some flavorful, familiar foods that you find more enjoyable than reduced calorie and carbohydrate foods, and having your doctor adjust your medication schedule and doses if necessary.
Medications and Supplies
CDC has identified non-adherence to prescription and glucose testing regimens as a reliable predictor of poor glycemic control, and so if you tend to be forgetful, or if calling in for refills and making trips to the drug store makes life unnecessarily complicated, consider a home delivery service that offers automatic refilling and insurance billing services.
Hypoglycemia adds to the risk of loss of consciousness and cognition, weakness, and injuring falls, and its incidence is age-related. Short acting sulfonylureas for people on an oral medication regimen have the benefit of reducing risk of lows, and are generally better than long acting sulfonylureas for people who have renal difficulties.
Metformin can bring on gastric discomfort, but switching to an extended release formulation can alleviate that.
Prefilled insulin pens have the benefit of eliminating inconvenience in handling vials, syringes, and needles, and the chances of mistake in dosing. Pens with an audible click to set the dose help in avoiding mistakes.
A GLP-1 drug in once-weekly formula is a more attractive alternative than a once or twice daily one for older patients. GLP-1 drugs aren’t known to contribute significantly to risk of hypoglycemia.
Common sense tells us, as do the the CDC and NIH researchers, that as life expectancies have improved through advances in health science in this century and the last, prevalence of T2D among older Americans, and the odds of complications setting in, have been the unfortunate by-products. But there’s at least one silver lining. The field of gerontology, which is the study of how the aging process affects physiology (the body’s biological functions), mental and emotional well-being, and susceptibility to disease and injury, has had a great many more people to study and for longer times.
Gerontologists and geriatricians (the specialists who care for older people), have contributed considerably to the evidence-based medical knowledge underlying the ADA Standards for care of older people. Because this knowledge will continue to evolve, as will what it is that you’re willing to put up with to maintain a satisfying way of life, it’s crucial to stay engaged with your health care professionals and talk candidly about what’s going on in your life.
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