Geriatric diabetes is diabetes that occurs in people over the age of 65. It includes patients with diabetes that occurs after the age of 65 as well as diabetes that occurs before the age of 65 and continues beyond the age of 65. Geriatric diabetes is mostly type 2 diabetes. It is very important to pay attention to the prevention and treatment of geriatric diabetes, pay attention to the characteristics of geriatric diabetes, and choose the suitable treatment plan for geriatric patients, in order to reduce the complications of diabetes and reduce the disability and death rate.
1.Characteristics of geriatric diabetes mellitus
Typical symptoms such as excessive drinking, polyphagia, polyuria and weight loss are rare in geriatric diabetes. Most of the onset is insidious, and a significant number of patients are seen for its complications, such as vision loss, hypertension, hyperlipoproteinemia, coronary heart disease, stroke, swelling or proteinuria, pruritus of the skin or vulva, numbness, tingling or other sensory disturbances in the extremities, and a significant number of patients are diagnosed with diabetes when elevated blood glucose is found during routine physical examination.
Type 2 diabetes in the elderly generally has the following characteristics.
①A variety of metabolic abnormalities generally coexist.
②The disease is insidious and typical clinical symptoms are rare.
③Postprandial blood glucose rises significantly, while fasting blood glucose rises relatively lightly.
④High incidence of chronic complications, multiple complications exist at the same time.
⑤ The renal sugar threshold is increased, and urine sugar cannot reflect the blood sugar situation.
⑥Acute complications are easy to be misdiagnosed, and the morbidity and mortality rate is high.
(7) Multi-organ function of the elderly is reduced, and the use of drugs is obviously limited.
(8) The symptoms of hypoglycemia are atypical, the relative hypoglycemia tolerance is poor, and there is a possibility of severe and fatal hypoglycemia.
⑨ Elderly patients have poor compliance to treatment. Elderly patients are often encouraged by advertisements or salespeople to buy the so-called “sugar-lowering Chinese medicine”, which “has no side effects” and “can stop the sugar-lowering medicine or insulin”.
2. General treatment of geriatric diabetes
The treatment of geriatric diabetes is the same as that of general diabetes, but taking into account the characteristics of the elderly. Health education for geriatric diabetes should take into account the characteristics of hearing, strength, and cognitive decline in the elderly, and education should be given to the family members or companions or guardians of the elderly patients.
Diet therapy remains the basis for the treatment of geriatric diabetes, and when exercise therapy is performed, more attention should be paid to the measured, gradual, and avoiding intense, competitive exercise. When choosing oral hypoglycemic drugs, it is important to review various situations, make a comprehensive judgment, and choose the appropriate drug.
3.Drug selection for geriatric diabetes
Principles of drug treatment for geriatric diabetes: The purpose of treatment for geriatric diabetes is: to make reasonable control of blood glucose, try to avoid the occurrence of serious hypoglycemia, prevent acute complications arising from hyperglycemia, and stop or delay the process of chronic complications of diabetes.
For the treatment of elderly diabetic patients, the following factors should be fully considered.
① Determine or estimate the remaining average life expectancy of the patient.
②The contradictory unity between smooth glycemic control and prevention and control of complications.
③Effectiveness of economic status, social support and security.
④Co-existing other diseases.
⑤ Complications of diabetes, etc.
When choosing hypoglycemic drugs, consideration should be given to elderly patients with age, kidney and liver function, drug metabolism and excretion slowing down; secondly, the use of multiple hypoglycemic drugs for elderly patients may produce drug interactions, change the metabolic kinetics of drugs and affect the effect of drugs; elderly patients often have one or more concomitant diseases, and the treatment of these diseases may adversely affect blood glucose control.
For elderly patients with type 2 diabetes mellitus whose blood glucose rise is not obvious, only reasonable diet and exercise treatment can be given at the beginning of treatment, and if blood glucose and glycosylated hemoglobin (HbA1c) cannot reach the predetermined target after 2~3 months, or if blood glucose is relatively high when first diagnosed, with fasting blood glucose above 11.1mmol/lL or 2h postprandial blood glucose above 13.9mmol/lL, the use of drug treatment.
4.Pro-insulin secreting agent
Sulfonylurea drugs can be considered for non-obese elderly patients with type 2 diabetes. The main mechanism of action is to stimulate the release of insulin from the pancreas, and there are also extra-pancreatic effects such as strengthening the binding of insulin to the corresponding receptors. The risk of hypoglycemia is high in the elderly, especially in the elderly, and strong, long half-life sulfonylureas are generally not recommended.
It should be noted that it is prohibited for those who are allergic to sulfonylureas; it should be used with caution or prohibited for those with hepatic and renal insufficiency; it should not be used for elderly patients with type 1 diabetes; it should be prohibited in emergency situations, such as trauma, major surgery, acute cardiovascular disease, severe infection, ketoacidosis, and hyperosmolar syndrome; fee sulfonylurea insulin-producing agents (nateglinide, repaglinide) have a half-life, mainly control postprandial blood glucose, and the requirements for The requirements of renal function are relatively low, while the incidence of hypoglycemia is relatively low, relatively safe and convenient to take, and relatively safe to apply in elderly patients.
The most serious adverse reactions of sulfonylureas are hypoglycemic reactions, which have a higher incidence in elderly patients, among which the incidence of euglycemia is especially high and the side effects are long-lasting. Therefore, the elderly should pay attention to close observation when applying sulfonylureas.
(1)Biguanides
The indications and contraindications for the use of metformin should be strictly controlled in elderly patients. The incidence of lactic acidosis of metformin is lower than that of phenylephrine and relatively safe. The main mechanism of action of metformin is to increase glucose uptake in peripheral tissues, reduce hepatic glycogen output and intestinal glucose absorption, and at the same time, it can improve insulin sensitivity. The following conditions should be noted when applied to elderly patients.
①It is prohibited in patients with chronic hypoxic diseases.
②Prohibited in elderly patients with renal insufficiency.
③It is contraindicated in patients with hepatic insufficiency.
④It is generally contraindicated in elderly patients of advanced age.
⑤Application is not considered for elderly patients with gastrointestinal diseases, chronic anemia, and wasting.
(6) The dose should be reduced appropriately in elderly patients.
⑦Patients who apply contrast examination should stop using bivalirudin on the same day.
⑧Patients with previous history of lactic acidosis, alcoholics and patients with hematological disorders are contraindicated. Metformin can be used in combination with other types of hypoglycemic drugs, and also with insulin. Patients applying metformin should have regular check of liver and kidney function, blood lactate, blood picture, etc.
(2) α-glucosidase inhibitors
The main mechanism of action is to reduce the postprandial blood glucose peak through reversible competitive inhibition of α-glucosidase at the brush border of small intestinal villi, slowing down the degradation of carbohydrates in the intestine and delaying their absorption. When applied to elderly patients, attention should be paid to.
(i) Contraindicated in patients with chronic or acute intestinal flatulence.
(2) Contraindicated in patients with chronic gastrointestinal disorders with significant digestive and absorption disorders.
(iii) Contraindicated in patients after abdominal surgery. It is contraindicated in patients with hernia, abdominal incisional hernia, etc.
④Prohibited in patients with ketoacidosis.
⑤ It is contraindicated in patients with severe infection, severe trauma and other emergency states.
(6) Contraindicated in patients with severe hepatic and renal impairment.
(7) Not recommended for patients with malignant tumors and alcoholism.
⑧It is not recommended for those who are applying laxatives or anti-diarrheal drugs, or taking digestive enzyme preparations (such as amylase, pancreatic enzymes). The characteristics are that it can play the role of drug meal sharing, and the combination with insulin can reduce insulin dosage and blood sugar fluctuations, and the incidence of hypoglycemia is low when applied alone, but the occurrence of hypoglycemia should be noted when combined with other drugs.
(3) Insulin sensitizer
The main mechanism of action is to increase insulin sensitivity, strengthen the role of insulin and lower blood glucose, and new research also has effects other than hypoglycemia, such as improving blood lipids, lowering blood pressure and anti-atherosclerosis. Elderly patients should pay particular attention when applying.
①Patients with acute and chronic liver damage are prohibited.
②These drugs can cause water and sodium retention and aggravate potential cardiac insufficiency, so the patient’s respiratory and circulatory function should be understood before application.
(3) Prohibited in patients with diabetic ketoacidosis, the application of adaptation to regular checks of liver and kidney function, cardiac function, peripheral blood picture.
(4) Insulin
Elderly patients with type 1 diabetes must be treated with insulin. Elderly patients with type 2 diabetes mellitus should add or switch to insulin therapy promptly when reasonable diet, exercise and oral hypoglycemic drugs cannot effectively control blood sugar. In addition, insulin therapy should be used in cases of diabetic ketosis, hyperosmolar coma, progressive retinopathy, active tuberculosis, severe infection, surgery and severe liver and kidney impairment and various serious complications. The following issues should be noted when administering insulin therapy.
①Adhere to a reasonable diabetic diet and appropriate exercise therapy.
②Starting with small doses, especially for patients with low body mass index or who have never applied insulin before, should be highly individualized, and attention should be paid to the fact that the insulin requirements of the same patient may vary greatly at different stages of the disease during the treatment.
(3) Older patients may combine a variety of drugs, many of which can affect insulin secretion or insulin action, and the application or discontinuation of such drugs can lead to large fluctuations in blood glucose, which should be noted. Drugs that enhance the effect of insulin mainly include: oral anticoagulants, salicylates, sulfonamides, methotrexate and oral hypoglycemic drugs, anabolic hormones, chloramphenicol, etc. Drugs that antagonize the effect of insulin: adrenocorticotropic hormone, thyroxine, growth hormone, thiazide diuretics, oral contraceptives, hydrochloric acid derivatives, beta-blockers, etc.
④ When taking insulin intensive therapy, the incidence of hypoglycemia increases, and attention should be paid to timely adjustment of the treatment plan. Intensive insulin therapy is not recommended for elderly patients of advanced age, those with increased cardiovascular risk, those with mental abnormalities, drug dependence or those with advanced serious complications and unable to self-monitor their blood glucose.
5. Other drugs
Such as entero-insulin agonists, dipeptidyl peptidase-IV inhibitors, tryptic precipitin analogues and other drugs have been applied in foreign countries, but not yet marketed in China, due to the short application time and lack of information on the application in the elderly.