Diabetes in the Older Adult

Diabetes in an older adult is often less about achieving the lowest possible A1C and more about preventing the glucose extremes that cause falls, confusion, injury, hospitalization, and loss of independence. With aging, pancreatic beta-cell function declines and insulin resistance increases, making hyperglycemia more likely. At the same time, the hormonal response that normally raises glucose during hypoglycemia becomes less reliable. An older adult may therefore have a modest appetite change, take the usual diabetes medication, and develop clinically significant hypoglycemia with fewer warning symptoms than expected. This changes the clinical presentation. Instead of reporting tremor, diaphoresis, and palpitations, an older adult with hypoglycemia may be found confused, unusually quiet, irritable, unsteady, or on the floor after an unexplained fall. Hyperglycemia may similarly appear as fatigue, dehydration, urinary frequency, worsening incontinence, blurred vision, or an abrupt decline in cognition. An experienced nurse does not assume that a new mental-status change is “just dementia” in a patient with diabetes. Check glucose promptly while simultaneously assessing for other acute causes such as infection, medication effects, stroke, dehydration, or hypoxia.