- Kenneth L. Minaker
Sites of Care
Care of the older diabetic patient, similar to the care of other complex geriatric patients, has become a multidisciplinary issue with very high stakes in terms of vascular, renal, and ocular disability. Recent studies have demonstrated the value of careful management on the improvement in patient outcomes, and large-scale studies are under way to deter or prevent the emergence of clinical disease.
Increasingly, the focus of care is planning a comprehensive, multidisciplinary treatment and assessment program designed to prevent end-organ injury and to intervene early in the course of illness. It is an encouraging time to be involved in the treatment of diabetic patients, particularly outpatients treated early in the course of their illness. Improved care of the vascular and renal complications in those with advanced disease has also produced promise for their higher quality of life.
Demographics, Epidemiology, and Risk Factors
Diabetes mellitus prevalence increases with age, and the numbers of older persons with diabetes are expected to grow as the elderly population increases in number (Figure 46.1). The National Health and Nutrition Examination Survey (NHANES III) demonstrated that, in the population over 65 years old, almost 18% to 20% have diabetes. Of great diagnostic and clinical significance is that one-half of those with diabetes mellitus are not aware they have the disease. Other abnormalities in carbohydrate metabolism that have been observed include an additional 20% to 25% older patients meeting the criteria for impaired glucose tolerance. These unknown diabetic individuals and those potentially at risk were uncovered using glucose tolerance tests, which are very sensitive to abnormalities in carbohydrate economy.
The incidence of diabetes mellitus is approximately 2 per 1000 among those older than 45 and increases for those individuals more than 75 years old. Prevalence is much higher in older Hispanics, African Americans, Native Americans (Indians), Scandinavians, Japanese, and Micronesians.
Individuals with diabetes mellitus who are older than 65 usually have noninsulin-dependent diabetes (NIDDM). Insulin-dependent diabetes mellitus (IDDM) accounts for only 5% to 10% newly diagnosed diabetes mellitus in late life. In addition, a small proportion of older individuals who initially have NIDDM appear to become insulin dependent over time. A few clues as to who will require insulin exist. Ketosis at the time of diagnosis suggests that insulin therapy will be necessary. However, some elderly individuals with diabetes and ketosis can subsequently be treated with oral agents. The human leukocyte antigen (HLA)-DR3 serotype is more common in older adults who require insulin treatment. The frequency of antibodies to islet cells in older diabetic patients is not increased.
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