Older and Wiser-Seniors and Diabetes

| Aug 1, 1998

Two things that affect every aspect of one's life are having diabetes and becoming a senior citizen. When these happen together their impacts can become even more pronounced. As if this isn't enough, seniors with diabetes have to confront less-than-flattering stereotypes every day. This can be especially frustrating, and potentially damaging, when dealing with health care providers. Despite these added challenges, the plight of seniors with diabetes is often overlooked.

These problems can be overcome, but it takes work. We'll look at the dilemmas unique to seniors managing diabetes and some of the possible solutions.As we age, many things we once took for granted may become difficult to do. It gets harder to read fine print, harder to hear comments in a conversation and harder to get out of that favorite chair. The physical changes that accompany aging may also make driving a thing of the past, making it more difficult to get the doctor's office, the pharmacy or simply over to a friend's house to socialize or talk about a hard day. All of these changes can affect one's ability to perform good diabetes self care.

"In fact, the patient's functional skills may be of more immediate importance than his or her metabolic status," notes John F. Zrebiec, MSW, in the book, Practical Psychology for Diabetes Clinicians. "For example, impaired hearing and vision can interfere with effective communication and the ability to understand educational directions or medical recommendations."

Patient advocate Joan Hoover agrees that a person's functional skills are key to good diabetes care. She is concerned, however, that these changes in physical capability aren't recognized or taken into account by many health care professionals. "For example, you are always told to check your feet regularly," says Hoover. "If you are visually impaired, you may not be able to see them clearly, you may not be able to reach them due to physical limitations and you may not have even been educated as to what to look for. If you then develop a complication you are labeled as negligent."

Zrebiec agrees and points out that, "Practical medical management and realistic treatment goals rest upon the understanding of the capabilities of the older patient. It is imperative to ask patients how diabetes affects their life and what parts of diabetes care are difficult," he writes.

While some of the physical changes that accompany aging result from diabetes and can be prevented or delayed with good blood sugar control, others are simply the result of aging. Learning to accept these changes and preparing for them is also important.

"Part of knowing about your condition is knowing what's up ahead," says Janice Wright, MS, RN, chief of the Preventative Health Care for the Aging program of the California Department of Health Services. "If you are in denial when it [aging] happens, then it becomes a huge change that you don't have the mechanisms for coping with."


When Diabetes Isn't Alone

Another aspect of aging that can affect diabetes self-care is the fact that for many seniors, diabetes is only one of several chronic medical concerns. Having to manage multiple conditions can have a profound effect on one's diabetes care.

"When an elderly person has diabetes, but also has another health problem, they rarely have diabetes as their primary concern unless a complication forces them to do so," says Gary Gilles, MA, LCPC, a diabetes counselor at Holy Family Medical Center in Des Plaines, Illinois. "The severity of the other health concerns usually determines the amount of energy they spend on their diabetes management."

He recommends that his patients first address their most urgent medical problems and "then address the diabetes, since it is likely that their other health problems stem in some way from diabetes."

Marge King is a 77-year-old with type 2 diabetes who manages multiple medical conditions. She points out some of the special challenges this presents, "I have many medications that I have to keep track of. I couldn't trust my memory for a minute, so I've got this big log book and I write everything down. If I don't write it down, I forget. It's just the way we are at this age."

Stephen M. Setter, PharmD, an assistant professor of pharmacy practice at Washington State University's Elder Services and Visiting Nurses Association also suggests writing down the particulars of each medication being taken. For an outline of Setter's recommendations regarding such a list see page 20.

Patricia Lanoie Blanchette, MD, MPH, suggests that this written documentation begin in the doctor's office when the medications are being prescribed. "With multiple conditions what you have to do is make sure you get the instructions in writing, because a lot of them are very complicated and it is best to get one piece of information at a time to truly understand it," says Blanchette,.

According to King being a creature of habit is also helpful. "Managing multiple medications requires that I be vigilant about my routine," she says. "I run into trouble only when something breaks the routine, like visitors or trips away from home. Otherwise I am fine."


Memory Loss

Keeping a routine and written instructions are key because the gradual degeneration of cognitive function is something that affects a good number of senior citizens, whether they have diabetes or not. It can manifest itself as short-term memory loss which often goes unrecognized.

"We've documented in our studies of dementia that ... as many as 60 percent of those found to have cognitive impairment were not recognized by either physician or family," says Blanchette.

This in turn can have a negative effect on one's diabetes care. "For example, let's say an 80-year-old person with diabetes spends 30 minutes with a CDE. They look like they understand everything and they are asking pertinent questions. If somebody along the line has not tested them for short-term memory deficit, a lot of what just transpired may not be remembered," says Blanchette.

Again, writing information down can be very helpful. Hoover recommends writing questions down before visiting a health care provider and as much of their answers as possible during every visit.

Blanchette suggests sharing this information and notes that, "If you can include family members in the discussion with the patient's permission, I think it is a great idea as well," she says.


Depression or Uncontrolled Diabetes?

Memory problems and cognitive impairment aren't the only mental changes that seniors with diabetes need to be watchful of. Depression is also a major concern.

"Depression may be three times more prevalent in people with diabetes than in the general adult population, and depression in the elderly is probably under-recognized and under-treated," Zrebiec writes.

Wright notes that there are several aspects of the aging process that can contribute to depression. Primary among them is the feeling of loss. "One thing that people need to understand is that seniors live with incremental risks as they age," says Wright. She points out some of the changes in physical performance that come with aging, like weaker muscles and the degeneration of hearing and vision, and notes that, "Those are incremental changes that are also losses."

"They also deal with their friends who are seniors and who may precede them in having significant disease that leads to deterioration and even death. They are living with loss from themselves and from those around them," she adds.

Setter agrees that older people with diabetes are at an increased risk of depression and that, "Untreated and unrecognized depression leads to other health problems, and depressed persons with diabetes do not take good care of themselves or their disease."

Setter also warns, however, that the symptoms of depression might reveal another problem.

"I see many depressed, worn-out elders who are not enjoying life," says Setter. "Often their health care giver is asking me for a recommendation on antidepressant therapy. My first question is, 'What is their HbA1c?' If their diabetes is not being well controlled, How could we realistically expect them to feel 'well?' Once we get their diabetes under control, these other symptoms resolve and their quality of life has improved without additional therapy for depression or other associated problems like insomnia."

Unfortunately, many health care providers take a very conservative approach when it comes to blood sugar control with seniors. As Setter points out, "Many times I run into the situation where the HbA1c is 9.5% or 10% and it is not stressed to the patient that this equals poor control and an increased risk of complications."

The hesitation to keep tight control with seniors runs deep. As the ADA recommends in its Complete Guide to Diabetes, "For many people with diabetes, getting normal blood glucose levels (like a person without diabetes) just isn't realistic or even desirable. For instance, if you are elderly and live alone, you may be more concerned with preventing severe low blood glucose than avoiding long-term complications."

A legitimate point, but if this conservative approach is keeping you from feeling healthy and vigorous, is it worth it? And who should be making that decision?


Is Your Doctor Treating You Like a Child?

Another reason some health care professionals may not push the importance of tight control is because they have a hard time empathizing with older patients. This can arise for a number of reasons. According to Zrebiec, many providers believe that old people cannot change or are unwilling to change, therefore making suggestions useless; view "diabetes as simply part of the aging process and, therefore, not very serious;" and also tend to, "infantilize the older person because he or she seems weak or vulnerable."

"Physicians are among the worst in my opinion with regard to treating seniors as children," says Gilles. "They assume seniors cannot learn some technical things and often don't attempt to educate them about lifestyle changes, blood glucose levels, HbA1c test results, etc."

On the other hand, even Gilles, who feels strongly about physicians' tendency to infantilize seniors, acknowledges that many seniors need to take a more proactive role in their disease management. "The biggest problem facing the average elderly person with diabetes in my work is their reluctance to take a more assertive role in their health management," he says.

Some seniors are too passive and unquestioning Gilles claims. "They tend ... 'follow the doctor's advice' even though they often do not understand much," he says. "They often do not know how to ask pointed questions and hence blindly follow generalized advice."

Marge King has seen both sides of this dynamic played out with some of her friends. An elderly friend of King's had been battling frequently high blood sugars - readings of 288 each morning for a week. "When she asked her doctor, he said that was OK! I think she is of the old school that believes the doctor sits at the right hand of God and is not to be questioned. I have pleaded with her to ask him to send her to a specialist or at least to a CDE, but so far as I can tell, this has not put a dent in her belief."

Hoover has noticed the same dynamic. "It is an age thing," she says. "Seniors grew up in a time when nothing was written for the patient. You went to the doctor and they said do this, this and this and gave you no explanation."


Stereotypes and Beyond

Blanchette is hesitant to fall into this kind of categorization, however. She feels that much of this characterization of seniors as unwilling to ask questions and speak their minds comes from those who aren't actually working with seniors.

"If you look at older people and you really work with them, you discover that this concept of the weak-willed, vulnerable older person who is easily swept aside or patronized is hilarious," she says. "They are a lot stronger than that, because the way you get to be 80 or 90 years old is being tough and insistent and being able to hang in there."


Now More Than Ever

If Blanchette is right, seniors may be better equipped to deal with the recent changes in the health care delivery than anyone. As Wright points out, "One of the interesting trends in health care delivery is that consumers are being given more responsibility in managing their own chronic conditions."

In this environment a tough and insistent nature is a valuable tool. The current system "requires seniors to be proactive and ask their health care providers when they are on drug regimens how those drugs interact and clarify the possible symptoms and side-effects those may have," Wright adds.

Seniors who fail to communicate in this way could be hurting themselves. "I see many clients who have a rather mild side-effect right after starting a medication and they stop taking it without telling anyone," says Setter. He adds that many of those side-effects could be lessened or eliminated with just s little advice from a physician or pharmacist.

"It is very critical to discuss medications with health care providers. I can't stress this enough," says Setter. "If medicines are going to have the greatest benefit they need to be respected and taken appropriately. The best way to achieve that is to know as much about what they are meant to treat and how to take them properly."

Gerald Lundstrom, a 67 year old who has had type 1 diabetes for 53 years, advises that asking questions is important in all aspects of one's care, not just in reference to medications. After being told by his doctor that a particular insulin wasn't available in the pen, Lundstrom kept looking around and finally found the product he wanted. "Stay involved and educated," says Lundstrom. "It helps to ask questions and pick their (health care providers') brains."

Hoover concurs. "Asking questions is paramount," she says. "Just because a doctor doesn't mention something doesn't mean it shouldn't be brought up."


Don't Let It Run Your Life

According to Wright, one of the most important aspects of successfully living with diabetes while adjusting to the physical, mental and psychological changes that come with aging "is to build the self confidence that they [seniors] are able to do these things and that these things are worthwhile. In some behavior modification theory this is called self-efficacy."

Wright says that, "Those seniors that successfully manage their disease, that I have had the opportunity to know, are those who become informed about their disease, but do not let the disease run their lives. They are more accepting of the changes that are occurring to them and let others help them find other roles for themselves. If they experience changes they are right up front and say, 'Hey, I can't do this like I did before. What else can I do?' "


"We'll All Face These Things"

Accepting change, keeping this sense of personal empowerment and maintaining a positive attitude are some of the most critically important steps that can be taken to maintain the best possible physical health. This is especially true for seniors with diabetes, but it is also more challenging.

All parties involved, from seniors themselves to health care providers to family members, would do well to recognize these challenges and work to develop strategies to cope with the multifaceted impact of aging on diabetes self-care. This will not only help those living with these challenges today, but will also benefit those who will face them tomorrow.

As Hoover points out, "No one has diabetes that is not going to have it for the rest of their lives. We all need to be thinking about creative solutions because we are all going to face these things."

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