Building Competency in Diabetes Education THE ESSENTIALS

4-40 | CHAPTER 4

The natural aging process can account for a decline in kidney function, reduced muscle strength and some loss of body function (74). Diabetes can accentuate these changes leading to an increased sensitivity to medications, visual loss and a greater propensity for falls.

Medications and the older person Safety is a primary concern in the elderly. Their multiple co-morbidities often lead to numerous prescription medications and polypharmacy (74). With their decrease in kidney function there is an increase in their susceptibility to hypoglycemia (82). Also, the decrease in the autonomic response and impaired counter-regulatory mechanisms leads to a higher prevalence of hypoglycemia unawareness (75,92).

Hypoglycemia Causes of asymptomatic hypoglycemia in the elderly: • Reduction in glucagon secretion • Impaired awareness • Altered psychomotor performance

Other complicating factors include the relationship of cognitive function to hypoglycemia. Recent studies looking at this relationship have concluded that there is a bidirectional association between hypoglycemia and dementia and cognitive dysfunction among older adults with diabetes (93-95). Frequent hypoglycemia leads to cognitive decline whereas those with evidence of cognitive impairment are noted to experience more frequent hypoglycemia (93,94). These findings highlight the necessity to be extra vigilant in the choice of anti-diabetic agents that can cause hypoglycemia and to be cautious when prescribing these medications in the elderly. Key Messages • Sulfonylureas should be used with caution because the risk of hypoglycemia increases substantially with age; Gliclazide and gliclazide MR are preferred over glyburide; ½ dose for initiation and increase slowly. • DPP-4 inhibitors as a second line should be used over sulfonylureas due to lower risk of hypoglycemia.