Editor’s viewpoint: Diabetes and old age: who cares?

‘About the only thing that comes to us without effort is old age’ (Gloria Pitzer)

Diabetes continues to be a scourge at the extremes of age. Locally, of more than 10 000 registered patients with diabetes, almost 4000 are aged >75 years (unpublished observation). The combination of old age and diabetes brings with it innumerable problems.

It has been known for many years that diabetes increases the risk of vascular dementia. More recently, an association between type 2 diabetes and the risk of developing Alzheimer’s disease has been recognised (Sastre AA and Grimley Evans J, 2003). As a corollary, patients with established Alzheimer’s have reduced insulin-mediated glucose disposal i.e. insulin resistance (Craft S et al, 1999). The mechanisms linking diabetes and this type of dementia are not known but may relate to modulation of levels of β-amyloid protein, the neuropathologic hallmark of Alzheimer’s disease, by insulin (Watson GS et al, 2002).

Further support for a possible link between diabetes and Alzheimer’s has been provided by the recent report of hippocampal and amygdalar atrophy – characteristics of early Alzheimer’s disease – on MRI imaging in patients with type 2 diabetes. Intriguingly, amygdalar atrophy is also demonstrable in individuals with insulin resistance but no diabetes (den Heijer T et al, 2003). This raises the possibility that targeting insulin resistance and avoiding hyperinsulinaemia may be potentially beneficial in protecting cognitive performance in older people.

Managing diabetes in old age is already not straightforward, but is just about to get even more difficult. From January 2004, the Community Care (delayed Discharge) Act comes into force, whereby social service departments will have 2 days to arrange a package of care at home or in other forms of accommodation for patients deemed to be medically fit for discharge or face a fine from the NHS. In addition, payments to NHS trusts are going to be influenced by length of stay – earlier discharge will bring in more money, and keeping someone in for longer than anticipated will cost more. Thus, there will be pressure to discharge patients as early as possible. In dealing with older individuals with diabetes, planning and timing of discharge is an art moulded by experience. With these new changes to NHS funding, clinicians are likely to come under pressure to move patients through the system as quickly as possible, forcing older individuals with long-term illnesses, such as diabetes, into inappropriate accommodation before they are ready and without giving them any choice (Rowlard DR and Pollock AM, 2004).

At a practical level, age, as an independent factor in diabetes care needs to be recognised and appreciated, whilst at the same time avoiding the inevitable shouts of ageism and discrimination. Coordination of multiple agencies, ensuring proper education and training, dealing with competing agendas and the bureaucracy of the NHS, whilst keeping the patient’s interests at the forefront, will be a Herculean task. In 2004, old people with diabetes will need gatekeepers much more than champions.

Happy New Year to all our readers.