DIABETES IN THE ELDERLY
DR ODILZA VITAL
Diabetes Mellitus

Syndrome for metabolic alterations: hyperglycemia and glicosuria for the absence of the biological action of the insulin. By deficiency of the secretion or by the action impossibility. The hyperglycemia takes to the glicação(conferir) of the proteins of whole cardiovascular apparel. Secondary vascular alterations include abnormalities of small vases (microangiopatia) and great vases (macroangiopatia).
Microangiopatia {retinopatia, nefropatia}
Macroangiopatia {AVE, infarct of the myocardium, outlying vascular disease}
They are due to vascular and metabolic alterations (neuropatia).

Diabetes mellitus type I ou insulin-dependent
Pathogeny
Pathogeny with diabetes type I: Antigens HLA and production of antibodies against the cells of the pancreatic islets, molecule of the insulin for the enzyme decarboxilase of the glutaminic acid.
These antibodies can be many years present before the installation of the diabetes.
Patient with type I develop ketose, what means a virtual absence of the insulin.
Without insulin replacement, the evolution is the coma and death.
About 6% of the population in U.S has some form of diabetes. But only 10% of these present diabetes type I.
Although most is children and young adults with less than 30 years, patient in the strip of 70 and 80 can present diabetic cetoacidose.
Diabetes no-insulino dependent type II
Adult type, involves a deficiency and relative resistance to the action of the insulin.
Insulin level normal or high with hyperglycemia, resistance to the insulin.
Groups of larger risk for the group type II - the obese and the elderly.
The obesity and the advanced age are independent risk factors for the diabetes mellitus type II.
The prevalence bends for each 20% of weight increase above the ideal, and for every decade after the 40.

Secundary Diabetes mellitus
It includes the diabetes resulting from diseases that destroy the pancreas (hemocromatose, pancreatitis, cystic fibrosis) endocrine diseases in which the excess of hormones interferes in the action of the insulin (GH - acromegalia, (cortisol - Cushing), (catecolaminas) - feocromocitoma) drugs that suppress the insulin secretion (phenitóina) or inhibit the action of the insulin (glicocorticóides).

Symptoms and signs
When the metabolism of the carbohydrates deteriorates for the resistance to the insulin, the glucose posprandial don't return to the levels preprandiais in 3 at 5 hours. The symptoms and signs don't appear while the glycemia not cross the renal capacity of reabsorption of the same - 180mg/dL.
Elderly with renal disease, this limit is higher (not evaluate for this test).
When it happens the glicosuria, the urine formed after the meals becomes positive for glucose, while the urine formed before the meals is negative (glicosuria) in fast has limited value).
The patients can have intermittent glicosuria and they are usually asymptomatic.

In the progression of the metabolic abnormality, the fast glycemia rises, and the levels exceed the renal threshold in most of the day. The patients have persistent glicosuria, but they are usually asymptomatic, except maybe for the complaint of fatigue.

With the progression, the glicosuria promotes an osmotic diuresis that takes to the poliúria and this to the polidipsia.
As the endogenous insulin is more and more inefficient, the body cannot take advantage calories originating from of carbohydrates that takes to the weight loss in spite of the polifadiga.

The vision is cloudy for the alteration in the crystalline lens for the osmotic alterations induced by the hyperglycemia.
Increase of the susceptibility to certain infections, especially mushrooms and staphylococci.
If the hyperglycemia progresses, the patient can present cetoacidose, especially if happened to another complication concomitantly (urine infection) the syndrome no cetótica hiperosmolar appears and it can be the first indication of the diabetes. In this situation, the hyperglycemia can arrive at extremely high levels as 1000mg/dL-coma hiperosmolar.
When there is accumulation of ketonic bodies, which occur in the patient with diabetes of the type I the systems lid of the organism is not able to neuralizá-los and the kidneys cannot excrete them.
The excess of ketonic bodies accumulates in the blood causing anorexia and occasionally nauseas.
The evolution takes to the cetoacidose. If the patient is not treaty-coma and death.

Diagnostic
The diagnosis of the diabetes type II is usually made in the asymptomatic patient that makes a glycemia in a "checkup" or that it is evaluating another medical problem.
Senior patients can try vague symptoms as fatigue or loss of energy, probably due to his/her renal threshold loud for the glucose.
The outlying neuropatia can be the initial manifestation.
The diabetes are so frequent in the senior that it is mandatório to test it frequently.

Any one of the following items is enough for the diagnosis of the diabetes mellitus:
1- Glycemia level without larger fast or same to 200 mg/dL with symptoms of diabetes descompensado (poliuria, polidipsia).
2- Glycemia of jejum bigger or equal to 140 mg/dL.
3- Level of larger plasmatic glucose or equal to 200 mg/dL2 hours after after 75g of glucose. TTG is rarely necessary or advisable in the elderly.
Patient with glycemia of normal fast and values 2 hours after the glucose ingestion among 140-199mg / dL has tolerance to the impeded glucose.

With the running of the years, 50% of these patient ones continue with the tolerance to the impeded glucose, 30% return to the normal and only 20% develop diabetes mellitus in a reason from 1 to 5% a year.

About 10 to 30% of all of the people above 65 years has tolerance to the impeded glucose. Although those patients don't develop microangiopatia, they are more predisposed to complications macrovasculares-bird, disease coronariana and outlying vascular disease than those that have normal levels.

Treatment
They are composed of four itens:

-Diet
-Exercises
-Oral Hipoglicemiantes
-Insulin

Patient of the type I should be treated with insulin. About 35% of the one of the type II they also request this hormone, 45% control with hipoglicemiantes and 20% just with diet.

Diet
Patients in insulin use should have more flexible outline and guided to consume carbohydrates to the first hypoglycemia manifestations.
The distribution of carbohydrates in 4 to 6 meals a day having guided also for the use and the nick of insulin action that the patient is making use.
For the insulins of intermediate action in the morning early is necessary the snack in the middle of the afternoon.
As the exercises increase the reason of absorption of the insulin and also the effectiveness, the patients should ingest enough amounts of carbohydrates before the exercises to prevent the hypoglycemia.
Patient that don't take insulin, the content of the meals is important - low tenor of complex carbohydrates - with low index glicêmico.
The amount of carbohydrates is an important factor in the increase of the glucose in the posprandial.

When ingested without other foods, the simple carbohydrates can increase the levels of plasmatic glucose quickly in the diabetics - high glycemia index.

The carbohydrates compounds are polymeric long found in vegetables, such as rice, potatoes and others vegetate, and they make the sanguine glucose to increase slowly - we have index lower glicemic.

As diabetics are more susceptíveis to the microvascular disease to maintain low levels of cholesterol and mainly of LDL and VLDL they are important.

Mono fats or polish-unsaturated are important to maintain appropriate proportion to avoid the ateroma plate.

The use of foods has been stimulating as avocado, dried fruits, olives, complementing with the use of olive oils, canola, saffron and mainly to water the foods as salads.

The current concenso extols for the diabetic, poor diet in refined and rich carbohydrates in fibers.
The diabetic's diet should be the closest possible of the usual to increase the chances of execution of the same.
Although in general the patients want immediate results, the elderly and obese patient's diet should be softer with a reduction of approximately 500 calories in relation to their needs.
This allows to arrive to a more important objective than it is the reformulation of the eating habits.

Exercises
Regular exercises make the people fell better, they benefit the cardiovascular system when vigorous and lingering, and help to burn extra calories in the obese patients and reduce the resistance to the insulin.
Patient that use insulin can develop hypoglycemia with moderate exercises the vigorous ones basically because the absorption of the injected insulin increases. The second cause of the hypoglycemia is the glucose consumption for the muscles.
Patient of the type I that are badly controlled, they can worsen your picture after exercise with additional increase of the glicemiae of the ketose probably for the increase in the catecolaminas, glucagon, and GH, being opposed to the action of the insulin, what usually happens after extremaly exercises.

Hipoglicemiantes Agents
Sulfoniluréias
These stimulate the secretion of the insulin directly and they potentiate the effect of other insulino secretagogos - for many they perpetuate the problem and they take to the diabetes type I.
They also potentiate the action of the insulin in the sensitive fabrics to the same (liver, muscle and fatty fabric).
Although this fact was attributed at the beginning to an increase in the connection of the insulin, more recent evidences indicate that these agents act in the postreceptor.
Sulfonilurérias are inefficient in the type I.
No sulfoniluréria is better than the other. The selection should base on four criteria: effectiveness, side effects, socket executes of the medication and cost.

The potency is clinically irrelevant. The tolbutamida is less effective, following by the acetohexamida.
The clorpropamida, tolazamide, glibirida, glibenclamida and glipizida are equally effective.
Special care should be given to the clorpropamida in patients above 65 years, thin or that you/they reduce the ingestion of foods drastically, because they can develop lingering hypoglycemia.

Symptoms and hypoglycemia signs
Weakness .......................... headache
Perspiration ........................ hipothermia
Taquicardia ........................ visual disturbs
Palpitations ........................ mental confusion
Tremor .............................. amnesia
Nervossismo ....................... convulsions
Irritability............................ coma
Tingling
Hunger
Nausea
Vomits

Side effects
Minus than 5% have side effects. The most frequent are G I and dermatologic reactions.
Clorpropamida can cause the blush syndrome for the alcohol in more or less 20% of the patients. This same drug can cause hiponatremia and syndrome of secretion inapropriate of ADH.
Hypoglycemia can happen with any type of renal sulfoniluréia and those that don't feed regularly.
As the hypoglycemia can be lingering, patient with mental alterations for the hypoglycemia they should be interned with glucose I.V., until that the glucose levels stay stable.
Colestase reversible intra-liverwort taking to the jaundice is another side effect and more common to the clorpropamida. These drugs don't have noxious effects for the cardiovascular apparel.

Biguanidas - Mechanisms of action
She acts inhibiting the glucose absorption for the intestine. It reduces the gliconeogenese decreasing of this sorts things out, the hepatic production of glucose in fast and consequently the fast glycemia. They have especially been showing an increase in the outlying reception of glucose at muscular level.
Several studies in vitro and alive demonstrate a study of the increase of insulin receivers, observed in diabetic patients no insulin-dependent.
Now used is Metformin, useful for the control of the diabetes associated to the obesity, for its anorexic effect. In adjusted doses, they help the weight loss without hypoglycemia risk.

The most frequent side effects are linked to the digestive system: nauseas, vomits, diarrhea, anorexia, metallic taste in the mouth, increase in production of lactic acid and pirúvico, and ketonic bodies.

In cases of anorexia tecidual and important acidoses, these drugs can preciptar lactic acidosis, taking to the patients' death 20%.

Inhibitors of the absorption of carbohydrates in the small intestine (acarbose).

Insulins
The elderly's insulintherapy belongs plenty similar to the young diabetic.
Patient that don't get to maintain fast glycemia same or inferior to 140m/dL in spite of the diet and oral hipoglicemiantes and exercises, has indication of doing insulintherapy as well as in situations sharp emergenciais-infections, surgery, or cases of sharp stress.
Staying appropriate diet the initial dose of an insulin of intermediate action should be from 10 to 20 U a day, for subcutaneous road.
Increases the dose gradually until that the glycemia falls at inferior levels of 200mg/dL in the posprandial-hemoglobin glicosada and normal frutosamina.

Diabetes Mellitus and Disorders of Carbohydrate Metabolism
Approximate time-activity relationships of various insulin preparations given subcutaneously

Endocrinologic factors and metabolic disordered affect the control of the diabetes in the elderly
-Alteration of the senses
-Decrease of the vision
-Decrease of exercises and of the mobility
-Decrease of the sense of smell
-Drugs
-Altered perception
-Medication (non-potassium-diuretic saved, glucocorticóides, phenytoin)
- Difficulties in preparing the food
-Alcohol
-Consumerism
-Neuro-psychiatric problems - Tremor
-Bereavement
-Arthritis
-Depression
-Neoplastia
-Proprioception Alteration
-Deficient teething
-Congnitive impairment and dementia
-Alteration in the GI function and absorption of nutritious -Recognição(conferir), palate and hunger altered
-Alteration of the hepatic and renal function
-Live alone
-Sharp infections
-Inadequate Education
-Deficient dietary habits
-Poverty
-Social Factors
_________________________________________
Modification of Lipson LG: " Diabetes in the elderly people:
Diagnostic: patogenese and therapy." American newspaper of the medicine 80
(suppl Ä)10-21, 1986: used with permission.

Special challenges in the elderly diabetic's control

The treatment of the diabetes in the elderly can be difficult, due to the conditions associated with the own aging.
Patient very elderly can have problems when preparing their own meals due to the tremor, ostoartrite or alterations affectionate or cognitive.
Depression and negligence can take few cares with the hygiene, the anorexia and the non execution of the orientations. The cognitive impediment can also contribute to these problems.
People with severe insanity can be particularly insensitive to hunger and thirst, the first taking to the weight loss, and the last taking to the dehydration, that if no corrected, they can take to the syndrome Hiperosmolar no cetótica.

The palate can change, with the bitter and the salty becoming the predominant ones.
Many elderly patients or don't have teeth, or they have prostheses with precarious adaptation, that interferes in the mastication.
These factors turn difficult the appropriate feeding and nutritious meals to regular intervals.
The fact can be particularly dangerous in patients that make insulin use.
For all these factors, the elderly diabetic's treatment is a special challenge. As the prevalence of the disease is very high in this population, the problem becomes still larger, ally to the drop income.
For this, the senior diabetic should be treated with special patience and understanding.

Levels of control of the Diabetes

Level 1 Level of glucose preprandial < 180 mg/dL
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Level 2 Level of glucose preprandial < 150 mg/dL
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Level 3 Level of glucose preprandial <120 mg/dL
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Level 4 1 - to 2h level of glucose preprandial < 210 mg/dL*
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Level 5 1 - to 2h level of glucose preprandial <150 mg/dL
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* < 200 mg/dL if it uses glucose meter; < 210 mg/dL if Chemstrips

The preserved action of the insulin of Anthipolytic is associated with less profile of the lipid of the plasma of Atherogic in the health Centenarianas

Giuseppe Paolisso, MD, * Antonio Gambardella, MD, * Stefania Ammendola, MD, * Maria Rosaria Tagliamonte, MD, * Maria Rosaria Rizzo, MD, * Antonio Carpuso, MD, + e Michele Varricchio, MD *

OBJECTIVE: The recent studies demonstrated that the centennial have an action of tolerance to the insulin, to the stored glucose and a more favorable distribution of the fat composition in the body than aged subjects. The strong relationship among the tolerance of the glucose, the action of the insulin, the concentration of the lipid, of the plasma, and the metabolism of the lipoprotein would lead to the hypothesis that the healthy centenarianos can also have a profile less aterogênico of the ones of less than 100 years.

The cholesterol of the plasma LDL fasting (2,4 ± 0,6 against 3,7 mmol/L of the 6 of ± P <010) was significantly higher in aged subjects than in the centenarians, because the cholesterol of the plasma HDL fasting (1,0 ± 0,4 against 1,7 mmol/L of the 4 of ± P <005) had it in the opposite to the tendency.

In the centenarians, the insulin-moderated uptake of the glucose was bigger (34,6 ± 0,5 against 23,3 ± 0,5 mmol/Kg FFM x minute P <010) than in aged subjects and correlated with the triglycerides of the plasma fasting, FFA, LDL, and cholesterol of Hdl, concentrations of Apo B, and of Apo A1.

Finally, the infusion of the insulin suppressed the concentration of the plasma FFA in similar ways in the adults and in the centenarians. CONCLUSION: Our study demonstrates that the centenarians has a profile less atherogenic of the lipid and of the lipoprotein of the plasma than the aged subjects J Am Geriatr Soc 45:1504-1509,1997.

The relationship among the insulin fasting levels, action of the insulin, and the profile of the lipid of the plasma is known well. Momentarily, it is supposed that the hyperinsulinemia/insulin resistance is associated with the increase of the in the in the lipoprotein of the very low density (VLDL), a derease in the high lipoprotein of the density (HDL), and the composition altered in the one of the lipoproteins of the density lowers (LDL).

These abnormalities are also associated with the increased risk of the disease of heart coronary (CHD). Aging for himself is also associated with the hyperinsulinemia/insulin resistance, the profile atherogenic of the lipid of the plasma of the in the, and the risk increased in the one of CHD. In what he/she concerns the association among the profile moving forward of the lipid of the plasma of the age, the Mykkanen et the al.

They supplied the evidence in the subjects 70-year-old that the hyperinsulinemia is associated with the development of changes compositional in the lipoproteins as well as changes of the wich in absolute concentrations of the lipids and in the lipoproteins that favor the atherosclerosis.

We have already been demonstrating in precedent studies that the centenarians has a mass free lower fat and some higher percent of body fat than aged subjects. In the contrast, the action of the insulin of the centenarians is better than that of the aged abd of the similar subjects to that of the adults.

However, in this last study any data regarding the relationship between the action of the insulin and the wre of the concentration of the lipid of the plasma supplied, because the actioncontributes of the insulin to the control of the concentration of the lipid of the plasma, a they could hope the centenarianos could have a better profile of the lipid and of the lipoprotein of the plasma than some older insulin-resistant subjects.

To our best knowledge, no study went to the relationship between the action of the insulin and the profile of the lipid of the plasma in the centenarians.

Our study investigates the effect antipolytic of the insulin in healthy centenarians and it compares such data with the those obtained in the adults (<50 years old) and it aged subjects
(> 75 years old).

We also investigated the relationship among concentrations of the action of the insulin and of the lipid and of the lipoprotein of the plasma and the effect of the infusina(conferir) the plasma FFA in all of the studied groups.

For this purpose, the concentration of the lipid of the plasma was determined in the baseline, and the effect antipolytic of the insulin was evaluated by the technique of the handle of the glucose.