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There is an increase in the incidence and in the overall number of older people with type 1 diabetes, and this is a very unique population and a very heterogeneous population you can think depending on their duration of diabetes, their management of diabetes, using pump, CGM, multiple injection, as well as living status, functional status, cognitive function, and presence of hypoglycemia and awareness and comorbidities, and micro and macrovascular complication. Each person has a unique disease, and therefore, the clinician should personalize and devise the best approach to diabetes management and glycemic targets, as well as management of the comorbidities and complications.

There’s been a recent publication that has shown that up to 30 new cases, over 100,000 individuals of age six years and older are diagnosed every year with type 1 diabetes, so it is important to recognize that this is a potential possibility.  There are also adults that are diagnosed with type 1 diabetes.  It is important to know that also adults that are diagnosed with diabetes can have type 1 diabetes, so the primary care doctor should have a low threshold, especially if a patient presents with not a classic picture of type 2 diabetes.

To manage type 1 diabetes, it’s important to start from the very beginning to manage well glycemic control, but also to screen for comorbidities and complication, particular in micro and macrovascular complication, and therefore, to do annual screening for eye disease, as well as for kidney function and presence of albumin in the urine to assess macroalbuminuria early on, as well as a foot exam for assessing peripheral neuropathy, as well as to manage and prevent cardiovascular complications that are also present in type 1 diabetes. And we know that long duration of diabetes, early onset, age less than 10 years when the diabetes was diagnosed are associated with an increased risk of cardiovascular complications.  Therefore, management of lipid profile, blood pressure, as well as avoidance of smoking and healthy lifestyle are important to prevent long-term complications.

One thing that has been described in older adults with type 1 diabetes, especially with long duration, even increased risk of hypoglycemia, and hypoglycemia can have very dramatic consequences due to the fact the person may have a fall and/or cardiovascular events and require assistance from a third party with potential calls to EMS, as well as emergency room visit and hospitalization.

Hypoglycemia is being described more frequently in the older people with type 1 diabetes, and part is due to the fact that with longer duration of diabetes, many people develop hypoglycemia and awareness.  Their autonomic system and their neuroglycopenic symptom may come much later or may be completely blunted, and therefore, the person may have the classic symptoms of hypoglycemia at all, or they come very, very late when the glucose level are very, very low, and therefore, putting them in much higher risk of acute complication of severe hypoglycemia but also of potential impact on cognitive function, cardiovascular function, as well as sleep quality.  And there's been an association between the presence of hypoglycemia or glycemic fluctuation and cognitive decline, and therefore, avoidance of hypoglycemia is important in this population to reduce impact on overall general health, in particular cognitive function. 

In the recent past we had a new tool, the continuous glucose monitor, that has been shown to improve avoidance of hypoglycemia and severe hypoglycemia.  Therefore, patients with type 1 diabetes should be using this device.  So over the last several decades, we have changed the name of diabetes related to insulin deficiency from juvenile diabetes, the diabetes of the kids, to type 1 diabetes, and these reflect the fact that actually many more and more patients with type 1 diabetes a live long and healthy life.  And it is important to start proactive in the management of diabetes and lifestyle engagement, as well as periodic assessment to prevent micro and macrovascular complication. 

In the older population, this is even more important, in particular with the presence of hypoglycemia awareness and the higher risk of severe hypoglycemia.  Therefore, patients should be assessed not only for micro and macrovascular complications but also of those complications that can occur while we are aging.  So visual and auditory impairment, cognitive decline, functional decline that can occur in aging may occur a little faster in this population, and so the clinician should assess those and modify glycemic target, as well as diabetes self-management strategies according to the health status, as well as incorporate in the team educators to support the older patient, as well as family member and caregivers because the more we age becomes management with a team of clinician, educator, caregiver to make the best outcome for the person with diabetes.

Announcer:
That was Dr. Elena Toschi discussing the increase in type 1 diabetes among adults. To access this and other episodes in our series, visit Diabetes Discourse on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!