Geriatric Medicine
The elderly is a heterogeneous group with different physiological profiles and varying functional capabilities and life expectancy. It is more important to consider the physiological or vascular age. It varies according to genetic background, environmental factors and presence or lack of morbidities, such as DM, high blood pressure, arthritis or other rheumatologic diseases, obesity, cognitive dysfunction, renal insufficiency, and heart failure.
Cardiovascular diseases are the most common complications because of accelerated atherosclerosis Old people usually have severe osteoporosis due to gonadal and/or vitamin deficiencies. Under nutrition due to isolation, depression, dental and/or socioeconomic problems contribute to bone demineralization. Vitamin D deficiency is one of the most frequent deficiencies in the elderly. It predisposes to metabolic, cardiovascular, and cancerous diseases. It is also a strong factor for proximal muscle weakness, falls, and fractures. Solar exposure is usually limited because of poor outdoor activity. It promotes diabetes through insulin resistance and insulin deficiency. Urinary and faecal incontinence is also an important issue.
The elderly can be classified into three groups .
- The first category includes people who are functionally independent and rely on their own.
- The second category is composed of people who are not autonomous and are functionally dependent on someone else. This group is subdivided into two subcategories: Frail patients and patients with cognitive impairment.
- Frail or fragile patients are characterized by a combination of fatigue, weight loss, and severe restriction in their mobility and/or strength, which increases the risk of falls and institutionalization
- The second subcategory includes patients with dementia, which means they have cognitive impairment and are unable to self-care.
- The third group includes patients at the end of life care. These persons have a significant medical illness or malignancy. Consequently, they have a short life expectancy.
Diabetes mellitus (DM) frequency is a growing problem worldwide, because of long life expectancy and life style modifications. In old age (≥60–65 years old), DM is becoming an alarming public health problem in developed and developing countries .DM complications and co-morbidities are more frequent in old diabetics compared to their young counterparts. The most frequent are cardiovascular diseases due to old age and to precocious atherosclerosis specific to DM and the most bothersome are visual and cognitive impairments, especially Alzheimer disease and other kind of dementia. Alzheimer disease seems to share the same risk factors as DM, which means insulin resistance due to lack of physical activity and eating disorders. Visual and physical handicaps, depression, and memory troubles are a barrier to care for DM treatment. The fragile or frail persons with diabetes, the treatment needs to be individualized according to the presence or lack of cognitive impairment and other co-morbidities. The fundamental rule is “go slowly and individualize” to avoid interaction with poly medicated elder persons and fatal iatrogenic hypoglycaemias.