Best Practices for Older Adults With Diabetes

The American Diabetes Association released the 2020 practice standards for caring for older adults with diabetes.

As those who care for individuals with diabetes, we need to focus on helping our residents achieve long-term positive outcomes for their health.

But, there are many nuances and special considerations for caring for older adults with diabetes. This article will break down the most important recommendations you need to know.

Taking a careful approach

Traditionally with diabetes, we control the blood sugar as closely as possible because we want to prevent long-term complications.

 We tend to think about hyperglycemia with diabetes, but with older folks, it’s especially important to watch for hypoglycemia.

With older adults, there is a risk of treating hyperglycemia too aggressively because it could cause low blood sugar. According to another ADA report, “The risks of overtreatment of hyperglycemia in older adults are significant and include hypoglycemia and increased treatment burden.”

 “When our residents get low blood sugar, it could cause other problems like falls. Or, they could become less clear cognitively and struggle to complete activities of daily living,” said Margaret Roche, founder of Roche Dietitians.

 The ADA notes, “Glycemic goals for some older adults might reasonably be relaxed as part of individualized care, but hyperglycemia leading to symptoms or risk of acute hyperglycemia complications should be avoided in all patients.”

 However, from the other perspective, if our residents have high blood sugar that we don’t treat, then they can easily become dehydrated. They can fall from high blood sugar, too.

The bottom line is we have to take a careful approach.

 Older adults with diabetes need to eat well

 Older adults are at risk of not eating well. If they don’t eat well, they’re at risk for all kinds of problems.

 As dietitians or dietary managers, our approach is to make sure that all our residents — and especially our residents with diabetes — are eating well.

 We achieve this goal by tailoring our community menus to our residents’ culture, preferences, and personal goals for eating. When we tailor our diets to our residents, they’re more likely to be satisfied with their meals, eat more, improve their nutritional status, and better their quality of life.

 “That’s why, at Roche Dietitians, we promote the general diet as the preferred diet over a restrictive therapeutic diabetic diet, such as the carbohydrate-controlled diet, for our residents with diabetes,” said Roche.

READ MORE: Your Ultimate Guide to IDDSI

Many older adults with diabetes do well on a general diet

 Most of the menus that we plan for our residents are based on meal patterns.

 For example, for the main meal of the day, we typically serve three ounces of protein, one to two servings of vegetables, two to three servings of grains or starchy vegetables, two servings of fat, and one serving of milk. We serve meals consistently every day at the same time.

 Since we’re already doing portion control as a regular dining practice, most residents with diabetes do well on a general diet. Because of that, there is already carbohydrate consistency in what residents with diabetes are receiving at mealtime.

 Of course, all this is individualized. The doctor prescribes how often we need to monitor the blood sugar of residents with diabetes. That information helps us determine how well the diet is controlling our residents’ blood sugar.

 According to the ADA, “Treatments for each patient should be individualized. Special management considerations include the need to avoid both hypoglycemia and the complications of hyperglycemia.”

Older adults are at risk for undernutrition

 It’s hard to overemphasize the importance of making sure the older adults under our care are eating well.

 Our residents who don’t eat well tend to be frail. We don’t want to risk them not eating well by restricting their diets in any way.

 Their primary risk is not eating enough. These residents don’t eat a lot of food, so they likely won't have high blood sugar from their diets.

 We need to work with the resident to identify foods they will enjoy. Then, we will manage their blood sugar accordingly, depending on what they’re eating.

 The ADA is also recommending that staff of long term care and rehabilitation facilities have additional education on caring for older adults with diabetes. The ADA notes, “Consider diabetes education for the staff of long-term care and rehabilitation facilities to improve the management of older adults with diabetes.”

 Ultimately, our priority is ensuring our residents eat well and not lose weight.

READ MORE: How Dysphagia Chefs and Dietitians Around the World Are Teaming Up to Tackle IDDSI

Practical tips for older adults with diabetes

What are the dietary priorities for older adults with diabetes?

 The number one priority for older adults with diabetes is that they eat and don’t lose weight.

 The number two priority is controlling blood sugar through the diet by the total carbohydrate. For an older adult, we can manage total carbohydrates throughout the day by having a meal plan and using portion control.

 People need carbohydrates. For older adults, carbohydrates can be up to 50 percent of their calories. But we want to make sure they're nutritionally dense. Some examples are fruit, oatmeal, bread, or milk. Each of these foods has about 15 grams of carbohydrates.

 The problem comes when our residents are eating carbohydrates that aren’t nutrient-dense, such as empty calories like sugar and sweetened beverages. Think of it this way: One tablespoon of sugar is 12 grams of carbohydrates. You can easily eat a tablespoon of sugar, and it costs you as much as a small apple, piece of bread, or glass of milk.

What about desserts and other sweets?

 Desserts are a big question. That’s why we may need to restrict foods with added sugar like sweetened beverages and desserts.

 Strategies with desserts include smaller portions or half portions, use of a serving of fruit, or artificially sweetened desserts. But, there could be a problem with artificially sweetened desserts. Some sweeteners, such as sugar alcohols, have carbohydrates in them. Some sugar-free desserts have as many grams of carbohydrates as the original, but they have no added sugar.

 We have to consider the total carbohydrates of the dessert. One example is a cookie. Some no sugar added desserts still have a lot of carbohydrates, such as a no sugar added fruit pie. It still has crust and fruit, and it has 40 grams of carbohydrates in it. Whereas if we gave a resident a nice bowl of strawberries with whipped cream on it, that would be 15 grams of carbohydrates.

 Many of our residents who have diabetes, even for up to 50 years, are used to eating sugar-free products. Sugar-free products can save them carbohydrates, especially when it comes to condiments. Sugar substitutes for coffee and tea, sugar-free pancake syrup, and sugar-free beverages can help our residents save carbohydrates.

READ MORE: Best Practices for Starting with IDDSI During the Era of COVID-19

What about obesity?

 Overweight and obese people can indeed be undernourished. So we have to be careful about restricting the diets of older adults, especially because calorie restriction of older adults could lead to sarcopenia.

 Our strategy for these residents is eliminating added sugar, using portion control, and encouraging them to take part in as much activity as they can tolerate, especially resistance exercises.

What’s the strategy for more independent, healthier older adults with diabetes?

 For older adults with diabetes who are healthy and function well, there is a lot of benefit to well-controlled blood sugar. They live longer.

 Healthy older adults with diabetes with good functional status should follow the same diabetes management strategies as younger people and they will benefit from good outcomes.

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References

 Alzheimer's Association. “Food and Eating.” Alzheimer's Association, www.alz.org/help-support/caregiving/daily-care/food-eating.

American Diabetes Association. “12. Older Adults: Standards of Medical Care in Diabetes-2020.” American Diabetes Association Diabetes Care, American Diabetes Association, 1 Jan. 2020, care.diabetesjournals.org/content/43/Supplement_1/S152.

American Diabetes Association. “Standards of Medical Care in Diabetes-2020 Abridged for Primary Care Providers.” American Diabetes Association Clinical Diabetes, American Diabetes Association, 1 Jan. 2020, clinical.diabetesjournals.org/content/38/1/10.

Beaudry, Kayleigh M, and Michaela C Devries. “Nutritional Strategies to Combat Type 2 Diabetes in Aging Adults: The Importance of Protein.” Frontiers in Nutrition, Frontiers Media S.A., 28 Aug. 2019, www.ncbi.nlm.nih.gov/pmc/articles/PMC6724448/.

Centers for Disease Control and Prevention. “National Diabetes Statistics Report, 2020.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 28 Aug. 2020, www.cdc.gov/diabetes/data/statistics-report/index.html.

Complete Care Coordination. “Diabetes in the Elderly: Making a Diabetic Diet More Enjoyable.” Complete Care Coordination, Complete Care Coordination, 8 July 2019, www.completecare.ca/blog/diabetes-elderly-make-diabetic-diet-more-enjoyable/.

Health, Bethesda. “A Healthy Diet for Older Adults to Manage Diabetes.” Bethesda Health Group, 20 Aug. 2019, www.bethesdahealth.org/blog/2019/08/20/a-healthy-diet-for-older-adults-to-manage-diabetes/.

Kalyani, Rita R., et al. “Diabetes and Aging: Unique Considerations and Goals of Care.” American Diabetes Association Diabetes Care, American Diabetes Association, 1 Apr. 2017, care.diabetesjournals.org/content/40/4/440.

Langford, Scott. “Overcoming Nutrition Challenges for Memory Care.” Gordon Food Service, www.gfs.com/en-us/ideas/overcoming-nutrition-challenges-for-memory-care.

Samuels, Claire. “A Delicious Diet Plan to Help Manage Diabetes in the Elderly.” A Place for Mom, 21 July 2020, www.aplaceformom.com/caregiver-resources/articles/diabetic-diet-plan.