Nor. Afr. J. Food Nutr. Res. 2022; 6(13): 9-21 https://doi.org/10.51745/najfnr.6.13.9-21 https://www.najfnr.com REVIEW ARTICLE Epidemiology, diagnosis, and assessment of diabetes mellitus in the elderly population: a purposive review Mohammed Amine Chami 1,2 *, Meghit Boumediene Khaled 3 1 Grand Hôpital de l’Est Francilien (GHEF), Site de Meaux, Court séjour gériatrique, France. 2 University of Oran 1- Ahmed Benbella, Department of Internal Medicine at the University Hospital , Oran 31000, Algeria. 3 Faculty of Life and Natural Science, Department of Biology, Djillali Liabes University of Sidi-Bel-Abbes. Laboratoire de Nutrition, Pathologie, Agro-Biotechnologie et Santé (Lab- NuPABS), Sidi-Bel-Abbes, 22000, Algeria Abstract The elderly population with diabetes mellitus is rapidly growing worldwide and has become a major social burden with significant impact on health and economics. This social category requires considerations that are not traditionally associated with diabetes mellitus management. Several epidemiological studies have shown that the prevalence of diabetes mellitus increases with advancing age. According to the recent International Diabetes Federation (IDF) published data, the number of people with diabetes mellitus among those 65 and over has reached 136 million (19.3%) with more frequent diabetes mellitus complications and co-morbidities compared to the young counterparts. Cardiovascular complications are the leading cause of death and the quality of life is strongly impacted by geriatric syndromes such as poor vision, dementia and functional dependence. The elderly diabetic population is classified into three categories; the robust, the fragile and the patient at the end of life. In practical terms, they can also be classified into two categories: the autonomous patients and the dependent patients, requiring support and assistance. Keywords: diabetes mellitus, elderly, epidemiology, geriatric syndromes, geriatric evaluation. Received: July 24, 2021 / Accepted: December 31, 2021 / Published: January 03, 2022 1 Diabetes mellitus 2 Diabetes mellitus epidemiology in the elderly Several studies have shown that the prevalence of diabetes mellitus increases with advancing age 1-5. The elderly and/or According to the International Diabetes Federation (IDF), the those with multiple co-morbidities have often been excluded diabetes mellitus pandemic is dramatically arising worldwide. In from randomized controlled trials of treatments for diabetes and 2019, the number of diabetes mellitus patients reached 463 its associated conditions 6. The management of this chronic million and will be 578 million in 2030 and 700 million in disease in the elderly suffers from a great insufficiency, especially 2045 8. Several epidemiological studies have shown that the in countries where the specialty of geriatrics is not taught and prevalence of diabetes mellitus increases with advancing age. where structures dedicated to this age group are non-existent. According to the IDF, the number of diabetic people among those The aim of the current purposive review article is to provide, on 65 and over has reached 136 million (19.3%). The projections are the one hand, an update on the epidemiology of diabetes mellitus more alarming since they will be 195.2 million and 276.2 million in the elderly, on the other hand, to shed the light on the respectively in 2030 and 2045 8. specificities of this pathology in the elderly people in terms of diagnosis, of diabetes evaluation considering macro- and As summarized in Table 1, the prevalence of diabetes mellitus in microangiopathic complications. As well as the evaluation of the the elderly by continent is as follows: In Europe 20.1%, in North elderly person as a whole with an emphasis on the geriatric America 27%, in Middle East and North Africa (MENA) 24.2%, evaluation being an essential prerequisite for the management of in Central and South America 22.7%, in western pacific 18.9%, the elderly diabetic patients by looking for geriatric syndromes. in Africa 8.4% and in Southeast Asia: 13.6% 9. In the United The geriatric assessment will classify the elderly as robust States, a third of people aged 65 and over are diabetic and half (healthy), fragile, and at the end of their life and the treatment suffer from prediabetes 10. In our region (North Africa), two objectives will be according to this categorization 7. The search prevalence studies were carried out, one in Tunisia which found a strategy was developed using the following keywords: “Elderly”, prevalence of 27.4% 11 and the other in Algeria and which found “Diabetes Mellitus”, Epidemiology”, Geriatric assessment”, 26.7% in subjects aged 65 and over 12. What should be noted is “Geriatric syndrome”. To retrieve relevant articles to the research that the prevalence of diabetes mellitus decreases after the age of question of this review, databases of PubMed/Medline, Scopus, 75, this is explained by the high mortality linked to diabetes were searched in English and French with no time restriction. mellitus but also to the weight loss after 75 years which decreases The grey literature was also searched (Google, Google Scholar). the incidence of diabetes mellitus 13. 9 * Corresponding author: University of Oran 1- Ahmed Ben-Bella, Department of Internal Medicine at the University Hospital , Oran 31000, Algeria. Tel: +213 661 416 353 E-mail: [email protected] Chami & Khaled Diabetes mellitus in the elderly al 2 ed by 2019 prevalence estimates 2045 Number of people Prevalence with diabetes (%) (millions) 19.6 276.2 (15.2–25.4) (214.8–358.9) 27.5 34.0 (21.9–33.9) (27.1–42.0) 25.2 25.2 (13.9–35.6) (13.9–35.6) 23.1 24.0 (18.5–30.1) (19.2–31.2) 20.5 46.3 (15.2–26.8) (34.5–60.8) 19.8 107.3 (17.3–23.9) (93.5–129.6) 14.0 32.2 (10.4–19.7) (24.0–45.1) 8.4 7.3 (3.1–16.8) (2.7–14.6) and Caribbean; SACA: South and Centr 5, rank of with 1) 9 merica older than 65 years by IDF Region in 2017, 2019, 2030 and 204 2019 2030 Number of Number Prevalence people with Prevalence people (%) diabetes (%) diabetes (millions) (millions) 19.3 135.6 19.6 195.2 (15.3–24.2) (107.6–170.6) (15.5–24.8) (154.7–247. 26. 27.0 19.2 27.3 (22.0–32.5) (22.2–32.6) (15.7–23.1) (22.4–33.0) 24.2 8.4 24.7 13.7 (13.2–34.0) (4.6–11.8) (13.7–34.6) (7.6–19.2) 22.7 10.3 23.1 15.7 (18.3–29.3) (8.3–13.2) (18.7–29.7) (12.7–20.2) 20.1 31.0 20.2 38.8 (15.3–25.8) (23.5–39.8) (15.2–26.1) (29.2–50.0) 18.9 50.3 19.6 75.4 (16.7–22.1) (44.4–58.9) (17.2–23.1) (66.4–89.1) 13.6 13.6 13.9 20.5 (10.1–18.6) (10.1–18.6) (10.3–19.1) (15.3–28.2) 8.4 2.8 8.7 4.2 (3.0–15.5) (1.0–5.1) (3.1–16.2) (1.5–7.8) Europe; MENA: Middle East and North Africa; NAC: North A Table 1:Diabetes mellitus prevalence in people IDF Rank 2017 Region Number of Prevalence people with (%) diabetes (millions) 18.8 122.8 World i(15.4–23.4) (100.2–152.3) 26.3 17.7 1 NAC (23.4–29.4) (15.7–19.7) 20.4 6.5 2 MENA (12.6–29.0) (4.0–9.3) 19.0 7.9 3 SACA (15.1–24.4) (6.3–10.2) 19.4 28.5 4 EUR (14.9–25.0) (21.9–36.7) 20.0 48.1 5 WP (17.8–23.0) (42.7–55.2) 13.5 12.5 6 SEA (9.5–18.6) (8.7–17.1) 5.2 1.6 7 AFR (2.8–12.8) (0.9–4.0) IDF: International Diabetes Federation; AFR: Africa; EUR: America; SEA: South-East Asia; WP: Western Pacific. i: 95% confidence intervals are reported in brackets. Nor. Afr. J. Food Nutr. Res. 2022; 6 (13): 9-21 10 Chami & Khaled Diabetes mellitus in the elderly 3 Diagnosis of diabetes mellitus in the 4.2 Search for macroangiopathic complications elderly and circumstances of discovery The practice of an electrocardiogram (ECG) is systematic in the search of a cardiac complication such as cardiac ischemia or an The diagnostic criteria for diabetes mellitus in the elderly are unnoticed myocardial infarction or further abnormalities, such as identical as in the young population. Glycated hemoglobin left ventricular hypertrophy (LVH), atrial fibrillation (AF), etc. 23. (HbA1c) is also a parameter used for the diagnosis of diabetes mellitus, but it is often distorted by comorbidities, in particular Peripheral arterial disease is sought by using a pocket vascular anemia in the elderly 14. The most frequent circumstances of Doppler. The Ankle Brachial Index (ABI) is calculated while discovery are a fortuitous diagnosis either during a check-up keeping in mind that it is often faulted by the arterial stiffness routine, either on the occasion of a cardiovascular complication, being frequent in the elderly and therefore it is often necessary to an infection (most often urinary) or a lesion of the foot 15. supplement by a vascular echo Doppler, even an angiography of the arteries of the lower limbs 24. In emergencies, diabetes mellitus can be revealed mainly by a hyperosmolar coma or precoma where the elderly subject do not The search for a plaque or carotid artery stenosis is also feel thirsty. This complication is encountered during the hot recommended by the practice of an echo Doppler of the supra seasons, in the event of diarrhea, vomiting, fever or medication aortic trunks 23. (diuretics or laxatives), or when taking corticosteroids 16. Finally, the search for heart failure must be part of the A distinction must be considered between recent diabetes assessment of the elderly diabetes mellitus patients because of its mellitus occurring at an advanced age and aged diabetes, this high prevalence and its seriousness. It is frequently a heart failure distinction is crucial since the clinical data are not identical. with preserved ejection fraction and an echocardiography should Diabetes mellitus occurring at an advanced age requires the use be performed in the event of any symptom leading to heart of insulin less often, it presents less microvascular complications, failure such as dyspnea, cough on exertion, an abnormality on in particular less diabetic retinopathy, however there is no the ECG 25. difference in the prevalence of neuropathy or other complications mainly the cardiovascular ones 17. 4.3 Diabetic neuropathy (DN) In most cases, aged type 2 diabetes mellitus (T2DM) does not DN is frequent in the elderly but it is always necessary to look constitute a major issue of classification, this type of diabetes for further cause of neuropathy such as vitamin B12 deficiencies, mellitus requires insulin therapy after a certain period of especially in patients on metformin. Painful neuropathy is development, the distinction then between insulin-treated diagnosed using Douleur Neuropathique en 4 Questions (DN4), T2DM and type 1 diabetes mellitus is important to take into one of the questionnaires that can be useful in diagnosing consideration 17. neuropathic pain. The painful neuropathy affects quality of life and must be treated 25. T2DM is generally asymptomatic, so the seniority cannot be specified, and the search for complications that have gone 4.4 Diabetic foot unnoticed must be systematic, in particular, by performing an Foot lesions are particularly frequent in the elderly due to the ophthalmological examination (fundus) in search of retinopathy, presence of several risk factors such as peripheral neuropathy, foot which can inform us about the duration of diabetes mellitus 18. deformities, arterial disease of the lower limbs, vision disorders, Diabetes mellitus poses a real concern of diagnosis and balance disorders, and reduced mobility. The risk of amputation classification when transient hyperglycemia must be eliminated, increases with age. The prevention of foot ulcerations is based on at this age, during stress (cardiovascular complication, the estimation of the podiatry risk, on the implementation of inflammation, hyperthyroidism) 19. Pancreatic disease should preventive measures and on therapeutic education. It is essential also be diagnosed. to avoid bad footwear, barefoot walking, exposure to heat sources (hammam, radiator), henna, dry feet after ablutions or a bath 26. 4 Assessment of the elderly diabetic Obliterating arterial disease of the lower limbs is a major cause of amputation; their prevention is based on the correction of 4.1 Search for microangiopathic complications cardiovascular risk factors by insisting on smoking cessation 27. Diabetic retinopathy should be sought systematically by The treatment of foot ulcers is based on ulcer area off-loading, performing a fundus. Retinopathy is considered as the fourth being crucial for the healing of plantar ulcers, including also cause of poor vision in the elderly 20. However, diabetic debridement of the wounds, and treatment of infection and nephropathy is sought by performing an ACR (Albumin-to- ischemia 26. creatinine ratio) on a fresh urine sample. This nephropathy may be of diabetes mellitus, vascular origin, or secondary to other 4.5 Geriatric assessment etiologies 21. The assessment of glomerular filtration rate (GFR) The overall geriatric assessment is at the heart of all care decisions must use the Modification of Diet in Renal Disease (MDRD) and will identify the different geriatric syndromes, and determine formula or the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula 22. the functional, clinical and social profile of the elderly 28, 29. 11 Nor. Afr. J. Food Nutr. Res. 2022; 6 (13): 9-21 Chami & Khaled Diabetes mellitus in the elderly 4.5.1 Social assessment of undiagnosed, untreated or insufficiently treated depression negatively impacts the management of diabetes mellitus, as It would be primordial to determine the lifestyle of the elderly consequence, patients show low adherence to the treatment 42. population, their marital status, living alone or with their family, the type of accommodation, the presence of a caregiver or not, The coexistence of depression and diabetes mellitus can income, health insurance, their autonomy for activities of daily accelerate cognitive decline, hence the importance of treatment living. All these would help to identify the needs of the elderly and for both depression and diabetes mellitus. Depression is often possibly provide the necessary home assistance and support 26. masked and it is necessary to know how to look for signs such as sleep disturbances, changes in appetite, asthenia, reduced 4.5.2 Cognitive disorders motivation and a lack of interest in participating in care. Several Diabetes mellitus accelerates cognitive decline in the elderly, treatment approaches are available, pharmaceutical, several studies showed that diabetics have impaired cognitive psychotherapeutic, behavioral, lifestyle interventions, and functions compared to the non-diabetic population 30-33. Studies combination therapies. The elderly may feel desperate in the face have also shown that the risk of vascular dementia and dementia of prescribed treatments 43. Alzheimer's is multiplied by 1.5 to 2.5 34, 35. Symptoms of depression in the elderly are unfortunately often The mechanisms of cognitive decline are not elucidated and attributed to natural aging, bereavement, illness or dementia, thus would be explained by the reduction of extracellular glucose in delaying diagnosis and the initiation of beneficial treatment 44. In the hippocampus that limits the memorization process. Another the elderly diabetes mellitus population, depressive symptoms explanation would be the prolonged and repeated hypoglycemia may be mistaken for symptoms due to diabetes mellitus or other in patients on hypoglycemic agents or insulin-therapy 28, 29. illnesses. Many of the symptoms of depression such as asthenia, loss of appetite and trouble sleeping are also found in diabetes Cognitive decline has a negative impact on the management of mellitus. It can therefore be difficult to differentiate symptoms diabetes mellitus and therefore diabetes mellitus patients no related to diabetes mellitus from those associated to depression 45. longer recognize hypoglycemia. This could aggravate cognitive The majority of older people with clinically significant depressive decline. As a consequence, patients cannot or no longer want to symptoms do not meet the standard diagnostic criteria for major self-monitor, and reaching glycemic objectives is difficult. depression 46, 47. Furthermore, these patients have a high risk of Therefore, an early diagnosis and management of cognitive and developing major depression afterwards and may also develop diabetes mellitus impairment should help prevent or at least suicidal thoughts 48-50. Depressed patients with diabetes mellitus delay the progression of a Mild Cognitive Impairment (MCI) to are at greater risk of developing chronic depression or making less severe dementia 36. complete recovery 51. The involvement of healthcare professionals as well as the family Depression is frequent, difficult to diagnose, it must be and primary caregiver plays a crucial role in improving the mentioned in the face of a wide variety of symptoms. The adherence and persistence of the diabetic patient to the treatment of depression has a favorable impact on adherence to treatment 37. diabetes mellitus treatment and therefore allows for better glycemic control 36. Hypoglycemia must be avoided, for this it would be better to provide drugs with a low risk of hypoglycemia, to avoid the use of 4.5.4 Functional profile HbA1c as the unique measure of glycemic monitoring. Capillary blood glucose levels or even better the continuous glucose Functional disability refers to the presence of "limitation in the monitoring (CGM) are more accurate. A simplified diagram and performance of socially defined roles and tasks in a socio-cultural patient education when possible and/or that of caregivers and environment due to physical impairment" 52. Frailty and family is imperative 36-38. sarcopenia are two risk factors for the development of disability. Frailty being a clinical entity, is characterized by a decrease in To assess cognition, several tests are available, three are particularly reserve and resistance to stressors (unsuitability to stress) resulting useful and rapid to perform, the Mini-Mental State Examination from the physiological decline of numerous systems 53. Sarcopenia (MMSE), the Montreal Cognitive Assessment (MoCA) and the is an important cause of frailty in the elderly. It is defined as a Mini-Cog 39. decrease in muscle mass associated with a decrease in muscle Elderly diabetic patients with cognitive impairment are generally function (strength or performance) 54. People with diabetes not included in therapeutic education and disease self- mellitus present a high risk of developing sarcopenia. Sarcopenia management programs. This situation can lead to the is thought to be an intermediate stage in the development of frailty institutionalization of the patient or to total care by the and disability in elderly people with diabetes mellitus 55. caregivers 40. It is important to identify the risk factors, especially when they 4.5.3 Thymic disorders are modifiable, for the development of sarcopenia in elderly people with diabetes mellitus. Several studies have shown that Diabetes mellitus increases the risk of developing or recurring elderly people with diabetes mellitus have an increased risk of depression, similarly, a history of depression increases the risk of functional disability, and show more impairment in simple and developing diabetes mellitus 41. In elderly diabetics, the presence complex activities of daily living than people without diabetes Nor. Afr. J. Food Nutr. Res. 2022; 6 (13): 9-21 12 Chami & Khaled Diabetes mellitus in the elderly mellitus 56, 57. Moreover, they also have a higher risk of falls and the diagnosis of undernutrition in a person aged 70 or over is fractures 58. based on the presence of one or more of the following criteria. According to Wong et al., diabetes mellitus increases the risk of To diagnose undernutrition at least one phenotypic criterion loss of mobility by 1.5, the risk of instrumental daily living should be present with no etiologic criterion 76. disability (IADL) by 1.6, and the risk of disability in activities of a. Undernutrition criteria: daily living (ADL) by 1.8 57. - Body weight loss: ≥ 5% in 1 month, or ≥ 10% in 6 There are several causes of disability in adults with diabetes months; mellitus, such as visual impairment, cardiovascular morbidity, - BMI <21 kg/m2; peripheral neuropathy and kidney failure. The frailty of the elderly - Albuminemia <35 g / L is most often sought by two tools, the Fried criteria and the - Global mini nutritional assessment (MNA)<17 Rockwood criteria 53, 59. b. Severe undernutrition: - Body weight loss: ≥ 10% in 1 month or ≥ 15% in 6 The two most widely used tools to assess functional disability are months activities of daily living (ADL) [60], and IADL 61. - BMI <18 kg/m2 4.5.5 Risk of falling - Albuminemia <30 g / L Falls are a leading cause of fractures in the elderly population 62, The factors favoring undernutrition in the elderly diabetic are: affecting a third of adults 65 years and over in the United retinopathy, vision disorders, reduced mobility, swallowing States 63. Falls are associated with the risk of fractures and disorders, intestinal absorption disorders, financial resources, hospitalization. Diabetes mellitus is associated with a high risk of depression and loneliness, cognition, decreased intestinal motility, recurrent falls and fractures in people with or without pre-existing frequent hospitalizations. Undernutrition is associated with risks functional disability; this risk is particularly high in diabetics after of infection, falls, functional disability, sarcopenia, frailty, delayed a long period of development. wound healing, prolonged hospital stays, cognitive impairment, depression and mortality 76. According to some studies, the risk factors are female sex, reduced mobility, postural hypotension, high body mass index (BMI) and Malnutrition screening tools poor diabetes mellitus control, but not hypoglycemia 64-66. In The diagnosis and management of undernutrition must be contrast, a systematic review and a meta-analysis revealed that systematic to preserve the quality of life, autonomy and survival in older people with diabetes mellitus have a higher risk of falls the elderly. The five main criteria for diagnosing undernutrition compared to non-diabetics. The same authors found that are: body weight loss, low BMI, reduced muscle mass, decreased hypoglycemia is a risk factor for falls, especially in patients treated food intake or absorption, and coexistence of disease and / or with insulin and peripheral neuropathy and retinopathy, induced inflammation 75. by poor blood sugar control, can also increase the risk of falls 67. Other risk factors, associated with diabetes mellitus, include visual The MNA is the best validated and most widely used nutritional impairment, peripheral neuropathy, foot deformities (including assessment tool 77-79. A score comprised between 17 and 23 is previous amputation), and polypharmacy 68. considered at risk of undernutrition and a score of less than 17 is in favor of protein-energy undernutrition. The major advantage Despite the fact that bone density is high in type 2 diabetics due of this test is that it does not require any laboratory testing. A short to obesity, there is an increase in fractures in this population 69. In version of the MNA has been developed and validated 80. the Study of Osteoporotic Fractures, diabetic women had a high risk of hip fracture, proximal humerus, but no vertebral fractures, Determining BMI in the elderly is often difficult, and therefore a after adjusting for age, BMI, bone density, and other factors 70. new revised version of the Mini Nutritional Assessment Short- The Health ABC Study also found an increased risk of fractures Form (MNA-SF) has been developed, showing that calf in diabetic patients (relative risk 1.64) after adjusting for bone circumference can replace BMI 81. When the MNA identifies mineral density and other fracture risk factors 71. Two simple and people at risk of undernutrition, they are often identified as fragile widely used tools to diagnose the risk of falls are the get up and go because the different items of the MNA-SF explore the and the monopodal support 72, 73. components of frailty such as body weight loss, low food intake and muscle strength (mobility and girth calf) 82-84. 4.5.6 Malnutrition Nutrition Management and Intervention Protein-energy malnutrition results from an imbalance between the body's intake and needs. This imbalance leads to tissue loss, It is essential to consider that the elderly with diabetes mellitus especially muscle loss, which has deleterious consequences 74. constitute a diverse population with various care needs requiring According to the Haute Autorité de Santé (HAS) or French individualized management and dietary treatment and therefore National Authority for Health, the prevalence of protein-energy should be involved in this management. To minimize the malnutrition is 4 to 10% of elderly people living at home, 15 to incidence of frailty and mortality in elderly people, sufficient 38% of those living in retirement homes and 30 to 70% of those energy intake is recommended. The European Society of Clinical who are hospitalized 74. In the 2007 HAS recommendations 75, Nutrition and Metabolism guidelines on clinical nutrition and 13 Nor. Afr. J. Food Nutr. Res. 2022; 6 (13): 9-21 Chami & Khaled Diabetes mellitus in the elderly hydration in geriatrics recommend an energy intake of 4.5.8 Vision disturbances approximately 30 kcal/kg body weight/day, based on the Diabetes mellitus increases the risk of poor vision and blindness nutritional status, physical activity level, disease status, and in elderly people with diabetes mellitus compared to the healthy tolerance 85. According to some authors, decreased energy intake population by a factor of 1.5 according to Sinclair et al. 104. in older patients with diabetes mellitus might lead to a lower Diabetic retinopathy represents the fourth leading cause of BMI, cognitive impairment, and higher prevalence of sarcopenia, blindness in elderly diabetes mellitus patients after age-related which might be associated with an increased risk for frailty and macular degeneration (AMD), cataracts and glaucoma. Unlike the mortality 86, 87. population under 60, in whom diabetes mellitus is the leading According to the 2019 Japan Diabetes Society guidelines, the total cause of blindness 105, vision disturbances in the elderly are energy intake requirement in older adults should be calculated associated with functional disability and poor quality of life. using age-dependent target body weight (kg)= (22–25 kg/m2 × Most older people relate poor vision to a physiological process of height [m]2) multiplied by coefficients of physical activity [88]. aging and therefore do not seek medical attention, even though An appropriate protein intake could reduce the incidence of frailty many conditions require effective treatment 106. In patients with or mortality in older individuals. A minimum of protein intake of diabetic retinopathy, the main cause of poor vision is macular 1.2–1.5 g/kg body weight/day is recommended by the European edema and not proliferative diabetic retinopathy 107. Poor vision Society of Clinical Nutrition and Metabolism guidelines for older worsens other geriatric syndromes such as falls, inability to subjects with acute or chronic illness 89. Together with sufficient function, undernutrition, depression and cognitive impairment. vitamin D intake can ameliorate cognitive function, reduce risks Therefore, a complete eye exam is required in any elderly diabetic of sarcopenia 90, 91 and might play a protective role in Alzheimer’s to determine the cause of poor vision and to suggest adequate disease 92. Concerning fatty acids, consumption of treatment. polyunsaturated fatty acids (PUFA) and -3 fatty acids was 4.5.9 Hearing problems associated with lower risk of mortality in diabetes mellitus patients ω aged over50 years 93 and reduced cognitive decline 94. The authors Aging is the most frequent cause of sensorineural hearing loss in of the Nurses' Health Study conducted on 1,486 female adults. Deafness seriously affects the quality of life of patients who participants aged ≥70 years, with diabetes mellitus type 2 showed no longer communicate, resulting in social isolation leading to an that higher intakes of saturated and trans fat and lower increased risk of depression, anxiety and cognitive impairment 108. polyunsaturated to saturated fat ratio, were each highly associated More than 35% of people over 60 and 50% of those over 70 have with worse cognitive decline 95. difficulty in activities of daily living due to hearing loss 109. A study that included 37,773 subjects, conducted from 2009 to 2012 The Mediterranean diet (MD) being widely considered as a aimed to assess the presence of hearing disorders according to age, healthy diet, is rich in vegetables, fish, and olive oil and known to reduce the risk of cardiovascular events 96. Meta-analysis of to the presence of hypertension and/or diabetes mellitus, showed that aging and diabetes mellitus were correlated with hearing loss observational studies showed that high adherence to the MD with (p<0.05). There was no statistically significant association higher intake of vegetables, fruits, and whole grains was associated between hearing loss and hypertension after adjusting for age and with lower risk of frailty and functional disability in the elderly population 97, 98. diabetes mellitus 110. 4.5.7 Pain 4.5.10 Polypharmacy The use of multiple drugs, often termed polypharmacy is Pain, in the elderly, is frequent. According to an American study, commonly defined as using from 5 to 10 prescription drugs. 52.8% of people aged 65 and over suffer from pain. In diabetes mellitus elderly population, pain reaches 61.5% 99 and is Among seniors living at home in the United States, 57% of women and 59% of men report using 5 or more medications, and dominated by pain of rheumatic and of neuropathic origin. almost 20% report taking 10 or more medications 111. - Rheumatic origin: concerns joint stiffness syndrome, Older people with diabetes mellitus are more likely to take Dupuytren's disease, tenosynovitis, carpal tunnel syndrome, shoulder capsulitis / periarthritis, osteoarthritis 100, 101. multiple medications than those without diabetes mellitus 112. - Neuropathic origin: the prevalence of neuropathic pain, in Polypharmacy is associated with increased risks of drug people with diabetes mellitus, is difficult to estimate because nonadherence 113, drug interactions 114 and adverse events 115. The definitions, populations studied, and methodologies vary presence of polypharmacy is also associated with cascading across studies. prescriptions, in which adverse drug events are interpreted as new pathologies, leading to the prescription of new drugs to treat these Pain regardless of its etiology has a negative impact on the quality of life 102. A Finnish study showed that the pain in elderly people pathologies 116. with diabetes mellitus was neither more frequent nor more intense 4.5.11 Urinary incontinence than in non-diabetics. The pain is due to depression and other comorbidities more than to diabetes mellitus 103. It is imperative Urinary incontinence (UI) is frequent in the elderly and is to assess and treat pain to improve quality of life. associated with significant morbidity and mortality. Diabetes Nor. Afr. J. Food Nutr. Res. 2022; 6 (13): 9-21 14 Chami & Khaled Diabetes mellitus in the elderly mellitus is a potent risk factor for UI, increasing both the - HbA1c: Glycated hemoglobin prevalence and severity of UI. 117, 118. UI dramatically decreases - IADL: instrumental activities of daily living quality of life, increasing the risk of social isolation, depression, - IDF: International Diabetes Federation falls, fractures, hospitalization and mortality 119-122. UI is little - LVH: left ventricular hypertrophy sought after by caregivers, yet studies show that its presence affects - MD: Mediterranean diet the prognosis. The UI diagnosis is based on questioning the - MDRD (Modification of Diet in Renal Disease) patient or family, and its management involves several therapies. - MENA: Middle East and North Africa - MMSE: mental state examination 5 Conclusion - MNA: mini nutritional assessment - MNA-SF: mini nutritional assessment short-form) Studies and epidemiological projections conclude that with a - MoCA: Montreal Cognitive Assessment significant increase in the prevalence of diabetes mellitus in the - T2DM: Type 2 diabetes mellitus elderly, it will undoubtedly constitute a major public health - UI: Urinary incontinence concern. Diabetes mellitus management in the elderly is based on: Acknowledgments: None. Author contribution: A.C. conceived and designed the study. C.A. and - a clinical assessment with eliminating transient M.B.K. undertook the literature research. C.A. and M.B.K. prepared, drafted hyperglycemia and distinguish aged type 2 diabetes mellitus and reviewed the manuscript. All authors approved the final version before patients with insulin treatment from type 1 diabetes ones, submission. All authors have read and agreed to the published version of the know how to look for secondary diabetes, mainly manuscript. pancreatitis; Funding: None. - diabetes assessment with looking for macroangiopathic, Conflict of interest: The authors declare that they have no conflict of interest. microangiopathic, neuropathic complications, and podiatry evaluation; References - and a global geriatric assessment with an emphasis on the cognitive and functional status of the elderly individuals. [1] Talukder, A., Hossain, M.Z. Prevalence of Diabetes Mellitus and Its Associated Factors in Bangladesh: Application of At the end of this evaluation, the treatment goals will be defined Two-level Logistic Regression Model. Sci Rep 10, 10237 according to the recommendations of the ADA (American (2020). https://doi.org/10.1038/s41598-020-66084-9 Diabetes Association). 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