How Should Diabetes Be Managed Among Older Adults?

Author:
Kim A. Carmichael, MD—Series Editor

Citation:
Carmichael KA. How should diabetes be managed among older adults? Consultant. 2017;57(7):423-424.

Q. What is the scope of diabetes among older adults?

A. According to a 2012 American Diabetes Association consensus report (ADA-CR),¹ the prevalence of diabetes in persons aged 65 years or older ranges from 22% to 33%. Although the incidence of new-onset diabetes levels off at 65 years of age, because of the increasing age of the US population in general, the prevalence of diabetes is expected to double during the next 20 years.

Overall, in approximately one-third of all older adults with diabetes, the condition remains undiagnosed. Twenty-five percent of persons living in long-term care facilities have diabetes. Diabetes in older adults is associated with increased mortality, with substantial heterogeneity of their overall health status.

Q. How is diabetes in the elderly different than diabetes among younger adults?

A. The ADA-CR¹ notes that older adults with newly diagnosed diabetes tend to have lower glycated hemoglobin (HbA_1c) levels, are more prone to have higher postprandial hyperglycemia, and are less likely to eventually require insulin therapy. Although the incidence of retinopathy is increased in this population, there is no difference in the rate of cardiovascular disease or nephropathy.

Individualized medical nutrition therapy may be needed in the elderly population as a result of the increased risk of overall nutritional deficiencies and sarcopenia, independent of total weight. Group analyses of data from the ACCORD (Action to Control Cardiovascular Risk in Diabetes) trial² indicate that persons older than 65 may be at a disproportionate risk of hypoglycemia with intensive therapy; however, the results of other large trials have been less conclusive.¹

Q. What are the current treatment guidelines for older persons with diabetes?

A. Glycemic goals of care may need to be modified among older persons, based on coexisting chronic illness, physical or cognitive impairments, and/or life-expectancy prognosis.

The ADA-CR¹ indicates that a reasonable HbA_1c goal of less than 7.5% is desirable among otherwise healthy persons, but if the health status is more complex, an HbA_1c goal of less than 8% would be preferable. If health status is very complex, with a very poor overall prognosis, then a goal of less than 8.5% may be acceptable. However, results of a more recent study³ indicate that an HbA_1c of greater than 8% is associated with greater all-cause mortality and cause-specific mortality in older adults with diabetes.

Treatment recommendations for hyperlipidemia¹ include statin therapy for all patients with diabetes, but among those with a very complex health status, one must consider the likelihood of benefit vs potential adverse effects. Since cardiovascular benefit occurs with the first 1 to 2 years of statin therapy, it is a worthwhile intervention even if it is initiated at a later age. Of note, fenofibrate therapy has been shown to have no demonstrable benefit in the older population. As part of the American Board of Internal Medicine Foundation’s Choosing Wisely campaign, the Society for Post-Acute and Long-Term Care Medicine recommends, “Don’t routinely prescribe lipid-lowering medications in individuals with a limited life expectancy.”⁴

Blood pressure goals for older individuals with diabetes are to maintain levels below 140/80 mm Hg, but a higher target goal of below 150/90 mm Hg may be acceptable in older persons who have a more complex health status or who have a poor prognosis.¹

Q. How do comorbidities affect management strategies in older adults with diabetes?

A. Older adults with diabetes are at greater risk of cardiovascular disease and should be on aspirin therapy unless it is contraindicated.¹ In persons with concomitant chronic kidney disease, medications and treatment goals may need to be modified. Diminished sensation of thirst may place older persons at greater risk of dehydration, so excessive hyperglycemia should be avoided.

Depression and cognitive impairment may affect self-care, increasing the risk of hypoglycemia, but these conditions may also be exacerbated by a history of recurrent hypoglycemia.

Functional impairments are more common in older persons with diabetes—visual loss is evident in 1 of 5, hearing loss is twice as likely, and neuropathy occurs in 50% to 70% of persons in this group. The neuropathy may cause abnormalities in gait and balance and thereby increase the risk of falls.¹

As with persons of all ages with diabetes, the presence of autonomic neuropathy increases many risks in the elderly population with diabetes, including hypoglycemia unawareness, impaired sweating, slowed gastric emptying, orthostatic hypotension, and cardiovascular dysfunction (eg, loss of respiratory or exercise-induced variation in pulse rate, loss of ability to sense myocardial ischemia), with adverse consequences being markedly enhanced in the setting of the presence of other medical comorbidities.

Q.What are desirable management strategies for older persons with diabetes?

A. The International Diabetes Federation global guideline⁵ offers a number of key guiding principles to help clinicians better care for older persons with type 2 diabetes. Among these is a holistic, individualized approach to care, including global medical assessment and quality educational support. Each older person requires a comprehensive medical risk assessment with a focus on safety and attention to comorbidities, functional status, costs, and overall life expectancy. Attention must be paid to the quality use of medications and medical devices.

Older patients with diabetes should have annual evaluations of functional status, assessments of fall risk, discussions about the avoidance of polypharmacy, and attention to foot care.¹ Complex medication regimens may be difficult for older patients to follow, which may be particularly problematic if the treatment plan increases the risk of hypoglycemia.

Medication options need to be individualized for older persons with diabetes,^1,5 with many needing adjustments based on renal function. Because they require manual dexterity, injectable therapies may be difficult for some older patients to self-administer, but pen devices can provide more accurate and manageable delivery.

Careful attention must be paid to possible adverse medication effects such as gastrointestinal tract upset or renal fluid imbalance (edema or dehydration), which can impart greater safety risks. Sulfonylureas should be avoided among older patients because of the associated significant risk for hypoglycemia.¹

Older patients may benefit from care partners and community support systems. As with all persons with diabetes, older individuals need to carry medical alert identification.

Kim A. Carmichael, MD, is an associate professor of medicine in the Department of Medicine, Division of Endocrinology, Metabolism and Lipid Research, at Washington University School of Medicine in St Louis, Missouri. He discloses that he is on the speakers bureau for Janssen, which may be relevant to the content of this article.

REFERENCES:

1. Kirkman MS, Briscoe VJ, Clark N, et al. Diabetes in older adults. Diabetes Care. 2012;35(12):​2650-2664.
2. Action to Control Cardiovascular Risk in Diabetes Study Group. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008;​358(24):2545-2559.
3. Palta P, Huang ES, Kalyani RR, Golden SH, Yeh H-C. Hemoglobin A_1c and mortality in older adults with and without diabetes: results from the National Health and Nutrition Examination Surveys (1988-2011) [published online February 17, 2017]. Diabetes Care. doi:10.2337/dci16-0042
4. AMDA–The Society for Post-Acute and Long-Term Care Medicine. Ten things physicians and patients should question. Choosing Wisely, an Initiative of the ABIM Foundation. http://www.choosingwisely.org/societies/amda-the-society-for-post-acute-and-long-term-care-medicine. Published September 4, 2013. Accessed June 23, 2017.
5. International Diabetes Federation. Managing Older People With Type 2 Diabetes: Global Guideline. Brussels, Belgium: International Diabetes Federation; 2013. http://www.idf.org/sites/default/files/IDF-Guideline-for-older-people-T2D.pdf. Accessed June 23, 2017.