Get Smart on Diabetes in Older Adults
Diabetes is one of those diseases that while serious, has been around for so long, that people may discount its dangers. Unless you have diabetes, or know someone who struggles with it, of course. That’s why it’s good to have a refresher of sorts in November which marks Diabetes Awareness Month.
More than 25 percent of adults over 65 have diabetes and with our aging population, the prevalence of diabetes will double in the next 20 years.
The fact is, older adults with diabetes present unique challenges and require considerations that aren’t traditionally associated with diabetes management.
They are at higher risk for acute and chronic microvascular (diabetic nephropathy, neuropathy and retinopathy) and macrovascular (coronary artery disease, peripheral arterial disease and stroke) complications from the disease, including major lower-extremity amputations, myocardial infarctions, visual impairments and end-stage renal disease.
And while there is no such thing as “one size fits all” for diabetes management in general, when it comes to older adults, care should be individualized to consider the person’s comorbidities, other medications, cognitive abilities, home care situation, and life expectancy. Especially in frail, elderly patients, there should be less emphasis on strict glycemic control than on avoiding malnutrition and hypoglycemia and achieving the best quality of life possible.
- The appropriate target for glycated hemoglobin (A1C) should be individualized based on overall health and life expectancy, as well as on identified patient-specific risks for hypoglycemia and the ability of the patient to adopt and adhere to specific treatment regimens.
- The vulnerability to hypoglycemia (deficiency of glucose in the bloodstream), is substantially increased in older adults; therefore, avoiding hypoglycemia is an important consideration in establishing goals and choosing therapeutic agents in older adults.
- Older patients are more likely to derive greater reduction in morbidity and mortality from cardiovascular risk reduction, particularly treatment of hypertension and lipid lowering with statin therapy, than from tight glycemic control.
- Older adults with diabetes should receive individualized counseling regarding lifestyle modification, including a medical nutrition evaluation and exercise counseling. The nutrition prescription is tailored for older people with diabetes based upon medical, lifestyle, and personal factors. Exercise is beneficial to help maintain physical function, reduce cardiac risk, and improve body composition and insulin sensitivity in older patients with diabetes.
- In the absence of specific contraindications, metformin is suggested as an initial therapy for older patients with diabetes (Grade 2B). Insulin can also be considered a first-line therapy for patients with type 2 diabetes, particularly patients presenting with A1C >9 percent (74.9 mmol/mol), fasting plasma glucose >250 mg/dL (13.9 mmol/L), random glucose consistently >300 mg/dL (16.7 mmol/L), or ketonuria.
- If glycemic goals are not met with a single agent, the older patient should be evaluated for contributing causes, such as difficulty adhering to the medication, side effects, or poor understanding of the nutrition plan. In addition, they should be screened for age-related barriers, such as cognitive or functional decline, depression, and socioeconomic factors.
- For older patients who have persistent hyperglycemia above their individualized glycemic target, despite treatment with lifestyle intervention and metformin, a second agent should be selected. The therapeutic options for patients who fail initial therapy with lifestyle intervention and metformin, or a sulfonylurea are similar in older and younger patients.
- Older adults with diabetes are at risk of developing a similar spectrum of microvascular complications as their younger counterparts with diabetes. Monitoring recommendations for older patients with diabetes are like those in younger patients. Complications that impair functional capacity (e.g., retinopathy, foot problems), should be identified and treated promptly.