Treatment of Diabetes in Older Adults Guideline Resources
Full Guideline: Treatment of Diabetes in Older Adults JCEM: May 2019 (online March 2019)
Derek LeRoith, Geert Jan Biessels, Susan S. Braithwaite, Felipe F. Casanueva, Boris Draznin, Jeffrey B. Halter, Irl B. Hirsch, Marie E. McDonnell, Mark E. Molitch, M. Hassan Murad, and Alan J. Sinclair
The 2019 guideline on treatment of diabetes in older adults:
Provides recommendations for the screening, diagnosis, and treatment of diabetes in older adults
Provides recommendations for older patients with diabetes and macro and microvascular co-morbidities
Emphasizes shared-decision making and lesser targets/goals depending on health condition
Prediabetes is highly prevalent in older people, however, interventions to delay progression from prediabetes to diabetes are especially effective in this age group.
The prevalence of type 2 diabetes increases as individuals age and exaggerates the incidence of both microvascular and macrovascular complications.
Clinicians should perform regular screening for prediabetes and diabetes in the older population and implement interventions as indicated in this guideline.
Given the heterogeneity of the health status of older people with diabetes, the guideline emphasizes shared decision-making and provides a framework to assist health care providers to individualize treatment goals.
The problems that older individuals with diabetes face, in contrast to younger people with the disease, include sarcopenia, frailty and cognitive dysfunction. Such complications can lead to an increased risk of poor medication adherence, hypoglycemia (from certain medications), falls, and loss of independence in daily living activities.
The guideline presents evidence for the various effects of diabetes in the older patients and the relevant therapies for glycemic control, hyperlipidemia and hypertension.
Guideline recommendations also address common co-morbidities such as renal impairment, which affects the pharmacokinetics and pharmacodynamics of specific agents, and concomitant heart disease.
1.1 In patients aged 65 years and older with newly diagnosed diabetes, we advise that an endocrinologist or diabetes care specialist should work with the primary care provider, a multidisciplinary team, and the patient in the development of individualized diabetes treatment goals. (Ungraded Good Practice Statement)
1.2 In patients aged 65 years and older with diabetes, an endocrinologist or diabetes care specialist should be primarily responsible for diabetes care if the patient has type 1 diabetes, or requires complex hyperglycemia treatment to achieve treatment goals, or has recurrent severe hypoglycemia, or has multiple diabetes complications. (Ungraded Good Practice Statement)
2.1 In patients aged 65 years and older without known diabetes, we recommend fasting plasma glucose and/or HbA1c screening to diagnose diabetes or prediabetes. (1|⊕⊕⊕⊕) Technical Remarks:
The measurement of HbA1c may be inaccurate in some people in this age group because of comorbidities that can affect the lifespan of red blood cells in the circulation.
Although the optimal screening frequency for patients whose initial screening test is normal remains unclear, the writing committee advocates repeat screening every 2 years thereafter.
As with any health screening, the decision about diabetes and prediabetes screening for an individual patient depends on whether some action will be taken as a result and the likelihood of benefit. For example, such screening may not be appropriate for an older patient with end-stage cancer or organ system failure. In these situations, shared decision-making with the patient is recommended.
2.2 In patients aged 65 years and older without known diabetes who meet the criteria for prediabetes by fasting plasma glucose or HbA1c, we suggest obtaining a 2-hour glucose post oral glucose tolerance test measurement. (2|⊕⊕⊕⚪) Technical Remarks:
This recommendation is most applicable to high-risk patients with any of the following characteristics: overweight or obese, first-degree relative with diabetes, high-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander), history of cardiovascular disease, hypertension (≥140/90 mmHg or on therapy for hypertension), high-density lipoprotein (HDL) cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L), sleep apnea, or physical inactivity.
Shared decision-making is advised for performing this procedure in frail older people or in those for whom it may be overly burdensome.
Standard dietary preparation for an oral glucose tolerance test is advised.
3.1 In patients aged 65 and older with diabetes, we advise assessing the patient’s overall health (see Table 2) and personal values prior to the determination of treatment goals and strategies (see Table 3). (Ungraded Good Practice Statement)
3.2 In patients aged 65 years and older with diabetes, we suggest that periodic cognitive screening should be performed to identify undiagnosed cognitive impairment. (2|⊕⊕⚪⚪) Technical Remarks:
Use of validated self-administered tests is an efficient and cost-effective way to implement screening (see text). Alternative screening test options, such as the Mini-Mental State Examination or Montreal Cognitive Assessment, are widely used.
An initial screening should be performed at the time of diagnosis or when a patient enters a care program.
Screening should be repeated every 2-3 years after a normal screening test result for patients without cognitive complaints or repeated one year after a borderline normal test result.
Always evaluate cognitive complaints and assess cognition in patients with complaints.
3.3 In patients aged 65 years and older with diabetes and a diagnosis of cognitive impairment (i.e., mild cognitive impairment or dementia), we suggest that medication regimens should be simplified (see Recommendation 3.1) and glycemic targets tailored (i.e., be more lenient; see Recommendation 4.1) to improve compliance and prevent treatment-related complications. (2|⊕⊕⚪⚪ Technical Remarks:
Medical and nonmedical treatment and care for cognitive symptoms in people with diabetes and cognitive impairment is no different from those in people without diabetes and cognitive impairment.
Depending on the situation and preferences of the patient, a primary caregiver can be involved in decision-making and management of medication.
4.1 In patients aged 65 years and older with diabetes, we recommend that outpatient diabetes regimens be designed specifically to minimize hypoglycemia. (1|⊕⊕⊕⚪) Technical Remark: Although evidence for specific targets is lacking, glycemic targets should be tailored to overall health and management strategies (e.g.,whether a medication that can cause hypoglycemia is used) (see Table 3).
Assessing Glycemia in Older Adults with Diabetes
4.2 In patients aged 65 years and older with diabetes who are treated with insulin, we recommend frequent fingerstick glucose monitoring and/or continuous glucose monitoring (to assess glycemia) in addition to HbA1c. (1|⊕⊕⚪⚪)
4.3 In patients aged 65 years and older with diabetes who are ambulatory, we recommend lifestyle modification as the first-line treatment for hyperglycemia. (1|⊕⊕⊕⊕)
4.4 In patients aged 65 years and older with diabetes, we recommend assessing nutritional status to detect and manage malnutrition. (1|⊕⊕⊕⊕) Technical Remark: Nutritional status can be assessed using validated tools such as the Mini Nutritional Assessment and Short Nutritional Assessment Questionnaire.
4.5 In patients aged 65 years and older with diabetes and frailty, we suggest the use of diets rich in protein and energy to prevent malnutrition and weight loss. (2|⊕⊕⚪⚪)
4.6 In patients aged 65 years and older with diabetes who cannot achieve glycemic targets with lifestyle modification, we suggest avoiding the use of restrictive diets and instead limiting consumption of simple sugars if patients are at risk of malnutrition. (2|⊕⚪⚪⚪) Technical Remarks:
Patients’ glycemic responses to changes in diet should be monitored closely.
This recommendation applies to both older adults living in the community and those in nursing homes.
Drug Therapy for Hyperglycemia
4.7 In patients aged 65 years and older with diabetes, we recommend metformin as the initial oral medication chosen for glycemic management in addition to lifestyle management. (1|⊕⊕⊕⚪) Technical Remark: This recommendation should not be implemented in patients who have significantly impaired kidney function (eGFR <30 mL/min/1.73 m2) or have a gastrointestinal intolerance.
4.8 In patients aged 65 years and older with diabetes who have not achieved glycemic targets with metformin and lifestyle, we recommend that other oral or injectable agents and/or insulin should be added to metformin. (1|⊕⊕⊕⊕) Technical Remarks:
To reduce the risk of hypoglycemia, avoid using sulfonylureas and glinides, and use insulin sparingly.
Glycemic treatment regimens should be kept as simple as possible.
Management of Hypertension in Older Adults with Diabetes
5.1 In patients aged 65 to 85 years with diabetes, we recommend a target blood pressure of 140/90 mmHg to decrease the risk of cardiovascular disease outcomes, stroke, and progressive chronic kidney disease. (1|⊕⊕⊕⚪) Technical Remarks:
Patients in certain high-risk groups could be considered for lower blood pressure targets (130/80 mmHg), such as those with previous stroke or progressing CKD (eGFR <60 mL/min/1.73 m2 and/or albuminuria). If lower BP targets are selected, careful monitoring of such patients is needed to avoid orthostatic hypotension.
Patients with high disease complexity (Group 3, Poor health, Table 3) could be considered for higher blood pressure targets (145–160/90 mmHg).
Choosing a blood pressure target involves shared decision-making between the clinician and patient, with full discussion of the benefits and risks of each target.
5.2 In patients aged 65 years and older with diabetes and hypertension, we recommend that an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker should be first-line therapy. (1|⊕⊕⊕⚪) Technical Remark: If one class is not tolerated, the other should be substituted.
Management of Hyperlipidemia in Older Adults with Diabetes
5.3 In patients aged 65 years and older with diabetes, we recommend an annual lipid profile. (1|⊕⊕⚪⚪)
5.4 In patients aged 65 years and older with diabetes, we recommend statin therapy and the use of an annual lipid profile to achieve the recommended levels for reducing absolute cardiovascular disease events and all-cause mortality. (1|⊕⊕⊕⊕) Technical Remarks:
The Writing Committee did not rigorously evaluate the evidence for specific LDL-C targets in this population, so we refrained from endorsing specific LDL-C targets in this guideline.
For patients aged 80 years old and older or with short life expectancy, we advocate that LDL-C goal levels should not be so strict.
5.5 In patients aged 65 years and older with diabetes, we suggest that if statin therapy is inadequate for reaching the LDL-C reduction goal, either because of side effects or because the LDL-C target is elusive, then alternative or additional approaches (such as including ezetimibe or proprotein convertase subtilisin/kexin type 9 inhibitors) should be initiated. (2|⊕⚪⚪⚪)
5.6 In patients aged 65 years and older with diabetes and fasting triglycerides >500 mg/dL, we recommend the use of fish oil and/or fenofibrate to reduce the risk of pancreatitis. (1|⊕⊕⚪⚪)
Management of Congestive Heart Failure in Older Adults with Diabetes
5.7 In patients aged 65 years and older who have diabetes and congestive heart failure, we advise treatment in accordance with published clinical practice guidelines on congestive heart failure. (Ungraded Good Practice Statement)
5.8 In patients aged 65 years and older who have diabetes and congestive heart failure, the following oral hypoglycemic agents should be prescribed with caution in order to prevent worsening of heart failure:
DPP4 inhibitors (Ungraded Good Practice Statement)
5.9 In patients aged 65 years and older with diabetes and a history of atherosclerotic cardiovascular disease, we recommend low-dosage aspirin (75-162 mg/day) for secondary prevention of cardiovascular disease after careful assessment of bleeding risk and collaborative decision-making with the patient, family, and other caregivers. (1|⊕⊕⚪⚪)
Eye Complications in Older Adults with Diabetes
5.10 In patients aged 65 years and older with diabetes, we recommend annual comprehensive eye exams to detect retinal disease. (1|⊕⊕⊕⊕) Technical Remark: Screening and treatment should be conducted by an ophthalmologist or optometrist in line with present-day standards.
Neuropathy, Falls, and Lower Extremity Problems in Older Adults with Diabetes
5.11 In patients aged 65 years and older with diabetes and advanced chronic sensorimotor distal polyneuropathy, we suggest treatment regimens that minimize fall risk, such as the minimized use of sedative drugs or drugs that promote orthostatic hypotension and/or hypoglycemia. (2|⊕⚪⚪⚪)
5.12 In patients aged 65 years and older with diabetes and peripheral neuropathy with balance and gait problems, we suggest referral to physical therapy or a fall management program to reduce the risk of fractures and fracture-related complications. (2|⊕⚪⚪⚪)
5.13 In patients aged 65 years and older with diabetes and peripheral neuropathy and/or peripheral vascular disease, we suggest referral to a podiatrist, orthopedist, or vascular specialist for preventive care to reduce the risk of foot ulceration and/or lower extremity amputation. (2|⊕⊕⚪⚪)
Chronic Kidney Disease in Older Adults with Diabetes
5.14 In patients aged 65 years and older with diabetes who are not on dialysis, we recommend annual screening for chronic kidney disease with an eGFR and urine albumin-to-creatinine ratio. (1|⊕⊕⊕⊕)
5.15 In patients aged 65 years and older with diabetes who are in Group 3 (poor health, Table 3) of the framework and have a previous albumin/creatinine ratio of <30 mg/g, we suggest against additional annual albumin-to-creatinine ratio measurements. (2|⊕⊕⚪⚪)
5.16 In patients aged 65 years and older with diabetes and decreased eGFR, we recommend limiting the use or dosage of many classes of diabetes medications to minimize the side effects and complications associated with chronic kidney disease. (1|⊕⊕⚪⚪) Technical Remark : Specific use/dosing guidance on each class of diabetes medication is provided in Table 7.
Management of Diabetes Away from Home – in Hospitals and Long-term Care Facilities – and Transitions of Care
6.1 In patients aged 65 years and over with diabetes in hospitals or nursing homes, we recommend establishing clear targets for glycemia at 100–140 mg/dL (5.55–7.77 mmol/L) fasting and 140–180 mg/dL (7.77–10 mmol/L) postprandial while avoiding hypoglycemia. (1|⊕⊕⚪⚪) Technical Remark: An explicit discharge plan should be developed to re-establish long-term glycemic treatment targets and glucose-lowering medications as the patient transitions to posthospital care.
6.2 In patients aged 65 years and older with diabetes and a terminal illness or severe comorbidities, we recommend simplifying diabetes management strategies. (1|⊕⚪⚪⚪)
6.3 In patients aged 65 years and older without diagnosed diabetes, we suggest routine screening for HbA1c during admission to the hospital to ensure detection and treatment where needed (see the Technical Remark in Recommendation 2.1). (2|⊕⊕⚪⚪)