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Diabetes and Older Adults

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eMediNexus    17 December 2022

The aging of the overall population significantly drives the diabetes epidemic. Although the burden of diabetes is often presented in terms of its impact on working-age adults, diabetes in older adults causes higher mortality, reduced functional status, and increased risk of institutionalization. This population is at substantial risk for the disease′s acute and chronic microvascular and cardiovascular complications.

 

The heterogeneity of the health status in older adults (even within an age range) and the absence of evidence from clinical trials challenges healthcare providers in determining standard intervention strategies that fit all older adults. The American Diabetes Association (ADA), in 2012, convened a Consensus Development Conference on Diabetes and Older Adults (defined as those aged >65 years) to aid healthcare professionals in managing this population.

 

It recommends screening older adults for prediabetes and diabetes if they are likely to benefit from the identification of the condition/disease and subsequent intervention. It recommends implementing lifestyle intervention for older adults with prediabetes who can participate and are likely to benefit from the prevention of type 2 diabetes. 

 

ADA advises encouraging physical activity in this population, even if not to optimal levels. It also recommends implementing medical nutrition therapy (MNT) using simple teaching strategies and community resources while considering patient safety and preferences. Diabetes self-management education/training (DSME/T) in older adults should consider sensory deficits, cognitive impairment, and various learning styles and teaching strategies and should include caregivers. For developing and updating an individualized treatment plan, it emphasized the need to screen this population periodically for cognitive dysfunction, functional status, and fall risk using simple tools.

 

ADA advises taking caution in choosing antihyperglycemic therapies, considering polypharmacy, and recommends avoiding glyburide in this population. Metformin is safe to use and can be preferred as initial therapy in many older adults with type 2 diabetes, but at a reduced dose in those with stage III chronic kidney disease and sparing those with stage IV or worse. Assess renal function using eGFR, not serum creatinine alone. ADA also advises assessing patients for hypoglycemia regularly by noting the symptoms or signs and reviewing blood glucose logs. In cases of recurrent or severe hypoglycemia, the healthcare provider must consider switching therapy and/or targets. Assessing the burden of treatment on older adult patients (caregivers), considering patient/caregiver preferences, and attempting to reduce treatment complexity is equally important in the treatment period.

 

Furthermore, the glycemic goals in hospitalized older adults with diabetes remain the same as those for the general population. The use of SSI alone for chronic glycemic management is deterred in inpatient settings and Long-term care (LTC) facilities. Transitions of older adults with diabetes (e.g., from home or LTC facility to hospital to postdischarge setting) mark the periods of high risk. Their risk for hyper- and hypoglycemia can be minimized by careful medication reconciliation and written information regarding medication dosing and timing. The early transition of diabetes care to an outpatient provider is crucial in altering drug therapy according to changes in clinical status.

 

Kirkman MS, Briscoe VJ, Clark N, et al. Diabetes in Older Adults. Diabetes Care. 2012; 35 (12): 2650–2664. https://doi.org/10.2337/dc12-1801

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