4.2.0.0 Overview

The care of older adults with di­a­betes is com­pli­cat­ed by their clin­i­cal, cog­ni­tive, and func­tion­al het­ero­gene­ity. Some older in­di­vid­u­als may have de­vel­oped di­a­betes years ear­li­er and have signifi- cant com­pli­ca­tions, oth­ers are newly di­ag­nosed and may have had years of undi­ag­nosed di­a­betes with re­sul­tant com­pli­ca­tions, and still other older adults may have truly re­cent-‍onset dis­ease with few or no com­pli­ca­tions (22). Some older adults with di­a­betes have other un­der­ly­ing chron­ic con­di­tions, sub­stan­tial di­a­betes-‍re­lat­ed co­mor­bid­i­ty, lim­it­ed cog­ni­tive or phys­i­cal func­tioning, or frailty (23,24). Other older in­di­vid­u­als with di­a­betes have lit­tle co­mor­bid­i­ty and are ac­tive. Life ex­pectan­cies are high­ly vari­able but are often longer than clin­i­cians re­al­ize. Providers car­ing for older adults with di­a­betes must take this het­ero­gene­ity into con­sid­eration when set­ting and pri­or­i­tiz­ing treat­ment goals (25) (Table 12.1). In ad­di­tion, older adults with di­a­betes should be as­sessed for dis­ease treat­ment and self-‍man­age­ment knowl­edge, health lit­er­a­cy, and math­e­mat­i­cal lit­er­a­cy (nu­mer­a­cy) at the onset of treat­ment. See Fig. 6.1 for pa­tient-‍ and dis­ease-‍re­lat­ed fac­tors to con­sid­er when de­ter­min­ing in­di­vid­u­al­ized glycemic tar­gets.

A1C is used as the stan­dard biomark­er for glycemic con­trol in all pa­tients with di­a­betes but may have lim­i­ta­tions in pa­tients who have med­i­cal con­di­tions that im­pact red blood cell turnover (see Sec­tion 2 “Clas­sification and Di­ag­no­sis of Di­a­betes” for ad­di­tional de­tails on the lim­i­ta­tions of A1C) (26). Many con­di­tions as­so­ci­at­ed with in­creased red blood cell turnover, such as hemodial­y­sis, re­cent blood loss or trans­fu­sion, or ery­thro­poi­etin ther­a­py, are com­monly seen in older adults with func­tion­al lim­i­ta­tions, which can false­ly in­crease or de­crease A1C. In these in­stances, plas­ma blood glu­cose and finger­stick read­ings should be used for goal set­ting (Table 12.1).

Table 12.1—Frame­work for con­sid­ering treat­ment goals for glycemia, blood pres­sure, and dys­lipi­demia in older adults with di­a­betes (2)

Table 12.1

This rep­re­sents a con­sen­sus frame­work for con­sid­ering treat­ment goals for glycemia, blood pres­sure, and dys­lipi­demia in older adults with di­a­betes. The pa­tient char­ac­ter­is­tic cat­e­gories are gen­er­al con­cepts. Not every pa­tient will clear­ly fall into a par­tic­u­lar cat­e­go­ry. Con­sid­eration of pa­tient and care­giv­er pref­er­ences is an im­por­tant as­pect of treat­ment in­di­vid­u­al­iza­tion. Ad­di­tion­al­ly, a pa­tient’s health sta­tus and pref­er­ences may change over time.
‡A lower A1C goal may be set for an in­di­vid­u­al if achiev­able with­out recur­rent or se­vere hy­po­glycemia or undue treat­ment bur­den.
*Co­ex­ist­ing chron­ic ill­ness­es are con­di­tions se­ri­ous enough to re­quire med­i­ca­tions or lifestyle manage­ment and may in­clude arthri­tis, can­cer, con­ges­tive heart fail­ure, de­pres­sion, em­phy­se­ma, falls, hy­per­ten­sion, in­con­ti­nence, stage 3 or worse chron­ic kid­ney dis­ease, my­ocar­dial in­farc­tion, and stroke.“Mul­ti­ple” means at least three, but many pa­tients may have five or more (54).
**The pres­ence of a sin­gle end-‍stage chron­ic ill­ness, such as stage 3-4 con­ges­tive heart fail­ure or oxy­gen-‍de­pen­dent lung dis­ease, chron­ic kid­ney dis­ease re­quir­ing dial­y­sis, or uncon­trolled metastat­ic can­cer, may cause significant symp­toms or im­pair­ment of func­tion­al sta­tus and significant­ly re­duce life ex­pectan­cy.
†A1C of 8.5% (69 mmol/‍mol) equates to an es­ti­mat­ed av­er­age glu­cose of ~200 mg/dL (11.1 mmol/‍L). Loos­er A1C tar­gets above 8.5% (69 mmol/‍mol) are not rec­om­mend­ed as they may ex­pose pa­tients to more fre­quent high­er glu­cose val­ues and the acute risks from gly­co­suria, de­hy­dra­tion, hy­per­glycemic hy­per­os­mo­lar syn­drome, and poor wound heal­ing. ADL, ac­tiv­i­ties of daily liv­ing.