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1.0.0.0 Older Adults

The Amer­i­can Di­a­betes As­so­ci­a­tion (ADA) “Stan­dards of Med­i­cal Care in Di­a­betes” in­cludes ADA’s cur­rent clin­i­cal prac­tice rec­om­men­da­tions and is in­tend­ed to pro­vide the com­po­nents of di­a­betes care, gen­er­al treat­ment goals and guide­lines, and tools to eval­u­ate qual­i­ty of care. Mem­bers of the ADA Pro­fes­sion­al Prac­tice Com­mit­tee, a mul­ti­dis­ci­plinary ex­pert com­mit­tee, are re­spon­si­ble for up­dat­ing the Stan­dards of Care an­nu­al­ly, or more fre­quent­ly as war­rant­ed. For a de­tailed de­scrip­tion of ADA stan­dards, state­ments, and re­ports, as well as the ev­i­dence-‍grad­ing sys­tem for ADA’s clin­i­cal prac­tice rec­om­men­da­tions, please refer to the Stan­dards of Care In­tro­duc­tion. Read­ers who wish to com­ment on the Stan­dards of Care are in­vit­ed to do so at pro­fes­sion­al.di­a­betes.org/‍SOC.

Rec­om­men­da­tions

12.1 Con­sid­er the as­sess­ment of med­i­cal, psy­cho­log­i­cal, func­tion­al (self-‍man­age­ment abil­i­ties), and so­cial geri­atric do­mains in older adults to pro­vide a frame­work to de­ter­mine tar­gets and ther­a­peu­tic ap­proach­es for di­a­betes man­age­ment. C

12.2 Screen­ing for geri­atric syn­dromes may be ap­pro­pri­ate in older adults ex­pe­ri­enc­ing lim­i­ta­tions in their basic and in­stru­men­tal ac­tiv­i­ties of daily liv­ing as they may af­fect di­a­betes self-‍man­age­ment and be re­lat­ed to healthre­lat­ed qual­i­ty of life. C

Di­a­betes is an im­por­tant health con­di­tion for the aging pop­u­la­tion; ap­prox­i­mate­ly one-‍quar­ter of peo­ple over the age of 65 years have di­a­betes and one-‍half of older adults have predi­a­betes (1), and this pro­por­tion is ex­pect­ed to in­crease rapid­ly in the com­ing decades. Older in­di­vid­u­als with di­a­betes have high­er rates of pre­ma­ture death, func­tion­al dis­abil­i­ty, ac­cel­er­at­ed mus­cle loss, and co­ex­ist­ing ill­ness­es, such as hy­per­ten­sion, coro­nary heart dis­ease, and stroke, than those with­out di­a­betes. Older adults with di­a­betes also are at greater risk than other older adults for sev­er­al com­mon geri­atric syn­dromes, such as polyphar­ma­cy, cog­ni­tive im­pair­ment, uri­nary in­con­ti­nence, in­ju­ri­ous falls, and per­sis­tent pain. These con­di­tions may im­pact older adults’ di­a­betes self-‍man­age­ment abil­i­ties (2). See Sec­tion 4 “Com­pre­hen­sive Med­i­cal Eval­u­a­tion and As­sess­ment of Co­mor­bidi­ties” for co­mor­bidi­ties to con­sid­er when car­ing for older adult pa­tients with di­a­betes.

Screen­ing for di­a­betes com­pli­ca­tions in older adults should be in­di­vid­u­al­ized and pe­ri­od­i­cal­ly re­vis­it­ed, as the re­sults of screen­ing tests may im­pact ther­a­peu­tic ap­proach­es and tar­gets (2-4). Older adults are at in­creased risk for de­pres­sion and should there­fore be screened and treat­ed ac­cord­ing­ly (5). Di­a­betes man­age­ment may re­quire as­sess­ment of med­i­cal, psy­cho­log­i­cal, func­tion­al, and so­cial do­mains. This may pro­vide a frame­work to de­ter­mine tar­gets and ther­a­peu­tic ap­proach­es, in­clud­ing whether re­fer­ral for di­a­betes self-‍man­age­ment ed­u­ca­tion is ap­pro­pri­ate (when com­pli­cat­ing fac­tors arise or when tran­si­ti­ons in care occur) or whether the cur­rent reg­i­men is too com­plex for the pa­tient’s self-‍man­age­ment abil­i­ty. Par­tic­u­lar at­ten­tion should be paid to com­pli­ca­tions that can de­vel­op over short pe­ri­ods of time and/‍or would significant­ly im­pair func­tion­al sta­tus, such as vi­su­al and lower-‍ex­trem­i­ty com­pli­ca­tions. Please refer to the Amer­i­can Di­a­betes As­so­ci­a­tion (ADA) con­sen­sus re­port “Di­a­betes in Older Adults” for de­tails (2).

As­so­ci­a­tion. 12. Older adults: Stan­dards of Med­i­cal Care in Di­a­betesd2019. Di­a­betes Care 2019;42 (Suppl. 1):S139–S147 © 2018 by the Amer­i­can Di­a­betes As­so­ci­a­tion. Read­ers may use this ar­ti­cle as long as the work is prop­er­ly cited, the use is ed­u­ca­tional and not for prof­it, and the work is not al­tered. More in­for­ma­tion is avail­able at http://www.di­a­betesjournals .org/‍con­tent/‍license

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2.0.0.0 NEU­ROCOG­NI­TIVE FUNC­TION

Rec­om­men­da­tion

12.3 Screen­ing for early de­tec­tion of mild cog­ni­tive im­pair­ment or de­men­tia and de­pres­sion is in­di­cat­ed for adults 65 years of age or older at the ini­tial visit and an­nu­al­ly as ap­pro­pri­ate. B

Older adults with di­a­betes are at high­er risk of cog­ni­tive de­cline and in­sti­tu­tion­al­iza­tion (6,7). The pre­sen­ta­tion of cog­ni­tive im­pair­ment ranges from sub­tle ex­ec­u­tive dys­func­tion to mem­o­ry loss and overt de­men­tia. Peo­ple with di­a­betes have high­er in­ci­dences of all-‍cause de­men­tia, Alzheimer dis­ease, and vas­cu­lar de­men­tia than peo­ple with nor­mal glu­cose tol­er­ance (8). The ef­fects of hy­per­glycemia and hy­per­in­su­line­mia on the brain are areas of in­tense re­search. Clin­i­cal tri­als of specific in­ter­ven­tionsd in­clud­ing cholinesterase in­hibitors and glu­ta­mater­gic an­tag­o­nists­d­have not shown pos­i­tive ther­a­peu­tic benefit in main­tain­ing or significant­ly im­prov­ing cog­ni­tive func­tion or in pre­vent­ing cog­ni­tive de­cline (9). Pilot stud­ies in pa­tients with mild cog­ni­tive im­pair­ment eval­u­at­ing the po­ten­tial benefits of in­tranasal in­sulin ther­a­py and met­formin ther­a­py pro­vide in­sights for fu­ture clin­i­cal tri­als and mech­a­nis­tic stud­ies (10-12).

The pres­ence of cog­ni­tive im­pair­ment can make it chal­leng­ing for clin­i­cians to help their pa­tients reach in­di­vid­u­al­ized glycemic, blood pres­sure, and lipid tar­gets. Cog­ni­tive dys­func­tion makes it dif- ficult for pa­tients to per­form com­plex self-‍care tasks, such as glu­cose mon­i­tor­ing and ad­just­ing in­sulin doses. It also hin­ders their abil­i­ty to ap­pro­pri­ately main­tain the tim­ing and con­tent of diet. When clin­i­cians are man­ag­ing pa­tients with cog­ni­tive dys­func­tion, it is crit­i­cal to sim­pli­fy drug reg­i­mens and to in­volve care­givers in all as­pects of care.

Poor glycemic con­trol is as­so­ci­at­ed with a de­cline in cog­ni­tive func­tion (13), and longer du­ra­tion of di­a­betes is as­so­ci­at­ed with wors­en­ing cog­ni­tive func­tion. There are on­go­ing stud­ies eval­u­at­ing whether pre­vent­ing or de­lay­ing di­a­betes onset may help to main­tain cog­ni­tive func­tion in older adults. How­ev­er, stud­ies ex­am­in­ing the ef­fects of in­ten­sive glycemic and blood pres­sure con­trol to achieve specific tar­gets have not demon­strat­ed a re­duc­tion in brain func­tion de­cline (14,15).

Older adults with di­a­betes should be care­ful­ly screened and mon­i­tored for cog­ni­tive im­pair­ment (2) (see Table 4.1 for de­pres­sion and cog­ni­tive screen­ing rec­om­men­da­tions). Sev­er­al or­ga­ni­za­tions have re­leased sim­ple as­sess­ment tools, such as the Mini- Men­tal State Ex­am­i­na­tion (16) and the Mon­tre­al Cog­ni­tive As­sess­ment (17), which may help to iden­ti­fy pa­tients re­quir­ing neuropsy­cho­log­i­cal eval­u­a­tion, par­tic­u­lar­ly those in whom de­men­tia is sus­pect­ed (i.e., ex­pe­ri­enc­ing mem­o­ry loss and de­cline in their basic and in­stru­men­tal ac­tiv­i­ties of daily liv­ing). An­nu­al screen­ing for cog­ni­tive im­pair­ment is in­di­cat­ed for adults 65 years of age or older for early de­tec­tion of mild cog­ni­tive im­pair­ment or de­men­tia (4,18). Screen­ing for cog­ni­tive im­pair­ment should ad­di­tion­al­ly be con­sid­ered in the pres­ence of a sig­nif­i­cant de­cline in clin­i­cal sta­tus, in­clu­sive of in­creased difficulty with self-‍care ac­tiv­i­ties, such as er­rors in cal­cu­lat­ing in­sulin dose, difficulty count­ing car­bo­hy­drates, skip­ping meals, skip­ping in­sulin doses, and difficulty rec­og­niz­ing, pre­vent­ing, or treat­ing hy­po­glycemia. Peo­ple who screen pos­i­tive for cog­ni­tive im­pair­ment should re­ceive di­ag­nos­tic as­sess­ment as ap­pro­pri­ate, in­clud­ing re­fer­ral to a be­hav­ioral health pro­vider for for­mal cog­ni­tive/neuropsy­cho­log­i­cal eval­u­a­tion (19).

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3.0.0.0 HY­PO­GLYCEMIA

Rec­om­men­da­tion

12.4 Hy­po­glycemia should be avoid­ed in older adults with di­a­betes. It should be as­sessed and man­aged by ad­just­ing glycemic tar­gets and phar­ma­co­log­ic in­ter­ven­tions. B

Older adults are at high­er risk of hy­po­glycemia for many rea­sons, in­clud­ing in­sulin deficien­cy ne­ces­si­tat­ing in­sulin ther­a­py and pro­gres­sive renal insuffi- cien­cy. In ad­di­tion, older adults tend to havehigh­erratesofunidentifiedcog­ni­tive deficits, caus­ing difficulty in com­plex self-‍care ac­tiv­i­ties (e.g., glu­cose mon­i­tor­ing, ad­just­ing in­sulin doses, etc.). These cog­ni­tive deficits have been as­so­ci­at­ed with in­creased risk of hy­po­glycemia, and, con­verse­ly, se­vere hy­po­glycemia has been linked to in­creased risk of de­men­tia (20). There­fore, it is im­por­tant to rou­tine­ly screen older adults for cog­ni­tive dys­func­tion and dis­cuss find­ings with the pa­tients and their care­givers.

Hy­po­glycemic events should be dili­gent­ly mon­i­tored and avoid­ed, where­as glycemic tar­gets and phar­ma­co­log­ic in­ter­ven­tions may need to be ad­just­ed to ac­com­mo­date for the chang­ing needs of the older adult (2). Of note, it is im­por­tant to pre­vent hy­po­glycemia to re­duce the risk of cog­ni­tive de­cline (20) and other major ad­verse out­comes. In­ten­sive glu­cose con­trol in the Ac­tion to Con­trol Cardiovas­cu­lar Risk in Di­a­betes-Mem­o­ry in Di­a­betes study (AC­CORD MIND) was not found to benefit brain struc­ture or cog­ni­tive func­tion dur­ing fol­low-‍up (14). In the Di­a­betes Con­trol and Com­pli­ca­tions Trial (DCCT), no significant long-‍term de­clines in cog­ni­tive func­tion were ob­served, de­spite par­tic­i­pants’ rel­a­tive­ly high rates of recur­rent se­vere hy­po­glycemia (21). To achieve the ap­pro­pri­ate bal­ance be­tween glycemic con­trol and risk for hy­po­glycemia, it is im­por­tant to care­ful­ly as­sess and reas­sess pa­tients’ risk for wors­en­ing of glycemic con­trol and func­tion­al de­cline.

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4.0.0.0 TREAT­MENT GOALS

4.1.0.0 Rec­om­men­da­tions

12.5 Older adults who are oth­er­wise healthy with few co­ex­ist­ing chron­ic ill­ness­es and in­tact cog­ni­tive func­tion and func­tion­al sta­tus should have lower glycemic goals (such as A1C <7.5% [58 mmol/‍mol]), while those with mul­ti­ple co­ex­ist­ing chron­ic ill­ness­es, cog­ni­tive im­pair­ment, or func­tion­al de­pen­dence should have less strin­gent glycemic goals (such as A1C <8.0–8.5% [64–69 mmol/‍mol]). C

12.6 Glycemic goals for some older adults might rea­son­ably be re­laxed as part of in­di­vid­u­al­ized care, but hy­per­glycemia lead­ing to symp­toms or risk of acute hy­per­glycemia com­pli­ca­tions should be avoid­ed in all pa­tients. C

12.7 Screen­ing for di­a­betes com­pli­ca­tions should be in­di­vid­u­al­ized in older adults. Par­tic­u­lar at­ten­tion should be paid to com­pli­ca­tions that would lead to func­tion­al im­pair­ment. C

12.8 Treat­ment of hy­per­ten­sion to in­di­vid­u­al­ized tar­get lev­els is in­di­cat­ed in most older adults. C

12.9 Treat­ment of other cardiovas­cu­lar risk fac­tors should be in­di­vid­u­al­ized in older adults con­sid­ering the time frame of benefit. Lipid-‍low­er­ing ther­a­py and as­pirin ther­a­py may benefit those with life ex­pectan­cies at least equal to the time frame of pri­ma­ry pre­vention or sec­ondary in­ter­ven­tion tri­als. E

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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 324 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.

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4.3.0.0 Healthy Pa­tients with Good Func­tion­al Sta­tus

There are few long-‍term stud­ies in older adults demon­strat­ing the benefits of in­ten­sive glycemic, blood pres­sure, and lipid con­trol. Pa­tients who can be ex­pect­ed to live long enough to reap the benefits of long-‍term in­ten­sive di­a­betes man­age­ment, who have good cog­ni­tive and phys­i­cal func­tion, and who choose to do so via shared de­ci­sion mak­ing may be treat­ed using ther­a­peu­tic in­ter­ven­tions and goals sim­i­lar to those for younger adults with di­a­betes (Table 12.1).

As with all pa­tients with di­a­betes, di­a­betes self-‍man­age­ment ed­u­ca­tion and on­go­ing di­a­betes self-‍man­age­ment sup­port are vital com­po­nents of di­a­betes care for older adults and their care­givers. Self-‍man­age­ment knowl­edge and skills should be reas­sessed when reg­i­men changes are made or an in­di­vid­u­al’s func­tion­al abil­i­ties di­min­ish. In ad­di­tion, de­clining or im­paired abil­i­ty to per­form di­a­betes self-‍care be­hav­iors may be an in­di­ca­tion for re­fer­ral of older adults with di­a­betes for cog­ni­tive and phys­i­cal func­tion­al as­sess­ment using age-nor­malized eval­u­a­tion tools (3,19).

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4.4.0.0 Pa­tients with Com­pli­ca­tions and Re­duced Func­tion­alityFunc­tion­ality

For pa­tients with ad­vanced di­a­betes

com­pli­ca­tions, life-‍lim­it­ing co­mor­bid ill­ness­es, or sub­stan­tial cog­ni­tive or func­tion­al im­pair­ments, it is rea­son­able to set less in­ten­sive glycemic goals (Table 12.1). Fac­tors to con­sid­er in in­di­vid­u­alizing glycemic goals are out­lined in Fig. 6.1. These pa­tients are less like­ly to benefit from re­duc­ing the risk of microvas­cu­lar com­pli­ca­tions and more like­ly to suf­fer se­ri­ous ad­verse ef­fects from hy­po­glycemia. How­ev­er, pa­tients with poor­ly con­trolled di­a­betes may be sub­ject to acute com­pli­ca­tions of di­a­betes, in­clud­ing de­hy­dra­tion, poor wound heal­ing, and hy­per­glycemic hy­per­os­mo­lar coma. Glycemic goals at a min­i­mum should avoid these con­se­quences.

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4.5.0.0 Vul­ner­a­ble Pa­tients at the End of Life

For pa­tients re­ceiv­ing pal­lia­tive care and end-‍of-‍life care, the focus should be to avoid symp­toms and com­pli­ca­tions from glycemic man­age­ment. Thus, when organ fail­ure de­vel­ops, sev­er­al agents will have to be down­ti­trat­ed or dis­con­tin­ued. For the dying pa­tient, most agents for type 2 di­a­betes may be re­moved (27). There is, how­ev­er, no con­sen­sus for the man­age­ment of type 1 di­a­betes in this sce­nario (28). See END-‍OF-‍LIFE CARE below, for ad­di­tional in­for­ma­tion.

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4.6.0.0 Be­yond Glycemic Con­trol

Al­though hy­per­glycemia con­trol may be im­por­tant in older in­di­vid­u­als with di­a­betes, greater re­duc­tions in mor­bid­i­ty and mor­tal­i­ty are like­ly to re­sult from con­trol of other cardiovas­cu­lar risk fac­tors rather than from tight glycemic con­trol alone. There is strong ev­i­dence from clin­i­cal tri­als of the value of treat­ing hy­per­ten­sion in older adults (29,30). There is less ev­i­dence for lipid-‍low­er­ing ther­a­py and as­pirin ther­a­py, al­though the benefits of these in­ter­ven­tions for pri­ma­ry pre­vention and sec­ondary in­ter­ven­tion are like­ly to apply to older adults whose life ex­pectan­cies equal or ex­ceed the time frames of the clin­i­cal tri­als.

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5.0.0.0 LIFESTYLE MAN­AGE­MENT

Rec­om­men­da­tion

12.10 Op­ti­mal nu­tri­tion and pro­tein in­take is rec­om­mend­ed for older adults; reg­u­lar ex­er­cise, in­clud­ing aer­o­bic ac­tiv­i­ty and re­sis­tance train­ing, should be en­cour­aged in all older adults who can safe­ly en­gage in such ac­tiv­i­ties. B

Di­a­betes in the aging pop­u­la­tion is as­so­ci­at­ed with re­duced mus­cle strength, poor mus­cle qual­i­ty, and ac­cel­er­at­ed loss of mus­cle mass, re­sulting in sar­cope­nia. Di­a­betes is also rec­og­nized as an in­de­pen­dent risk fac­tor for frailty. Frailty is char­ac­ter­ized by de­cline in phys­i­cal per­formance and an in­creased risk of poor health out­comes due to phys­i­o­log­ic vulnerabil­i­ty to clin­i­cal, func­tion­al, or psychoso­cial stres­sors. In­ad­e­quate nu­tri­tional in­take, par­tic­u­lar­ly in­ad­e­quate pro­tein in­take, can in­crease the risk of sar­cope­nia and frailty in older adults. Man­age­ment of frailty in di­a­betes in­cludes op­ti­mal nu­tri­tion with ad­e­quate pro­tein in­take com­bined with an ex­er­cise pro­gram that in­cludes aer­o­bic and re­sis­tance train­ing (31,32).

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6.0.0.0 PHAR­MA­CO­LOG­IC THER­A­PY

Rec­om­men­da­tions

12.11 In older adults at in­creased risk of hy­po­glycemia, med­i­ca­tion class­es with low risk of hy­po­glycemia are pre­ferred. B

12.12 Overtreat­ment of di­a­betes is com­mon in older adults and should be avoid­ed. B

12.13 Dein­ten­sification (or sim­plification) of com­plex reg­i­mens is rec­om­mend­ed to re­duce the risk of hy­po­glycemia, if it can be achieved with­in the in­di­vid­u­al­ized A1C tar­get. B

Fig 12.1

Fig. 12.1

Fig. 12.1—Al­go­rithm to sim­pli­fy in­sulin reg­i­men for older pa­tients with type 2 di­a­betes. eGFR, es­ti­mat­ed glomeru­lar filtra­tion rate. *Basal in­sulins: glargine U-100 and U-300, de­temir, degludec, and human NPH. **See Table 12.1. UMeal­time in­sulins: short-‍act­ing (reg­u­lar human in­sulin) or rap­i­dact­ing (lispro, as­part, and gluli­sine). §Pre­mixed in­sulins: 70/30, 75/25, and 50/50 prod­ucts. Adapt­ed with per­mis­sion from Mun­shi and col­leagues (39,55,56).

Spe­cial care is re­quired in pre­scrib­ing and mon­i­tor­ing phar­ma­co­log­ic ther­a­pies in older adults (33). See Fig. 9.1 for gen­er­al rec­om­men­da­tions re­gard­ing antihy­per­glycemia treat­ment for adults with type 2 di­a­betes and Table 9.1 for pa­tient-‍ and drug-‍specific fac­tors to con­sid­er when se­lect­ing antihy­per­glycemia agents. Cost may be an im­por­tant con­sid­eration, es­pe­cial­ly as older adults tend to be on many med­i­ca­tions. See Ta­bles 9.2 and 9.3 for me­di­an month­ly cost of nonin­sulin glu­cose-‍low­er­ing agents and in­sulin in the U.S., re­spec­tive­ly. It is im­por­tant to match com­plexity of the treat­ment reg­i­men to the self-‍man­age­ment abil­i­ty of an older pa­tient. Many older adults with di­a­betes strug­gle to main­tain the fre­quent blood glu­cose test­ing and in­sulin in­jec­tion reg­i­mens they pre­vi­ous­ly fol­lowed, per­haps for many decades, as they de­vel­op med­i­cal con­di­tions that may im­pair their abil­i­ty to fol­low their reg­i­men safe­ly. In­di­vid­u­al­ized glycemic goals should be es­tab­lished (Fig. 6.1) and pe­ri­od­i­cal­ly ad­just­ed based on co­ex­ist­ing chron­ic ill­ness­es, cog­ni­tive func­tion, and func­tion­al sta­tus (2). Tight glycemic con­trol in older adults with mul­ti­ple med­i­cal con­di­tions is con­sid­ered overtreat­ment and is as­so­ci­at­ed with an in­creased risk of hy­po­glycemia; un­for­tu­nate­ly, overtreat­ment is com­mon in clin­i­cal prac­tice (34-38). Dein­ten­sification of reg­i­mens in pa­tients tak­ing nonin­sulin glu­cose-‍low­er­ing med­i­ca­tions can be achieved by ei­ther low­er­ing the dose or dis­con­tin­u­ing some med­i­ca­tions, so long as the in­di­vid­u­al­ized A1C tar­get is main­tained. When pa­tients are found to have an in­sulin reg­i­men with com­plexity be­yond their self-‍man­age­ment abil­i­ties, low­er­ing the dose of in­sulin may not be ad­e­quate. Sim­plification of the in­sulin reg­i­men to match an in­di­vid­u­al’s self-‍man­age­ment abil­i­ties in these sit­u­a­tions has been shown to re­duce hy­po­glycemia and dis­ease-‍re­lat­ed dis­tress with­out wors­en­ing glycemic con­trol (39-41). Fig­ure 12.1 de­picts an al­go­rithm that can be used to sim­pli­fy the in­sulin reg­i­men (39). Table 12.2 pro­vides ex­am­ples of and ra­tio­nale for sit­u­a­tions where dein­ten­sification and/‍or in­sulin reg­i­men sim­plification may be ap­pro­pri­ate in older adults.

Met­formin

Met­formin is the first-‍line agent for older adults with type 2 di­a­betes. Re­cent stud­ies have in­di­cat­ed that it may be used safe­ly in pa­tients with es­ti­mat­ed glomeru­lar filtra­tion rate ≥30 mL/‍min/‍1.73 m2 (42). How­ev­er, it is contrain­di­cat­ed in pa­tients with ad­vanced renal insuffi- cien­cy and should be used with cau­tion in pa­tients with im­paired hep­at­ic func­tion or con­ges­tive heart fail­ure due to the in­creased risk of lac­tic aci­do­sis. Met­formin may be tem­porar­i­ly dis­con­tin­ued be­fore pro­ce­dures, dur­ing hos­pi­tal­iza­tions, and when acute ill­ness may com­pro­mise renal or liver func­tion.

Thi­a­zo­lidine­diones

Thi­a­zo­lidine­diones, if used at all, should be used very cau­tious­ly in those with, or at risk for, con­ges­tive heart fail­ure and those at risk for falls or frac­tures.

In­sulin Sec­re­t­a­gogues

Sul­fony­lureas and other in­sulin sec­re­t­a­gogues are as­so­ci­at­ed with hy­po­glycemia and should be used with cau­tion. If used, shorter-du­ra­tion sul­fony­lureas, such as glip­izide, are pre­ferred. Gly­buride is a longer-‍du­ra­tion sul­fony­lurea and contrain­di­cat­ed in older adults (43).

In­cretin-‍Based Ther­a­pies

Oral dipep­tidyl pep­ti­dase 4 (DPP-4) in­hibitors have few side ef­fects and min­i­mal hy­po­glycemia, but their costs may be a bar­ri­er to some older pa­tients. DPP-4 in­hibitors do not in­crease major ad­verse cardiovas­cu­lar out­comes (44).

Glucagon-‍like pep­tide 1 (GLP-1) re­cep­tor ag­o­nists are in­jectable agents, which re­quire vi­su­al, motor, and cog­ni­tive skills for ap­pro­pri­ate ad­min­is­tra­tion. They may be as­so­ci­at­ed with nau­sea, vom­it­ing, and di­ar­rhea. Also, weight loss with GLP-1 re­cep­tor ag­o­nists may not be de­sir­able in some older pa­tients, par­tic­u­lar­ly those with cachex­ia. In pa­tients with es­tab­lished atheroscle­rot­ic cardiovas­cu­lar dis­ease, GLP-1 re­cep­tor ag­o­nists have shown cardiovas­cu­lar benefits (44).

Table 12.2—Con­sid­erations for treat­ment reg­i­men sim­plification and dein­ten­sification/depre­scrib­ing in older adults with di­a­betes (39,55)

Table 12.2

Treat­ment reg­i­men sim­plification refers to chang­ing strat­e­gy to de­crease the com­plexity of a med­i­ca­tion reg­i­men, e.g., fewer ad­min­is­tra­tion times, fewer finger­stick read­ings, de­creas­ing the need for cal­cu­la­tions (such as slid­ing scale in­sulin cal­cu­la­tions or in­sulin-carbohydrate ratio cal­cu­la­tions). Dein­ten­sification/depre­scrib­ing refers to de­creas­ing the dose or fre­quen­cy of ad­min­is­tra­tion of a treat­ment or dis­con­tin­u­ing a treat­ment al­to­geth­er. ADL, ac­tiv­i­ties of daily liv­ing. †Con­sid­er ad­just­ment of A1C goal if the pa­tient has a con­di­tion that may in­ter­fere with ery­thro­cyte life span/‍turnover.

Sodi­um2Glu­cose Co­trans­porter 2 In­hibitors

Sodi­um2glu­cose co­trans­porter 2 inhibi-‍

tors are ad­min­is­tered oral­ly, which may be con­ve­nient for older adults with di­a­betes; how­ev­er, long-‍term ex­pe­ri­ence in this pop­u­la­tion is lim­it­ed de­spite the ini­tial efficacy and safe­ty data re­ported with these agents. In pa­tients with es­tab­lished atheroscle­rot­ic cardiovas­cu­lar dis­ease, these agents have shown cardiovas­cu­lar benefits (44).

In­sulin Ther­a­py

The use of in­sulin ther­a­py re­quires that pa­tients or their care­givers have good vi­su­al and motor skills and cog­ni­tive abil­i­ty. In­sulin ther­a­py re­lies on the abil­i­ty of the older pa­tient to ad­min­is­ter in­sulin on their own or with the as­sis­tance of a care­giv­er. In­sulin doses should be titrat­ed to meet in­di­vid­u­al­ized glycemic tar­gets and to avoid hy­po­glycemia. Once-‍daily basal in­sulin in­jec­tion ther­a­py is as­so­ci­at­ed with min­i­mal side ef­fects and may be a rea­son­able op­tion in many older pa­tients. Mul­ti­ple daily in­jec­tions of in­sulin may be too com­plex for the older pa­tient with ad­vanced di­a­betes com­pli­ca­tions, life-‍lim­it­ing co­ex­ist­ing chron­ic ill­ness­es, or lim­it­ed func­tion­al sta­tus. Fig­ure 12.1 pro­vides a po­ten­tial ap­proach to in­sulin reg­i­men sim­plification.

Other Fac­tors to Con­sid­er

The needs of older adults with di­a­betes and their care­givers should be eval­u­ated to con­struct a tai­lored care plan. Im­paired so­cial func­tioning may re­duce their qual­i­ty of life and in­crease the risk of func­tion­al de­pen­den­cy (45). The pa­tient’s liv­ing sit­u­a­tion must be con­sid­ered as it may af­fect di­a­betes man­age­ment and sup­port needs. So­cial and in­stru­men­tal sup­port net­works (e.g., adult chil­dren, care­tak­ers) that pro­vide in­stru­men­tal or emo­tion­al sup­port for older adults with di­a­betes should be in­cluded in di­a­betes man­age­ment dis­cussions and shared de­ci­sion mak­ing.

Older adults in as­sist­ed liv­ing fa­cil­i­ties may not have sup­port to ad­min­is­ter their own med­i­ca­tions, where­as those liv­ing in a nurs­ing home (com­mu­ni­ty liv­ing cen­ters) may rely com­plete­ly on the care plan and nurs­ing sup­port. Those re­ceiv­ing pal­lia­tive care (with or with­out hos­pice) may re­quire an ap­proach that em­pha­sizes com­fort and symp­tom man­age­ment, while de-‍em­pha­siz­ing strict metabol­ic and blood pres­sure con­trol.

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7.0.0.0 Tx in Skilled Nurs­ing Fa­cili. & Nurs­ing Homes

Rec­om­men­da­tions

12.14 Con­sid­er di­a­betes ed­u­ca­tion for the staff of long-‍term care fa­cil­i­ties to im­prove the man­age­ment of older adults with di­a­betes. E

12.15 Pa­tients with di­a­betes re­si­ding in long-‍term care fa­cil­i­ties need care­ful as­sess­ment to es­tab­lish glycemic goals and to make ap­pro­pri­ate choic­es of glu­cose-‍low­er­ing agents based on their clin­i­cal and func­tion­al sta­tus. E

Man­age­ment of di­a­betes in the long-‍term care (LTC) set­ting (i.e., nurs­ing homes and skilled nurs­ing fa­cil­i­ties) is unique. In­di­vid­u­al­iza­tion of health care is im­por­tant in all pa­tients; how­ev­er, prac­ti­cal guid­ance is need­ed for med­i­cal pro­viders as well as the LTC staff and care­givers (46). Train­ing should in­clude di­a­betes de­tec­tion and in­sti­tu­tion­al qual­i­ty as­sess­ment. LTC fa­cil­i­ties should de­vel­op their own poli­cies and pro­ce­dures for pre­vention and man­age­ment of hy­po­glycemia.

Re­sources

Staff of LTC fa­cil­i­ties should re­ceive ap­pro­pri­ate di­a­betes ed­u­ca­tion to im­prove the man­age­ment of older adults with di­a­betes. Treat­ments for each pa­tient should be in­di­vid­u­al­ized. Spe­cial man­age­ment con­sid­erations in­clude the need to avoid both hy­po­glycemia and the com­pli­ca­tions of hy­per­glycemia (2,47). For more in­for­ma­tion, see the ADA po­si­tion state­ment “Man­age­ment of Di­a­betes in Long-‍term Care and Skilled Nurs­ing Fa­cilities” (46).

Nu­tri­tion­al Con­sid­erations

An older adult re­si­ding in an LTC fa­cil­i­ty may have irreg­u­lar and un­pre­dictable meal con­sump­tion, undernu­tri­tion, anorex­ia, and im­paired swal­low­ing. Fur­ther­more, ther­a­peu­tic diets may in­ad­ver­tent­ly lead to de­creased food in­take and con­tribute to un­in­ten­tion­al weight loss and undernu­tri­tion. Diets tai­lored to a pa­tient’s cul­ture, pref­er­ences, and per­son­al goals may in­crease qual­i­ty of life, sat­is­fac­tion with meals, and nu­tri­tion sta­tus (48).

Hy­po­glycemia

Older adults with di­a­betes in LTC are es­pe­cial­ly vul­ner­a­ble to hy­po­glycemia. They have a dispro­por­tionately high num­ber of clin­i­cal com­pli­ca­tions and co­mor­bidi­ties that can in­crease hy­po­glycemia risk: im­paired cog­ni­tive and renal func­tion, slowed hor­mon­al reg­u­la­tion and counterreg­u­la­tion, subop­ti­mal hy­dra­tion, vari­able ap­petite and nu­tri­tional in­take, polyphar­ma­cy, and slowed in­testi­nal ab­sorp­tion (49). Oral agents may achieve sim­i­lar glycemic out­comes in LTC pop­u­la­tions as basal in­sulin (34,50).

An­oth­er con­sid­eration for the LTC set­ting is that, un­like the hos­pi­tal set­ting, med­i­cal pro­viders are not re­quired to eval­u­ate the pa­tients daily. Ac­cord­ing to fed­er­al guide­lines, as­sess­ments should be done at least every 30 days for the first 90 days after ad­mis­sion and then at least once every 60 days. Al­though in prac­tice the pa­tients may ac­tu­al­ly be seen more fre­quent­ly, the con­cern is that pa­tients may have uncon­trolled glu­cose lev­els or wide ex­cur­sions with­out the prac­ti­tion­er being notified. Providers may make ad­just­ments to treat­ment reg­i­mens by tele­phone, fax, or in per­son di­rect­ly at the LTC fa­cil­i­ties pro­vided they are given time­ly notification of blood glu­cose man­age­ment is­sues from a stan­dardized alert sys­tem.

The fol­lowing alert strat­e­gy could be con­sid­ered:

  1. Call pro­vider im­me­di­a­tely: in case of low blood glu­cose lev­els (≤70 mg/dL [3.9 mmol/‍L]).
  2. Call as soon as pos­si­ble: a) glu­cose val­ues be­tween 70 and 100 mg/dL (3.9 and 5.6 mmol/‍L) (reg­i­men may need to be ad­just­ed), b) glu­cose val­ues greater than 250 mg/dL (13.9 mmol/‍L) with­in a 24-h pe­ri­od, c) glu­cose val­ues greater than 300 mg/dL (16.7 mmol/‍L) over 2 con­sec­u­tive days, d) when any read­ing is too high for the glu­come­ter, or e) the pa­tient is sick, with vom­it­ing, symp­tomatic hy­per­glycemia, or poor oral in­take.

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8.0.0.0 END-‍OF-‍LIFE CARE

Rec­om­men­da­tions

12.16 When pal­lia­tive care is need­ed in older adults with di­a­betes, strict blood pres­sure con­trol may not be nec­es­sary, and with­draw­al of ther­a­py may be ap­pro­pri­ate. Sim­i­lar­ly, the in­ten­si­ty of lipid man­age­ment can be re­laxed, and with­draw­al of lipid-‍low­er­ing ther­a­py may be ap­pro­pri­ate. E

12.17 Over­all com­fort, pre­vention of dis­tressing symp­toms, and preser­va­tion of qual­i­ty of life and dig­ni­ty are pri­ma­ry goals for di­a­betes man­age­ment at the end of life. E

The man­age­ment of the older adult at the end of life re­ceiv­ing pal­lia­tive medicine or hos­pice care is a unique sit­u­a­tion. Over­all, pal­lia­tive medicine pro­motes com­fort, symp­tom con­trol and pre­vention (pain, hy­po­glycemia, hy­per­glycemia, and de­hy­dra­tion), and preser­va­tion of dig­ni­ty and qual­i­ty of life in pa­tients with lim­it­ed life ex­pectan­cy (47,51). A pa­tient has the right to refuse test­ing and treat­ment, where­as pro­viders may con­sid­er with­draw­ing treat­ment and lim­it­ing di­ag­nos­tic test­ing, in­clud­ing a re­duc­tion in the fre­quen­cy of finger­stick test­ing (52). Glu­cose tar­gets should aim to pre­vent hy­po­glycemia and hy­per­glycemia. Treat­ment in­ter­ven­tions need to be mind­ful of qual­i­ty of life. Care­ful mon­i­tor­ing of oral in­take is war­rant­ed. The de­ci­sion pro­cess may need to in­volve the pa­tient, fam­i­ly, and care­givers, lead­ing to a care plan that is both con­ve­nient and ef­fec­tive for the goals of care (53). The phar­ma­co­log­ic ther­a­py may in­clude oral agents as first line, fol­lowed by a sim­plified in­sulin reg­i­men. If need­ed, basal in­sulin can be im­ple­ment­ed, ac­com­pa­nied by oral agents and with­out rapid-‍act­ing in­sulin. Agents that can cause gastroin­testi­nal symp­toms such as nau­sea or ex­cess weight loss may not be good choic­es in this set­ting. As symp­toms progress, some agents may be slow­ly ta­pered and dis­con­tin­ued.

Dif­fer­ent pa­tient cat­e­gories have been pro­posed for di­a­betes man­age­ment in those with ad­vanced dis­ease (28).

  1. A sta­ble pa­tient: con­tin­ue with the pa­tient’s pre­vi­ous reg­i­men, with a focus on the pre­vention of hy­po­glycemia and the man­age­ment of hy­per­glycemia using blood glu­cose test­ing, keep­ing lev­els below the renal thresh­old of glu­cose. There is very lit­tle role for A1C mon­i­tor­ing and low­er­ing.

  2. A pa­tient with organ fail­ure: pre­vent­ing hy­po­glycemia is of greater significance. Dehy­dra­tion must be pre­vented and treat­ed. In peo­ple with type 1 di­a­betes, in­sulin ad­min­is­tra­tion may be re­duced as the oral in­take of food de­creases but should not be stopped. For those with type 2 di­a­betes, agents that may cause hy­po­glycemia should be down­ti­trat­ed. The main goal is to avoid hy­po­glycemia, al­low­ing for glu­cose val­ues in the upper level of the de­sired tar­get range.

  3. A dying pa­tient: for pa­tients with type 2 di­a­betes, the dis­con­tin­u­a­tion of all med­i­ca­tions may be a rea­son­able ap­proach, as pa­tients are un­like­ly to have any oral in­take. In pa­tients with type 1 di­a­betes, there is no con­sen­sus, but a small amount of basal in­sulin may main­tain glu­cose lev­els and pre­vent acute hy­per­glycemic com­pli­ca­tions.

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9.0.0.0 Ref­er­ences

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