Diabetes Management in the Elderly
IN BRIEF Older adults with diabetes present unique challenges and require considerations that are not traditionally associated with diabetes management. In this review, we focus on issues that are unique to the older population and provide practical guidance for clinicians who care for them.
Diabetes in Older Adults: A Growing Population With Special Challenges
The population of elderly patients with diabetes is rapidly growing, with a significant impact on population health and economics (Table 1). Currently in the United States, older adults (age ≥65 years of age) make up >25% of the total population with diabetes (1). Even if the diabetes incidence rates were to level off, the prevalence of diabetes will double in the next 20 years as the population ages (2).
|• More than 25% of adults >65 years of age have diabetes.|
|• Diabetes was the 7th leading cause of death in the United States in 2015.|
|• The average cost of medical expenditures for adults with diabetes is $13,239/year compared to $6,675 for a younger cohort.|
|• Older adults with diabetes have the highest rates of complications.|
Older adults with diabetes are at higher risk for both acute and chronic microvascular and macrovascular complications from the disease, including major lower-extremity amputations, myocardial infarctions, visual impairments, and end-stage renal disease, compared to any other age group (3). Patients who are >75 years of age are more likely to develop complications, have higher rates of death from hyperglycemic crises and have an increased rate of emergency department visits for hypoglycemia compared to those who are <75 years of age (1).
A recent analysis of the economic cost of diabetes showed that ∼61% of all health care costs attributed to diabetes are incurred by people with diabetes who are >65 years of age (4). The average annual expenditure for older adults (≥65 years of age) was $13,239 compared to $6,675 for the younger cohort. Thus, older adults with diabetes comprise a growing population posing high health and economic burdens to society.
All Older Adults Are Not the Same
Diabetes management in older adults presents challenges because there is extensive variability within this population in terms of clinical presentation, psychosocial environment, and resource availability. A person’s living situation and degree of available social support can affect both glycemic goals and the ways in which diabetes is managed. Diabetes management can differ across the spectrum according to where elderly patients live (i.e., whether they are community-dwelling or live in an assisted-living facility or a nursing home (5). Table 2 describes the characteristics of older adults in different living situations and how these characteristics may affect diabetes management.
|Living Situation||Patient Characteristics||Impact on Diabetes Care|
|Community dwelling||• High functioning||• Complex regimens can be dangerous if patients are unable to follow them|
|• Medically stable||• Acute illness can cause decline in cognitive or physical status|
|• May or may not need caregivers||• Patients need frequent education and reeducation|
|Residing in an assisted living facility||• High functioning||• Patients may or may not have control over the content of their meals|
|• Need partial assistance in ADL/IADL||• Patients need assistance with oral medication–taking but not with blood glucose monitoring or insulin administration|
|• Need more assistance from caregivers||• Patient have high risk of regimen failure after acute illness (i.e., failing to take medications as prescribed)|
|Residing in a short-term rehabilitation center||• High functioning||• Patients need tighter glycemic control for wound-healing|
|• Need temporary partial or full assistance||• Patients may benefit from education to improve glycemic control|
|• Goal is to return to permanent living situation|
|Residing in a nursing home||• Low functioning||• Patients have no control over the timing or content of their meals|
|• Need assistance or are dependent on others for ADL and IADL||• Patients have higher risk of side effects with oral medications|
|• Have limited life expectancy||• Patients have higher risk of acute illness, anorexia, and dementia/delirium|
|• Have a high burden of comorbidities||• Patients’ self-care is performed by nursing home staff|
ADL, activities of daily living (e.g., bathing, toileting, transferring from place to place, dressing, and eating); IADL, instrumental ADL (e.g., using the telephone, managing medications, handling finances, performing housework, cooking, and arranging transportation.
Some elderly people with diabetes are high functioning and medically stable, can perform self-care, and may or may not need caregivers. However, for others who are unable to follow instructions and manage their own medication regimen, diabetes management can be tricky and dangerous. In addition, the aging population with diabetes also has a higher risk of other conditions (termed “geriatric syndromes”) that include cognitive dysfunction, depression, physical disability, pain, polypharmacy, and urinary incontinence. The goals of diabetes management must differ for older adults based on the presence or absence of these comorbidities, as well as on the patients’ living situation and available resources. Another challenge in this population is a higher frequency of acute illnesses and frequent changes in overall health, which can affect glucose control and lead to decline in cognitive functioning and physical status. In such cases, it is important to adjust treatment goals as needed. Most of the discussion in the remainder of this article pertains to community-living older adults.
Current Guidelines for Diabetes Management in Community-Dwelling Older Adults
Several organizations have published guidelines regarding diabetes management in older adults. Most of these guidelines stress the importance of considering patients’ overall health, comorbidities, cognitive and physical status, hypoglycemia risk, and life expectancy to guide glycemic goal-setting. The details vary by guideline, and these differences are summarized below.
The European Diabetes Working Party for Older People in 2011 published clinical guidelines for treating older adults with diabetes who are ≥70 years of age (6). With regard to glycemic targets, these guidelines divide older adults into two categories. For those without other major comorbidities, an A1C goal of 7–7.5% and a fasting glucose target range of 6.5–7.5 mmol/L (117–135 mg/dL) are recommended, whereas for frail older adults and those with multisystem disease, an A1C goal of 7.6–8.5% and a fasting glucose target range of 7.6–9.0 mmol/L (137–162 mg/dL) are recommended to minimize the risk of hypoglycemia and metabolic decompensation.
The American Diabetes Association (ADA) in 2012 published a consensus report on managing diabetes in older adults (7). In this report, glycemic goals are stratified based on patient characteristics and health status. As shown in Table 3, major consideration is given to coexisting severe medical conditions, presence of cognitive dysfunction, and ability to perform day-to-day activities. Based on these parameters, patients are divided into healthy, complex/intermediate, or very complex/poor health categories, with recommended A1C goals of <7.5, <8, and <8.5%, respectively, and similarly stratified fasting and bedtime glucose target ranges.