Diabetes Control in the Elderly | July 2022 | Clinical Corner

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July 1, 2022

Diabetes Control in the Elderly

 

SUMMARY:

  • Management of the elderly patient with diabetes promote relaxed targets and avoidance of aggressive control.
  • Choice of diabetes medications in the elderly requires careful assessment of hypoglycemic risk1.
  • Adults > 65 years of age with diabetes should be a high priority for depression screening and treatment.

 

MANAGEMENT:

  1. Individualize Targets and Goals2
    1. 7 - 7.5% is reasonable for healthy patients over age 65 with no or few comorbidities and good functional status.
    2. 8.0 – 8.5% is appropriate for adults over age 65 with multiple comorbidities, poor health, and limited life expectancy.
  2. Avoid Hypoglycemia
    1. Causes impaired awareness of autonomic warning signs and deterioration of psychomotor coordination even when educated about the symptoms.
    2. History of severe hypoglycemia or repeated treatment for hypoglycemia nearly doubles the risk of mortality.
  3. Individualize Treatment
    1. Metformin is the preferred initial therapy in many older adults with type 2 diabetes, but at reduced dose in those with stage 3 CKD (avoid in those with ≥ stage 4 CKD).
    2. DPP4 inhibitors are preferred second line therapy owing to the lower risk of hypoglycemia.
    3. If sulfonylureas are to be used, Glipizide is the preferred agent due to its short duration.
    4. TZDs increase the risk of CHF from water retention and fractures due to decreased bone mass.
    5. SGLT2 inhibitors may be used in otherwise healthy persons with adequate nutrition and hydration while keeping vigilance for complications
    6. GLP1RA may be used, provided the oral or injectable therapy is accepted and tolerated
    7. Multiple daily insulin injections may be too complex for older adults with advanced complications, life-limiting comorbidities or limited functional status.

 

COMPLICATIONS:

  1. In addition to the traditional cardiovascular and microvascular complications, uncontrolled diabetes increases the risk of many geriatric conditions including:
    1. Falls, Urinary Incontinence, Sarcopenia and Frailty, Cognitive Impairment, Chronic Pain, and Depression which has the most significant impact on mortality and quality of life.

REFERENCES:

1. Kirkman MS. Diabetes in Older Adults ADA Consensus Report. Diabetes Care 2012

2. https://diabetesjournals.org/care/article/45/Supplement_1/S195/138920/13-Older-Adults-Standards-of-Medical-Care-in