CHAPTER 4. Guideline for the Care of the Older Adult With Diabetes

Objective: The Joslin Guideline for the Care of the Older Adult with Diabetes is designed to assist primary care physicians, specialists, and other healthcare providers in addressing the unique challenges and issues of the older person with diabetes. The guideline should be used in conjunction with Joslin’s Clinical Guideline for Adults with Diabetes as well as Joslin’s Clinical Guideline for Pharmacological Management of Adults with Type 2 Diabetes (T2D).

The primary goal of diabetes management in older adults is to achieve balance between optimal glycemic control to prevent and/or slow the onset and progression of acute and chronic complications, while avoiding hypoglycemia and its consequences. Hypoglycemia can result in worse outcomes in older adults as it can lead to traumatic falls and worsening of chronic conditions such as cognitive dysfunction. Therefore, in many cases, aggressive treatment may not be appropriate if the older adult’s comfort, safety, and overall quality of life are thereby compromised, or if aggressive treatment may not improve outcomes. Recent consensus on the management of diabetes recommends individualization of treatment goals based on coexisting medical conditions, cognitive status, functionality, and available resources. The older adult’s view on illness, health, and aging should also be considered. Appropriate support systems for complex diabetes are not uniformly available nationwide. As a result, treatment decisions become more complex as the capacity to cope with self-care declines.

To assist with self-care, education strategies also require adaptation for aging. Learning new diabetes self-management skills may be difficult for older people, increasing the need for education to proceed in a simple, step-like manner. Cognitive dysfunction, depression, and functional disabilities (such as vision and hearing deficits and a decline in dexterity) are important issues to consider when assessing the older adult’s ability for self-care. Involvement of family members or friends may be required to assure appropriate self-care and adherence to treatment programs.

4.1.0 GENERAL CONSIDERATIONS

Portions of this guideline are based upon recommendations of the International Diabetes Federation’s Global Guideline for Managing Older People with Type 2 Diabetes and the American Diabetes Association/American Geriatrics Society Consensus Report on Diabetes in Older Adults.

• In determining treatment plans and goals, individualized patient assessment is required, being cognizant of the following: Chronological age versus actual health status Duration of disease and age of onset (for example, older-age onset of T2D is more prominent in non-Hispanic whites and is associated with a lower likelihood of insulin use than middle-age onset; retinopathy is more likely to occur in middle-age—onset diabetes rather than older-age–onset diabetes. There is no difference in coronary artery disease or neuropathy prevalence in middle vs older age onset) Presence of complications and comorbidities Life expectancy Social support system Financial status Patient preferences
• Treatment programs should be simplified to decrease the potential of medication errors and to avoid overwhelming the patient and their caregivers.
• Treatment goals should be reassessed at frequent intervals as health status can change quickly in older adults.

4.2.0 GERIATRIC SYNDROME

4.3.0 DIAGNOSIS

The table in this guideline (Table 1) lists a group of conditions collectively called geriatric syndrome, which occurs more frequently in older adults with diabetes. These conditions can interfere with a patient’s ability to perform self-care activities and make healthcare more challenging for the older adult and for their caregivers. The table below includes the condition, possible clinical presentations, commonly used short clinical screening tests, and suggested modifications to treatment plans and goals to compensate for the condition.See Joslin’s Clinical Guideline for Adults with Diabetes (Chapter 1) for more details.

4.4.0 TREATMENT GOALS

CDC data indicate that about half of older adults have prediabetes. It is recommended that all adults >45 years of age be screened for diabetes every 1 to 3 years using a glycated hemoglobin (A1C), fasting glucose, or oral glucose tolerance test. This recommendation should be modified for those with shorter life expectancies and those with multiple comorbidities.See Joslin’s Clinical Guideline for Adults with Diabetes for more details. Treatment goals are modified for health status, based on recommendations from the American Diabetes Association.

4.5.0 EDUCATION

Treatment goals for A1C, glucose, blood pressure, and lipid levels should be modified for the older adult based on patient characteristics and on health status. See Table 2 below.Education strategies require adaptation for aging. Simplify and focus programs:

• Use focused educational material that is easy to follow and excludes extraneous information.
• Provide individual rather than group education if the patient has cognitive or physical deficits.
• Focus on 1 to 2 topics at a time. Repetition and re-education are needed for many older adults.
• Education sessions should be slow-paced, with instruction occurring in steps.
• Multiple sessions may need to be scheduled, to prevent “information overload.”
• Use memory aids (eg, personalized handouts) to reinforce points made during face-to-face sessions.
• When possible, simplify the patient’s medication program especially for those who have multiple medical problems, cognitive dysfunction, or functional disability (eg, changing insulin to 2 injections per day from 4 injections per day).
• When discussing medications, focus education on medication adherence by using charts, pill boxes, and other reminders.
• Caregivers should be instructed in how to track amounts of medication used.
• Educate the patient that uncommon symptoms such as confusion, dizziness, and weakness can be manifestations of hypoglycemia.
• Involve the patient’s caregiver or arrange for visiting nurse evaluation if medication adherence is an issue.
• Provide very specific guidelines on when the patient and/or caregiver should call the healthcare provider for assistance.

4.6.0 DEVICES

• Recommend equipment that is easy to hold, easy to read, and requires the least number of steps.
• Insulin pens, pens that contain noninsulin glucose- lowering medication, and prefilled syringes may be easier for older patients to use than manipulating a syringe and vial. Syringe magnifiers are available if vision is impaired.
• For some patients, inhaled insulin may be another option for prandial insulin.
• Choose blood glucose meters that have a large display, are easy to hold and use, and that minimize handling of strips and lancets. “Talking meters” are available for those with vision impairment.

4.7.0 MONITORING

• Emphasize the importance of regular self-monitoring of blood glucose (SMBG), especially before driving or using power tools.
• Checking glucose levels at different times of the day, on different days of the week, will allow the provider to assess glucose patterns throughout the day without having the patient check the glucose several times each day. For example, check the fasting and presupper glucose levels one day, and prelunch and bedtime levels another day.
• Some older adults may not be able to perform SMBG due to physical or cognitive impairment. To decrease the risk of hypoglycemia in these situations, glycemic goals may need to be adjusted and medication programs may need to be simplified. In T2D, if appropriate, use diabetes medications that have a low risk for hypoglycemia.
• Develop a plan to treat hypoglycemia. Encourage the patient to carry a source of glucose on their person and to have one at the bedside at all times.
• Develop a sick day plan.
• Encourage caregivers to accompany patients to education sessions and receive appropriate education in glucose monitoring and blood glucose interpretation.

4.8.0 DRIVING

• A referral for education and counseling should be advised if the patient’s ability to drive is in question. Organizations such as local elder services, the American Geriatric Society, and the various state motor vehicle registries may have additional information for patients as well as family members.
• Drive-wise programs, where available, can be useful to assess the patient’s ability to drive.

4.9.0 NUTRITION CHALLENGES (see Appendix for examples of nutrition prescriptions)

Although diabetes nutritional guidelines for the older adult are no different than for younger adults, unique challenges often exist due to:

• Lack of motivation
• Impaired food shopping or preparation capabilities
• Omission of meals due to cognitive dysfunction or depression
• Compromised dentition
• Altered taste perception
• Altered gastrointestinal function
• Weight loss and malnutrition
• Coexisting illnesses
• Limited finances

4.9.1 Nutritional recommendations:

Consider referral to a dietitian to work with the older adult patient and caregivers to:

• Assess nutritional needs
• Avoid making unnecessary dietary changes in life-long eating habits, remembering that to treat coexisting illnesses multiple changes may be required, such as reducing potassium, sodium, and dietary fats
• Minimize the complexity of meal planning and engage the spouse, or others living with the patient, in creating a home environment that supports positive lifestyle change
• Educate how consistency in carbohydrate intake and meal timing can help minimize fluctuations in blood glucose levels as well as help maintain or achieve a reasonable weight
• Consider giving prandial insulin after the meal rather than before, based on carbohydrate intake
• Assess the ability to buy and prepare healthy meals
• Help maximize a limited food budget
• Suggest community resources such as Meals on Wheels

4.9.2 Weight loss/potential malnutrition:

• Weight-loss diets commonly recommended to younger adults should be prescribed with great caution to the older adult, since undernutrition/malnutrition is often more of a problem than obesity in the older adult.
• Weight loss and the potential for malnutrition should be carefully monitored, especially after acute illness, hospitalization, and social stress. Use serial weight measurements to monitor changes.
• To avoid weight loss, it may be necessary to let patients eat what they enjoy and adjust diabetes medications accordingly.

4.9.3 Chronic care settings:

• In chronic care settings, there is no need for a rigid and restrictive meal plan. A regular meal plan with consistent, moderate carbohydrate intake may be sufficient and may help avoid undernutrition.

4.10.0 PHYSICAL ACTIVITY

(see Appendix for examples of activity prescriptions)

4.10.1 Benefits of activity:

Physical activity should be stressed in all older adults as it is crucial in maintaining functionality, independence, and acceptable quality of life.

• Regular exercise program offers other benefits to older adults, such as: Reduced glucose levels Improved lipid profile Improved blood pressure Increased muscle tone and strength Improved gait and balance Overall physical conditioning Decreased depression, and an overall sense of improved well-being.

4.10.2 Types of activity:

• Types of physical activities that may be appropriate for the older adult should take into account the current level of physical fitness/disability. It is important to develop an activity program to increase mobility, endurance, and strength, and to increase the duration of the activity gradually. Common activities to achieve these goals include: Aerobic activities Walking Swimming or water aerobics Stationary bicycle riding Resistance training Armchair exercises Weight lifting Balance exercise Tai chi Yoga Flexibility exercises Other physical activities: Gardening Household chores

4.10.3 Challenges to consider:

• Challenges to maintaining a regular physical activity program include: Fluctuations in health Comorbidities, such as cardiovascular disease, osteoarthritis, and osteoporosis Risk and fear of falls Finding a safe environment for exercise Issues with transportation Hypoglycemia The risk of hypoglycemia is increased among those using insulin and other diabetes medications that can cause hypoglycemia. More frequent SMBG may reduce this risk
• An exercise physiologist or a physical or occupational therapist can provide a supervised environment to help a patient perform exercises safely.

4.11.0 MEDICATIONS: GENERAL CONSIDERATIONS

General principles to consider when prescribing medications to an older adult include:

• “Start low and go slow” when dosing and titrating medications
• Agents with low risk of hypoglycemia are preferred in this age group
• Deintensification (or simplification) of complex regimens is recommended to reduce the risk of hypoglycemia

4.11.1 Overtreatment of diabetes

is common in older adults and should be avoided.

• Consider drug—drug interactions carefully, as most older adults are on multiple medications as well as supplements
• Evaluate renal function using the estimated glomerular filtration rate (eGFR) rather than serum creatinine because low muscle mass in the older population may result in a “normal” creatinine level despite significant renal dysfunction
• Monitor liver and kidney function with periodic tests
• Assess financial resources when using newer, generally more expensive agents

4.11.2 Oral glucose-lowering medications: (Table 3)

Please also refer to Joslin’s Clinical Guideline for Pharmacological Management of Adults With Type 2 Diabetes (Chapter 1) for more detailed information on diabetes medications.

4.11.3 Injectable noninsulin antidiabetic medications (Table 4)

4.11.4 Insulin products (Table 5)

4.12.0 HYPERTENSION: GENERAL CONSIDERATIONS

The goals of therapy for hypertension in the older adult are the same as those for younger adults with diabetes. The target blood pressure should be less than 140/90 mmHg as tolerated. Isolated systolic hypertension is much more common in the older adult. Systolic blood pressure <150 is acceptable in patients with multiple comorbidities or limited life expectancy. Care should be taken to treat with antihypertensive agents to bring systolic blood pressure to goal, if feasible. Blood pressure should be lowered gradually in order to reduce the risk of hypotensive symptoms. Older adults are prone to “white coat” hypertension. If suspected, patients should be asked to measure blood pres- sure at home and keep a log for periodic evaluation.

4.12.1 Antihypertensive drugs (Table 6)

4.13.0 LIPIDS

(for more detail please see Joslin’s Clinical Guideline for Adults with Diabetes Chapter 1)

GENERAL CONSIDERATIONS

• All individuals with preexisting cardiovascular disease (CVD): Based on a large body of clinical trial evidence, all individuals with preexisting CVD should be treated with high-intensity statin therapy designed to lower low-density lipoprotein cholesterol (LDL-C) by ≥50% from baseline, regardless of baseline cholesterol. The adherence to statin therapy should be monitored at 4 to 12 weeks after initiation, and every 3 to 12 months thereafter, as indicated.
• If age >75 years, or if adverse events occur while on a high-intensity statin dose, treat with moderate-inten- sity statin therapy, designed to lower LDL-C between 30% and 49% from baseline. If the baseline LDL-C is not known, the minimum target should be LDL-C <70 mg/dl, or non—HDL-C <100 mg/dl.
• For primary prevention in older people aged ≤75 years: Statin therapy should be based on 10-year CVD risk as calculated by the revised risk calculator (my.americanheart. org/cvriskcalculator).If the 10-year risk is <7.5%, a moderate-to-intensive statin therapy is indicated, designed to lower LDL-C by 30% to 50% from baseline. If the baseline LDL-C is not known, the minimum target should be LDL-C <100 mg/dl, or non— HDL-C <130 mg/dl.
• If the 10-year risk is ≥7.5%, intensive statin therapy should be instituted, designed to lower LDL-C by ≥50% from base- line, regardless of baseline cholesterol. If the baseline LDL-C is not known, the minimum target should be LDL-C <70 mg/ dl, or non—HDL-C <100 mg/dl.
• For primary prevention in older people aged >75 years: Initiation of statin therapy is of uncertain value, and should be individualized, based on comorbidities, life expectancy, safety considerations, and priorities of care. Consider stop- ping statin therapy if life expectancy is less than 1 year.

4.13.1 Lipid-lowering medications (Table 7)

4.14.0 FOOT CARE

• Recommendations for foot examinations and treatment in older adults with diabetes are the same as those for younger individuals. Older adults may require additional education and devices such as mirrors to examine their feet due to decreased mobility and dexterity. See Joslin’s Clinical Guideline for Adults With Diabetes for more detail.
• Older adults should be encouraged to see a podiatrist regularly. Medicare provides coverage for podiatrist visits every 9 weeks, along with special footwear for patients with diabetes-related qualifying foot problems.

4.15.0 EYE CARE

Recommendations for eye examinations and treatment in older adults with diabetes are the same as those recommended in Joslin’s Clinical Guideline for Adults with Diabetes.

• Providers should also consider eye conditions commonly seen in older adults, including glaucoma, macular degeneration, and cataracts, which may be present without evidence of diabetic eye disease or coincident with diabetic eye disease. Nondiabetic ocular conditions such as cataracts may complicate evaluation and treatment of diabetic retinopathy Interventions for nondiabetic ocular conditions may be risk factors for progression of diabetic retinopathy Interventions for diabetic eye disease may pose risk factors for progression of nondiabetic eye conditions such as cataracts and glaucoma Although tighter glycemic control has been shown to lower the risk of eye complications, the overall risk of hypoglycemia and increased mortality risk with tight control in the older population should be considered when setting the glycemic goals.

References

1. American Diabetes Association. Standards of medical care in diabetes. 2018. Diabetes Care. 2018;41(suppl 1):S119-125.
2. Christmas C, Andersen RA. Exercise and older patients: guidelines for the clinician. J Am Geriatr Soc. 2000;48(3):318-324. doi: 10.1111/j.1532-5415.2000.tb02654.x.
3. Collins R, Armitage J. High-risk elderly patients PROSPER from cholesterol-lowering therapy. Lancet. 2002;360(9346):1618-1619. doi: 10.1016/S0140-6736(02)11650-3.
4. Ganda OP. Deciphering cholesterol treatment guidelines. a clinician’s perspective.JAMA. 2015;313(10):1009-1010. doi: 10.1001/jama.2015.216.
5. Cannon CP, Blazing MA, Giugliano RP, et al; IMPROVE-IT Investigators. Ezetimibe added to statin therapy after acute coronary syndromes. N Engl J Med. 2015;372(25):2387-2397. doi: 10.1056/NEJMoa1410489.
6. D’Ath P, Katona P, Mullan E, Evans S, Katona C. Screening, detection and management of depression in elderly primary care attenders. I: the acceptability and performance of the 15 item Geriatric Depression Scale (GDS15) and the development of short versions. Fam Pract. 1994;11(3):260-266. doi: 10.1093/ fampra/11.3.260.
7. Ekbom T, Linjer E, Hedner T, et al. Cardiovascular events in elderly patients with isolated systolic hypertension. a subgroup analysis of treatment strategies in STOP- Hypertension-2. Blood Press. 2004;13(3):137-141.
8. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state.” a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res.1975;12(3):189-198.
9. Geller AI, Shehab N, Lovegrove MC, et al. National estimates of insulin-related hy- poglycemia and errors leading to emergency department visits and hospitalizations. JAMA Intern Med. 2014;174(5):678-686. doi: 10.1001/jamainternmed.2014.136.
10. International Diabetes Federation. Managing older people with diabetes: global guideline. ISBN 2-930229-86-1. Published and accessed 2013.
11. James PA, Oparil S, Carter BL, et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8) [published correction appears in JAMA.2014;311(7):1809]. JAMA. 2014;311(5):507-520. doi: 10.1001/jama.2013.284427.
12. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged. the index of ADL: a standardized measure of biological and psychosocial function.JAMA. 1963;185(12):914-919. doi: 10.1001/jama.1963.03060120024016.
13. Kirkman MS, Briscoe VJ, Clark N, et al. Diabetes in older adults. Diabetes Care. 2012;35(12):2650-2664. doi: 10.2337/dc12-1801.
14. Laiteerapong N, Karter AJ, Liu JY, et al. Correlates of quality of life in older adults with diabetes: the diabetes & aging study. Diabetes Care. 2011;34(8):1749-1753. doi: 10.2337/dc10-2424.
15. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9(3):179-186.
16. Lipska KJ, Ross JS, Miao Y, Shah ND, Lee SJ, Steinman MA. Potential overtreatment of diabetes mellitus in older adults with tight glycemic control. JAMA Intern Med. 2015;175(3):356-362. doi: 10.1001/jamainternmed.2014.7345.
17. Malloy PF, Cummings JL, Coffey CE, et al. Cognitive screening instruments in neuro-psychiatry: a report of the Committee on Research of the American Neuropsychiatric Association. J Neuropsychiatry Clin Neurosci. 1997;9(2):189-197.
18. MiniCog website. https://mini-cog.com/. Accessed May 31, 2018.
19. Montreal Cognitive Assessment. MoCA website. mocatest.org/splash//. Accessed May 31, 2018.
20. Morgan TO, Anderson AI, MacInnis RJ. ACE inhibitors, beta-blockers, calcium blockers, and diuretics for the control of systolic hypertension. Am J Hypertens. 2001;14(3):241-247. doi: 10.1016/S0895-7061(00)01266-8.
21. Munshi MN, Segal AR, Suhl E, et al. Frequent hypoglycemia among elderly patients with poor glycemic control. Arch Intern Med. 2011;171(4):362-364. doi: 10.1001/ archinternmed.2010.539.
22. Munshi M. Managing the “geriatric syndrome” in patients with type 2 diabetes.Consult Pharm. 2008;23(suppl B):12-16.
23. Munshi MN, Segal SR, Suhl E, et al. Assessment of barriers to improve diabetes management in older adults: a randomized controlled study. Diabetes Care. 2013;36(3):543-549. doi: 10.2337/dc12-1303.
24. Munshi MN, Pandya N, Umpierrez GE, DiGenio A, Zhou R, Riddle MC. Contributions of basal and prandial hyperglycemia to total hyperglycemia in older and younger adults with type 2 diabetes. J Am Geriatr Soc. 2013;61(4):535-541: doi: 10.1111/jgs.12167.
25. Munshi MN, Hayes M, Sternthal A, Ayres D. Use of serum c-peptide level to simplify diabetes treatment regimens in older adults. Am J Med. 2009;122(4):395-397. doi: 10.1016/j.amjmed.2008.12.008.
26. Nasreddine ZS, Phillips NA, Bedirian V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53(4):695-699.
27. Nishiwaki Y, Breeze E, Smeeth L, Bulpitt CJ, Peters R, Fletcher AE. Validity of the Clock-Drawing Test as a screening tool for cognitive impairment in the elderly. Am J Epidemiol. 2004;160(8):797-807.
28. Papademetriou V, Farsang C, Elmfeldt D, et al; Study on Cognition and Prognosis in the Elderly study group. Stroke prevention with the angiotensin II type 1-receptor blocker candesartan in elderly patients with isolated systolic hypertension: the Study on Cognition and Prognosis in the Elderly (SCOPE). J Am Coll Cardiol.2004;44(6):1175-1180.
29. Shulman KI. Clock-drawing: is it the ideal cognitive screening test? Int J Geriatr Psychiatry. 2000;15(6):548-561.
30. Sinclair AJ, Paolisso G, Castro M, Bourdel-Marchasson I, Gadsby R, Rodriguez Manas L; European Diabetes Working Party for Older People. European Diabetes Working Party for Older People 2011 clinical guidelines for type 2 diabetes mellitus. executive summary. Diabetes Metab. 2011;37(suppl 3):S27-S38. doi: 10.1016/S1262- 3636(11)70962-4.
31. Stokes GS. Treatment of isolated systolic hypertension. Curr Hypertens Rep. 2006;8(5):377-383.
32. Stone NJ, Robinson JG, Lichtenstein AH, et al; American College of Cardiology/ American Heart Association Task Force on Practice Guidelines. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines [published corrections appear in J Am Coll Cardiol. 2015;66(24):2812; J Am Coll Cardiol. 2014;63(25 Pt B):3024-3025]. J Am Coll Cardiol. 2014;63(25 Pt B):2889-2934. doi: 10.1016/j.jacc.2013.11.002.
33. Thorpe CT, Gellad WF, Good CB, et al. Tight glycemic control and use of hypoglycemic medications in older veterans with type 2 diabetes and comorbid dementia. Diabetes Care. 2015;38(4):588-595. doi: 10.2337/dc14-0599.
34. Tinetti ME. Performance-oriented assessment of mobility problems in elderly patients. J Am Geriatr Soc. 1986;34(2):119-126.
35. Tinetti ME, Williams TF, Mayewski R. Fall risk index for elderly patients based on number of chronic disabilities. Am J Med. 1986;80(3):429-434
36. Tseng C-L, Soroka O, Maney M, Aron DC, Pogach LM. Assessing potential glycemic overtreatment in persons at hypoglycemic risk. JAMA Intern Med. 2014;174(2):259- 268. doi: 10.1001/jamainternmed.2013.12963.
37. Zammitt NN, Frier BM. Hypoglycemia in type 2 diabetes: pathophysiology, frequency, and effects of different treatment modalities. Diabetes Care. 2005;28(12):2948-2961.

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