Diabetes is a chronic and complex disease impacting the lives of more than 30 million Americans.1 For those 65 years of age and older, approximately 25 percent have diabetes.1 Senior adults physiologically have unique needs, and adding diabetes to the mix further complicates these needs.2 Health-care professionals must understand the specific care needs of seniors with diabetes, provide comprehensive monitoring and develop appropriate treatment regimens.
Specific care needs
Many factors can compromise glycemic control in older adults.3 Table 1 lists the comorbidities that have the potential to adversely affect diabetes outcomes. Other functional disabilities that need to be evaluated include social isolation and depression. Both can disable a person when the inability to cope interferes with self-management of the day-to-day responsibilities of diabetes such as blood glucose monitoring, medication management, insulin administration, food preparation and decision-making. Diabetes is associated with an increased risk for cognitive decline and dementia; therefore, screening of cognition is recommended. Additionally, coexisting diseases such as hypertension, cardiovascular disease, stroke and chronic kidney disease significantly correlate to the macrovascular and microvascular changes that occur with chronic hyperglycemia. These comorbidities must be treated and managed concurrently with diabetes.
Other important areas that need to be assessed in older adults with diabetes include attitudes toward diabetes self-care to make changes in diabetes management, current self-care knowledge and the ability to perform self-care practices. Assess each person’s ability to read, write and use language and numbers so that appropriate resources are provided for the person to better understand information and skills. The ability to use technology is important if new treatment choices are being offered to an older adult, allowing for time to assimilate and practice these changes with daily care. Family and social support figure significantly in a person’s level of self-care. Social isolation and the inability to obtain and afford food and prescriptions or to travel to scheduled health-care appointments are significant factors that can have negative outcomes to diabetes care.
Older adults with diabetes are also at risk for geriatric syndromes (Table 2). They may suffer from urinary tract infections due to chronic hyperglycemia and urinary retention. Adults may experience chronic constipation with fecal impactions due to medications and lack of adequate fluids and fiber in the diet. And as the older adult loses flexibility and balance, takes psychotropic medications or has hazardous conditions in the home, the risk for falls increases by 50 percent.
Older adults with diabetes are at high risk for hypoglycemia due to potential physiological changes such as a slowed glucagon response, inadequate food intake and renal insufficiency.2 These physiological changes can delay a person’s response in recognizing the signs and symptoms of hypoglycemia, which can lead to hypoglycemic unawareness. Education on the signs and symptoms of hypoglycemia with appropriate treatment is important for recovery. Older adults taking beta blockers need to be instructed that symptoms of a rapid heart rate or tremors/shakiness may be masked. The threshold of a higher blood glucose level to initiate treatment may need to be considered. Severe hypoglycemia with blood glucose below 40 mg/dL may have a negative outcome such as unconsciousness or seizure activity. Family members need to be instructed on recognizing the neurological symptoms and the catecholamine responses with hypoglycemia and on appropriate treatment, including glucagon administration.
Hypersmolar hyperglycemia state (HHS) is a life-threatening condition that can occur with older adults with diabetes.4 This condition is usually precipitated by infections, medications or dehydration. The onset may be insidious with a gradual onset, and frail adults in long-term care facilities are at highest risk. They may lack the ability to ask for fluids to stay hydrated or describe changes in their general well-being. There is a high mortality risk if left the condition is undiagnosed, and it may require emergent resuscitation in an acute care setting.
Monitoring and treatment regimens
American Diabetes Association (ADA) glycemic targets
When one is caring for older adults with diabetes, it is vital to consider the customization of glycemic targets based on health status. Hypoglycemia is a major concern because it increases risk of cognitive decline and falls. Glycemic targets and pharmacological therapy should be adjusted accordingly to prevent hypoglycemic episodes. Glycemic targets are individualized to optimize outcomes and overall health status (Tables 3 and 4).
Encouraging self-monitoring of blood glucose (SMBG) is an integral part of a patient’s diabetes management plan. Patterns in blood glucose guide treatment decisions in terms of initiation, adjusting and discontinuing drug therapy as well as the overall treatment plan. When using SMBG as part of a management plan, knowledge and understanding must be assessed and continuous instruction must be given because of cognitive impairment or functional status.
When one is monitoring the health of senior adults with diabetes, several considerations are unique to this patient population. Blood glucose target ranges are individualized based on the complexity and life expectancy.3 Seniors with greater complexity of disease states and limited life expectancy have relaxed glycemic targets compared to those who are less complex with longer life expectancy. Additionally, prevention of hypoglycemia is a key goal in managing glycemia in the older population. Thus, assessing for hypoglycemia is vital. Similarly, blood pressure goals are individualized. According to the ADA, elderly patients with diabetes should be screened for depression.2 In those 65 years of age and older, annual screening for mild cognitive impairment or dementia is vital. The Mini Mental State Examination is one tool for cognitive impairment screening. Due to an increased risk of ulcers and amputations with diabetes, an annual comprehensive foot examination that assesses feeling, smaller and large fiber function and current symptoms of neuropathy and vascular disease is recommended. During each clinic visit, patients with diabetes should have their feet inspected. Another common complication of diabetes in older adults is nephropathy, so at a minimum, measuring urinary albumin and estimated glomerular filtration rate (eGFR) to assess kidney function is vital. This population has several recommended immunizations due to their increased risk of complications from illnesses such as cold or flu.
• Pneuomococcal: PCV-13 and PPSV-23
• Herpes zoster
• Hepatitis B
These adults should have medical nutrition therapy provided by a dietitian. A thorough review of dietary intake, physical activity and supplementation (i.e., vitamins) should be assessed. For obese patients, moderate caloric restriction is recommended. Carbohydrates should be distributed consistently throughout the day. Alcohol consumption must be assessed because it contributes to overall caloric intake and has potential to cause hypoglycemia. Adequate dentition should be assessed and the patient should be referred as needed to a dental specialist for dentures to ensure the patient is able to consume adequate nutrition. Access to food and meal preparation abilities are vital in the overall nutrition of senior adults. For those older adults without adequate access to food, referrals to community programs such as Meals on Wheels is key. Constipation is a common condition in older adults, so review bowel function and assess for need of medications or supplements to prevent or treat constipation.
Being physically active is essential for seniors with diabetes. Evaluation of physical activity ability must be completed prior to making specific exercise recommendations. Several conditions can limit the types of exercises that these adults can safely perform (see Table 6). General principles guiding physical activity in seniors are being as active as possible and incorporating exercises that maintain or improve balance and resistance exercise (i.e., free weights or weight machines) twice weekly. These exercises improve flexibility and decrease risk for falls.
When one is determining an appropriate diabetes medication regimen for older adults, many factors must be considered, including renal and hepatic function (Table 7). Due to concern about hypoglycemia, medication classes with high risk of hypoglycemia should be avoided (Table 8).3,5 It is preferable to use medicines from classes with low risk of hypoglycemia, such as metformin. If metformin is prescribed, discuss possible supplementation of vitamin B12 due to its association with decreased levels. Even for those senior adults not on metformin, evaluating vitamin B12 status is important.
Another common issue in senior adults is overtreatment, which can also lead to hypoglycemia.2 To prevent overtreatment, avoid complex regimens and simplify the pharmacotherapy plan to regimens with fewest number of drugs and less frequent dosing. Metformin is the first-line agent for Type 2 diabetes. However, the use of metformin is contraindicated in patients with advanced renal impairment. Also, it should be used cautiously in those with impaired hepatic function or congestive heart failure, which increases the risk of lactic acidosis. Thiazolidinediones should be used cautiously in patients with or at risk of congestive heart failure. Incretin-based therapies such as DPP-IV inhibitors and GLP-1 agonists may not be feasible for older adults due to their higher costs. SGLT-2 inhibitors have limited long-term experience and should be avoided in advanced renal impairment. The use of insulin requires the patient or caregiver have good cognitive function, vision and motor skills. The use of once-daily basal insulin may be a reasonable option for these patients based on minimal adverse effects and simplicity of regimen.
When choosing a regimen for older adults, socioeconomic status and the presence of support systems must also be considered. The patient’s income is perhaps the most important factor to consider. Insurance formularies should always be consulted when initiating or adjusting a medication regimen to ensure the most affordable option is selected. An established support system may also play a vital role in the management of diabetes. Family members or caregivers are essential to ensure emotional and social support, adherence to medication, monitoring of blood glucose and overall lifestyle changes associated with diabetes.
Diabetes is certainly not a one-size-fits-all condition. Especially with geriatric adults with diabetes, customization of the treatment plan with consideration of specific and unique needs of this population is key. Comorbidities and potential geriatric syndromes must be assessed prior to setting goals and developing a care plan. Glycemic targets must be developed with consideration of current health status. A treatment plan must incorporate comprehensive monitoring, meal planning, physical activity and drug therapy. One of the keys with drug therapy is prevention of hypoglycemia due to its serious consequences. Integration of multiple factors and considerations into the care of older adults with diabetes is essential to ensure safe and effective management of diabetes while maintaining an optimal quality of life.
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About our experts: Sara (Mandy) Reece, PharmD, CDE, BC-ADM, FAADE, Vice Chair and Associate Professor Department of Pharmacy Practice, Georgia Campus Philadelphia College of Osteopathic Medicine; Terry Compton, MS, APRN, CDE, Diabetes Education Program Manager, St. Tammany Parish Hospital; Lauren Avery, PharmD.