Diabetes and Older Adults

As the general population continues to age, the number of adults 65 years or older affected by diabetes is also increasing. An estimated 33% of adults aged 65 or older have diabetes. This population is more at risk of developing diabetes-related complications like hypoglycemia (low blood sugar), kidney failure and heart disease than younger people living with diabetes.

There is new and emerging information to improve the understanding and treatment for diabetes in older adults. Special considerations should be addressed to support overall health and quality of life. Older adults often have one or more co-existing conditions like cognitive impairment, cardiovascular disease and others, that impact diabetes education and management.

Terms you should know

Estimated Glomerular Filtration Rate (eGFR) - A test to measure the level of kidney function and determine the stage of kidney disease.

Functional status- A person's ability to perform normal daily activities required to meet basic needs, fulfill usual roles, and maintain health and well-being.

Geriatric syndromes- A group of risk factors like cognitive impairment, functional status, and mobility impairment that may occur in older people, especially those with diabetes.

Macrovascular complications- Complication related to diabetes that affect large blood vessels such as heart disease, or stroke.

Microvascular complications- Complications related to diabetes that affect small blood vessels such as eye problem or kidney disease.

Older adult- Age 65 years or older.

Sarcopenia- Loss of muscle tissue, function, and strength which can occur with aging, diabetes, and other coexisting health problems.

 

Common Complications

There are many ways to reduce the risk of diabetes complications, including: keeping your blood sugar and hemoglobin A1C within recommended range, keeping your blood pressure and cholesterol under control, staying active by exercising, eating a healthy diet, avoiding alcohol and cigarette smoking.

It is important to follow your doctor’s recommendations including seeing an eye specialist and getting your kidney function checked every year. Your healthcare team can help you establish personal goals for diabetes management. Common complications of diabetes affecting adults aged 65 and older are:

• Kidney disease including kidney failure
• Loss of vision
• Heart disease
• Stroke
• Peripheral vascular disease (PVD) – narrowed blood vessels
• Peripheral neuropathy (nerve damage
• Low blood sugar (hypoglycemia)

Collaborative Care

Collaborative care is very important for all people living with diabetes. However, it is extremely critical for some older adults who have complex health care needs. Some important care considerations include:

• Supporting “at home” needs
• Monitoring interactions between medications
• Preventing falls
• Family or community support
• Access to proper medications and food

Your primary care doctor, geriatrician, diabetes educator, endocrinologist, nutritionist, and social worker work together to make sure all aspects of care are carefully developed to achieve personal goals and to prevent short and long-term complications.

Lifestyle Considerations

Older adults should consider lifestyle changes such as exercise, nutrition, managing blood sugar, limiting alcohol, and avoiding smoking. Progression from prediabetes to diabetes can be slowed with a diabetes prevention program.

A healthcare provider will assess your overall health and develop the best care plan based on personal goals, functional status, geriatric syndromes, sarcopenia, and other chronic illnesses. Care plans are customized and different for each person. A diabetes prevention program is recommended for people with prediabetes to prevent progression to diabetes.

Recommended Assessments and Screenings

The treatment of diabetes in adults 65 years and older should be based on an assessment of your overall health and other medical conditions. Medication regimens should be simplified in adults 65 years to improve adherence and prevent treatment-related complications. Glycemic targets should be a shared decision between you and your healthcare team and tailored to each individual.

General Health Assessments:

• Functional Status (ADLs/IADLs)
• Mental Health Screening
• Screening for cognitive impairment and dementia
• Frailty & Physical Exam
• Body Mass Index (BMI)
• Lifestyle Assessment
• Medication Review
• Cancer Screening
• Hearing Test

General Health Tests:

• Electrocardiogram (EKG)- used to evaluate the condition of your heart
• Lipid Panel- measures the amount of cholesterol and fats in the blood
• Bone Mineral Density
• Abdominal Aortic Aneurysm (AAA) Ultrasound- an abdominal screening to help check for kidney stones, liver disease, tumors, and many other conditions
• Hemoglobin A1C test, oral glucose tolerance test and fasting blood glucose test are used diagnose diabetes or prediabetes. These tests estimate your average blood glucose level over a 3-month period.

Diabetes- Specific Assessments:

• Eye Exam (Retinopathy)
• Kidney Screening (Nephropathy)
• Nerve Damage (Neuropathy)
• Medical Nutrition Therapy
• Diabetes Self-Management and Training

If you have hyperglycemia (high blood sugar), chronic kidney disease (CKD), or cardiovascular disease (CVD) your doctor may adjust your diabetes medication dosage based on your estimated glomerular filtration rate (eGFR) level to help reach glycemic targets and minimize complications. This chart can be used to help you have a more informed conversation with your healthcare provider about your medication dosage.

Medication Class	Use in Older Patients	Use in Patients with Chronic Kidney Disease (Stages 3-5)	Use in Patients with Cardiovascular Disease
Insulin	Can cause hypoglycemia (low blood sugar)	Decreased clearance. Increased risk of hypoglycemia (low blood sugar). Dosages may need adjusting. Consider giving rapid-acting insulin postprandially because of gastroparesis.	May worsen fluid retention when used with thiazolidinediones. Hypoglycemia (low blood sugar) to be avoided because of potential arrhythmias and stroke.
Metformin	Can cause GI intolerance Usually, does not cause hypoglycemia May cause Vitamin B12 deficiency	Reduce dosage to 1000 mg/d if eGFR <45*. Do not start if eGFR <45* Stop if eGFR <30* Stop if increased risk of acute kidney injury (radiocontrast dye, hypotension, sepsis, shock, hypoxia).	May be beneficial in patients with coronary artery disease (CAD). Avoid use in patients with severe congestive heart failure (CHF). to avoid lactic acidosis.
Sulfonylureas	Can cause hypoglycemia (low blood sugar)   Can cause weight gain   Avoid glyburide	Glyburide: avoid if eGFR <60* Glimepiride: avoid if eGFR <30* Glipizide: use with caution if eGFR <30*	Can cause hypoglycemia (low blood sugar), which is to be avoided because of potential arrhythmias and stroke.
Glinides	Can cause hypoglycemia (low blood sugar)   May be useful for individuals who skip meals	Nateglinide: stop if eGFR <60* but can use if patient on dialysis. Repaglinide: use with caution if eGFR <30*	Can cause hypoglycemia (low blood sugar), which is to be avoided because of potential arrhythmias and stroke.
Thiazolidinediones (TZD)	Does not cause hypoglycemia (low blood sugar) Can increase fracture risk Can cause fluid retention Can cause weight gain	No dosage adjustment needed. Can cause fluid retention. Can increase fractures.	Pioglitazone has been shown to reduce cardiovascular disease (CVD) mortality. Can cause fluid retention with the potential to worsen HF.
Alpha-Glucosidase Inhibitors	Does not cause hypoglycemia (low blood sugar) GI side effects may cause nonadherence	Avoid if serum creatinine >2.0 mg/dL because of lack of studies in such patients.
Dipeptidyl Peptidase – 4 (DPP4) Inhibitors	Does not cause hypoglycemia (low blood sugar)	Sitagliptin: eGFR >50*: 100 mg/d eGFR 30–50*: 50 mg/d eGFR <30*: 25 mg/d   Saxagliptin: eGFR >50*: 2.5 or 5 mg daily eGFR <50*: 2.5 mg daily Alogliptin: eGFR >60*: 25 mg daily eGFR 30–60*: 12.5 mg daily eGFR <30*: 6.25 mg daily   Linagliptin: No dosage adjustment needed.	Saxagliptin has been shown to increase the risk of HF.
Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitors	Does not cause hypoglycemia (low blood sugar) Empagliflozin can reduce cardiovascular events and progression of chronic kidney disease (CKD) Volume depletion adverse effects more common in older patients Canagliflozin may increase fracture risk; has also been associated with an increased risk of toe and foot amputations May rarely cause ketoacidosis	Canagliflozin: eGFR 45–60*: 100 mg/d eGFR <45*: avoid use   Dapagliflozin: eGFR <60*: avoid use   Empagliflozin: eGFR <45*: avoid use   Ertugliflozin: eGFR<60*: avoid use   Canagliflozin and dapagliflozin have been associated with acute kidney injury.   Empagliflozin and canagliflozin can reduce the progression of chronic kidney disease (CKD).	Empagliflozin and canagliflozin have been demonstrated to reduce major adverse cardiovascular events and congestive heart failure (CHF).
Glucagon-Like Peptide 1 Receptor Agonists	Does not cause hypoglycemia (low blood sugar) May cause GI side effects	Exenatide: eGFR <30*: avoid use   Liraglutide, dulaglutide, semaglutide: No dosage adjustment needed.   Lixisenatide – avoid if eGFR <15*	Liraglutide and semaglutide have been demonstrated to reduce major adverse cardiovascular disease (CVD)events.
Bromocriptine	May cause nausea Does not cause hypoglycemia (low blood sugar)	Use with caution. Not studied in chronic kidney disease (CKD).
Colesevelam	May cause GI side effects Does not cause hypoglycemia (low blood sugar)	No dosage adjustment needed, but limited data are available.

Questions to ask your healthcare team

Diabetes management goals will not be the same for everyone and may change over time. It is important to talk honestly with your healthcare team to have the best outcomes and prevent complications. Questions to ask your doctor may include:

1. What is my target goal for managing blood glucose and hemoglobin A1c?
2. How can I prevent diabetes complications?
3. How can I prevent low blood sugar?
4. How often should I see an endocrinologist and other specialists?

Developed for patients based on Treatment of Diabetes in Older Adults: An Endocrine Society Clinical Practice Guideline