Transforming Chronic Care
Strategies For Better Health
The 3MinuteExtraMile™ Pharmacy Newsletter
February 2023
Diabetes in Older Adults
Approximately 25% of people over the age of 65 have diabetes. Some have had diabetes for decades while others were only recently diagnosed. Longer exposure to diabetes correlates with an increased incidence of microvascular complications (retinopathy, nephropathy, and neuropathy) as well as macrovascular complications including cardiovascular disease. Regardless of diabetes status, older adults may have a variety of comorbidities and/or age-related complications, such as reduced kidney function, isolated systolic hypertension, sensory impairment, and cognitive decline. The heterogenous nature of this population therefore requires a different set of screening and treatment strategies. The American Diabetes Association 2023 guidelines section 13 addresses treatment of diabetes in older adults.
Other Than Age What Is Different?
Older adults are more likely to be taking multiple medications treating conditions other than diabetes, they may be suffering from some degree of cognitive impairment and may have difficulty with one or more of activities of daily living (ADL). Many older adults are frail, have chronic pain, urinary incontinence and suffer from depression. These and other considerations specific to the elderly are termed “geriatric syndrome”.
Key Points
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Screening for complications in the elderly should be done more frequently, particularly those that could impair functional status e.g., sight or hearing.
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Adults over 65 should be screened for cognitive dysfunction annually or more often when showing signs of clinical decline due to the inability to carry out routine diabetes care activities.
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Diabetes Self-Management Education and Support (DSMES) is important throughout the life cycle and a person’s self-care skills should be re-evaluated as needed.
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Older adults have a higher incidence of hypoglycemia, cognitive decline is associated with hypoglycemia, and severe hypoglycemia is associated with dementia.
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Glycemic goals are more flexible in older individuals (see chart).
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Continuous glucose monitoring (CGM) should be recommended for all type 1 and considered for those type 2 patients using multiple daily insulin doses.
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In all but the “very complex” population treat blood pressure to below 130/80 mmHg and add or continue statin therapy.
Go the 3MinuteExtraMile™: take a closer look at your older adult diabetes patients.
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For those whose regimens include medications associated with a high risk of hypoglycemia, i.e., sulfonylureas, insulin, or combinations thereof:
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Is the target A1c below recommended levels considering age and comorbidities? If so suggest deintensification of goals according to the glycemic control chart. This may allow discontinuation of a sulfonylurea or lowering of insulin dose.
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If type 2 and on basal/bolus insulin or basal plus sliding scale, is that regimen appropriate for the person’s age and comorbidities? Consider simplifying the insulin regimen by changing to long acting basal with addition of weekly GLP-1 RA.
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Older patients taking sulfonylureas or insulin may have “unrecognized hypoglycemia”, manifested by mental confusion but not recognized as a symptom of hypoglycemia. Advise more frequent blood glucose monitoring.
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If on insulin, do they qualify for CGM and if so, do they have the skills to use it.
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Can their medication regimen be simplified to accommodate for decline in cognitive function? A complicated insulin regimen (i.e., sliding scale) may be simplified in a variety of ways by other regimens (see medication choices resource). Combination medications may be available in single pill versions.
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Assess non-diabetes medications such as those with high anticholinergic activity and central nervous system depressants (Beers Criteria).
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Is hypertension being treated to a goal of <130/80 mm/Hg and are they taking a statin for primary or secondary prevention of ASCVD?
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Consider social determinants of health older adults, including affordability of recommended medications, numeracy, and health literacy.
Resources:
This is my website offering patient and professional education
James Bennett BsPharm, CDCES, BCGP
Diabetes and Cardiometabolic Health
Bozeman MT
3MinuteExtraMile™ Pharmacy Newsletter