Key Points
- Prediabetes is highly prevalent in older people, however, interventions to delay progression from prediabetes to diabetes are especially effective in this age group.
- The prevalence of type 2 diabetes increases as individuals age and exaggerates the incidence of both microvascular and macrovascular complications.
- Clinicians should perform regular screening for prediabetes and diabetes in the older population and implement interventions as indicated in this guideline.
- Given the heterogeneity of the health status of older people with diabetes, the guideline emphasizes shared decision-making and provides a framework to assist health care providers to individualize treatment goals.
- The problems that older individuals with diabetes face, in contrast to younger people with the disease, include sarcopenia, frailty and cognitive dysfunction. Such complications can lead to an increased risk of poor medication adherence, hypoglycemia (from certain medications), falls, and loss of independence in daily living activities.
- The guideline presents evidence for the various effects of diabetes in the older patients and the relevant therapies for glycemic control, hyperlipidemia and hypertension.
- Guideline recommendations also address common co-morbidities such as renal impairment, which affects the pharmacokinetics and pharmacodynamics of specific agents, and concomitant heart disease.
Diagnosis and Prevention
- In patients aged 65 years and older without known diabetes, Endocrine Society (ES) recommends fasting plasma glucose and/or HbA1c screening to diagnose diabetes or prediabetes. (1|⊕⊕⊕⊕)
Technical Remarks:
- The measurement of HbA1c may be inaccurate in some people in this age group because of comorbidities that can affect the lifespan of red blood cells in the circulation.
- Although the optimal screening frequency for patients whose initial screening test is normal remains unclear, the writing committee advocates repeat screening every 2 years thereafter.
- As with any health screening, the decision about diabetes and prediabetes screening for an individual patient depends on whether some action will be taken as a result and the likelihood of benefit. For example, such screening may not be appropriate for an older patient with end-stage cancer or organ system failure. In these situations, shared decision-making with the patient is recommended.
- In patients aged 65 years and older without known diabetes who meet the criteria for prediabetes (see Table 1) by fasting plasma glucose or HbA1c, ES suggests obtaining a 2-hour glucose post oral glucose tolerance test measurement. (2|⊕⊕⊕◯)
Technical Remarks:
- This recommendation is most applicable to high-risk patients with any of the following characteristics: overweight or obese, first-degree relative with diabetes, high-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander), history of CVD, hypertension (≥140/90 mmHg or on therapy for hypertension), high-density lipoprotein (HDL) cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L), sleep apnea, or physical inactivity.
- Shared decision-making is advised for performing this procedure in frail older people or in those for whom it may be overly burdensome.
- Standard dietary preparation for an oral glucose tolerance test is advised.
- In patients aged 65 years and older who have prediabetes, ES recommends a lifestyle program similar to the Diabetes Prevention Program to delay progression to diabetes. (1|⊕⊕⊕⊕)
Technical Remarks:
- Metformin is not recommended for diabetes prevention at this time, as it is not approved by the FDA for this indication.
- As of 2018, a Diabetes Prevention Program-like lifestyle intervention is a covered benefit for Medicare beneficiaries in the US who meet the criteria for prediabetes (see Table 1).
Table 1. ADA Criteria for Prediabetesa
| Prediabetesa | Diabetesb |
|---|---|
| FPG 100 mg/dL (5.6 mmol/L) to 125 mg/dL (6.9 mmol/L) = IFG | FPG ≥126 mg/dL (7.0 mmol/L) |
| OR | OR |
| 2-h PG during 75-g OGTT 140 mg/dL (7.8 mmol/L) to 199 mg/dL (11.0 mmol/L) = IGT | 2-h PG ≥200 mg/dL (11.1 mmol/L) during OGTTc |
| OR | OR |
| A1C 5.7%–6.4% (39–47 mmol/mol)d | A1C ≥6.5% (48 mmol/mol)d |
| In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random PG ≥200 mg/dL (11.1 mmol/L). |
b In the absence of unequivocal hyperglycemia, diagnosis requires two abnormal test results from the same sample or in two separate test samples.
c The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75-g anhydrous glucose dissolved in water.
d The test should be performed in a laboratory using a method that is National Glycohemoglobin Standardization Program certified and standardized to the Diabetes Control and Complications Trial assay.
[Data from American Diabetes Association. 2. Classification and diagnosis of diabetes: standards of medical care in diabetes-2019. Diabetes Care. 2019;42:S13–s28].
Assessment
Overall Health Assessment of Older Patients With Diabetes
- In patients aged 65 and older with diabetes, we advise assessing the patient’s overall health (see Tables 2–5) and personal values prior to the determination of treatment goals and strategies. (UGPS)
- In patients aged 65 years and older with diabetes, ES suggests that periodic cognitive screening should be performed to identify undiagnosed cognitive impairment. (2|⊕⊕◯◯)
Technical Remarks:
- Use of validated self-administered tests is an efficient and cost-effective way to implement screening (see full text guideline). Alternative screening test options, such as the Mini-Mental State Examination or Montreal Cognitive Assessment, are widely used.
- An initial screening should be performed at the time of diagnosis or when a patient enters a care program.
- Screening should be repeated every 2–3 years after a normal screening test result for patients without cognitive complaints or repeated one year after a borderline normal test result.
- Always evaluate cognitive complaints and assess cognition in patients with complaints.
- In patients aged 65 years and older with diabetes and a diagnosis of cognitive impairment (i.e., mild cognitive impairment or dementia), ES suggests that medication regimens should be simplified and glycemic targets tailored (i.e., be more lenient) to improve compliance and prevent treatment-related complications. (2|⊕⊕◯◯)
Technical Remarks:
- Medical and nonmedical treatment and care for cognitive symptoms in people with diabetes and cognitive impairment is no different from those in people without diabetes and cognitive impairment.
- Depending on the situation and preferences of the patient, a primary caregiver can be involved in decision-making and management of medication.
Table 2. Clinical Care of Older People
| General Health Assessmenta | General Health Testsb | Diabetes-Specific Healthc |
|---|---|---|
| Functional status (ADLs/IADLsd) | EKG | Retinopathy |
| Depression | Lipid panel | Nephropathy |
| Cognition | Bone mineral density | Neuropathy |
| Fall risk | AAA ultrasound | Medical Nutrition Therapy |
| Weight (kg)/ Height (m)2 = BMI | Diabetes screening (for nondiabetic persons) | Diabetes Management |
| Blood pressure | Diabetes Self-Management Training | |
| Tobacco use | ||
| Alcohol use | ||
| Medication review | ||
| Cancer screening | ||
| Hearing | ||
| Comorbid conditions | ||
| Visual acuity | ||
| Frailty/Physical performance |
b All items are services covered by Medicare for people in the US over age 65 as part of Annual Wellness Exams at intervals varying from annually to once per lifetime (Medicare Interactive. Annual wellness visit. https://www.medicareinteractive.org/get-answers/medicare-covered-services/preventive-services/annual-wellness-visit. Accessed October 17, 2017).
c All items are services covered by Medicare for people in the US over age 65 as part of standard diabetes care (Medicare Interactive. Annual wellness visit. https://www.medicareinteractive.org/get-answers/medicare-covered-services/preventive-services/annual-wellness-visit. Accessed October 17, 2017). These are covered annually except for Diabetes Management visits, which are covered as recommended by the diabetes care team.
d Note: Our analysis included dependency (having difficulty and receiving assistance) in 5 ADLs (bathing, dressing, eating, toileting, and transferring) and 5 IADLs (preparing meals, shopping, managing money, using the telephone, and managing medications) (Applegate WB, Blass JP, Williams TF. Instruments for the functional assessment of older patients. N Engl J Med. 1990;322(17):1207–1214.).
Table 3. Conceptual Framework for Considering Overall Health and Patient Values in Determining Clinical Targets in Adults Aged 65 and Older
| Overall Health Category | Group 1 | Group 2 | Group 3 | |
|---|---|---|---|---|
| Good health | Intermediate health | Poor health | ||
| Patient characteristics | No comorbidities or 1–2 non-diabetes chronic illnessesa and No ADLe impairments and ≤1 IADL impairment | 3 or more non-diabetes chronic illnessesa and/or Any one of the following:
| Any one of the following:
| |
| Reasonable glucose target ranges and HbA1c by group Shared decision-making: individual goal may be lower or higher | ||||
| Use of drugs that may cause hypoglycemia (e.g., insulin, sulfonylurea, glinides) | No | Fasting: 90–130 mg/dL Bedtime: 90–150 mg/dL <7.5% | Fasting: 90–150 mg/dL Bedtime: 100–180 mg/dL <8% | Fasting: 100–180 mg/dL Bedtime: 110–200 mg/dL <8.5%d |
| Yesc | Fasting: 90–150 mg/dL Bedtime: 100–180 mg/dL ≥7.0 and <7.5% | Fasting: 100–150 mg/dL Bedtime: 150–180 mg/dL ≥7.5 and <8.0% | Fasting: 100–180 mg/dL Bedtime: 150–250 mg/dL ≥8.0 and <8.5%d | |
Notes: While glucose targets are highlighted for each group in this framework, overall health categories can also be considered for other treatment goals such as blood pressure and dyslipidemia.
a Coexisting chronic illnesses may include osteoarthritis, hypertension, chronic kidney disease stages 1–3, or stroke, among others.b One or more chronic illnesses with limited treatments and reduced life expectancy. These include metastatic cancer, oxygen-dependent lung disease, end-stage kidney disease requiring dialysis, and advanced heart failure.
c As long as achievable without clinically significant hypoglycemia; otherwise, higher glucose targets may be appropriate. Note also that the lower HbA1c boundary was included as data suggesting increased hypoglycemia and mortality risk at lower HbA1c levels are strongest in the setting of insulin use. However, the lower boundary should not reduce vigilance for detailed hypoglycemia assessment.
d HbA1c of 8.5% correlates with an average glucose level of approximately 200 mg/dL. Higher targets than this may result in glycosuria, dehydration, hyperglycemic crisis and poor wound healing.
e ADLs include bathing, dressing, eating, toileting, and transferring, and IADLs include preparing meals, shopping, managing money, using the telephone, and managing medications.
Source: Adapted from: Cigolle CT, Kabeto MU, Lee PG, Blaum CS. Clinical complexity and mortality in middle-aged and older adults with diabetes. J Gerontol A Biol Sci Med Sci 2012; 67 (12):1313-20 and Kirkman MS, Jones Briscoe V, Clark N, et al. Diabetes in older adults. Diabetes Care 2012; 35(12): 2650-2664.
Table 4. Tools to Detect Frailty
| Assessment Tool | Comments |
|---|---|
| Fried Score | Well-established physical frailty tool based on data from the Cardiovascular Health Study; often seen as a reference frame for studies of frailty in community-dwelling older adults; requires 2 procedures/measures (gait speed and grip strength) and answers to 3 questions (relating to weight loss, level of exhaustion, and amount of physical activity); can identify ‘prefrail’ individuals (Fried LP, Tangen CM et al. Frailty in older adults: Evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56(3): M146-156). |
| Clinical Frailty Scale Note: A larger 70-item assessment tool called the Frailty Index is also available. | Based on data from the Canadian Study of Health & Aging; 7-point scale; predictive of future events including mortality; easy to employ in routine clinical practice (Rockwood K, Song X et al. A global clinical measure of fitness and frailty in elderly people. CMAJ 2005; 173(5): 489-495). |
| FRAIL score | Well-validated in multiple population groups; sensitivity and specificity similar to that of the Fried scale. Comprises only 5 questions (no procedures) covering fatigue, climbing stairs, walking, number of illnesses, and weight loss (Abellan van Kan G, Rolland Y et al. The I.A.N.A Task Force on frailty assessment of older people in clinical practice. J Nutr Health Aging 2008; 12(1): 29-37). |
Table 5. Commonly Employed Measures to Screen for Physical Impairment
| Measure | Comments |
|---|---|
| Timed Get up and Go test | Most adults can complete this test. Good correlation with gait speed, Barthel Index and measures of balance (Mathias S, Nayak USL, Isaacs B. Balance in elderly patients - the Get-up and Go Test. Archives of Physical Medicine and Rehabilitation 1986; 67(6): 387-389, Bischoff HA, Stahelin HB et al. Identifying a cut-off point for normal mobility: a comparison of the timed 'up and go' test in community-dwelling and institutionalised elderly women. Age and Ageing 2003; 32(3): 315-320). |
| 4-m gait speed | Robust, clinically friendly measure. Easy to perform. Can be used to measure functional status in older adults and to predict future health and well-being. Population norms available (Studenski S, Perera S et al. Physical performance measures in the clinical setting. Journal of the American Geriatrics Society 2003; 51(3): 314-322, Cesari M. Role of gait speed in the assessment of older patients. JAMA 2011; 305(1): 93-94). |
| Grip strength | Requires a dynamometer for objective measurement; normative ranges in older people available. Predictive of increased future functional limitations and disability, increased fracture risk, and increased all-cause mortality (Roberts HC, Denison HJ et al. A review of the measurement of grip strength in clinical and epidemiological studies: Towards a standardised approach. Age and Ageing 2011; 40(4): 423-429). |
