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].
