Design and created by Guideline Central in participation with the Endocrine Society.
Treatment of Diabetes in Older Adults
Endocrine Society
Publication Date: March 23, 2019
Key Points
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
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.
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.
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 OGTT |
| 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
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.
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 |
a All items are required services to qualify for Medicare coverage of Annual Wellness Exams for people in the US over age 65, except for Frailty/Physical performance (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 generally conducted by primary care providers.
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 ADL impairments and ≤1 IADL impairment | 3 or more non-diabetes chronic illnessesa and/or Any one of the following:
| Any one of the following:
| |
|
| ||||
| 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). |
Treatment
Role of the Endocrinologist and Diabetes Care Specialist
Treatment of Hyperglycemia
Setting Glycemic Targets and Goals
- Although evidence for specific targets is lacking, glycemic targets should be tailored to overall health and management strategies (e.g., whether or not a medication that can cause hypoglycemia is used) (see Table 3).
Assessing Glycemia
Lifestyle Interventions
- Nutritional status can be assessed using validated tools such as the Mini Nutritional Assessment (MNA) and Short Nutritional Assessment Questionnaire (SNAQ+65).
Technical Remarks:
- Patients’ glycemic responses to changes in diet should be monitored closely.
- This recommendation applies to both older adults living in the community and those in nursing homes.
Drug Therapy for Hyperglycemia
- This recommendation should not be implemented in patients who have significantly impaired kidney function (eGFR <30 mL/min/1.73 m2) or have a gastrointestinal intolerance.
Technical Remarks:
- To reduce the risk of hypoglycemia, avoid using sulfonylureas and glinides, and use insulin sparingly.
- Glycemic treatment regimens should be kept as simple as possible.
Treating Complications of Diabetes
Hypertension
Technical Remarks:
- Patients in certain high-risk groups could be considered for lower BP targets (130/80 mmHg), such as those with previous stroke or progressing CKD (eGFR <60 mL/min/1.73 m and/or albuminuria). If lower BP targets are selected, careful monitoring of such patients is needed to avoid orthostatic hypotension.
- Patients with high disease complexity (Group 3, Poor health, Table 3) could be considered for higher BP targets (145–160/90 mmHg).
- Choosing a BP target involves shared decision-making between the clinician and patient, with full discussion of the benefits and risks of each target.
- If one class is not tolerated, the other should be substituted.
Hyperlipidemia
Technical Remarks:
- The Writing Committee did not rigorously evaluate the evidence for specific LDL-C targets in this population, so we refrained from endorsing specific LDL-C targets in this guideline.
- For patients aged 80 years old and older or with short life expectancy, ES advocates that LDL-C goal levels should not be so strict.
Congestive Heart Failure
- Glinides
- Rosiglitazone
- Pioglitazone
- DPP4 inhibitors
Atherosclerosis
Eye Complications
- Screening and treatment should be conducted by an ophthalmologist or optometrist in line with present-day standards.
Neuropathy, Falls, and Lower Extremity Problems
Chronic Kidney Disease
- Specific use/dosing guidance on each class of diabetes medication is provided in Table 6.
Table 6. Medications Used to Treat Hyperglycemia and Special Concerns with Use in Older Patients With CKD and CVD
| Medication Class | Use in Older Patients | Use in Patients with CKD | Use in Patients with CVD |
|---|---|---|---|
| Insulin | Can cause hypoglycemia. | Decreased clearance. Increased risk of hypoglycemia. Dosages may need adjusting. Consider giving rapid-acting insulin postprandially because of gastroparesis. | May worsen fluid retention when used with thiazolidinediones. Hypoglycemia to be avoided because of potential arrhythmias and stroke. |
| Metformin | Can cause GI intolerance. | Reduce dosage to 1000 mg/d if eGFR <45.a Do not start if eGFR <45.a | May be beneficial in patients with coronary artery disease (CAD). Avoid use in patients with severe CHF to avoid lactic acidosis. |
| Does not cause hypoglycemia. | Stop if eGFR <30.a | ||
| May cause Vitamin B12 deficiency. | Stop if increased risk of acute kidney injury (radiocontrast dye, hypotension, sepsis, shock, hypoxia). | ||
| Sulfonylureas | Can cause hypoglycemia. | Glyburide: avoid if eGFR <60a | Can cause hypoglycemia, which is to be avoided because of potential arrhythmias and stroke. |
| Can cause weight gain. | Glimepiride: avoid if eGFR <30a | ||
| Avoid glyburide. | Glipizide: use with caution if eGFR <30a | ||
| Glinides | Can cause hypoglycemia. | Nateglinide: stop if eGFR <60a but can use if patient on dialysis. | Can cause hypoglycemia, which is to be avoided because of potential arrhythmias and stroke. |
| May be useful for individuals who skip meals. | Repaglinide: use with caution if eGFR <30a | ||
| Thiazolidinediones (TZD) | Does not cause hypoglycemia. | No dosage adjustment needed. Can cause fluid retention. Can increase fractures. | Pioglitazone has been shown to reduce CVD mortality. Can cause fluid retention with potential to worsen HF. |
| Can increase fracture risk. | |||
| Can cause fluid retention. | |||
| Can cause weight gain. | |||
| Alpha- Glucosidase Inhibitors | Does not cause hypoglycemia. | Avoid if serum creatinine >2.0 mg/dL because of lack of studies in such patients. | |
| GI side effects may cause nonadherence. | |||
| Dipeptidyl Peptidase – 4 (DPP4) Inhibitors | Does not cause hypoglycemia. | Sitagliptin: | Saxagliptin has been shown to increase the risk of HF. |
| eGFR >50a: 100 mg/d | |||
| eGFR 30–50a: 50 mg/d | |||
| eGFR <30a: 25 mg/d | |||
| Saxagliptin: | |||
| eGFR >50a: 2.5 or 5 mg daily | |||
| eGFR ≤50a: 2.5 mg daily | |||
| Alogliptin: | |||
| eGFR >60a: 25 mg daily | |||
| eGFR 30–60a: 12.5 mg daily | |||
| eGFR <30a: 6.25 mg daily | |||
| Linagliptin: | |||
| No dosage adjustment needed. | |||
| Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitors | Does not cause hypoglycemia. | Canagliflozin: | Empagliflozin and canagliflozin have been demonstrated to reduce major adverse cardiovascular events and CHF. |
| Empagliflozin can reduce cardiovascular events and progression of CKD. | eGFR 45–60a: 100 mg/d | ||
| Volume depletion adverse effects more common in older patients. | eGFR <45a: avoid use | ||
| Canagliflozin may increase fracture risk; has also been associated with an increased risk of toe and foot amputations. | Dapagliflozin: | ||
| May rarely cause ketoacidosis. | eGFR <60a: avoid use | ||
| Empagliflozin: | |||
| eGFR <45a: avoid use | |||
| Ertugliflozin: | |||
| eGFR <60a: avoid use | |||
| Canagliflozin and dapagliflozin have been associated with acute kidney injury. | |||
| Empagliflozin and canagliflozin can reduce progression of CKD. | |||
| Glucagon- Like Peptide 1 Receptor Agonists | Does not cause hypoglycemia. | Exenatide: eGFR <30a: avoid use | Liraglutide and semaglutide have been demonstrated to reduce major adverse CVD events. |
| May cause GI side effects. | Liraglutide, dulaglutide, semaglutide: No dosage adjustment needed. | ||
| Lixisenatide – avoid if eGFR <15a | |||
| Bromocriptine | May cause nausea. | Use with caution. | |
| Does not cause hypoglycemia. | Not studied in CKD. | ||
| Colesevelam | May cause GI side effects. | No dosage adjustment needed, but limited data are available. | |
| Does not cause hypoglycemia. | |||
Management of Diabetes Away From Home – in Hospitals and Long-term Care Facilities
- An explicit discharge plan should be developed to re-establish long-term glycemic treatment targets and glucose-lowering medications as the patient transitions to posthospital care.
Grading System
| Quality of Evidence | ||||
|---|---|---|---|---|
| Description of Evidence | High Quality | Moderate Quality | Low Quality | Very Low Quality |
|
|
|
| |
| Strength of Recommendation | ||||
| Strong (1): "ES recommends..." Benefits clearly outweigh harms and burdens or vice versa | 1-H | 1-M | 1-L | 1-VL |
| Conditional (2): "ES suggests..." Benefits closely balanced with harms and burdens | 2-H | 2-M | 2-L | 2-VL |
| Ungraded Good Practice Statement | UGPS | |||
Abbreviations
- A1C
- Hemoglobin A1C
- ACE
- angiotensin-converting enzyme
- ACR
- albumin-to-creatinine ratio
- ADA
- American Diabetes Association
- ADL
- activities of daily living
- ARB
- angiotensin receptor blocker
- BP
- blood pressure
- CGM
- continuous glucose monitoring
- CHF
- congestive heart failure
- CKD
- chronic kidney disease
- CVD
- cardiovascular disease
- DPP
- Diabetes Prevention Program
- DPP-4
- dipeptidyl peptidase 4
- eGFR
- estimated glomerular filtration rate
- FPG
- fasting plasma glucose
- GFR
- glomerular filtration rate
- GLP-1
- glucagon-like peptide-1
- HbA1C
- hemoglobin A1C
- IADL
- instrumental activity of daily living
- IFG
- impaired fasting glucose
- IGT
- impaired glucose tolerance
- LDL-C
- low density lipoprotein-cholesterol
- MCI
- mild cognitive impairment
- OGTT
- oral glucose tolerance test
- PG
- plasma glucose
- RCT
- randomized controlled trial
- SDM
- shared decision-making
- SGLT-2
- sodium-glucose co-transporter-2
- SU
- sulfonylurea
- T1D
- type 1 diabetes
- T2D
- type 2 diabetes
- TZD
- thiazolidinedione
Source Citation
Derek LeRoith, Geert Jan Biessels, Susan S Braithwaite, Felipe F Casanueva, Boris Draznin, Jeffrey B Halter, Irl B Hirsch, Marie E McDonnell, Mark E Molitch, M Hassan Murad, Alan J Sinclair, Treatment of Diabetes in Older Adults: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 104, Issue 5, May 2019, Pages 1520–1574, https://doi.org/10.1210/jc.2019-00198
Disclaimer
This resource is for informational purposes only, intended as a quick-reference tool based on the cited source guideline(s), and should not be used as a substitute for the independent professional judgment of healthcare providers. Practice guidelines are unable to account for every individual variation among patients or take the place of clinician judgment, and the ultimate decision concerning the propriety of any course of conduct must be made by healthcare providers after consideration of each individual patient situation. Guideline Central does not endorse any specific guideline(s) or guideline recommendations and has not independently verified the accuracy hereof. Any use of this resource or any other Guideline Central resources is strictly voluntary.
Guideline Central and select third party use “cookies” on this website to enhance the user experience.
This technology helps us gather statistical and analytical information to optimize the relevant content for you.
The user also has the option to opt-out which may have an effect on the browsing experience.