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New Position Statement on Diabetes Mellitus in Older People
Troy Brown
July 3, 2012 — Three international diabetes groups have taken the first step toward developing a global initiative to improve diabetes care for older people by writing a position paper that addresses age-related issues involved in their care.
Alan Sinclair MD, FRCP, director of the Institute of Diabetes for Older People at the University of Bedfordshire in the United Kingdom, is the lead author of the position statement, published in the July issue of JAMDA.
Age-Related Issues Largely Ignored
The group wrote the position paper because most international clinical diabetes guidelines fail to address issues that are common in the elderly, including frailty, functional limitation, mental health changes, and increasing dependency.
“The effective management of the older patient with diabetes requires an emphasis on safety, diabetes prevention, early treatment for vascular disease, and functional assessment of disability because of limb problems, eye disease, and stroke. Additionally, in older age, prevention and management of other diabetes-related complications and associated conditions, such as cognitive dysfunction, functional dependence, and depression, become a priority,” the authors write.
The International Association of Gerontology and Geriatrics, the European Diabetes Working Party for Older People, and the International Task Force of Experts in Diabetes worked together to develop a document that addresses 8 domains of interest: hypoglycemia, therapy, diabetes in the nursing home, influence of comorbidities, glucose targets, family/caretaker perspectives, diabetes education, and patient safety. The expert group wrote a set of consensus statements for each domain of interest that will be used for further policy
Glucose Targets
The authors write that individual comorbid conditions, as well as cognitive and functional status, should be considered in determining glucose goals, but in general they recommend a hemoglobin A1c (HbA1c) target range of 53 to 59 mmol/mol (HbA1c 7.0% – 7.5%) on treatment.
Low glucose states (glucose levels < 5.0 mmol/L) should be strictly avoided; no patient should begin glucose-lowering therapy with medications until the fasting glucose level is consistently 7 mmol/L or higher, and no patient should have a fasting glucose level less than 6.0 mmol/L while receiving treatment.
Hypoglycemia
Hypoglycemia (blood glucose level < 4 mmol/L) is very common and underrecognized in older people. It can have severe consequences, including falls, cognitive impairment, and hospital admission. The risk for hypoglycemia is increased in individuals with polypharmacy, cognitive impairment, or malnourishment; patients recently discharged from the hospital; and patients who reside in a nursing home. Patients who are hospitalized for hypoglycemia should be seen by a diabetes specialist.
Influence of Comorbid Conditions
Older people with diabetes should have a comprehensive geriatric assessment conducted regularly. A nutritional screening assessment tool should be used regularly to identify any nutritional impairment that could influence other comorbid conditions.
The authors note that the blood pressure threshold for treatment of hypertension is 140/80 mm Hg (150/90 mm Hg for patients age 75 years and older). However, a lower systolic blood pressure threshold might be appropriate for patients with evidence of renal impairment (estimated glomerular filtration rate [eGFR] , 60 mL/min per 1.73 m2).
For functionally dependent patients with diabetes, an acceptable blood pressure target is below 150/90 mm Hg.
Newly diagnosed patients with diabetes should be screened for renal impairment and receive annual testing of the eGFR.
Therapy
All patients should have an individualized physical activity program that includes resistance training, balance exercises, and cardiovascular fitness training.
Restrictive diets should be avoided in those older than age 70 years and those with undernutrition.
In older people with type 2 diabetes, metformin can be considered as a first-line glucose-lowering therapy. Metformin can also be used as an adjunct to insulin therapy in patients recommended for combination therapy.
Sulfonylurea therapy should be avoided in patients at higher risk for hypoglycemia. A basal insulin regimen may be safer in terms of hypoglycemia risk than a basal/bolus or premixed insulin regimen for selected patients.
The use of a dipeptidyl peptidase 4 inhibitor can be considered as second-line therapy for selected older patients who are not in target or who have poor tolerance to the glucose-lowering agents.
In patients who are obese (body mass index > 35 kg/m2) or who have poor tolerance or lack of response to other agents, a glucagon-like peptide 1 agonist can be considered for both second-line and third-line therapy.
Treatment with pioglitazone can be considered as second-line therapy after metformin in selected patients without bladder cancer who are not at high risk for heart failure or of bone loss and do not have a previous diagnosis of osteoporosis.
Patient Safety
Older people with diabetes should be screened for mood disorder, cognitive impairment, and hearing and visual loss, at least annually. Simplified regimens, such as once-daily dosing, should be used whenever possible, and polypharmacy should be avoided when possible.
Diabetes in Care Homes
The authors recommend that diabetes care policies be in place in nursing homes, but treatment should be individualized. Primary aims of caring for residents with diabetes are to (1) prevent hypoglycemia, (2) avoid acute metabolic complications, (3) decrease the risk for infection, (4) prevent hospitalization, and (5) introduce timely end-of-life care and advanced care directives.
Residents with diabetes have a higher prevalence of pressure ulcers of the lower extremities, infection, and pain, and these should be managed in a timely manner.
Staff should be educated regularly so that clinical and social care standards are maintained and patients’ needs are met.
Further Research Needed
The group identified major research areas that need to be explored, including:
- the use of exercise, nutrition, and glucose-lowering therapies in the effective management of type 2 diabetes in older people;
- practical community-based interventions to reduce hospitalization;
- methods to decrease hypoglycemia rates in various clinical settings;
- health economic evaluations of metabolic treatment;
- interventions to delay/prevent diabetes-related complications that are important in older age, such as cognitive impairment and functional dependence; and
- development of technical devices that help to maintain autonomy and safety for older people with diabetes.
The authors note that although functional status and well-being are a major focus of experts in geriatric diabetes, the issue of glucose targets is a fundamental one that needs to be addressed.
They expect that the next step in this process will be to put together a multicenter clinical audit of diabetes care in countries in all continents.
This study was supported by the International Association of Geriatrics and Gerontology and the European Diabetes Working Party for Older People.
JAMDA. 2012;13:497-502. Abstract