Diabetes in the Elderly Addressed in Consensus Report

Miriam E. Tucker

October 25, 2012

Treatment goals for older adults with type 2 diabetes should take into account life expectancy and the presence of comorbidities, according to a new consensus statement from the American Diabetes Association and the American Geriatrics Society.

The statement, which represents the opinion of the authors and not the official position of the organizations, was published online October 25 in both Diabetes Care and the Journal of the American Geriatrics Society .

"Older patients are extremely heterogeneous in terms of duration of diabetes, comorbidities, and life expectancy. Individualization and consideration of patient preferences and goals, which are important for all patients with diabetes, are especially so in this age group," lead author M. Sue Kirkman, MD, senior vice president, Medical Affairs and Community Information at the American Diabetes Association in Alexandria, Virginia, told Medscape Medical News.

More than 25% of the US population aged 65 years and older has diabetes, yet those with multiple comorbidities are typically excluded from randomized controlled treatment trials (RCTs), the authors note.

"Older adults are disproportionately burdened by diabetes and its acute and chronic complications.... There are problems both with overtreatment of some older patients and undertreatment of others," Dr. Kirkman said.

The statement provides a "framework" for consideration of treatment goals for glycemia, blood pressure, and dyslipidemia among adults aged 65 years and older with diabetes, based on 3 broad groupings:

  • healthy, with few coexisting chronic conditions and intact cognitive and functional status;

  • complex/intermediate, with multiple coexisting chronic illnesses or 2 or more impairments in activities of daily living or mild to moderate cognitive impairment; and

  • very complex/poor health, in long-term care or with end-stage chronic illnesses or moderate to severe cognitive impairment or with 2 or more activities of daily living dependencies.

Life expectancy is taken into account for each group, and treatment goals are adjusted accordingly. For example, an individual in the first group, with longer life expectancy, might be given a target hemoglobin A1c level of less than 7.5%. In the second group, the target might shift to less than 8% to minimize the risk for hypoglycemia and falls. For the third group, with limited remaining life expectancy and uncertain benefit of treatment, a goal of less than 8.5% might suffice.

Groupings Are General Guidelines

The authors stress that the groupings are just general concepts. Not every patient will fall into a particular category, and consideration of patient/caregiver preference is an important aspect of individualized treatment. In addition, a patient's status may change over time. "[One] can't use a one-size-fits-all mindset, or protocols driven by age alone," Dr. Kirkman said.

Indeed, according to Paul Jellinger, MD, a former president of the American Association of Clinical Endocrinologists, "It is important to not allow age itself dictate therapy....We have all seen patients in their 70s and 80s far healthier than many chronologically younger individuals. Individualizing therapy is the name of the game," he told Medscape Medical News.

"While one could argue with the specific A1c goals as outlined in this statement, the principle of higher goals for increasing comorbidities is quite appropriate," said Dr. Jellinger, who is professor of clinical Medicine at the University of Miami in Florida.

The statement also provides additional consensus recommendations regarding screening for and prevention of diabetes, management approaches and screening for complications, pharmacotherapy, and management in settings outside the home. Among them:

  • Older adults should be screened for prediabetes and diabetes as long as they will be likely to benefit from identification of the condition and subsequent intervention.

  • Physical activity and medical nutrition therapy should be encouraged, using simple teaching strategies.

  • Older adults should be screened periodically for cognitive dysfunction, functional status, and fall risk.

  • Older patients should be assessed for hypoglycemia regularly, and their therapy changed if it occurs frequently or is severe.

  • Glyburide should be avoided. Metformin is the preferred initial therapy for type 2 diabetes, as with younger adults, but doses might need to be lowered for patients with severe chronic kidney disease.

  • Use of sliding-scale insulin regimens alone is discouraged in settings outside the home.

Dr. Jellinger told Medscape Medical News, "I would try and avoid all sulfonylureas [SUs] — not just glyburide — in the elderly, since all SUs are associated with hypoglycemia, particularly in the elderly." However, "occasionally, the judicious use of very low doses of SUs may be helpful in otherwise healthy older patients with relatively short duration of diabetes."

Incretin-based therapies appear to be safe and effective in this population when metformin alone is inadequate or when metformin cannot be used, he added.

The statement concludes with a long list of research questions. Said Dr. Kirkman, "There's a lot we don't know, and a great need for real-world research studies that include patients often excluded from RCTs."

The consensus development conference was sponsored by the Association of Subspecialty Professors though a grant from the John A. Hartford Foundation, educational grants from Lilly USA, LLC, and Novo Nordisk, and sponsorships from the Medco Foundation and sanofi aventis. Sponsors had no influence on the selection of speakers or writing group members, topics and content presented at the conference, or the content of this report. Dr. Kirkman is an employee of the American Diabetes Association and has no other disclosures. Other authors are partially supported by the Department of Veterans Affairs Geriatric Research, Education and Clinical Centers program; the National Institutes of Health; the US Department of Health and Human Services; the National Institute on Aging Claude D. Pepper Older Americans Independence Center; the National Institute of Diabetes and Digestive and Kidney Diseases; and the Chicago Center for Diabetes Translational Research. Several authors have a variety of financial relationships with one or more of the following companies: Novo Nordisk, Amylin, sanofi aventis, Regeneron, Novartis, Merck, Lilly, Roche, Takeda, GlaxoSmithKline, MannKind, Eisai, Bristol Meyers Squibb, Astra Zeneca, Pfizer, and Lexicon. Dr. Jellinger serves on the speaker's bureau for Novo Nordisk, Amylin, Merck, and Boehringer Ingelheim.

Diabetes Care. Published online October 25, 2012.

J Am Geriatr Soc. Published online October 25, 2012. Abstract