New IDF Guidelines Target Diabetes Care in the Elderly

December 12, 2013

MELBOURNE, Australia — New guidelines from the International Diabetes Federation (IDF) address what the organization says are shortfalls in diabetes care for older people. Although other recommendations for treatment of this condition usually "have a section about older people," there is "none with this amount of detail," said Trisha Dunning, RN, PhD, CDE, vice president of IDF and a coauthor of the new guidance.

Designed for those aged over 70 years of age, the Managing Older People with Type 2 Diabetes Global Guidelines can also be applied to the elderly with type 1 diabetes, said Dr. Dunning, as "the issues are very similar" among both groups of patients. The guidelines were published last week to coincide with the IDF World Diabetes Congress 2013.

"The key messages are prevention — by proactively making risk assessments and screening to minimize risks, planning care around functional status, namely mental and physical competence, and the imperative to individualize that care," Dr. Dunning told Medscape Medical News.

In older people, assessments should often be more frequent than they are in younger patients, she said. "Older people do very well until something goes wrong, and then they often deteriorate suddenly, so those assessments might need to be more frequent than the annual ones we normally do." Finally, but also of "extreme importance," is the issue of managing medicines, she said.

Dr. Dunning acknowledged that many physicians or healthcare providers who treat older people with diabetes may not be familiar with their specific needs or comfortable caring for these patients. In these instances, patients should, if possible, be referred to geriatricians or diabetes doctors skilled in the care of the elderly, she noted, adding that diabetes nurses are also often well-informed on the needs of such patients. In fact, "you need a really good, multidisciplinary team that communicates really well," she observed.

Individualize Treatment, Consider Functional Capacity

The guidelines are mainly based on expert consensus and clinical expertise for the most part because "there isn't much [clinical-trial] evidence to support the recommendations," Dr. Dunning acknowledged, noting that many older people are excluded from studies because of their age, comorbidities, or other factors.

"We wrote a guiding philosophy...respecting the fact that older people are not just a homogenous group, there's not just a group called 'older people'; they are individuals, and they are highly individual," and their needs can differ dramatically, depending, for example, on where they live and the kind of support they have at home. Recognizing this is of the utmost importance, she said.

"Functional capacity is very important to consider. Patients might be functionally independent, living in the community, in full charge of their faculties. In that group of patients, we would expect to try to keep reasonably good glucose control and targets fairly close to normal."

Still, there are "issues in older people that don't apply to younger people," she noted, necessitating the use of this new guidance. These include decisions such as when to stop driving, for example, or end-of-life care planning.

Managing Medicines Is Critical

Among the critical considerations is the management of medicines and the prevention of medicine-related adverse events, Dr. Dunning explained. "The one thing that doesn't happen as often as it should is stopping medicines — not just keeping on prescribing [more and more] medicines. In older people, a lot of medicines are contraindicated or there are precautions to using them. So a comprehensive medicines assessment and stopping treatment, where possible, is an imperative part of the assessment process."

She recommends that doctors go through a thought process: "Is a medicine necessary? Or is it necessary for this person at this point in time? And what is the risk/benefit to prescribing that medicine given this person's health status and life expectancy? And if it's still a yes, what's the safest medicine at the lowest possible and least frequent dose? And what sort of therapy should it be? A tablet or something else? And the next decision is whether they can administer it themselves or need help.

"It's quite complicated, but it should just become part of the assessment," she stressed, adding that a good practice is to get the older person to bring in all their medicines to their appointments.

Hypoglycemia and Foot Infections Are Major Concerns

There are some specific problems to watch out for when treating older people with diabetes, in particular the issue of hypoglycemia, she stressed. Indeed, a study just published in JAMA Internal Medicine pinpoints hypoglycemia as the most common diabetes-medication complication among a contemporary cohort of older individuals and an even bigger problem than cardiovascular disease in some subgroups of the elderly.

If patients are older and frail and/or they have dementia, "they are at significant risk of hypo- or hyperglycemia," Dr. Dunning observed. "Hypoglycemia is a significant problem as you get older, and trying to prevent this is key," she says. "Both those states are associated with falls and [subsequent] fractures, worsening cognition, and a whole range of other issues."

This means that, in practice, for a frail person, HbA1c should be stabilized at around 8.5%, she said. Below 7% is a "very significant" risk for hypoglycemia, and above that is a risk for hyperglycemia. With the latter comes an increased risk for urinary-tract infections and foot wound infections, "which is a huge problem in some countries; people have amputations and die from foot problems," she observed.

"The other big issue is a hyperosmolar state where people become very dehydrated. They can have cognitive changes and delirium and end up in hospital with a 30% mortality rate, so it's not a benign condition.

"If you talk to old people, they will tell you they don't like feeling high [hyperglycemic] or low [hypoglycemic] because they know what it feels like, and it interferes with their quality of life, their ability to exercise, to eat properly — there are really wide-ranging effects," she concluded.

International Diabetes Federation. Managing Older People with Type 2 Diabetes Global Guidelines .

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