Summary

The Endocrine Society recently released its clinical practice guideline for the treatment of diabetes in adults aged 65 or older. The guideline focuses on simplifying medication regimens and tailoring glycaemic targets in older adults with diabetes and cognitive impairment to improve compliance and prevent treatment-related complications.

Diabetes is a growing public health concern and age is a major contributor to the diabetes epidemic. Diabetes in the elderly is linked to higher mortality and reduced functional status. The presence of various concomitant diseases in the elderly severely affects diabetes self-management in this population.

The Endocrine Society Clinical Practice Guideline for diabetes in the elderly addresses treatment strategies that take into consideration the overall health and quality of life of older adults with diabetes, defined as ages 65 or older.

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The guideline emphasises the following issues:

• Screening, prevention, and management of glycaemia, blood pressure, and lipids, as well as comorbidities and complications
• Diabetes care in the hospital and long-term care facilities, and management of type 1 diabetes in older adults
• The importance of shared decision-making and provides a framework to assist healthcare providers to individualize treatment goals

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Role of the endocrinologist and diabetes care specialist

The guideline emphasises that in patients with newly diagnosed diabetes, individualised treatment goals should be set up and an endocrinologist or diabetes care specialist should be primarily responsible for diabetes care in order to achieve these goals.

Screening for diabetes and prediabetes, and diabetes prevention in adults aged 65 years and older

1. In patients without known diabetes, fasting plasma glucose and/or HbA1c screening is recommended to diagnose diabetes or prediabetes. The committee advocates repeat screening every 2 years.
2. In patients without known diabetes who meet the criteria for prediabetes by fasting plasma glucose or HbA1c, a 2-hour glucose post– oral glucose tolerance test measurement is suggested. This recommendation is most applicable to high-risk patients with any of the following characteristics:

• Overweight or obese
• First-degree relative with diabetes or high-risk race/ethnicity
• History of cardiovascular disease
• Hypertension (≥140/90 mm Hg or on therapy for hypertension)
• High-density lipoprotein cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L)
• Sleep apnoea, or physical inactivity

A lifestyle program similar to the Diabetes Prevention Program is recommended in those with prediabetes. The authors do not recommend metformin for diabetes prevention at this time, as it is not approved by the Food and Drug Administration for this indication.

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Assessment of older patients with diabetes- identifying undiagnosed cognitive impairment

1. Before setting up the treatment goals and strategies, the guideline emphasises on assessing the patient’s overall health and personal values.
2. Periodic cognitive screening should be performed to identify undiagnosed cognitive impairment. Validated self-administered tests, the Mini-Mental State Examination and the Montreal Cognitive Assessment are some suggested screening test options. It is important to assess cognition in patients with cognitive complaints. In cases with normal results, the screening can be repeated every 2 to 3 years; however, it should be repeated 1 year after a borderline normal test result.
3. In diabetic patients with cognitive impairment, a simplified medication regimen is recommended. The authors suggest that glycaemic targets should be tailored and more lenient; which will lead to improving compliance and preventing treatment-related complications.

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Treatment of hyperglycaemia in older adults with diabetes

Outpatient diabetes regimens should be designed specifically to minimise hypoglycaemia. Patients, who are treated with insulin, should undergo frequent fingerstick glucose monitoring and/or continuous glucose monitoring (to assess glycaemia) in addition to HbA1c. Lifestyle modification is recommended as the first-line treatment of hyperglycaemia in ambulatory patients.

It is also important to assess the nutritional status in elderly patients to detect and manage malnutrition. The use of tools such as the Mini Nutritional Assessment and Short Nutritional Assessment Questionnaire is recommended. A diet rich in protein and energy is recommended in frail patients. The use of restrictive diets is not recommended in patients at risk for malnutrition; limiting the consumption of simple sugars is, however, required.

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Treatment and Management of complications of diabetes in older adults

Management of hypertension

1. The authors recommend a target blood pressure of 140/90 mm Hg to decrease the risk of cardiovascular disease outcomes, stroke, and progressive chronic kidney disease.

• A lower target (130/80 mm Hg) can be considered in high-risk groups (previous stroke or progressing chronic kidney disease); however, the risk of orthostatic hypotension should not be overlooked
• Higher blood pressure targets (145 to 160/90 mm Hg) can be considered in patients with poor health such as end-stage medical conditions or cognitive and ADL (activities of daily living) impairments

2. An angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker should be the first-line therapy in patients with diabetes and hypertension

Management of hyperlipidaemia

1. Statin therapy and an annual lipid profile are recommended for reducing absolute cardiovascular disease events and all-cause mortality. If statin therapy is inadequate, alternative or additional approaches such as ezetimibe or proprotein convertase subtilisin/kexin type 9 inhibitors may be initiated.
2. To reduce the risk of pancreatitis, fish oil and/or fenofibrate is recommended in patients with fasting triglycerides >500 mg/dL.

Management of congestive heart failure

For the management of patients with diabetes and congestive heart failure, the authors recommend following the published clinical practice guidelines on congestive heart failure. The use of following oral hypoglycaemic agents should be prescribed with caution to prevent worsening of heart failure:

• Glinides
• Rosiglitazone
• Pioglitazone
• Dipeptidyl peptidase-4 inhibitors

Management of atherosclerosis

In patients with a history of atherosclerotic cardiovascular disease, low-dosage aspirin (75 to 162 mg/d) is recommended for secondary prevention of cardiovascular disease. The therapy should be prescribed after monitoring the bleeding risk.

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Eye complications

Annual comprehensive eye examination should be done to detect retinal disease.

Neuropathy falls, and lower extremity problems in older adults with diabetes

1. In patients with advanced chronic sensorimotor distal polyneuropathy, sedative drugs or drugs that promote orthostatic hypotension or hypoglycaemia should be minimally used.
2. Physical therapy or a fall management program is advised in patients with peripheral neuropathy and balance and gait problems. Patients with peripheral neuropathy and/or peripheral vascular disease should be referred to a podiatrist, orthopedist, or vascular specialist to reduce the risk of foot ulceration and amputations.

Chronic kidney disease (CKD)

In diabetic patients who are not on dialysis, annual screening for chronic kidney disease is suggested. In patients with a previous albumin-to-creatinine ratio of <30 mg/g and end-stage medical conditions or cognitive and ADL (activities of daily living) impairments, additional annual albumin-to-creatinine ratio measurements are not suggested.

In patients with decreased estimated glomerular filtration rate, the use of many diabetes medications such as insulin, metformin, sulphonylureas and glinides, thiazolidinediones, α-glucosidase inhibitors, DPP-4 inhibitors, SGLT2 inhibitors and GLP-1 receptor agonists should be limited. This would minimize the side effects and complications associated with CKD.

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Management of diabetes away from home (hospitals and long-term care facilities) and transitions of care

For patients in hospitals or nursing homes, the following glycemic target is recommended:

• Fasting - 100 to 140 mg/dL (5.55 to 7.77 mmol/L)
• Postprandial - 140 to 180 mg/dL (7.77 to 10 mmol/L)

As the patient is discharged, long-term glycaemic treatment targets and glucose-lowering medications should be mentioned clearly in the discharge plan. For patients with a terminal illness or severe comorbidities, the focus should be on simplifying diabetes management strategies.

Admission HbA1c levels have been associated with greater morbidity and mortality in patients with acute myocardial infarction, heart failure, and poor functional outcome after acute ischemic stroke; hence, a routine screening for HbA1c is suggested in older adults without diagnosed diabetes, during admission to the hospital to ensure prompt detection and treatment.