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1 Older PT T2DM Ada 2022
1 Older PT T2DM Ada 2022
Recommendations
13.1 Consider the assessment of medical, psychological, functional (self-
management abilities), and social domains in older adults to provide a
framework to determine targets and therapeutic approaches for diabe-
tes management. B
13.2 Screen for geriatric syndromes (i.e., polypharmacy, cognitive impair-
ment, depression, urinary incontinence, falls, persistent pain, and
frailty) in older adults, as they may affect diabetes self-management
and diminish quality of life. B
Diabetes is a highly prevalent health condition in the aging population. Over one-
quarter of people over the age of 65 years have diabetes, and one-half of older
adults have prediabetes (1,2), and the number of older adults living with these con-
ditions is expected to increase rapidly in the coming decades. Diabetes manage- *A complete list of members of the American
ment in older adults requires regular assessment of medical, psychological, Diabetes Association Professional Practice
functional, and social domains. Older adults with diabetes have higher rates of pre- Committee can be found at https://doi.org/
10.2337/dc22-SPPC.
mature death, functional disability, accelerated muscle loss, and coexisting ill-
Suggested citation: American Diabetes Asso-
nesses, such as hypertension, coronary heart disease, and stroke, than those ciation Professional Practice Committee. 13.
without diabetes. Screening for diabetes complications in older adults should be Older adults: Standards of Medical Care in
individualized and periodically revisited, as the results of screening tests may Diabetes—2022. Diabetes Care 2022;45(Suppl.
impact targets and therapeutic approaches (3–5). At the same time, older adults 1):S195–S207
with diabetes are also at greater risk than other older adults for several common © 2021 by the American Diabetes Association.
geriatric syndromes, such as polypharmacy, cognitive impairment, depression, uri- Readers may use this article as long as the
work is properly cited, the use is educational
nary incontinence, injurious falls, persistent pain, and frailty (1). These conditions
and not for profit, and the work is not altered.
may impact older adults’ diabetes self-management abilities and quality of life if More information is available at https://
left unaddressed (2,6,7). See Section 4, “Comprehensive Medical Evaluation and diabetesjournals.org/journals/pages/license.
S196 Older Adults Diabetes Care Volume 45, Supplement 1, January 2022
Assessment of Comorbidities” (https:// targets have not demonstrated a reduc- recognizing, preventing, or treating hypo-
doi.org/10.2337/dc22-S004), for the full tion in brain function decline (17,18). glycemia. People who screen positive for
range of issues to consider when caring Clinical trials of specific interven- cognitive impairment should receive
for older adults with diabetes. tions—including cholinesterase inhibi- diagnostic assessment as appropriate,
The comprehensive assessment des- tors and glutamatergic antagonists— including referral to a behavioral health
cribed above may provide a framework have not shown positive therapeutic provider for formal cognitive/neuropsy-
to determine targets and therapeutic benefit in maintaining or significantly chological evaluation (30).
approaches (8–10), including whether improving cognitive function or in pre-
referral for diabetes self-management venting cognitive decline (19). Pilot HYPOGLYCEMIA
education is appropriate (when compli- studies in patients with mild cognitive
cating factors arise or when transitions in impairment evaluating the potential Recommendations
care occur) or whether the current regi- benefits of intranasal insulin therapy 13.4 Because older adults with
and metformin therapy provide insights diabetes have a greater risk of
from multiple randomized controlled tri- longer than clinicians realize. Multiple
glycemic goals (such as A1C
als, such as the Action to Control Car- prognostic tools for life expectancy for
less than 7.0–7.5% [53–58
diovascular Risk in Diabetes (ACCORD) older adults are available (46), including
mmol/mol]), while those with
study and the Veterans Affairs Diabetes tools specifically designed for older
multiple coexisting chronic ill-
Trial (VADT), which showed that inten- adults with diabetes (47). Older patients
sive treatment protocols targeting A1C nesses, cognitive impairment,
also vary in their preferences for the
<6.0% with complex drug regimens sig- or functional dependence
intensity and mode of glucose control
nificantly increased the risk for hypogly- should have less stringent gly- (48). Providers caring for older adults
cemia requiring assistance compared cemic goals (such as A1C less with diabetes must take this heteroge-
with standard treatment (37,38). How- than 8.0% [64 mmol/mol]). C neity into consideration when setting
ever, these intensive treatment regi- 13.7 Glycemic goals for some and prioritizing treatment goals (9,10)
mens included extensive use of insulin older adults might reasonably (Table 13.1). In addition, older adults
and minimal use of glucagon-like be relaxed as part of individu- with diabetes should be assessed for
Table 13.1—Framework for considering treatment goals for glycemia, blood pressure, and dyslipidemia in older adults with
diabetes
Fasting or
Patient characteristics/ Reasonable preprandial
health status Rationale A1C goal‡ glucose Bedtime glucose Blood pressure Lipids
Healthy (few Longer remaining <7.0–7.5% 80–130 mg/dL 80–180 mg/dL <140/90 Statin unless
coexisting chronic life expectancy (53–58 mmol/mol) (4.4–7.2 (4.4–10.0 mmHg contraindicated
illnesses, intact mmol/L) mmol/L) or not tolerated
cognitive and
functional status)
Complex/ Intermediate <8.0% (64 90–150 mg/dL 100–180 mg/dL <140/90 Statin unless
intermediate remaining life mmol/mol) (5.0–8.3 (5.6–10.0 mmHg contraindicated
(multiple coexisting expectancy, mmol/L) mmol/L) or not tolerated
Very complex/poor Limited remaining Avoid reliance on A1C; 100–180 mg/dL 110–200 mg/dL <150/90 Consider
health (LTC or end- life expectancy glucose control (5.6–10.0 (6.1–11.1 mmHg likelihood of
stage chronic makes benefit decisions should be mmol/L) mmol/L) benefit with
illnesses** or uncertain based on avoiding statin
moderate-to-severe hypoglycemia and
cognitive symptomatic
impairment or 21 hyperglycemia
ADL impairments)
This table represents a consensus framework for considering treatment goals for glycemia, blood pressure, and dyslipidemia in older adults
with diabetes. The patient characteristic categories are general concepts. Not every patient will clearly fall into a particular category. Consider-
ation of patient and caregiver preferences is an important aspect of treatment individualization. Additionally, a patient’s health status and
preferences may change over time. ADL, activities of daily living; LTC, long-term care. ‡A lower A1C goal may be set for an individual if
achievable without recurrent or severe hypoglycemia or undue treatment burden. *Coexisting chronic illnesses are conditions serious enough
to require medications or lifestyle management and may include arthritis, cancer, heart failure, depression, emphysema, falls, hypertension,
incontinence, stage 3 or worse chronic kidney disease, myocardial infarction, and stroke. “Multiple” means at least three, but many patients
may have five or more (60). **The presence of a single end-stage chronic illness, such as stage 3–4 heart failure or oxygen-dependent lung
disease, chronic kidney disease requiring dialysis, or uncontrolled metastatic cancer, may cause significant symptoms or impairment of func-
tional status and significantly reduce life expectancy. Adapted from Kirkman et al. (3).
had multiple clinical benefits that are PHARMACOLOGIC THERAPY Special care is required in prescribing and
important to the quality of life of older monitoring pharmacologic therapies in
adults. Benefits included weight loss, Recommendations
older adults (75). See Fig. 9.3 for general
improved physical fitness, increased HDL 13.13 In older adults with type 2 dia-
recommendations regarding glucose-low-
cholesterol, lowered systolic blood pres- betes at increased risk of hypo-
ering treatment for adults with type 2
sure, reduced A1C levels, reduced waist glycemia, medication classes
diabetes and Table 9.2 for patient- and
circumference, and reduced need for with low risk of hypoglycemia
are preferred. B drug-specific factors to consider when
medications (66). Additionally, several selecting glucose-lowering agents. Cost
subgroups, including participants who 13.14 Overtreatment of diabetes is
common in older adults and may be an important consideration,
lost at least 10% of baseline body
should be avoided. B especially as older adults tend to be on
weight at year 1, had improved cardio-
13.15 Deintensification (or simplifi- many medications and live on fixed
vascular outcomes (67). Risk factor
cation) of complex regimens incomes (76). Accordingly, the costs of
control was improved with reduced utili-
is recommended to reduce care and insurance coverage rules should
zation of antihypertensive medications,
the risk of hypoglycemia and be considered when developing treat-
statins, and insulin (68). In age-stratified
polypharmacy, if it can be ment plans to reduce the risk of cost-
analyses, older patients in the trial (60
achieved within the individu- related nonadherence (77,78). See Table
to early 70s) had similar benefits com-
alized A1C target. B 9.3 and Table 9.4 for median monthly
pared with younger patients (69,70). In
13.16 Consider costs of care and cost in the U.S. of noninsulin glucose-low-
addition, lifestyle intervention produced
insurance coverage rules when ering agents and insulin, respectively. It is
benefits on aging-relevant outcomes
developing treatment plans in important to match complexity of the
such as reductions in multimorbidity
order to reduce risk of cost-
and improvements in physical function treatment regimen to the self-manage-
related nonadherence. B
and quality of life (71–74). ment ability of older patients and their
S200 Older Adults Diabetes Care Volume 45, Supplement 1, January 2022
available social and medical support. studies have indicated that it may be prespecified, they were not powered to
Many older adults with diabetes struggle used safely in patients with estimated detect differences.
to maintain the frequent blood glucose glomerular filtration rate $30 mL/min/ GLP-1 receptor agonists have demon-
monitoring and insulin injection regimens 1.73 m2 (89). However, it is contraindi- strated cardiovascular benefits among
they previously followed, perhaps for cated in patients with advanced renal patients with established atherosclerotic
many decades, as they develop medical insufficiency and should be used with cardiovascular disease (ASCVD) and
conditions that may impair their ability caution in patients with impaired hepatic those at higher ASCVD risk, and newer
to follow their regimen safely. Individual- function or heart failure because of the trials are expanding our understanding
increased risk of lactic acidosis. Metfor- of their benefits in other populations
ized glycemic goals should be established
min may be temporarily discontinued (94). See Section 9, “Pharmacologic
(Fig. 6.2) and periodically adjusted based
before procedures, during hospitaliza- Approaches to Glycemic Treatment”
on coexisting chronic illnesses, cognitive
tions, and when acute illness may (https://doi.org/10.2337/dc22-S009), and
function, and functional status (2). Inten- Section 10, “Cardiovascular Disease and
Figure 13.1—Algorithm to simplify insulin regimen for older patients with type 2 diabetes. eGFR, estimated glomerular filtration rate. *Basal insu-
lins: glargine U-100 and U-300, detemir, degludec, and human NPH. **See Table 13.1. ¥Prandial insulins: short-acting (regular human insulin) or
rapid-acting (lispro, aspart, and glulisine). §Premixed insulins: 70/30, 75/25, and 50/50 products. Adapted with permission from Munshi and col-
leagues (85,123,124).
benefits than younger patients (100–102). older patients (103). When choosing a must be considered as it may affect dia-
While understanding of the clinical bene- basal insulin, long-acting insulin analogs betes management and support needs.
fits of this class is evolving, side effects have been found to be associated with a Social and instrumental support net-
such as volume depletion, urinary tract lower risk of hypoglycemia compared works (e.g., adult children, caretakers)
infections, and worsening urinary inconti- with NPH insulin in the Medicare popula- that provide instrumental or emotional
nence may be more common among tion. Multiple daily injections of insulin support for older adults with diabetes
older patients. may be too complex for the older patient should be included in diabetes manage-
with advanced diabetes complications, ment discussions and shared decision-
Insulin Therapy life-limiting coexisting chronic illnesses, or making.
The use of insulin therapy requires that limited functional status. Fig. 13.1 pro- The need for ongoing support of
patients or their caregivers have good vides a potential approach to insulin regi- older adults becomes even greater
visual and motor skills and cognitive abil- men simplification. when transitions to acute care and
ity. Insulin therapy relies on the ability of long-term care (LTC) become necessary.
the older patient to administer insulin on Other Factors to Consider Unfortunately, these transitions can
their own or with the assistance of a The needs of older adults with diabetes lead to discontinuity in goals of care,
caregiver. Insulin doses should be titrated and their caregivers should be evaluated errors in dosing, and changes in diet
to meet individualized glycemic targets to construct a tailored care plan. and activity (104). Older adults in
and to avoid hypoglycemia. Impaired social functioning may reduce assisted living facilities may not have
Once-daily basal insulin injection ther- these patients’ quality of life and support to administer their own medi-
apy is associated with minimal side effects increase the risk of functional depen- cations, whereas those living in a nurs-
and may be a reasonable option in many dency (7). The patient’s living situation ing home (community living centers)
S202 Older Adults Diabetes Care Volume 45, Supplement 1, January 2022
Table 13.2—Considerations for treatment regimen simplification and deintensification/deprescribing in older adults with
diabetes (85,123)
When may treatment
deintensification/
Patient characteristics/ Reasonable A1C/ When may regimen deprescribing be
health status treatment goal Rationale/considerations simplification be required? required?
Healthy (few coexisting A1C <7.0–7.5% (53–58 Patients can generally If severe or recurrent If severe or recurrent
chronic illnesses, mmol/mol) perform complex tasks to hypoglycemia occurs in hypoglycemia occurs in
intact cognitive and maintain good glycemic patients on insulin patients on noninsulin
functional status) control when health is therapy (regardless of therapies with high risk
stable A1C) of hypoglycemia
During acute illness, If wide glucose excursions (regardless of A1C)
patients may be more at are observed If wide glucose
risk for administration or If cognitive or functional
Community-dwelling Avoid reliance on A1C Glycemic control is If treatment regimen If the hospitalization for
patients receiving Glucose target: important for recovery, increased in complexity acute illness resulted in
care in a skilled 100–200 mg/dL wound healing, during hospitalization, it weight loss, anorexia,
nursing facility for (5.55–11.1 mmol/L) hydration, and avoidance is reasonable, in many short-term cognitive
short-term of infections cases, to reinstate the decline, and/or loss of
rehabilitation Patients recovering from prehospitalization physical functioning
illness may not have medication regimen
returned to baseline during the rehabilitation
cognitive function at the
time of discharge
Consider the type of
support the patient will
receive at home
Very complex/poor Avoid reliance on A1C. No benefits of tight If on an insulin regimen If on noninsulin agents
health (LTC or end- Avoid hypoglycemia glycemic control in this and the patient would like with a high
stage chronic illnesses and symptomatic population to decrease the number of hypoglycemia risk in the
or moderate-to-severe hyperglycemia Hypoglycemia should be injections and fingerstick context of cognitive
cognitive impairment avoided blood glucose monitoring dysfunction, depression,
or 21 ADL Most important outcomes events each day anorexia, or inconsistent
impairments) are maintenance of If the patient has an eating pattern
cognitive and functional inconsistent eating pattern If taking any medications
status without clear benefits
At the end of life Avoid hypoglycemia and Goal is to provide comfort If there is pain or If taking any
symptomatic and avoid tasks or discomfort caused by medications without
hyperglycemia interventions that cause treatment (e.g., clear benefits in
pain or discomfort injections or fingersticks) improving symptoms
Caregivers are important in If there is excessive and/or comfort
providing medical care and caregiver stress due to
maintaining quality of life treatment complexity
Treatment regimen simplification refers to changing strategy to decrease the complexity of a medication regimen (e.g., fewer administration
times, fewer blood glucose checks) and decreasing the need for calculations (such as sliding-scale insulin calculations or insulin-carbohydrate
ratio calculations). Deintensification/deprescribing refers to decreasing the dose or frequency of administration of a treatment or discontinu-
ing a treatment altogether. ADL, activities of daily living; LTC, long-term care.
care.diabetesjournals.org Older Adults S203
may rely completely on the care plan settings regarding insulin dosing and use inadvertently lead to decreased food
and nursing support. Those receiving of pumps and CGM is recommended as intake and contribute to unintentional
palliative care (with or without hospice) part of general diabetes education (see weight loss and undernutrition. Diets tai-
may require an approach that empha- Recommendations 13.17 and 13.18). lored to a patient’s culture, preferences,
sizes comfort and symptom manage- and personal goals may increase quality
ment, while de-emphasizing strict TREATMENT IN SKILLED NURSING of life, satisfaction with meals, and nutri-
metabolic and blood pressure control. FACILITIES AND NURSING HOMES tion status (112). It may be helpful to
give insulin after meals to ensure that
SPECIAL CONSIDERATIONS FOR Recommendations the dose is appropriate for the amount
OLDER ADULTS WITH TYPE 1 13.17 Consider diabetes education of carbohydrate the patient consumed in
DIABETES for the staff of long-term the meal.
care and rehabilitation facili-
Due in part to the success of modern dia-
ties to improve the manage-
c) glucose values are consistently whereas providers may consider with- insulin may maintain glucose levels
>300 mg/dL (16.7 mmol/L) over drawing treatment and limiting diagnostic and prevent acute hyperglycemic
2 consecutive days, testing, including a reduction in the fre- complications.
d) any reading is too high for the quency of blood glucose monitoring
glucose monitoring device, or (120,121). Glucose targets should aim to References
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