Diabetes em Idosos 2023 ADA PDF

S216 Diabetes Care Volume 46, Supplement 1, January 2023
13. Older Adults: Standards of Nuha A. ElSayed, Grazia Aleppo,

Vanita R. Aroda, Raveendhara R. Bannuru,
Care in Diabetes—2023 Florence M. Brown, Dennis Bruemmer,
Billy S. Collins, Marisa E. Hilliard,
Diabetes Care 2023;46(Suppl. 1):S216–S229 | https://doi.org/10.2337/dc23-S013 Diana Isaacs, Eric L. Johnson, Scott Kahan,
Kamlesh Khunti, Jose Leon, Sarah K. Lyons,
Mary Lou Perry, Priya Prahalad,
Richard E. Pratley, Jane Jeffrie Seley,
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Robert C. Stanton, and Robert A. Gabbay,
on behalf of the American Diabetes
Association
The American Diabetes Association (ADA) “Standards of Care in Diabetes” in-

cludes the ADA’s current clinical practice recommendations and is intended to
13. OLDER ADULTS
provide the components of diabetes care, general treatment goals and guide-
lines, and tools to evaluate quality of care. Members of the ADA Professional
Practice Committee, a multidisciplinary expert committee, are responsible for up-
dating the Standards of Care annually, or more frequently as warranted. For a de-
tailed description of ADA standards, statements, and reports, as well as the
evidence-grading system for ADA’s clinical practice recommendations and a full
list of Professional Practice Committee members, please refer to Introduction
and Methodology. Readers who wish to comment on the Standards of Care are
invited to do so at professional.diabetes.org/SOC.
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 dia-
betes management. B
13.2 Screen for geriatric syndromes (i.e., polypharmacy, cognitive impairment,
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 in older
adults is also a highly heterogeneous condition. While type 2 diabetes predomi-
nates in the older population as much as in the younger population, improvements
in insulin delivery, technology, and care over the last few decades have led to in-
creasing numbers of people with childhood and adult-onset type 1 diabetes surviv- Disclosure information for each author is
ing and thriving into their later decades. Diabetes management in older adults available at https://doi.org/10.2337/dc23-SDIS.
requires regular assessment of medical, psychological, functional, and social do- Suggested citation: ElSayed NA, Aleppo G, Aroda
mains. When assessing older adults with diabetes, it is important to accurately cat- VR, et al., American Diabetes Association. 13.
egorize the type of diabetes as well as other factors, including diabetes duration, Older adults: Standards of Care in Diabetes—
2023. Diabetes Care 2023;46(Suppl. 1):S216–S229
the presence of complications, and treatment-related concerns, such as fear of hy-
poglycemia. Screening for diabetes complications in older adults should be individu- © 2022 by the American Diabetes Association.
alized and periodically revisited, as the results of screening tests may impact Readers may use this article as long as the
work is properly cited, the use is educational
targets and therapeutic approaches (3–5). Older adults with diabetes have higher and not for profit, and the work is not altered.
rates of premature death, functional disability, accelerated muscle loss, and coexist- More information is available at https://www.
ing illnesses, such as hypertension, coronary heart disease, and stroke, than those diabetesjournals.org/journals/pages/license.
Marcelle Coviello - marcellecoviello@hotmail.com - IP: 179.190.120.194

diabetesjournals.org/care Older Adults S217
without diabetes. At the same time, is associated with a decline in cognitive mild cognitive impairment or dementia
older adults with diabetes are also at function (15,16), and longer duration of (4,29). Screening for cognitive impairment
greater risk than other older adults for diabetes is associated with worsening cog- should additionally be considered when
several common geriatric syndromes, nitive function. There are ongoing studies an individual presents with a significant
such as polypharmacy, cognitive impair- evaluating whether preventing or delay- decline in clinical status due to increased
ment, depression, urinary incontinence, ing diabetes onset may help to maintain problems with self-care activities, such as
injurious falls, persistent pain, and frailty cognitive function in older adults. How- errors in calculating insulin dose, difficulty
(1). These conditions may impact older ever, studies examining the effects of counting carbohydrates, skipped meals,
adults’ diabetes self-management abili- intensive glycemic and blood pressure con- skipped insulin doses, and difficulty rec-
ties and quality of life if left unaddressed trol to achieve specific targets have not ognizing, preventing, or treating hypo-
(2,6,7). See Section 4, “Comprehensive demonstrated a reduction in brain function glycemia. People who screen positive
Medical Evaluation and Assessment of decline (17,18). for cognitive impairment should receive
Clinical trials of specific interventions—

Comorbidities,” for the full range of is- diagnostic assessment as appropriate,
sues to consider when caring for older including cholinesterase inhibitors and including referral to a behavioral health
adults with diabetes. glutamatergic antagonists—have not shown professional for formal cognitive/neuro-
The comprehensive assessment de- positive therapeutic benefit in maintain- psychological evaluation (30).
scribed above may provide a framework ing or significantly improving cognitive
to determine targets and therapeutic function or in preventing cognitive de- HYPOGLYCEMIA
approaches (8–10), including whether cline (19). Pilot studies in individuals
referral for diabetes self-management with mild cognitive impairment evaluat- Recommendations
education is appropriate (when compli- ing the potential benefits of intranasal 13.4 Because older adults with di-
cating factors arise or when transitions insulin therapy and metformin therapy abetes have a greater risk of
in care occur) or whether the current provide insights for future clinical trials hypoglycemia than younger
plan is too complex for the individual’s and mechanistic studies (20–23). adults, episodes of hypogly-
self-management ability or the care- Despite the paucity of therapies to cemia should be ascertained
givers providing care (11). Particular atten- prevent or remedy cognitive decline, and addressed at routine
tion should be paid to complications that identifying cognitive impairment early visits. B
can develop over short periods of time has important implications for diabetes 13.5 For older adults with type 1
and/or would significantly impair func- care. The presence of cognitive impair- diabetes, continuous glucose
tional status, such as visual and lower- ment can make it challenging for clinicians monitoring is recommended to
extremity complications. Please refer to the to help their patients reach individualized reduce hypoglycemia. A
American Diabetes Association (ADA) con- glycemic, blood pressure, and lipid tar- 13.6 For older adults with type 2
sensus report “Diabetes in Older Adults” gets. Cognitive dysfunction makes it diffi- diabetes on multiple daily
for details (3). cult for individuals to perform complex doses of insulin, continuous
self-care tasks (24), such as monitoring glucose monitoring should be
NEUROCOGNITIVE FUNCTION glucose and adjusting insulin doses. It considered to improve glyce-
also hinders their ability to appropriately mic outcomes and decrease
Recommendation maintain the timing of meals and content glucose variability. B
13.3 Screening for early detection of the diet. When clinicians are providing 13.7 For older adults with type 1 dia-
of mild cognitive impairment care for people with cognitive dysfunc- betes, consider the use of auto-
or dementia should be per- tion, it is critical to simplify care plans and mated insulin delivery systems
formed for adults 65 years to facilitate and engage the appropriate B and other advanced insulin
of age or older at the ini- support structure to assist individuals in delivery devices such as con-
tial visit, annually, and as all aspects of care. nected pens E to reduce risk
appropriate. B Older adults with diabetes should be of hypoglycemia, based on
carefully screened and monitored for individual ability.
cognitive impairment (2). Several simple
Older adults with diabetes are at higher assessment tools are available to screen
risk of cognitive decline and institution- for cognitive impairment (24,25), such Older adults are at higher risk of hypo-
alization (12,13). The presentation of as the Mini-Mental State Examination glycemia for many reasons, including
cognitive impairment ranges from sub- (26), Mini-Cog (27), and the Montreal insulin deficiency necessitating insulin
tle executive dysfunction to memory Cognitive Assessment (28), which may therapy and progressive renal insuffi-
loss and overt dementia. People with di- help to identify individuals requiring ciency (31). As described above, older
abetes have higher incidences of all- neuropsychological evaluation, particu- adults have higher rates of unidenti-
cause dementia, Alzheimer disease, and larly those in whom dementia is sus- fied cognitive impairment and demen-
vascular dementia than people with nor- pected (i.e., experiencing memory loss tia, leading to difficulties in adhering to
mal glucose tolerance (14). The effects and decline in their basic and instru- complex self-care activities (e.g., glucose
of hypoglycemia, hyperglycemia, and hy- mental activities of daily living). Annual monitoring, insulin dose adjustment).
perinsulinemia on the brain are areas of screening is indicated for adults 65 years Cognitive decline has been associated
intense research. Poor glycemic control of age or older for early detection of with increased risk of hypoglycemia,
S218 Older Adults Diabetes Care Volume 46, Supplement 1, January 2023
and conversely, severe hypoglycemia has 8% (95% CI 6.0–11.5) increase in time improvements in time in range compared
been linked to increased risk of de- spent in range between 70 and 180 mg/dL. with sensor-augmented pump therapy
mentia (32,33). Therefore, as dis- A 6-month extension of the trial demon- (46). Moreover, they found small but sig-
cussed in Recommendation 13.3, it is strated that these benefits were sustained nificant decreases in hypoglycemia with
important to routinely screen older for up to a year (42). These and other the hybrid closed-loop strategy. Boughton
adults for cognitive impairment and short-term trials are supported by obser- et al. (47) reported results of an open-
dementia and discuss findings with vational data from the Diabetes Control label, crossover design clinical trial in
the patients and their caregivers. and Complications Trial/Epidemiology of 37 older adults ($60 years) in which
People with diabetes and their care- Diabetes Interventions and Complications 16 weeks of treatment with a hybrid
givers should be routinely queried about (DCCT/EDIC) study indicating that among closed-loop advanced insulin delivery
hypoglycemia (e.g., selected questions older adults (mean age 58 years) with system was compared with sensor-
from the Diabetes Care Profile) (34) and long-standing type 1 diabetes, routine augmented pump therapy. They found
hypoglycemia unawareness (35). Older CGM and insulin pump use was associ- that hybrid closed-loop insulin delivery

adults can also be stratified for future risk ated with fewer hypoglycemic events improved the proportion of time glucose
for hypoglycemia with validated risk calcu- and hyperglycemic excursions and was in range largely due to decreases in
lators (e.g., Kaiser Hypoglycemia Model) lower A1C levels (43). While the current hyperglycemia. In contrast to the ORACL
(36). An important step to mitigate hypo- evidence base for older adults is pri- study, no significant differences in hypo-
glycemia risk is to determine whether the marily in type 1 diabetes, the evidence glycemia were observed. Both studies
person with diabetes is skipping meals demonstrating the clinical benefits of enrolled older individuals whose blood
or inadvertently repeating doses of their CGM for people with type 2 diabetes glucose was relatively well managed
medications. Glycemic targets and phar- using insulin is growing (44) (see Sec- (mean A1C 7.4%), and both used
macologic treatments may need to be tion 7, “Diabetes Technology”). The DI- a crossover design comparing hybrid
adjusted to minimize the occurrence of AMOND (Multiple Daily Injections and closed-loop insulin delivery to sensor-
hypoglycemic events (2). This recommen- Continuous Glucose Monitoring in Diabe- augmented pump therapy. These trials
dation is supported by results from mul- tes) study demonstrated that in adults provide the first evidence that older
tiple randomized controlled trials, such $60 years of age with either type 1 or individuals with long-standing type 1
as the Action to Control Cardiovascular type 2 diabetes using multiple daily injec- diabetes can successfully use advanced
Risk in Diabetes (ACCORD) study and the tions, CGM use was associated with im- insulin delivery technologies to improve
Veterans Affairs Diabetes Trial (VADT), proved A1C and reduced glycemic glycemic outcomes, as has been seen in
which showed that intensive treatment variability (45). Another population for younger populations. Use of such technol-
protocols targeting A1C <6.0% with com- which CGM may play an increasing role is ogies should be periodically reassessed,
plex drug regimens significantly increased older adults with physical or cognitive lim- as the burden may outweigh the bene-
the risk for hypoglycemia requiring assis- itations who require monitoring of blood fits in those with declining cognitive or
tance compared with standard treat- glucose by a surrogate. functional status.
ment (37,38). However, these intensive The availability of accurate CGM devi-
treatment plans included extensive use ces that can communicate with insulin TREATMENT GOALS
of insulin and minimal use of glucagon- pumps through Bluetooth has enabled Recommendations
like peptide 1 (GLP-1) receptor agonists, the development of advanced insulin
13.8 Older adults who are other-
and they preceded the availability of delivery algorithms for pumps. These al-
wise healthy with few coexist-
sodium–glucose cotransporter 2 (SGLT2) gorithms fall into two categories: pre-
ing chronic illnesses and intact
inhibitors. dictive low-glucose suspend algorithms
cognitive function and func-
For older people with type 1 diabetes, that automatically shut off insulin deliv-
tional status should have lower
continuous glucose monitoring (CGM) is ery if a hypoglycemic event is imminent
glycemic goals (such as A1C
a useful approach to predicting and re- and hybrid closed-loop algorithms that
<7.0–7.5% [53–58 mmol/mol]),
ducing the risk of hypoglycemia (39). In automatically adjust insulin infusion
while those with multiple
the Wireless Innovation in Seniors with rates based on feedback from a CGM to
coexisting chronic illnesses,
Diabetes Mellitus (WISDM) trial, adults keep glucose levels in a target range. Ad-
cognitive impairment, or
over 60 years of age with type 1 diabe- vanced insulin delivery devices have been
functional dependence should
tes were randomized to CGM or stan- shown to improve glycemic outcomes in
have less-stringent glycemic
dard blood glucose monitoring. Over both children and adults with type 1 dia-
goals (such as A1C <8.0%
6 months, use of CGM resulted in a small betes. Most trials of these devices have
[64 mmol/mol]). C
but statistically significant reduction in included a broad range of people with
13.9 Glycemic goals for some older
time spent with hypoglycemia (glucose type 1 diabetes but relatively few older
adults might reasonably be
level <70 mg/dL) compared with standard adults. Recently, two small randomized
relaxed as part of individual-
blood glucose monitoring (adjusted treat- controlled trials in older adults have been
ized care, but hyperglycemia
ment difference 1.9% [ 27 min/day]; published. The Older Adult Closed Loop
leading to symptoms or risk
95% CI 2.8% to 1.1% [ 40 to (ORACL) trial in 30 older adults (mean
of acute hyperglycemia com-
16 min/day]; P < 0.001) (40,41). Among age 67 years) with type 1 diabetes found
plications should be avoided
secondary outcomes, glycemic variability that a hybrid closed-loop insulin delivery
in all people with diabetes. C
was reduced with CGM, as reflected by an strategy was associated with significant
13.10 Screening for diabetes compli- determining individualized glycemic Based on concepts of competing mortal-
cations should be individualized targets. ity and time to benefit, people with ad-
in older adults. Particular atten- A1C may have limitations in those vanced diabetes complications are less
tion should be paid to compli- who have medical conditions that im- likely to benefit from reducing the risk of
cations that would lead to pact red blood cell turnover (see Sec- microvascular complications (55). In addi-
functional impairment. C tion 2, “Classification and Diagnosis of tion, they are more likely to suffer seri-
13.11 Treatment of hypertension to Diabetes,” for additional details on the ous adverse effects of therapeutics, such
individualized target levels is in- limitations of A1C) (54). Many condi- as hypoglycemia (56). However, those
dicated in most older adults. C tions associated with increased red with poorly managed diabetes may be
13.12 Treatment of other cardiovas- blood cell turnover, such as hemodialy- subject to acute complications of diabe-
cular risk factors should be sis, recent blood loss or transfusion, or tes, including dehydration, poor wound
individualized in older adults erythropoietin therapy, are commonly healing, and hyperglycemic hyperosmo-
seen in older adults and can falsely in-

considering the time frame of lar coma. Glycemic goals should, at a
benefit. Lipid-lowering therapy crease or decrease A1C. In these instan- minimum, avoid these consequences.
and aspirin therapy may bene- ces, plasma blood glucose fingerstick While Table 13.1 provides overall
fit those with life expectancies and sensor glucose readings should be guidance for identifying complex and
at least equal to the time used for goal setting (Table 13.1). very complex patients, there is not yet
frame of primary prevention or global consensus on geriatric patient
secondary intervention trials. E Older Adults With Good Functional classification. Ongoing empiric research
Status and Without Complications on the classification of older adults with
There are few long-term studies in older diabetes based on comorbid illness has
adults demonstrating the benefits of in- repeatedly found three major classes
The care of older adults with diabetes is tensive glycemic, blood pressure, and
complicated by their clinical, cognitive, of patients: a healthy, a geriatric, and a
lipid control. Older adults who can be ex- cardiovascular class (9,57). The geriatric
and functional heterogeneity. Some older pected to live long enough to realize the
class has the highest prevalence of obe-
individuals may have developed diabetes benefits of long-term intensive diabetes
sity, hypertension, arthritis, and inconti-
years earlier and have significant compli- management, who have good cognitive
nence, and the cardiovascular class has
cations, others are newly diagnosed and and physical function, and who choose
the highest prevalence of myocardial
may have had years of undiagnosed dia- to do so via shared decision-making may
infarctions, heart failure, and stroke.
betes with resultant complications, and be treated using therapeutic inter-
Compared with the healthy class, the
still, other older adults may have truly ventions and goals similar to those
cardiovascular class has the highest risk
recent-onset disease with few or no com- for younger adults with diabetes (Table
of frailty and subsequent mortality. Ad-
plications (48). Some older adults with di- 13.1).
ditional research is needed to develop a
abetes have other underlying chronic As for all people with diabetes, diabe-
reproducible classification scheme to
conditions, substantial diabetes-related tes self-management education and on-
distinguish the natural history of disease
comorbidity, limited cognitive or physical going diabetes self-management support
are vital components of diabetes care as well as differential response to glu-
functioning, or frailty (49,50). Other older cose control and specific glucose-lowering
individuals with diabetes have little co- for older adults and their caregivers. Self-
management knowledge and skills should agents (58).
morbidity and are active. Life expectan-
cies are highly variable but are often be reassessed when treatment plan
changes are made or an individual’s func- Vulnerable Patients at the End of Life
longer than clinicians realize. Multiple For people with diabetes receiving pallia-
prognostic tools for life expectancy for tional abilities diminish. In addition, de-
clining or impaired ability to perform tive care and end-of-life care, the focus
older adults are available (51), includ- should be to avoid hypoglycemia and
diabetes self-care behaviors may be an
ing tools specifically designed for older symptomatic hyperglycemia while reduc-
indication that an older person with dia-
adults with diabetes (52). Older pa- ing the burdens of glycemic management.
betes needs a referral for cognitive and
tients also vary in their preferences Thus, as organ failure develops, several
physical functional assessment, using age-
for the intensity and mode of glucose agents will have to be deintensified or
normalized evaluation tools, as well as
control (53). Health care professionals discontinued. For a dying person, most
help establishing a support structure
caring for older adults with diabetes for diabetes care (3,30). agents for type 2 diabetes may be re-
must take this heterogeneity into con- moved (59). There is, however, no con-
sideration when setting and prioritizing Patients With Complications and sensus for the management of type 1
treatment goals (9,10) (Table 13.1). In Reduced Functionality diabetes in this scenario (60). See the sec-
addition, older adults with diabetes For people with advanced diabetes comp- tion END-OF-LIFE CARE below for additional
should be assessed for disease treat- lications, life-limiting comorbid illnesses, information.
ment and self-management knowledge, or substantial cognitive or functional im-
health literacy, and mathematical pairments, it is reasonable to set less- Beyond Glycemic Management
literacy (numeracy) at the onset of intensive glycemic goals (Table 13.1). Although minimizing hyperglycemia
treatment. See Fig. 6.2 for patient/ Factors to consider in individualizing gly- may be important in older individuals
disease-related factors to consider when cemic goals are outlined in Fig. 6.2. with diabetes, greater reductions in
Table 13.1—Framework for considering treatment goals for glycemia, blood pressure, and dyslipidemia in older adults with
diabetes
Fasting or
Patient characteristics/ preprandial Bedtime Blood
health status Rationale Reasonable A1C goal‡ glucose glucose pressure Lipids
Healthy (few coexisting Longer remaining <7.0–7.5% (53–58 80–130 mg/dL 80–180 mg/dL <130/80 Statin, unless
chronic illnesses, intact life expectancy mmol/mol) (4.4–7.2 (4.4–10.0 mmHg contraindicated
cognitive and functional mmol/L) mmol/L) or not tolerated
status)
Complex/intermediate Intermediate <8.0% (64 mmol/mol) 90–150 mg/dL 100–180 mg/dL <130/80 Statin, unless
(multiple coexisting remaining life (5.0–8.3 (5.6–10.0 mmHg contraindicated
chronic illnesses* or two expectancy, mmol/L) mmol/L) or not tolerated
or more instrumental high treatment

ADL impairments or burden,
mild-to-moderate hypoglycemia
cognitive impairment) vulnerability,
fall risk
Very complex/poor health Limited remaining Avoid reliance on 100–180 mg/dL 110–200 mg/dL <140/90 Consider likelihood
(LTC or end-stage chronic life expectancy A1C; glucose (5.6–10.0 (6.1–11.1 mmHg of benefit with
illnesses** or moderate- makes benefit control decisions mmol/L) mmol/L) statin
to-severe cognitive uncertain should be based on
impairment or two or avoiding
more ADL impairments) hypoglycemia and
symptomatic
hyperglycemia
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 (66). **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).
morbidity and mortality are likely to LIFESTYLE MANAGEMENT Lifestyle management in older adults
result from a clinical focus on compre- should be tailored to frailty status. Dia-
Recommendations
hensive cardiovascular risk factor modifi- betes in the aging population is associ-
13.13 Optimal nutrition and pro-
cation. There is strong evidence from ated with reduced muscle strength, poor
tein intake is recommended
clinical trials of the value of treating hy- muscle quality, and accelerated loss of
for older adults; regular ex-
pertension in older adults (61,62), with muscle mass, which may result in sarco-
ercise, including aerobic ac-
treatment of hypertension to individual- penia and/or osteopenia (65,66). Diabetes
tivity, weight-bearing exercise,
ized target levels indicated in most. is also recognized as an independent risk
and/or resistance training,
There is less evidence for lipid-lowering factor for frailty. Frailty is characterized by
should be encouraged in all
therapy and aspirin therapy, although decline in physical performance and an
older adults who can safely
the benefits of these interventions for increased risk of poor health outcomes
engage in such activities. B
primary and secondary prevention are due to physiologic vulnerability and func-
13.14 For older adults with type 2
likely to apply to older adults whose life tional or psychosocial stressors. Inadequate
diabetes, overweight/obesity,
expectancies equal or exceed the time nutritional intake, particularly inadequate
and capacity to safely exer-
frames of the clinical trials (63). In the protein intake, can increase the risk of
cise, an intensive lifestyle in-
case of statins, the follow-up time of sarcopenia and frailty in older adults.
tervention focused on dietary
clinical trials ranged from 2 to 6 years. Management of frailty in diabetes in-
changes, physical activity, and
While the time frame of trials can be cludes optimal nutrition with adequate
modest weight loss (e.g.,
used to inform treatment decisions, a protein intake combined with an exercise
5–7%) should be considered
more specific concept is the time to program that includes aerobic, weight-
for its benefits on quality of
benefit for a therapy. For statins, a bearing, and resistance training. The ben-
life, mobility and physical func-
meta-analysis of the previously men- efits of a structured exercise program (as
tioning, and cardiometabolic
tioned trials showed that the time to in the Lifestyle Interventions and Inde-
risk factor control. A
benefit is 2.5 years (64). pendence for Elders [LIFE] study) in frail
older adults include reducing sedentary the risk of hypoglycemia if it determination of whether a person is
time, preventing mobility disability, and can be achieved within the in- considered overtreated requires an elicita-
reducing frailty (67,68). The goal of these dividualized A1C target. B tion of the person’s perceptions of the
programs is not weight loss but en- 13.18 Simplification of complex treat- current medication burden and preferen-
hanced functional status. ces for treatments. For those seeking to
ment plans (especially insulin)
For nonfrail older adults with type 2 simplify their diabetes regimen, deintensi-
is recommended to reduce the
diabetes and overweight or obesity, an fication of regimens in individuals taking
risk of hypoglycemia and poly-
intensive lifestyle intervention designed noninsulin glucose-lowering medications
pharmacy and decrease the
to reduce weight is beneficial across can be achieved by either lowering the
multiple outcomes. The Look AHEAD burden of the disease if it can
be achieved within the individ- dose or discontinuing some medications,
(Action for Health in Diabetes) trial is
ualized A1C target. B as long as the individualized glycemic tar-
described in Section 8, “Obesity and
13.19 Consider costs of care and in- gets are maintained (89). When older
Weight Management for the Prevention

surance coverage rules when adults are found to have an insulin regi-
and Treatment of Type 2 Diabetes.”
Look AHEAD specifically excluded indi- developing treatment plans in men with complexity beyond their self-
viduals with a low functional status. order to reduce risk of cost- management abilities, lowering the dose
It enrolled people between 45 and related barriers to adherence. B of insulin may not be adequate (90). Sim-
74 years of age and required that they plification of the insulin plan to match an
be able to perform a maximal exercise individual’s self-management abilities and
Special care is required in prescribing their available social and medical support
test (69,70). While the Look AHEAD trial
and monitoring pharmacologic therapies in these situations has been shown to re-
did not achieve its primary outcome of
reducing cardiovascular events, the in- in older adults (80). See Fig. 9.3 for gen- duce hypoglycemia and disease-related
tensive lifestyle intervention had multiple eral recommendations regarding gluco- distress without worsening glycemic out-
clinical benefits that are important to se-lowering treatment for adults with comes (91–94). Figure 13.1 depicts an al-
the quality of life of older adults. Bene- type 2 diabetes and Table 9.2 for per- gorithm that can be used to simplify the
fits included weight loss, improved physi- son- and drug-specific factors to consider insulin regimen (93). There are now multi-
cal fitness, increased HDL cholesterol, when selecting glucose-lowering agents.
ple studies evaluating deintensification
lowered systolic blood pressure, reduced Cost may be an especially important
protocols in diabetes as well as hyperten-
A1C levels, reduced waist circumference, consideration, as older adults tend to be
sion, demonstrating that deintensification
and reduced need for medications (71). on many medications and live on fixed
is safe and possibly beneficial for older
Additionally, several subgroups, including incomes (81). Accordingly, the costs of
adults (89). Table 13.2 provides examples
participants who lost at least 10% of care and insurance coverage rules should
of and rationale for situations where de-
baseline body weight at year 1, had be considered when developing treat-
intensification and/or insulin regimen
improved cardiovascular outcomes (72). ment plans to reduce the risk of cost-
simplification may be appropriate in
Risk factor control was improved with related barriers to adherence (82,83).
older adults.
reduced utilization of antihypertensive See Table 9.3 and Table 9.4 for median
medications, statins, and insulin (73). monthly cost in the U.S. of noninsulin
Metformin
In age-stratified analyses, older adults glucose-lowering agents and insulin, re-
in the trial (60 to early 70s) had simi- Metformin is the first-line agent for older
spectively. It is important to match
lar benefits compared with younger complexity of the treatment plan to the adults with type 2 diabetes. Recent stud-
people (74,75). In addition, lifestyle in- self-management ability of older adults ies have indicated that it may be used
tervention produced benefits on aging- with diabetes and their available social safely in individuals with estimated glo-
relevant outcomes such as reductions and medical support. Many older adults merular filtration rate $30 mL/min/
in multimorbidity and improvements with diabetes struggle to maintain the fre- 1.73 m2 (95). However, it is contraindi-
in physical function and quality of life quent blood glucose monitoring and insu- cated in those with advanced renal insuf-
(76–79). lin injection regimens they previously ficiency and should be used with caution
followed, perhaps for many decades, as in those with impaired hepatic function
PHARMACOLOGIC THERAPY they develop medical conditions that may or heart failure because of the increased
impair their ability to follow their treat- risk of lactic acidosis. Metformin may be
Recommendations
ment plan safely. Individualized glycemic temporarily discontinued before proce-
13.15 In older adults with type 2 dia- dures, during hospitalizations, and when
goals should be established (Fig. 6.2) and
betes at increased risk of hy- acute illness may compromise renal or
periodically adjusted based on coexisting
poglycemia, medication classes liver function. Additionally, metformin can
chronic illnesses, cognitive function, and
with low risk of hypoglycemia cause gastrointestinal side effects and a
functional status (2). Intensive glycemic
are preferred. B
control with regimens including insulin reduction in appetite that can be prob-
13.16 Overtreatment of diabetes is
and sulfonylureas in older adults with lematic for some older adults. Reduction
common in older adults and
complex or very complex medical con- or elimination of metformin may be nec-
should be avoided. B
ditions has been identified as over- essary for those experiencing persistent
13.17 Deintensification of treatment
treatment and found to be very common gastrointestinal side effects. For those tak-
goals is recommended to reduce
in clinical practice (84–88). Ultimately, the ing metformin long-term, monitoring for
Simplification of Complex Insulin Therapy

Patient on basal (long- or intermediate-acting) and/or prandial (short- or rapid-acting) insulins¥* Patient on premixed insulin§
Basal insulin Prandial insulin
Use 70% of total dose as

basal only in the morning
Change timing from bedtime to morning
Titrate dose of basal insulin based on fasting If mealtime insulin ≤10 units/dose:
fingerstick glucose test results over a week Discontinue prandial insulin and add
If prandial insulin >10 units/dose:
noninsulin agent(s)
↓ dose by 50% and add noninsulin

Fasting Goal: 90–150 mg/dL (5.0–8.3 mmol/L)

May change goal based on overall health agent
and goals of care** Titrate prandial insulin doses down as
noninsulin agent doses are increased
with aim to discontinue prandial insulin
Add noninsulin agents:

If 50% of the fasting fingerstick glucose
If eGFR is ≥45 mg/dL, start metformin 500 mg
values are over the goal:
daily and increase dose every 2 weeks, as
↑ dose by 2 units
tolerated
If >2 fasting fingerstick values/week are <80 If eGFR is <45 mg/dL, patient is already
mg/dL (4.4 mmol/L): taking metformin, or metformin is not tolerated,
↓ dose by 2 units proceed to second-line agent
Additional Tips Using patient and drug characteristics to guide decision-making, as depicted in
Fig. 9.3 and Table 9.2, select additional agent(s) as needed:
Do not use rapid- and short-acting insulin at bedtime
Every 2 weeks, adjust insulin dose and/or add glucose-lowering agents based on
While adjusting prandial insulin, may use simplified fingerstick glucose testing performed before lunch and before dinner
sliding scale, for example:
Goal: 90–150 mg/dL (5.0–8.3 mmo/L) before meals; may change
{Premeal glucose >250 mg/dL (13.9 mmol/L), goal based on overall health and goals of care**
give 2 units of short- or rapid-acting insulin
If 50% of premeal fingerstick values over 2 weeks are above goal, increase the
{Premeal glucose >350 mg/dL (19.4 mmol/L), dose or add another agent
give 4 units of short- or rapid-acting insulin
If >2 premeal fingerstick values/week are <90 mg/dL (5.0 mmol/L),
Stop sliding scale when not needed daily decrease the dose of medication
Figure 13.1—Algorithm to simplify insulin regimen for older adults with type 2 diabetes. eGFR, estimated glomerular filtration rate. *Basal insulins: glar-
gine 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 et al. (93).
vitamin B12 deficiency should be consid- Incretin-Based Therapies other populations (100). See Section 9,
ered (96). Oral dipeptidyl peptidase 4 (DPP-4) “Pharmacologic Approaches to Glycemic
inhibitors have few side effects and Treatment,” and Section 10, “Cardio-
minimal risk of hypoglycemia, but their vascular Disease and Risk Management,”
Thiazolidinediones
cost may be a barrier to some older for a more extensive discussion regard-
Thiazolidinediones, if used at all, should be
adults. DPP-4 inhibitors do not reduce ing the specific indications for this class
used very cautiously in older adults on in-
or increase major adverse cardiovascular of agents. In a systematic review and
sulin therapy as well as in those with or at
outcomes (100). Across the trials of this meta-analysis of GLP-1 receptor agonist
risk for heart failure, osteoporosis, falls or
drug class, there appears to be no inter- trials, these agents have been found to
fractures, and/or macular edema (97,98).
action by age-group (101–103). A chal- reduce major adverse cardiovascular
Lower doses of a thiazolidinedione in com-
lenge of interpreting the age-stratified events, cardiovascular deaths, stroke, and
bination therapy may mitigate these side
analyses of this drug class and other car- myocardial infarction to the same degree
effects.
diovascular outcomes trials is that while for people over and under 65 years of
most of these analyses were prespeci- age (104). While the evidence for this class
Insulin Secretagogues fied, they were not powered to detect of agents for older adults continues to
Sulfonylureas and other insulin secreta- differences. grow, there are a number of practical is-
gogues are associated with hypoglyce- GLP-1 receptor agonists have demon- sues that should be considered specifi-
mia and should be used with caution. strated cardiovascular benefits among cally for older people. These drugs are
If used, sulfonylureas with a shorter du- people with diabetes and established injectable agents (with the exception of
ration of action, such as glipizide, are atherosclerotic cardiovascular disease oral semaglutide) (105), which require
preferred. Glyburide is a longer-acting (ASCVD) and those at higher ASCVD visual, motor, and cognitive skills for ap-
sulfonylurea and should be avoided in risk, and newer trials are expanding propriate administration. Agents with a
older adults (99). our understanding of their benefits in weekly dosing schedule may reduce the
Table 13.2—Considerations for treatment regimen simplification and deintensification/deprescribing in older adults with
diabetes (93,128)
When may treatment
Patient characteristics/ Reasonable A1C/ When may regimen deintensification/
health status treatment goal Rationale/considerations simplification be required? deprescribing be required?
Healthy (few coexisting <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, patients If wide glucose excursions (regardless of A1C)
may be more at risk for are observed If wide glucose excursions
administration or dosing If cognitive or functional are observed

errors that can result in decline occurs following In the presence of
hypoglycemia, falls, acute illness polypharmacy
fractures, etc.
Complex/intermediate <8.0% Comorbidities may affect If severe or recurrent If severe or recurrent
(multiple coexisting (64 mmol/mol) self-management abilities hypoglycemia occurs in hypoglycemia occurs in
chronic illnesses or and capacity to avoid patients on insulin patients on noninsulin
two or more hypoglycemia therapy (even if A1C is therapies with high risk
instrumental ADL Long-acting medication appropriate) of hypoglycemia (even if
impairments or formulations may decrease If unable to manage A1C is appropriate)
mild-to-moderate pill burden and complexity complexity of an insulin If wide glucose excursions
cognitive impairment) of medication regimen regimen are observed
If there is a significant In the presence of
change in social polypharmacy
circumstances, such as
loss of caregiver, change
in living situation, or
financial difficulties
Community-dwelling Avoid reliance Glycemic control is If treatment regimen If the hospitalization for
patients receiving on A1C, important for recovery, increased in complexity acute illness resulted in
care in a skilled glucose target wound healing, hydration, during hospitalization, it weight loss, anorexia,
nursing facility for 100–200 mg/dL and avoidance of infections is reasonable, in many short-term cognitive
short-term (5.55–11.1 mmol/L) Patients recovering from cases, to reinstate the decline, and/or loss of
rehabilitation illness may not have prehospitalization physical functioning
returned to baseline medication regimen
cognitive function at the during the rehabilitation
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 glycemic If on an insulin regimen If on noninsulin agents
health (LTC or end- and avoid control in this population and the patient would with a high hypoglycemia
stage chronic hypoglycemia and Hypoglycemia should be like to decrease the risk in the context of
illnesses or symptomatic avoided number of injections and cognitive dysfunction,
moderate-to-severe hyperglycemia Most important outcomes fingerstick blood glucose depression, anorexia, or
cognitive impairment are maintenance of monitoring events each inconsistent eating
or two or more ADL cognitive and functional day pattern
impairments) status If the patient has an If taking any medications
inconsistent eating without clear benefits
pattern
At the end of life Avoid hypoglycemia Goal is to provide comfort If there is pain or If taking any medications
and symptomatic and avoid tasks or discomfort caused by without clear benefits in
hyperglycemia interventions that cause treatment (e.g., improving symptoms
pain or discomfort injections or finger sticks) and/or comfort
Caregivers are important in If there is excessive
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.

burden of administration. GLP-1 receptor Other Factors to Consider A1C, reducing glycemic variability, and
agonists may also be associated with The needs of older adults with diabetes reducing risk of hypoglycemia (45) (see
nausea, vomiting, and diarrhea. Given and their caregivers should be evaluated Section 7, “Diabetes Technology,” and
the gastrointestinal side effects of this to construct a tailored care plan. Im- Section 9, “Pharmacologic Approaches to
class, GLP-1 receptor agonists may not paired social functioning may reduce Glycemic Treatment”). In older people
be preferred in older adults who are these individuals’ quality of life and in- with type 1 diabetes, administration of
experiencing unexplained weight loss. crease the risk of functional dependency insulin may become more difficult as
(7). The person’s living situation must complications, cognitive impairment,
Sodium–Glucose Cotransporter 2 be considered as it may affect diabetes and functional impairment arise. This in-
Inhibitors management and support needs. Social creases the importance of caregivers in
SGLT2 inhibitors are administered orally, and instrumental support networks (e.g., the lives of these individuals. Many
which may be convenient for older adults adult children, caretakers) that provide older people with type 1 diabetes re-
instrumental or emotional support for

with diabetes. In those with established quire placement in LTC settings (i.e.,
ASCVD, these agents have shown cardio- older adults with diabetes should be in- nursing homes and skilled nursing facili-
vascular benefits (100). This class of cluded in diabetes management discus- ties) and unfortunately can encounter
agents has also been found to be ben- sions and shared decision-making. staff that are less familiar with insulin
eficial for people with heart failure and The need for ongoing support of older pumps or CGM. Some staff may be less
to slow the progression of chronic kidney adults becomes even greater when tran- knowledgeable about the differences
disease. See Section 9, “Pharmacologic sitions to acute care and long-term care between type 1 and type 2 diabetes. In
Approaches to Glycemic Treatment,” and (LTC) become necessary. Unfortunately, these instances, the individual or the
Section 10, “Cardiovascular Disease and these transitions can lead to discontinu- person’s family may be more familiar
Risk Management,” for a more extensive ity in goals of care, errors in dosing, and with their diabetes management plan
discussion regarding the indications for changes in nutrition and activity (110).
than the staff or health care professio-
this class of agents. The stratified analy- Older adults in assisted living facilities
nals. Education of relevant support staff
may not have support to administer
ses of the trials of this drug class indicate and health care professionals in rehabil-
their own medications, whereas those
that older adults have similar or greater itation and LTC settings regarding insu-
living in a nursing home (community liv-
benefits than younger people (106–108). lin dosing and use of pumps and CGM
ing centers) may rely completely on
While understanding of the clinical bene- is recommended as part of general dia-
the care plan and nursing support.
fits of this class is evolving, side effects betes education (see Recommendations
Those receiving palliative care (with or
such as volume depletion, urinary tract 13.20 and 13.21).
without hospice) may require an ap-
infections, and worsening urinary incon-
proach that emphasizes comfort and
tinence may be more common among TREATMENT IN SKILLED NURSING
symptom management while de-
older people. FACILITIES AND NURSING HOMES
emphasizing strict metabolic and blood
pressure control. Recommendations
Insulin Therapy 13.20 Consider diabetes education for
The use of insulin therapy requires that the staff of long-term care and
SPECIAL CONSIDERATIONS FOR OLDER
individuals or their caregivers have good ADULTS WITH TYPE 1 DIABETES rehabilitation facilities to im-
visual and motor skills and cognitive abil- Due in part to the success of modern di- prove the management of older
ity. Insulin therapy relies on the ability of abetes management, people with type 1 adults with diabetes. E
the older person with diabetes to admin- diabetes are living longer, and the popu- 13.21 People with diabetes residing
ister insulin on their own or with the assis- lation of these people over 65 years of in long-term care facilities need
tance of a caregiver. Insulin doses should age is growing (111–113). Many of the careful assessment to establish
be titrated to meet individualized glycemic recommendations in this section regard- individualized glycemic goals
targets and to avoid hypoglycemia. ing a comprehensive geriatric assessment and to make appropriate
Once-daily basal insulin injection ther- and personalization of goals and treat- choices of glucose-lowering
apy is associated with minimal side ef- ments are directly applicable to older agents based on their clini-
fects and may be a reasonable option in adults with type 1 diabetes; however, this cal and functional status. E
many older adults (109). When choosing population has unique challenges and re- 13.22 Consider use of continuous
a basal insulin, long-acting insulin ana- quires distinct treatment considerations glucose monitoring to assess
logs have been found to be associated (114). Insulin is an essential life-preserving risk for hypoglycemia in older
with a lower risk of hypoglycemia com- therapy for people with type 1 diabetes, adults treated with sulfonylur-
pared with NPH insulin in the Medicare unlike for those with type 2 diabetes. To eas or insulin. E
population. Multiple daily injections of avoid diabetic ketoacidosis, older adults
insulin may be too complex for an older with type 1 diabetes need some form of
person with advanced diabetes compli- basal insulin even when they are unable Management of diabetes in the LTC set-
cations, life-limiting coexisting chronic to ingest meals. Insulin may be delivered ting is unique. Individualization of health
illnesses, or limited functional status. through an insulin pump or injections. care is important for all people with dia-
Figure 13.1 provides a potential ap- CGM is approved for use by Medicare betes; however, practical guidance is
proach to insulin regimen simplification. and can play a critical role in improving needed for health care professionals as
well as the LTC staff and caregivers Another consideration for the LTC set- and dignity are primary goals
(115). Training should include diabetes ting is that unlike in the hospital setting, for diabetes management at
detection and institutional quality as- health care professionals are not required the end of life. C
sessment. LTC facilities should develop to evaluate patients daily. According to
their own policies and procedures for federal guidelines, assessments should
prevention and management of hypogly- be done at least every 30 days for the The management of the older adult at
cemia. With the increased longevity of first 90 days after admission and then the end of life receiving palliative medi-
populations, the care of people with dia- at least once every 60 days. Although in cine or hospice care is a unique situation.
betes and its complications in LTC is an practice patients may actually be seen Overall, palliative medicine promotes
area that warrants greater study. more frequently, the concern is that comfort, symptom control and preven-
these individuals may have uncontrolled tion (pain, hypoglycemia, hyperglycemia,
Resources glucose levels or wide excursions with- and dehydration), and preservation of
out the practitioner being notified. Health

Staff of LTC facilities should receive ap- dignity and quality of life in older adults
propriate diabetes education to improve care professionals may adjust treat- with limited life expectancy (116,120). In
the management of older adults with ment plans by telephone, fax, or in
the setting of palliative care, health care
diabetes. Treatments for each patient person directly at the LTC facilities, pro-
professionals should initiate conversa-
should be individualized. Special manage- vided they are given timely notification
tions regarding the goals and intensity of
ment considerations include the need to of blood glucose management issues
diabetes care; strict glucose and blood
avoid both hypoglycemia and the compli- from a standardized alert system.
pressure control may not be consistent
The following alert strategy could be
cations of hyperglycemia (2,116). For with achieving comfort and quality of
considered:
more information, see the ADA position life. Avoidance of severe hypertension
statement “Management of Diabetes in 1. Call health care professional imme- and hyperglycemia aligns with the goals
Long-term Care and Skilled Nursing Facili- diately in cases of low blood glucose of palliative care. In a multicenter trial,
ties” (115). levels (<70 mg/dL [3.9 mmol/L]). withdrawal of statins among people with
2. Call as soon as possible when diabetes in palliative care was found to
Nutritional Considerations a) glucose values are 70–100 mg/dL improve quality of life (121–123). The ev-
An older adult residing in an LTC facility (3.9–5.6 mmol/L) (treatment plan idence for the safety and efficacy of de-
may have irregular and unpredictable may need to be adjusted), intensification protocols in older adults is
meal consumption, undernutrition, an- b) glucose values are consistently growing for both glucose and blood pres-
orexia, and impaired swallowing. Further- >250 mg/dL (13.9 mmol/L) within sure control (88,124) and is clearly rele-
more, therapeutic diets may inadvertently a 24-h period, vant for palliative care. An individual has
lead to decreased food intake and con- c) glucose values are consistently the right to refuse testing and treatment,
tribute to unintentional weight loss and >300 mg/dL (16.7 mmol/L) over whereas health care professionals may
undernutrition. Meals tailored to a per- 2 consecutive days, consider withdrawing treatment and lim-
son’s culture, preferences, and personal d) any reading is too high for the iting diagnostic testing, including a
goals may increase quality of life, satisfac- glucose monitoring device, or reduction in the frequency of blood
tion with meals, and nutrition status e) the person is sick, with vomiting, glucose monitoring (125,126). Glucose
(117). It may be helpful to give insulin af- symptomatic hyperglycemia, or targets should aim to prevent hypoglyce-
ter meals to ensure that the dose is ap- poor oral intake. mia and hyperglycemia. Treatment inter-
propriate for the amount of carbohydrate ventions need to be mindful of quality
the individual consumed in the meal. END-OF-LIFE CARE of life. Careful monitoring of oral intake
is warranted. The decision process may
Recommendations
Hypoglycemia need to involve the individual, family,
13.23 When palliative care is needed
Older adults with diabetes in LTC are es- and caregivers, leading to a care plan
in older adults with diabetes,
pecially vulnerable to hypoglycemia. They that is both convenient and effective for
health care professionals should
have a disproportionately high number the goals of care (127). The pharmaco-
initiate conversations regard-
of clinical complications and comorbid- logic therapy may include oral agents as
ing the goals and intensity of
ities that can increase hypoglycemia risk: first line, followed by a simplified insulin
care. Strict glucose and blood
impaired cognitive and renal function, regimen. If needed, basal insulin can be
pressure control are not nec-
slowed hormonal regulation and counter- implemented, accompanied by oral agents
essary E, and simplification of
regulation, suboptimal hydration, variable and without rapid-acting insulin. Agents
regimens can be considered.
appetite and nutritional intake, polyphar- that can cause gastrointestinal symptoms
Similarly, the intensity of lipid
macy, and slowed intestinal absorption such as nausea or excess weight loss may
management can be relaxed,
(118). Oral agents may achieve glycemic not be good choices in this setting. As
and withdrawal of lipid-lowering
outcomes similar to basal insulin in LTC symptoms progress, some agents may
therapy may be appropriate. A
populations (84,119). CGM may be a use- be slowly tapered and discontinued.
13.24 Overall comfort, prevention
ful approach to monitoring for hypogly- Different patient categories have been
of distressing symptoms, and
cemia among individuals treated with proposed for diabetes management in
preservation of quality of life
insulin in LTC, but the data are limited. those with advanced disease (59).
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S216 Diabetes Care Volume 46, Supplement 1, January 2023

13. Older Adults: Standards of Nuha A. ElSayed, Grazia Aleppo,

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The American Diabetes Association (ADA) “Standards of Care in Diabetes” in-

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Simplification of Complex Insulin Therapy

Basal insulin Prandial insulin

Use 70% of total dose as

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Add noninsulin agents:

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