In 2012, three international organizations issued guidelines on the recommended care for older adults with diabetes, largely driven by the fact that the standardized guidelines for the management of diabetes do not address the unique needs of older adults with diabetes. The three organizations, International Association of Gerontology and Geriatrics, the European Diabetes Working Party for Older People, and the International Task force of Experts in Diabetes, met to develop the guidelines using the Delphi process. The position statement is summarized as: “The effective management of the older patient with diabetes requires an emphasis on safety, diabetes prevention, early treatment for vascular disease, and functional assessment of disability because of limb problems, eye disease, and stroke. Additionally, in older age, prevention and management of other diabetes-related complications and associated conditions, such as cognitive dysfunction, functional dependence, and depression, become a priority”
What they agreed on as specific areas of concern are:
- Safety- Addressing the concern of low blood glucose episodes (hypoglycemia) which can lead to confusion, falls and hospitalization. An Hemoglobin A1C between 7.0% and 7.5% is a recommended target for older adults since as A1C is lowered, the risk for hypoglycemia is increased. Hypoglycemia is also a risk factor for cognitive impairment worsening in older adults and the damage may be irreversible.
- Proper therapy selection- Select drug therapies that are safe and effective in older adults, avoiding medications known to cause harm from hypoglycemia. Metformin should be an initial choice in those newly diagnosed. Target therapies that can prevent the negative impact from peripheral vascular disease and peripheral neuropathy.
- Prevention- All older adults with diabetes should have an individualized program of physical activity that includes balance exercises, cardiovascular fitness and resistance training.
- Functional disability- Older adults should have regular geriatric assessments that include a nutritional screening. All older adults should also be screened annually for hearing and vision loss, mood disorders, and cognitive impairment. Deficiencies in these areas can affect how the person with diabetes is able to successfully manage their condition and lead to dependence on others.
- Co-morbid conditions- Co-morbid conditions in older adults can greatly impact the function of older adults and alter the goals of diabetes management. All older adults with diabetes should also be screened for kidney disease upon diagnosis and routinely thereafter. Blood pressure targets should be set higher in older adults with diabetes suggesting that 140/90 is an acceptable target (150/90 for those >75). Isolated systolic hypertension is a singular, and strong, predictor of stroke and treatment should be effective yet not exceed the blood pressure lowering needed to reduce risk. Otherwise lower blood pressures in older adults is associated with increased risk of harms. Note: Blood pressure targets should be individualized based on whether other co-morbid conditions dictate lower targets, eg. kidney disease or congestive heart failure.
- Nursing home care- Nursing homes and long term care facilities need to offer individualized diabetes care in order to meet the needs of the unique older adult. The focus should be on: preventing hypoglycemia and infections, adequately managing pain and monitoring and preventing leg ulcers.