6.3 Diabetes in elderly

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  • Prevalence of diabetes is high in older population. One fourth of older adult age >65-years old are diabetic and one half of older adult have prediabetes. Older adults with diabetes have high incidence of premature death, disability, muscle loss, and associated with other coexistent illness like hypertension, coronary heart disease and stroke, than those without diabetes.
  • Assessment of medical and psychological factors, self-management abilities, social factors in older adults are necessary for better diabetes management, and to determine the target and therapeutic options.
  • Screening for early detection of mild cognitive impairment or dementia should be performed for adults 65 years of age or older at the initial visit, annually and as appropriate.

6.3.1 Treatment goals

6.3.1 Treatment goals7

  • Older adults who are otherwise healthy with few coexisting chronic illnesses and intact cognitive function and functional status should have lower glycemic goals (such as HbA1c less than 7.5%, FPG <7.2 mmol/L, PPG <10.0 mmol/L).
  • Those with multiple coexisting chronic illnesses, cognitive impairment or functional dependence should have less stringent glycemic goals (such as HbA1c 8.0-8.5%, FPG <10 mmol/L, PPG <11.1 mmol/L).
  • Screening for diabetes complications should be individualized in older adults, particularly complications that would lead to functional impairment.
  • Treatment of hypertension to individualized target levels is indicated in most older adults.
  • Treatment of other cardiovascular risk factors should be individualized in older adults considering the time frame of benefit.
  • Lipid lowering therapy and aspirin therapy may benefit those with life expectancies at least equal to the time frame of primary prevention or secondary intervention trials.

6.3.2 Management

6.3.2 Management7

Lifestyle management

Optimal nutrition and protein intake is recommended for older adults; regular exercise, including aerobic activity, weight-bearing exercise, and/or resistance training should be encouraged in all older adults who can safely perform such activities.

Modest weight loss (e.g. 5-7%) should be considered for obese older adult with diabetes.

Pharmacologic therapy

  • As increased risk of hypoglycemia in older diabetic people, medication classes with low risk of hypoglycemia are preferred.
  • Avoid overtreatment of diabetes.
  • Simplification of complex regimens is recommended to reduce the risk of hypoglycemia and polypharmacy.
  • Consider costs of care when developing treatment plans to reduce risk of cost-related nonadherence.
  • Oral drug Metformin is the first line therapy, but should be used cautiously.
  • Those who are on short acing (prandial) insulin, with prandial insulin >10 units/dose, consider 50% reduction of dose and addition of non-insulin agent. If dose of prandial insulin <10 units/dose discontinue prandial insulin and no-insulin agent.
  • SGLT2 inhibitors, GLP1-RA can be used if tolerated and not contraindicated.