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Guidelines for Diabetes Management in Older Adults

Apr 16, 2025

2018 Clinical Practice Guidelines for Diabetes and Older People

Presenters and Contributors

  • Presented by Grady Meneely
  • Co-authors: Eileen Nip, David Miller, Diana Sheriff, Oli Daniel, Teshe, and Half Chenza

Key Changes in Guidelines

  • New information on screening with fasting plasma glucose and HbA1c
  • Role of deprescribing medications for older people with diabetes

Diabetes in the Elderly Checklist

  1. Assessment of Functional Dependency and Frailty

    • Determine individualized glycemic targets
    • A1c < 8.5% for frail elderly; use targets similar to younger people if otherwise healthy
    • Avoid hypoglycemia and cognitive impairment

  2. Antihyperglycemic Therapy Selection

    • Use caution with sulfonylureas and thiazolidinediones
    • Prefer DPP-4 inhibitors over sulfonylureas
    • Use basal analogues instead of NPH or human 30/70
    • Regular diets preferable over diabetic diets in nursing homes

Understanding Frailty

  • Frailty denotes increased vulnerability with aging
  • Clinical Frailty Scale:
    • 1 to 3: Functionally independent
    • 4 to 5: Moderately frail, impairment in instrumental ADLs
    • 6 to 8: Severely frail, impairment in basic ADLs
    • 9: Terminally ill

A1c Targets

  • < 7% for most adults with Type 1 or 2 diabetes
  • < 6.5% for adults with Type 2 diabetes at low risk of hypoglycemia
  • 7.1-8% for functionally independent individuals
  • 7.1-8.5% for recurrent severe hypoglycemia and frail elderly
  • Avoid higher A1c to prevent symptomatic hyperglycemia and complications
  • End of life: A1c measurements not recommended

Glycemic Targets for Older Patients

  • Clinical frailty index 1-3: A1c < 7%
  • Functionally dependent (frailty index 4-5): A1c < 8%
  • Severely frail (frailty index 6-8): A1c < 8.5%
  • End of life: Avoid symptomatic hyperglycemia or hypoglycemia

Comparative Guidelines

  • Diabetes Canada vs. ADA and IDF
    • Canada: A1c < 7% for functionally independent
    • ADA/IDF: A1c < 7.5%
  • Blood pressure and lipid targets vary slightly

Study Insights: Goal-Oriented Control in Elderly

  • Study in Canada with 833 patients, showing good A1c, LDL, BP values
  • Need for better implementation of lifestyle modifications
  • Over-treatment in some high-complexity patients

Treatment Recommendations

  • Healthy Behavior Interventions: Include nutritional therapy, weight management, physical activity
  • Medication Adjustments: Based on cardiovascular risk, renal function, hypoglycemia risk
  • SGLT2 Inhibitors: Effective but caution needed for dehydration, falls, fractures
  • DPP-4 Inhibitors: Safe and effective in elderly
  • Avoid Thiazolidinediones: Risk of fluid retention, fractures

Insulin Use

  • Ensure patient capability to administer independently
  • Use clock drawing test to assess potential difficulties

Long-term Care Considerations

  • Regular diets over diabetic-specific diets
  • Avoid sliding-scale insulin in long-term care residents

Key Messages

  • Diabetes in older people requires customized care plans
  • Personalized strategies to prevent over-treatment
  • Use less stringent A1c targets and safer antihyperglycemic agents

Resources

Full transcript