A Delicate Balance: Treating Older Patients with Diabetes

Older patients with diabetes can benefit from even more carefully personalized treatment than their younger counterparts. A new Endocrine Society clinical practice guideline provides a new look at how to care for this growing population.

A new Endocrine Society clinical practice guideline aimed at treating diabetes patients 65 years and older stresses that longer life expectancies mean that these patients will benefit from treatment similar to that offered younger patients. But it also highlights the need for special care because the population is more susceptible to acute problems such as hypoglycemia that can be triggered by avid efforts to prevent long-term complications.

And because cognitive impairment is more common in older diabetes patients than in their healthier counterparts, providers may need to simplify drug regimens to make them easier for patients to follow.

Providers must resist the outdated belief that because the patients are older, they may not live long enough for potential complications to progress to problems, according to Derek LeRoith, MD, PhD, of Mount Sinai School of Medicine in New York City. LeRoith chaired the committee that developed the guideline.

“A lot of physicians look at somebody 70 and above [and] say, ‘[their problems are] part of the aging process, we don’t have to do too much,’” LeRoith says. “We now know that even older [patients with diabetes] live for many more years, so the guideline stresses that they should be fully treated to reduce the acute effects [as well as] the chronic complications of diabetes.” The guideline provides strategies for providers to find a balance between long-term and short-term goals.

A Tie to Aging

In the U.S., a third of those over 65 have diabetes and almost half have prediabetes, so the guideline applies to a broad swath of the population. And the aging process is an important part of the equation.

“The underlying pathophysiology of the disease in these patients is exacerbated by the direct effects of aging on metabolic regulation,” the guideline says. “Similarly, aging effects interact with diabetes to accelerate the progression of many common diabetes complications.”

In a nod to this interplay, the guideline recommends that providers be careful to avoid overtreatment in older patients and design treatment regimens specifically to minimize hypoglycemia.

Personalizing Treatment

And just as individuals age uniquely, LeRoith emphasizes the need for “personalized medicine. Each individual needs to be evaluated differently.” For example, healthier patients without cognitive impairment might pursue good glycemic control using hemoglobin A1c testing and good blood pressure control to prevent complications.

“We now know that even older [patients with diabetes] live for many more years, so the guideline stresses that they should be fully treated to reduce the acute effects [as well as] the chronic complications of diabetes.” – Derek LeRoith, MD, PhD, Mount Sinai School of Medicine, New York; chair, guideline-writing committee

But many older adults with diabetes have co-morbidities such as cognitive impairment, frailty, renal disease, cardiovascular disease, impaired vision, and rheumatoid arthritis that affect diabetes self-management. For these patients, LeRoith says that it may be better to “back off in our goals to make sure that, in our enthusiasm to prevent the long-term complications, we don’t cause short-term complications. Overtreating or not following the patients closely enough can lead to problems like hypotension and hypoglycemia.”

“The guideline encourages clinicians to consider available evidence and a patient’s overall health, likelihood to benefit from interventions, and personal values when considering treatment goals such as glucose, blood pressure, and cholesterol. Our framework prioritizes blood glucose targets over the hemoglobin A1c test when managing diabetes in older adults,” LeRoith says.

Diabetes exacerbates the decline in cognitive function that can come with the aging process, and providers should take this into account. In patients with a diagnosis of cognitive impairment, the guideline suggests that “medication regimens be simplified and glycemic targets tailored to improve compliance and prevent treatment-related complications.” But when it comes to treating cognitive impairment itself, the guideline recommends the same treatment for diabetes patients as for non-diabetes patients.

Diagnostic Testing Surprise

LeRoith said that one surprise from the literature review that the committee performed in preparation for the guideline related to tests used for diagnosing diabetes. Many conditions that are relatively common in this age group can affect the lifespan of red blood cells in the circulation and therefore affect the accuracy of hemoglobin A1c test results.

Patients who meet the criteria for only prediabetes by fasting plasma glucose or hemoglobin A1c tests may be tipped over to a diagnosis of diabetes if they are given a two-hour glucose post–oral glucose tolerance test. The oral glucose tolerance test may be revelatory in high-risk patients who have conditions or risk factors such as overweight or obesity; a first-degree relative with diabetes; higher risk because of race or ethnicity; or cardiovascular disease, hypertension, or sleep apnea.

“The guideline encourages clinicians to consider available evidence and a patient’s overall health, likelihood to benefit from interventions, and personal values when considering treatment goals such as glucose, blood pressure, and cholesterol. Our framework prioritizes blood glucose targets over the hemoglobin A1c test when managing diabetes in older adults.” – Derek LeRoith, MD, PhD, Mount Sinai School of Medicine, New York; chair, guideline-writing committee

The patient may benefit because a diagnosis of prediabetes can limit treatment options to recommending lifestyle changes, whereas crossing the border into diabetes opens the possibility of prescribing medications.

And on the subject of medications, the guideline recommends metformin as the initial oral medication for glycemic management (in addition to lifestyle management). For those who do not achieve glycemic targets with metformin and lifestyle, the guideline recommends the addition of “other oral or injectable agents and/or insulin.” But to reduce the risk of hypoglycemia, it recommends avoiding sulfonylureas and glinides and using insulin sparingly.

Recommendations for Specific Situations

The guideline contains many specific targets and recommendations for managing the common co-morbidities a provider may be called on to treat, including:

  • Targeting blood pressure levels of 140/90 mm Hg to decrease the risk of cardiovascular disease outcomes, stroke, and progressive chronic kidney disease
  • Ordering an annual lipid profile and using statin therapy to achieve the recommended lipid levels for reducing absolute cardiovascular disease events and all-cause mortality
  • Administering annual comprehensive eye exams to detect retinal disease

“This [guideline] is a good clinical tool,” says Anne Peters, MD, director of the University of Southern California Clinical Diabetes Program, who was not on the guideline committee but provided input during the writing and review process. “Many of these older patients require a great deal of individualization of care, and it can be hard to create a ‘one size fits all’ set of targets. The authors give us a good paradigm for thinking about patients and targets.”

–Seaborg is a freelance medical writer based in Charlottesville, Va. He wrote about treating osteoporosis in post-menopausal patients in the May issue.

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