More than 25% of the U.S. population aged ≥65 years has diabetes (1), and the aging of the overall population is a significant driver of the diabetes epidemic. Although the burden of diabetes is often described in terms of its impact on working-age adults, diabetes in older adults is linked to higher mortality, reduced functional status, and increased risk of institutionalization (2). Older adults with diabetes are at substantial risk for both acute and chronic microvascular and cardiovascular complications of the disease.

Despite having the highest prevalence of diabetes of any age-group, older persons and/or those with multiple comorbidities have often been excluded from randomized controlled trials of treatments—and treatment targets—for diabetes and its associated conditions. Heterogeneity of health status of older adults (even within an age range) and the dearth of evidence from clinical trials present challenges to determining standard intervention strategies that fit all older adults. To address these issues, the American Diabetes Association (ADA) convened a Consensus Development Conference on Diabetes and Older Adults (defined as those aged ≥65 years) in February 2012. Following a series of scientific presentations by experts in the field, the writing group independently developed this consensus report to address the following questions:

1. What is the epidemiology and pathogenesis of diabetes in older adults?

2. What is the evidence for preventing and treating diabetes and its common comorbidities in older adults?

3. What current guidelines exist for treating diabetes in older adults?

4. What issues need to be considered in individualizing treatment recommendations for older adults?

5. What are consensus recommendations for treating older adults with or at risk for diabetes?

6. How can gaps in the evidence best be filled?

According to the most recent surveillance data, the prevalence of diabetes among U.S. adults aged ≥65 years varies from 22 to 33%, depending on the diagnostic criteria …

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Diabetes in Older Adults

More than 25% of the U.S. population aged 65 years has diabetes mellitus (hereafter referred to as diabetes), 1 and the aging of the overall population is a significant driver of the diabetes epidemic. Although the burden of diabetes is often described in terms of its impact on working-age adults, diabetes in older adults is linked to higher mortality, reduced functional status, and increased risk of institutionalization. 2 Older adults with diabetes are at substantial risk for both acute and chronic microvascular and cardiovascular complications of the disease. Despite having the highest prevalence of diabetes of any age-group, older persons and/or those with multiple comorbidities have often been excluded from randomized controlled trials of treatments—and treatment targets— for diabetes and its associated conditions. Heterogeneity of health status of older adults (even within an age range) and the dearth of evidence from clinical trials present challenges to determining standard intervention strategies that fit all older adults. To address these issues, the American Diabetes Association (ADA) convened a Consensus Development Conference on Diabetes and Older Adults (defined as those aged 65 years) in February 2012. Following a series of scientific presentations by experts in the field, the writing group independently developed this consensus report to address the following questions:

/pdf/diabetes-in-older-adults-a-consensus-report-24tmzi95dr.pdf

Diabetes in Older Adults: A Consensus Report

Supplementary Table S1 Continuous Glucose Monitoring (CGM) has been demonstrated to be clinically valuable, reducing risks of hypoglycemia and hyperglycemia, glycemic variability (GV), and improving patient quality of life for a wide range of patient populations and clinical indications. Use of CGM can help reduce HbA1c and mean glucose. One CGM device, with accuracy (%MARD) of approximately 10%, has recently been approved for self-adjustment of insulin dosages (nonadjuvant use) and approved for reimbursement for therapeutic use in the United States. CGM had previously been used off-label for that purpose. CGM has been demonstrated to be clinically useful in both type 1 and type 2 diabetes for patients receiving a wide variety of treatment regimens. CGM is beneficial for people using either multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII). CGM is used both in retrospective (professional, masked) and real-time (personal, unmasked) modes: both approaches can be ben...

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Continuous Glucose Monitoring: A Review of Recent Studies Demonstrating Improved Glycemic Outcomes

Objective: The objective is to formulate clinical practice guidelines for the treatment of diabetes in older adults. Conclusions: Diabetes, particularly type 2, is becoming more prevalent in the general population, especially in individuals over the age of 65 years. The underlying pathophysiology of the disease in these patients is exacerbated by the direct effects of aging on metabolic regulation. Similarly, aging effects interact with diabetes to accelerate the progression of many common diabetes complications. Each section in this guideline covers all aspects of the etiology and available evidence, primarily from controlled trials, on therapeutic options and outcomes in this population. The goal is to give guidance to practicing health care providers that will benefit patients with diabetes (both type 1 and type 2), paying particular attention to avoiding unnecessary and/or harmful adverse effects.

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Treatment of Diabetes in Older Adults: An Endocrine Society Clinical Practice Guideline

Objective: To formulate clinical practice guidelines for the use of continuous glucose monitoring and continuous subcutaneous insulin infusion in adults with diabetes. Participants: The participants include an Endocrine Society-appointed Task Force of seven experts, a methodologist, and a medical writer. The American Association for Clinical Chemistry, the American Association of Diabetes Educators, and the European Society of Endocrinology co-sponsored this guideline. Evidence: The Task Force developed this evidence-based guideline using the Grading of Recommendations, Assessment, Development, and Evaluation system to describe the strength of recommendations and the quality of evidence. The Task Force commissioned one systematic review and used the best available evidence from other published systematic reviews and individual studies. Consensus Process: One group meeting, several conference calls, and e-mail communications enabled consensus. Committees and members of the Endocrine Society, the American A...

Diabetes Technology—Continuous Subcutaneous Insulin Infusion Therapy and Continuous Glucose Monitoring in Adults: An Endocrine Society Clinical Practice Guideline

Background Episodes of hypoglycemia are particularly dangerous in the older population. To reduce the risk of hypoglycemia, relaxation of the standard hemoglobin A 1c (HbA 1c ) goals has been proposed for frail elderly patients. However, the risk of hypoglycemia in this population with higher HbA 1c levels is unknown. Methods Patients 69 years or older with HbA 1C values of 8% or greater were evaluated with blinded continuous glucose monitoring for 3 days. Results Forty adults (mean [SD] age, 75 [5] years; HbA 1C value, 9.3% [1.3%]; diabetes duration, 22 [14] years; 28 patients [70%] with type 2 diabetes mellitus; and 37 [93%] using insulin) were evaluated. Twenty-six patients (65%) experienced 1 or more episodes of hypoglycemia (glucose level Conclusions Hypoglycemic episodes are common in older adults with poor glycemic control. Raising HbA 1C goals may not be adequate to prevent hypoglycemia in this population.

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Frequent hypoglycemia among elderly patients with poor glycemic control.

In Brief Diabetes self-management education (DSME) for older adults is complicated 
by the high prevalence of medical comorbidities and declining functional 
status among this patient population. To adequately meet the DSME needs of 
older adults, DSME should be individualized, involve multiple disciplines, 
involve care partners when patients cannot assume full responsibility for 
their own self-care, and carefully weigh the potential effects of diabetes 
treatments on quality of life. This article presents pointers for effective 
DSME for older adults and a case study illustrating some of the particular 
challenges involved.

https://spectrum.diabetesjournals.org/content/diaspect/19/4/234.full.pdf

Patricia Bonsignore

Papers

Frequent hypoglycemia among elderly patients with poor glycemic control.

Diabetes Self-Management Education for Older Adults: General Principles and Practical Application