Diabetes in the Elderly

Canadian Diabetes Association Clinical Practice Guidelines Expert Committee

Graydon S. Meneilly MD, FRCPC, FACP Aileen Knip RN, MN, CDE Daniel Tessier MD, MSc, FRCPC

  • Key Messages
  • Recommendations
  • Figures
  • Highlights
  • Full Text
  • References

Key Messages

  • Diabetes in the elderly is metabolically distinct from diabetes in younger people and the approach to therapy should be different.
  • Sulphonylureas should be used with caution because the risk of hypoglycemia increases exponentially with age.
  • Long-acting basal analogues are associated with a lower frequency of hypoglycemia than conventional insulins in this age group.
  • In elderly people, if mixture of insulin is required, the use of premixed insulins as an alternative to mixing insulins minimizes dose errors.

Highlights of Revisions

  • A new recommendation for glycemic targets among the frail elderly of glycated hemoglobin (A1C) ≤8.5%, and fasting and preprandial plasma glucose of 5.0 to 12.0 mmol/L has been added.
  • The chapter recognizes the importance of hypoglycemia avoidance over achieving glycemic targets among the frail elderly and those with cognitive impairment.
  • A new recommendation about the use of regular diets in nursing homes instead of "diabetic diets" has been added.

Recommendations

  1. 1.Healthy elderly people with diabetes should be treated to achieve the same glycemic, blood pressure and lipid targets as younger people with diabetes [Grade D, Consensus].
  2. 2.In the frail elderly, while avoiding symptomatic hyperglycemia, glycemic targets should be A1C ≤8.5% and fasting plasma glucose or preprandial PG 5.0–12.0 mmol/L, depending on the level of frailty. Prevention of hypoglycemia should take priority over attainment of glycemic targets because the risks of hypoglycemia are magnified in this patient population [Grade D, Consensus].
  3. 3.In elderly people with cognitive impairment, strategies should be used to strictly prevent hypoglycemia, which include the choice of antihyperglycemic therapy and less stringent A1C target [Grade D, Consensus].
  4. 4.Elderly people with type 2 diabetes should perform aerobic exercise and/or resistance training, if not contraindicated, to improve glycemic control [Grade B, Level 2 (1–5)].
  5. 5.In elderly people with type 2 diabetes, sulphonylureas should be used with caution because the risk of hypoglycemia increases exponentially with age [Grade D, Level 4 (6) ].
    • In general, initial doses of sulphonylureas in the elderly should be half of those used for younger people, and doses should be increased more slowly [Grade D, Consensus].
    • Gliclazide and gliclazide MR [Grade B, Level 2 (7,8) ] and glimepiride [Grade C, Level 3 (9) ] should be used instead of glyburide, as they are associated with a reduced frequency of hypoglycemic events.
    • Meglitinides may be used instead of glyburide to reduce the risk of hypoglycemia [Grade C Level 2 (10) for repaglinide; Grade C, Level 3 (11) for nateglinide], particularly in patients with irregular eating habits [Grade D Consensus].
  6. 6.In elderly people, thiazolidinediones should be used with caution due to the increased risk of fractures and heart failure [Grade D Consensus].
  7. 7.Detemir and glargine may be used instead of NPH or human 30/70 insulin to lower the frequency of hypoglycemic events [Grade B, Level 2 (12,13)].
  8. 8.In elderly people, if insulin mixture is required, premixed insulins and prefilled insulin pens should be used instead of mixing insulins to reduce dosing errors and to potentially improve glycemic control [Grade B, Level 2 (14–16)].
  9. 9.The clock drawing test may be used to predict which elderly subjects will have difficulty learning to inject insulin [Grade D, Level 4 (17)].
  10. 10.In elderly nursing home residents, regular diets may be used instead of “diabetic diets” or nutritional formulas [Grade D, Level 4 (18–20)].

References

  1. Tessier D, Ménard J, Fülöp T, et al. Effects of aerobic physical exercise in the elderly with type 2 diabetes mellitus. Arch Gerontol Geriatr 2000;31:121-32.
  2. Ligtenberg PC, Godaert GLR, Hillenaar EF, et al. Influence of a physical training program on psychological well being in elderly type 2 diabetes patients: psychological well being, physical training, and type 2 diabetes [letter]. Diabetes Care 1998;21:2196-7.
  3. Ligtenberg PC, Hoekstra JBL, Bol E, et al. Effects of physical training on metabolic control in elderly type 2 diabetes mellitus patients. Clin Sci (Lond) 1997;93:127-35.
  4. Dunstan DW, Daly RM, Owen N, et al. High-intensity resistance training improves glycemic control in older patients with type 2 diabetes. Diabetes Care 2002;25:1729-36.
  5. Castaneda C, Layne JE, Munoz-Orians L, et al. A randomized controlled trial of resistance exercise training to improve glycemic control in older adults with type 2 diabetes. Diabetes Care 2002;25:2335-41
  6. Asplund K, Wiholm BE, Lithner F. Glibenclamide-associated hypoglycaemia: a report on 57 cases. Diabetologia 1983;24:412-7.
  7. Tessier D, Dawson K, Tétrault JP, et al. Glibenclamide vs gliclazide in type 2 diabetes of the elderly. Diabet Med 1994;11:974-80.
  8. Diamicron MR Study Group, Drouin P. Diamicron MR once daily is effective and well tolerated in type 2 diabetes: a double-blind, randomized, multinational study. J Diabetes Complications 2000;14:185-91.
  9. Holstein A, Plaschke A, Egberts EH. Lower incidence of severe hypoglycaemia in patients with type 2 diabetes treated with glimepiride versus glibenclamide. Diabetes Metab Res Rev 2001;17:467-73.
  10. Papa G, Fedele V, Rizzo MR, et al. Safety of type 2 diabetes treatment with repaglinide compared with glibenclamide in elderly people: a randomized, open-label, two-period, cross- over trial. Diabetes Care 2006;29:1918-20.
  11. Schwartz SL, Gerich JE, Marcellari A, et al. Nateglinide, alone or in combination with metformin, is effective and well tolerated in treatment-naïve elderly patients with type 2 diabetes. Diabetes Obes Metab 2008;10:652-60.
  12. Janka HU, Plewe G, Busch K. Combination of oral antidiabetic agents with basal insulin versus premixed insulin alone in randomized elderly patients with type 2 diabetes mellitus. J Am Geriatr Soc 2007;55:182-8.
  13. Garber AJ, Clauson P, Pedersen CB, Kolendorf K. Lower risk of hypoglycemia with insulin detemir than with neutral protamine hagedorn insulin in older persons with type 2 diabetes: a pooled analysis of Phase III trials. J Am Geriatr Soc 2007;55:1735-40.
  14. Coscelli C, Calabrese G, Fedele D, et al. Use of premixed insulin among the elderly. Reduction of errors in patient preparation of mixtures. Diabetes Care 1992;15:1628-30.
  15. Corsi A, Torre E, Coronel GA, et al. Pre-filled insulin pen in newly insulin-treated diabetic patients over 60 years old. Diabetes Nutr Metab 1997;10:78-81.
  16. Coscelli C, Lostia S, Lunetta M, et al. Safety, efficacy, acceptability of a pre-filled insulin pen in diabetic patients over 60 years old. Diabetes Res Clin Pract 1995; 28:173-7.
  17. Trimble LA, Sundberg S, Markham L, et al. Value of the clock drawing test to predict problems with insulin skills in older adults. Can J Diabetes 2005;29: 102-4.
  18. Coulston AM, Mandelbaum D, Reaven GM. Dietary management of nursing home residents with non-insulin-dependent diabetes mellitus. Am J Clin Nutr 1990;51:67-71.
  19. Tariq SH, Karcic E, Thomas DR, et al. The use of a no-concentrated-sweets diet in the management of type 2 diabetes in nursing homes. J Am Diet Assoc 2001; 101:1463-6.
  20. Levinson Y, Epstein A, Adler B, et al. Successful use of a sucrose-containing enteral formula in diabetic nursing home elderly. Diabetes Care 2006;29: 698-700.

 

Reproduced with permission from Canadian Journal of Diabetes © 2013 Canadian Diabetes Association. To cite this article, please refer to For citation.