1. Canadian Diabetes Association Clinical Practice Guidelines Diabetes in the Elderly Chapter 37 Graydon S. Meneilly, Daniel Tessier, Aileen Knip

2. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Diabetes in the Elderly Checklist ASSESS for level of functional dependency (frailty) INDIVIDUALIZE glycemic targets based on the above (A1C ≤8.5% for frail elderly) but if otherwise healthy, use the same targets as younger people AVOID hypoglycemia in cognitive impairment SELECT antihyperglycemic therapy carefully Caution with sulfonylureas or thiazolidinediones Basal analogues instead of NPH or human 30/70 insulin Premixed insulins instead of mixing insulins separately GIVE regular diets instead of “diabetic diets” or nutritional formulas in nursing homes 2013

3. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association “Frailty is a widely used term associated with aging that denotes a multidimensional syndrome that gives rise to increased vulnerability”

4. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Moorhouse P, Rockwood K. J R Coll Physicians Edinb 2012;42:333-340.

5. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Consider A1C 7.1-8.5% if … Limited life expectancy High level of functional dependency Extensive coronary artery disease at high risk of ischemic events Multiple co-morbidities History of recurrent severe hypoglycemia Hypoglycemia unawareness Longstanding diabetes for whom is it difficult to achieve an A1C ≤7%, despite effective doses of multiple antihyperglycemic agents, including intensified basal-bolus insulin therapy 2013

6. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Individualizing A1C Targets which must be balanced against the risk of hypoglycemia Consider 7.1-8.5% if: 2013

7. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Among Frail Elderly ParameterTarget A1C≤8.5% FPG or preprandial glucose 5.0-12.0 mmol/L (depending on level of frailty) FPG= Fasting Plasma Glucose 2013 AVOID HYPOGLYCEMIA

8. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Older Patients have Less Perception of Hypoglycemia Bremer JP et al. Diabetes Care. 2009; 32 (8):1513-17 12 14 10 8 6 4 2 0 Autonomic symptoms BaselineHypoRecovery ** 12 10 8 6 4 2 0 Neuroglycopenic symptoms BaselineHypoRecovery * Middle-aged (39-64 years) Older (≥65 years)

9. Start metformin immediately Consider initial combination with another antihyperglycemic agent Start lifestyle intervention (nutrition therapy and physical activity) +/- Metformin A1C <8.5% Symptomatic hyperglycemia with metabolic decompensation A1C  8.5% Initiate insulin +/- metformin If not at glycemic target (2-3 mos) Start / Increase metformin If not at glycemic targets LIFESTYLELIFESTYLE Add an agent best suited to the individual: Patient Characteristics Degree of hyperglycemia Risk of hypoglycemia Overweight or obesity Comorbidities (renal, cardiac, hepatic) Preferences & access to treatment Other See next page… AT DIAGNOSIS OF TYPE 2 DIABETES Agent Characteristics BG lowering efficacy and durability Risk of inducing hypoglycemia Effect on weight Contraindications & side-effects Cost and coverage Other 2013

10. If not at glycemic target From prior page… Add another agent from a different class Add/Intensify insulin regimen Make timely adjustments to attain target A1C within 3-6 months 2013 LIFESTYLELIFESTYLE

11. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Add an agent best suited to the individual (agents listed in alphabetical order): ClassRelative A1C Lowering Hypo- glycemia WeightOther therapeutic considerationsCost  -glucosidase inhibitor (acarbose)  RareNeutral to  Improved postprandial control, GI side-effects $$ Incretin agents: DPP-4 Inhibitors GLP-1 receptor agonists   to  Rare N to  GI side-effects $$$ $$$$ Insulin  Yes  No dose ceiling, flexible regimens$-$$$$ Insulin secretagogue: Meglitinide Sulfonylurea  Yes* Yes  *Less hypoglycemia in context of missed meals but usually requires TID to QID dosing Gliclazide and glimepiride associated with less hypoglycemia than glyburide $$ $ Thiazolidinediones  Rare  CHF, edema, fractures, rare bladder cancer (pioglitazone), cardiovascular controversy (rosiglitazone), 6-12 weeks required for maximal effect $$ Weight loss agent (orlistat)  None  GI side effects$$$ CAUTION in the elderly Initial doses = HALF of usual dose Avoid glyburide Use gliclazide, gliclazide MR, glimepiride, nateglinide or repaglinide instead CAUTION in the elderly Increased risk of fractures Increased risk of heart failure May use detemir or glargine instead of NPH or human 30/70 for less hypos Premixed insulins and prefilled insulin pens instead of mixing insulin to reduce dosing errors

12. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association If Choosing to Use Insulin … Clock drawing test can be used to predict who is likely to have problems with insulin therapy “Write numbers on the blank clock face and draw hands on the clock to show 10 minutes past 11 o’clock” Trimble LA et al. Can J Diabetes 2005;29(2):102-104. 2013

13. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Diabetes in Nursing Homes Under nutrition is a problem in people with diabetes living in nursing homes “Regular diets” may be used in nursing homes instead of “diabetic diets” or “diabetic nutritional formulas” Mooradian AD et al. J Am Geriatr Soc 1988;36:391-396 Coulston AM et al. Am J Clin Nutr 1990;51:67-71. 2013

14. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 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].

15. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 2 2.In the frail elderly, while avoiding symptomatic hyperglycemia, glycemic targets should be an A1C of ≤8.5% and FPG or pre-prandial PG of 5.0-12.0 mmol/L, depending on the level of frailty. Avoidance of hypoglycemia should take priority over attainment of glycemic targets because the risks of hypoglycemia are magnified in this patient population [Grade D, Consensus]. 2013

16. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendations 3 and 4 3.In elderly people with cognitive impairment, strategies should be employed to strictly avoid hypoglycemia, which include the choice of antihyperglycemic therapy and less stringent A1C target [Grade D, Consensus]. 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].

17. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 5 5.In elderly people with T2DM, sulfonylureas should be used with caution because the risk of hypoglycemia increases exponentially with age [Grade D, Level 4]. –In general, initial doses of sulfonylureas 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] and glimepiride [Grade C, Level 3] 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 for repaglinide; Grade C, Level 3 for nateglinide], particularly in patients with irregular eating habits [Grade D, Consensus].

18. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 6 6.In elderly people, thiazolidinediones should be used with caution due to the increased risk of fractures and heart failure [Grade D, Consensus].

19. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendations 7 and 8 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]. 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]. 2013

20. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendations 9 and 10 9.The clock drawing test may be used to predict which elderly subjects will have difficulty learning to inject insulin [Grade D, Level 4]. 10.In elderly nursing home residents, regular diets may be used instead of “diabetic diets” or nutritional formulas [Grade D, Level 4]. 2013

21. CDA Clinical Practice Guidelines www.guidelines.diabetes.cawww.guidelines.diabetes.ca – for professionals 1-800-BANTING (226-8464) www.diabetes.ca www.diabetes.ca – for patients