1. Diabetes in Elderly Adults

2. By the age of 75, approximately 20% of the population are afflicted with this illness.. By the age of 75, approximately 20% of the population are afflicted with this illness..

3. obese older patients have resistance to insulin-mediated glucose disposal. obese older patients have resistance to insulin-mediated glucose disposal.

4. delayed gastric emptying or gastroparesis is frequently reported for older adults with diabetes. delayed gastric emptying or gastroparesis is frequently reported for older adults with diabetes.

5. Lean older patients with type 2 diabetes had a marked impairment in glucose- reduced insulin secretion. It has recently been suggested that thin elderly diabetics have a syndrome intermediate between type 1 and 2 diabetes, which might properly be thought of as type 1 1/2 diabetes. Lean older patients with type 2 diabetes had a marked impairment in glucose- reduced insulin secretion. It has recently been suggested that thin elderly diabetics have a syndrome intermediate between type 1 and 2 diabetes, which might properly be thought of as type 1 1/2 diabetes.

6. 50% older persons with diabetes are unaware they have the illness, suggesting that symptoms of hyperglycemia are rarely present in this patient population. 50% older persons with diabetes are unaware they have the illness, suggesting that symptoms of hyperglycemia are rarely present in this patient population.

7. This may be because the renal threshold for glucose increases with age, so that no sugar is spilled into the urine until the glucose level is markedly elevated. In addition, because thirst is impaired with normal aging, polydipsia is unlikely in elderly patients with diabetes, even if they are hyperosmolar as a result of marked hyperglycemia. This may be because the renal threshold for glucose increases with age, so that no sugar is spilled into the urine until the glucose level is markedly elevated. In addition, because thirst is impaired with normal aging, polydipsia is unlikely in elderly patients with diabetes, even if they are hyperosmolar as a result of marked hyperglycemia.

8. Often, diabetes presents for the first time in an elderly person who is hospitalized with a complication that may be related to diabetes, such as a myocardial infarction or a stroke. In frail elderly nursing home patients, nonketotic hyperosmolar coma may be the first sign of diabetes. Often, diabetes presents for the first time in an elderly person who is hospitalized with a complication that may be related to diabetes, such as a myocardial infarction or a stroke. In frail elderly nursing home patients, nonketotic hyperosmolar coma may be the first sign of diabetes.

9. The goals of DM care in older adults, as in younger persons, The goals of DM care in older adults, as in younger persons, include control of hyperglycemia and its symptoms; prevention, evaluation, and treatment of macrovascular and microvascular complications of DM; DM self-management through education; and maintenance or improvement of general health status. include control of hyperglycemia and its symptoms; prevention, evaluation, and treatment of macrovascular and microvascular complications of DM; DM self-management through education; and maintenance or improvement of general health status.

10. Chronically ill, institutionalized patients with a short life expectancy do not require aggressive glucose control, but do require adequate control to facilitate healing and prevent: Chronically ill, institutionalized patients with a short life expectancy do not require aggressive glucose control, but do require adequate control to facilitate healing and prevent: o Dehydration o Symptoms of hyperglycemia or hypoglycemia o Weight loss

11. Polypharmacy: Older adults with DM are at risk for drug side effects and drug-drug and drug- disease interactions. Polypharmacy is a major problem for older adults with DM, who may require several medications to manage glycemia, hyperlipidemia, hypertension, and other associated conditions. Older adults with DM are at risk for drug side effects and drug-drug and drug- disease interactions. Polypharmacy is a major problem for older adults with DM, who may require several medications to manage glycemia, hyperlipidemia, hypertension, and other associated conditions.

12. Older adults tend to have less muscle than younger people and generally have a higher percentage of body fat. The elderly are generally less hydrated than younger individuals and thus tend to have less total body water.Blood flow to organs such as the kidneys and liver is diminished with age, which can lead to decreased metabolism and elimination of many drugs.

13. Polypharmacy: Clinicians should perform a careful review of each medication currently being used by the patient during the initial visit and at each subsequent visit and document whether the patient is taking each medication properly. Clinicians should perform a careful review of each medication currently being used by the patient during the initial visit and at each subsequent visit and document whether the patient is taking each medication properly.

14. Urinary Incontinence: The older adult who has DM should be evaluated for symptoms of urinary incontinence during annual screening. The older adult who has DM should be evaluated for symptoms of urinary incontinence during annual screening. women with DM are at higher risk than the general population for urinary incontinence.

15. The risk factors for urinary incontinence that are more common in older adults with DM include polyuria, overflow secondary to neurogenic bladder and autonomic insufficiency, urinary tract infection, candida vaginitis, and fecal impaction due to autonomic insufficiency. Urinary incontinence is commonly unreported by patients and undetected by providers. The risk factors for urinary incontinence that are more common in older adults with DM include polyuria, overflow secondary to neurogenic bladder and autonomic insufficiency, urinary tract infection, candida vaginitis, and fecal impaction due to autonomic insufficiency. Urinary incontinence is commonly unreported by patients and undetected by providers.

17. Glycemic Control: For older persons, target hemoglobin A1c (A1C) should be individualized. A reasonable goal for A1C in relatively healthy adults with good functional status is 7% or lower. For frail older adults, persons with life expectancy of less than 5 years, and others in whom the risks of intensive glycemic control appear to outweigh the benefits, a less stringent target such as 8% is appropriate. For older persons, target hemoglobin A1c (A1C) should be individualized. A reasonable goal for A1C in relatively healthy adults with good functional status is 7% or lower. For frail older adults, persons with life expectancy of less than 5 years, and others in whom the risks of intensive glycemic control appear to outweigh the benefits, a less stringent target such as 8% is appropriate.

18. Chronically ill, institutionalized patients with a short life expectancy do not require aggressive glucose control, but do require adequate control to facilitate healing and prevent: Chronically ill, institutionalized patients with a short life expectancy do not require aggressive glucose control, but do require adequate control to facilitate healing and prevent: o Dehydration o Symptoms of hyperglycemia or hypoglycemia o Weight loss

19. Monitoring: For the older adult with DM, a schedule for self-monitoring of blood glucose should be considered, depending on the individual's functional and cognitive abilities. The schedule should be based on the goals of care, target A1C levels, the potential for modifying therapy, and the individual's risk for hypoglycemia. For the older adult with DM, a schedule for self-monitoring of blood glucose should be considered, depending on the individual's functional and cognitive abilities. The schedule should be based on the goals of care, target A1C levels, the potential for modifying therapy, and the individual's risk for hypoglycemia.

20. .Some older adults may not be able to perform SMBG due to physical or cognitive impairment. In such situations, the glycemic goals may need to be adjusted to keep blood glucose levels higher, and the regimen should be simplified to avoid hypoglycemia for those at risk.

21. “Start low and go slow” with all medications “Start low and go slow” with all medications Consider drug-drug interactions carefully as most older adult patients are on multiple drugs as well as supplements. Consider drug-drug interactions carefully as most older adult patients are on multiple drugs as well as supplements.

22. Do not assume that because the creatinine is normal that kidney function is normal, since an older adult with decreased muscle mass can have normal creatinine levels with significant renal dysfunction as seen by low glomerular filtration rate (GFR). Do not assume that because the creatinine is normal that kidney function is normal, since an older adult with decreased muscle mass can have normal creatinine levels with significant renal dysfunction as seen by low glomerular filtration rate (GFR). Monitor liver and kidney function tests periodically even though diabetes medications, alone or in combination, are safe in older adult patients when selected carefully. Monitor liver and kidney function tests periodically even though diabetes medications, alone or in combination, are safe in older adult patients when selected carefully.

23. In general, a creatinine clearance estimated at < 60 ml/min warrants dose adjustments of most renally cleared medications. In an older woman (68 years) weighing 60 Kg with a serum creatinine of 1.0, this would translate to an estimated creatinine clearance of 51 ml/min, just under this threshold. In general, a creatinine clearance estimated at < 60 ml/min warrants dose adjustments of most renally cleared medications. In an older woman (68 years) weighing 60 Kg with a serum creatinine of 1.0, this would translate to an estimated creatinine clearance of 51 ml/min, just under this threshold.

24. Medications: Sulfonylureas: Sulfonylureas: o Use with caution in older adult patients because of the risk of hypoglycemia. o Avoid agents like chlorpropamide and glyburide because of their prolonged length of action. o Shorter acting agents like glipizide, or the non-sulfonylurea insulin secretagogues repaglinide and nateglinide, can be useful to avoid nocturnal hypoglycemia, or to avoid hypoglycemia in patients with erratic oral intake.

27. Metformin Metformin o Use with caution in the older adult with diabetes because of an increased risk of lactic acidosis in patients with impaired renal function. o Use with caution in the older adult with diabetes because of an increased risk of lactic acidosis in patients with impaired renal function. o Measure serum creatinine and liver function tests (LFTs) periodically in the older individual who receives metformin, and with any increase in dose. o Measure serum creatinine and liver function tests (LFTs) periodically in the older individual who receives metformin, and with any increase in dose. o Measure creatinine clearance with a timed urine collection at least annually and with increases in dosage of metformin in frail older adults, or those with decreased muscle mass. o Measure creatinine clearance with a timed urine collection at least annually and with increases in dosage of metformin in frail older adults, or those with decreased muscle mass. o Avoid initiating in patients ≥ 80 years of age unless creatinine clearance is within normal limits. o Avoid initiating in patients ≥ 80 years of age unless creatinine clearance is within normal limits..

28. Thiazolidinediones (TZDs Thiazolidinediones (TZDs o TZDs are well tolerated by older adults as they do not cause hypoglycemia. Side effects of fluid retention and leg edema can be limiting factors in using this class of medications in the older adult. o TZDs should be avoided in patients with Class III and Class IV congestive heart failure.

29. Alpha-Glucosidase Inhibitors: Alpha-Glucosidase Inhibitors: o Alpha-glucosidase inhibitors are less effective than other agents and may cause gastrointestinal side effects.

30. Insulin: Insulin: Elderly subjects often make errors when trying to mix insulin on their own. The accuracy of insulin injections has been shown to be improved in older patients when they are treated with premixed insulin. Elderly subjects often make errors when trying to mix insulin on their own. The accuracy of insulin injections has been shown to be improved in older patients when they are treated with premixed insulin.

31. In these situations, it is beneficial to use simpler insulin regimens with fewer daily injections, such as pre-mixed insulin preparations, pre-measured doses, and easier injection systems (e.g., insulin pens with easy to set dosages). In these situations, it is beneficial to use simpler insulin regimens with fewer daily injections, such as pre-mixed insulin preparations, pre-measured doses, and easier injection systems (e.g., insulin pens with easy to set dosages).

32. Recommend equipment that is easy to hold, easy to read and requires the least amount of steps. Insulin pens and pre-filled syringes may be easier for older patients to use than a syringe. Syringe magnifiers are available if vision is a problem.

33. Hypoglycemia: Older adult patients commonly exhibit neuroglycopenic manifestations of hypoglycemia that include confusion, Older adult patients commonly exhibit neuroglycopenic manifestations of hypoglycemia that include confusion, delirium, dizziness, weakness or falls as compared to adrenergic symptoms. It is important that older adult patients and their caregivers recognize these symptoms as hypoglycemia and treat appropriately. delirium, dizziness, weakness or falls as compared to adrenergic symptoms. It is important that older adult patients and their caregivers recognize these symptoms as hypoglycemia and treat appropriately.

34. Frail older adult patients may have poor outcomes from even mild hypoglycemia. For example, injurious falls can lead to unintended consequences such as institutionalization. In addition, hypoglycemia can exacerbate existing conditions (e.g., coronary artery disease or cerebrovascular disease). Frail older adult patients may have poor outcomes from even mild hypoglycemia. For example, injurious falls can lead to unintended consequences such as institutionalization. In addition, hypoglycemia can exacerbate existing conditions (e.g., coronary artery disease or cerebrovascular disease).

35. The older adult with DM who is on an ACE inhibitor or ARB should have renal function and serum potassium levels monitored within 1 to 2 weeks of initiation of therapy, with each dose increase, and at least yearly. The older adult with DM who is on an ACE inhibitor or ARB should have renal function and serum potassium levels monitored within 1 to 2 weeks of initiation of therapy, with each dose increase, and at least yearly.

36. The older adult with DM who is prescribed a thiazide or loop diuretic should have electrolytes checked within 1 to 2 weeks of initiation of therapy or of an increase in dosage and at least yearly. The older adult with DM who is prescribed a thiazide or loop diuretic should have electrolytes checked within 1 to 2 weeks of initiation of therapy or of an increase in dosage and at least yearly.

37. Management of Hyperlipidemia The targets of therapy, interval of lipid profile screening, and choice of medications for treatment of hyperlipidemia in older adult patients with diabetes are the same as those in younger adults. The targets of therapy, interval of lipid profile screening, and choice of medications for treatment of hyperlipidemia in older adult patients with diabetes are the same as those in younger adults. When an individual does not have evidence of CVD and has a life expectancy that is determined by the provider to be three years or less, relaxation of the goals of therapy may be made. When an individual does not have evidence of CVD and has a life expectancy that is determined by the provider to be three years or less, relaxation of the goals of therapy may be made.

38. Eye and Foot Care: Recommendations for eye and foot examinations and treatment in older adults with diabetes are the same as those for younger individuals. Older adults may require additional education and devices such as mirrors to examine their feet due to decreased mobility and dexterity. Recommendations for eye and foot examinations and treatment in older adults with diabetes are the same as those for younger individuals. Older adults may require additional education and devices such as mirrors to examine their feet due to decreased mobility and dexterity.

39. Nutrition: The current trend is to distribute the patient’s carbohydrate intake as evenly as possible throughout the day. Education regarding the importance of consistency in carbohydrate intake and the timing of meals can help avoid large fluctuations in blood glucose levels. The current trend is to distribute the patient’s carbohydrate intake as evenly as possible throughout the day. Education regarding the importance of consistency in carbohydrate intake and the timing of meals can help avoid large fluctuations in blood glucose levels.

40. Every effort should be made to minimize the complexity of meal planning and to engage the spouse, or others living with the patient, in creating a home environment that supports positive lifestyle change. Every effort should be made to minimize the complexity of meal planning and to engage the spouse, or others living with the patient, in creating a home environment that supports positive lifestyle change. In chronic care settings, there is no need for a rigid and restrictive meal plan. A regular diet with consistent, moderate carbohydrate intake may be sufficient and may help to avoid under nutrition. In chronic care settings, there is no need for a rigid and restrictive meal plan. A regular diet with consistent, moderate carbohydrate intake may be sufficient and may help to avoid under nutrition.

41. Physical Activity: Types of physical activities that may be appropriate for the older adult include: Types of physical activities that may be appropriate for the older adult include: o Walking o Swimming or water aerobics o Bicycle riding o Yoga o Gardening o Household chores