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DIABETES MELLITUS
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OBJECTIVES
Know and understand:
• Consequences of diabetes in older adults
• Pre-diabetes and diabetes and how to establish
these diagnoses
• Managing hypertension, dyslipidemia, and
microvascular complications in patients with diabetes
• The importance of individualized diabetes
management for different types of patients
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TO P I C S C O V E R E D
• Epidemiology of Diabetes in Older Adults
• Pathophysiology of Diabetes in Older Adults
• Diagnosis & Evaluation of Diabetes
• Prevention of Diabetes
• Managing Diabetes and Its Complications
• Interventions for Diabetes Care
 Control of Co-Morbid Illness
 Education and Self-Management Support
 Medications
EPIDEMIOLOGY OF DIABETES
IN OLDER ADULTS (1 of 2)
• One of the most common chronic diseases affecting
older adults
• Of people ≥65 years old, 27% have diagnosed or
undiagnosed diabetes
• Age-adjusted prevalence higher among Black and
Hispanic Americans than White Americans
• Black Americans suffer from complications of
diabetes at disproportionately higher rates than White
Americans
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EPIDEMIOLOGY OF DIABETES
IN OLDER ADULTS (2 of 2)
• Older adults with diabetes:
 Have higher rates of vascular complications and
geriatric syndromes, which in turn lead to increased
morbidity and mortality
 Have a 10-year reduction in life expectancy and a
mortality rate nearly twice that of people without
diabetes
 Are at higher risk than those without diabetes for
geriatric syndromes, including incontinence, falls,
frailty, cognitive impairment, and depressive symptoms
 Have a higher prevalence of functional impairment and
disability
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C L A S S I F I C AT I O N O F D I A B E T E S
• Type 1—Results from absolute deficiency in
insulin secretion due to autoimmune destruction
of pancreatic β cells
• Type 2—Usually due to tissue resistance to
insulin action and relative insulin deficiency
• Third category—injuries to the pancreas,
endocrinopathies characterized by excesses of
hormone that antagonize insulin action, drug- or
chemical-induced diabetes, and infections that
destroy β cells
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PAT H O P H Y S I O L O G Y O F D I A B E T E S
I N O L D E R A D U LT S
• About 90% of older adults have Type 2 diabetes
 Diagnosis usually follows years of “pre-diabetes”
(glucose intolerance, insulin resistance, metabolic
syndrome)
 Pre-diabetes itself raises the risk of atherosclerosis
• Prevalence of both type 2 diabetes and glucose
intolerance increases with age
 Genetics
 Certain medications
 Lifestyle
 Concurrent illnesses
 Influence of aging
 Other physiologic stresses
F O U R WAY S TO E S TA B L I S H T H E
DIAGNOSIS OF DIABETES
• HbA1c ≥6.5% using an assay standardized to the NGSP
• Symptoms of polyuria, polydipsia, and unexplained
weight loss plus casual plasma glucose ≥200 mg/dL
• Plasma glucose after an 8-hour fast ≥126 mg/dL
• Plasma glucose ≥200 mg/dL measured 2 hours after
ingestion of 75 g glucose in 300 mL water, administered
after an overnight fast
• Must be confirmed, on a subsequent day, preferably by
the same method
• None of the diagnostic criteria include any adjustments
for age.
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DIAGNOSIS OF PREDIABETES
Prediabetes
• Fasting blood glucose = 110–25 mg/dL
• 2 hour plasma glucose of 140–199 mg/dL after a
75 g oral glucose tolerance test (OGTT)
• HbA1c = 5.7%–6.5%
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P R E V E N T I ON O F D I A B E T E S
• Several diabetes prevention trials demonstrated that in
people with impaired glucose tolerance at high risk of
developing type 2 DM, lifestyle modification that focuses
on diet, exercise, and weight loss can delay or prevent
progression to diabetes (SOE=A)
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C L I N I C A L E VA L U AT I O N
O F O L D E R A D U LT S W I T H D I A B E T E S
• Evaluate risk factors for atherosclerotic disease and
presence of comorbid diseases
• Take thorough medication history
• Assess functional status
• Screen for common geriatric syndromes: Urinary
incontinence, falls, pain, cognitive impairment, and
depression are more common in older adults with
diabetes (SOE=B).
• Assess need for education and self-management
support, and whether to involve a caregiver
GOALS OF DIABETES
MANAGEMENT (1 of 2)
Goals should be individualized clinical targets for each
older adult with diabetes, involving the caregiver when
appropriate
Management Goals Include:
• Control hyperglycemia and its symptoms
• Evaluate and treat associated risks for atherosclerotic and
microvascular disease
• Evaluate and treat diabetes complications
• Avoid hypoglycemia
• Support diabetes self-management and education
• Maintain or improve general health status
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GOALS OF DIABETES
MANAGEMENT (2 of 2)
• Must consider life expectancy and the time needed for
clinical benefit from a specific intervention in treating
older adults with diabetes
• Clinical trials have demonstrated that: (SOE=A)
 Greater than 8 years are needed before the benefits of glycemic
control are reflected in reduced microvascular complications
such as diabetic retinopathy or kidney disease
 Only 2–3 years are required to see benefits from better control of
blood pressure and lipids
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GENERAL PRINCIPLES
OF DIABETES MANAGEMENT
• Healthy, functional older adults: Management should
be directed toward reducing risks associated with
diabetes and treating comorbid conditions
• For some older patients, intensive management is
not likely to provide benefit and may even be harmful
• Patients with intermediate health status should
participate in management decisions based on their
preferences and available evidence
• Diabetes management goals and clinical targets
should be individualized
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I N T E RV E N T I O N S I N D I A B E T E S
MANAGEMENT (1 of 2)
• Evidence (SOE=A) supports the effectiveness of several
components of diabetes care:
 Control of lipids and blood pressure
 Smoking cessation
 Appropriate eye and foot care
 Diabetes education and self-management support for
medication adherence
 Appropriate nutrition
 Weight loss, if indicated
 Increased physical activity
• Home monitoring of blood glucose has not been found to
be cost-effective (SOE=A).
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I N T E RV E N T I O N S I N D I A B E T E S
MANAGEMENT (2 of 2)
• Older adults with diabetes should undergo ageappropriate prevention interventions such as influenza
and pneumococcal vaccination
• Careful foot examination is recommended due to lower
extremity infections and amputations being more
common among older adults with diabetes
• Screen for kidney disease by testing for the presence of
albuminuria should be performed at diagnosis and
annually (SOE=C)
 If a patient is taking an ACE inhibitor or angiotensin-receptor
blocker, there is no need for continued screening (SOE=D)
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E D U C AT I O N A N D
SELF-MANAGEMENT SUPPORT (1 of 2)
• If the patient is clinically complex, consider
referral to a diabetes educator, disease
management program, or specialty physician
care
• Annual diabetes self-management training is
covered under Medicare Part B
• Involve and educate a caregiver if the patient
is cognitively impaired, significantly disabled
or frail, or has limited proficiency in English
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E D U C AT I O N A N D
SELF-MANAGEMENT SUPPORT (2 of 2)
Educate patients and caregivers about:
• Hypo- and hyperglycemia—precipitating factors,
prevention, symptoms, monitoring, treatment, when
to notify the physician
• Blood glucose self-monitoring, when appropriate
• Diet and physical activity
• Medications—purpose of drug, how to take it,
common side effects, important adverse reactions
• Foot care
PREVENTING AND MANAGING
CARDIOVASCULAR RISK FACTORS
Counsel the patient regarding:
• Maintaining appropriate weight
• Increasing physical activity
• Discontinuing smoking
• Limiting fat and carbohydrate intake
Consider drug therapy to:
• Treat hypertension
• Prevent MI (ie, aspirin)
• Treat dyslipidemia
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MANAGING HYPERTENSION IN OLDER
A D U LT S W I T H D I A B E T E S ( 1 o f 2 )
• The best target blood pressure (BP) for older diabetic
patients is unclear
• For healthier patients, with few comorbidities and
functional limitations, a target BP of 120–140 systolic
and 70–80 diastolic may be ideal
• Some older adults may not be able to tolerate
aggressive blood pressure lowering and harms may
outweigh the benefits of treatment
 Orthostatic hypotension leading to a fall and potential hip
fracture resulting in functional limitations
• Must use a patient-centered approach when deciding
on treatment of blood pressure
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MANAGING HYPERTENSION IN OLDER
A D U LT S W I T H D I A B E T E S
• Lower BP gradually to avoid complications
• Most antihypertensive drug classes have comparable
effectiveness
• ACE inhibitors (SOE= A) and angiotensin II receptor
blockers (SOE=B) have cardiovascular and renal
benefits for people with diabetes
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MANAGING DYSLIPIDEMIA IN
O L D E R A D U LT S W I T H D I A B E T E S ( 1 o f 2 )
• Dyslipidemia should be corrected if reasonable
considering the patient’s overall health
• Measure ALT within 12 weeks of initiation or dose
increase of a statin or niacin
• Measure liver enzymes annually after initiation or
dose increase of a fibrate
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MANAGING DYSLIPIDEMIA IN
O L D E R A D U LT S W I T H D I A B E T E S ( 2 o f 2 )
• In 2013, guidelines from the AHA, ACC, and the NHLBI stated
that there is little evidence that treating to a specific LDL
target is beneficial
• Specific to older adults they recommended:
 For older adults with diabetes age 40–75 and LDL between 70–
189 mg/dL, high-dose statins are recommended for those with
10-year atherosclerotic cardiovascular disease (ASCVD) risk
>7.5% and moderate-dose statins for those with ASCVD risk
<7.5%
 Continuation of statins beyond age 75 is warranted
 Unclear whether starting statins for primary prevention is
beneficial for those >75 year old
• Imperative to use a patient-centered approach and shareddecision making process before starting any medication
M A N A G I N G H Y P E R G LY C E M I A I N
O L D E R A D U LT S W I T H D I A B E T E S
• No evidence that intensive hyperglycemia management
(HbA1c ≤ 6.5%) prevents cardiovascular disease in
older adults with established diabetes (SOE=A)
• A1c targets are still actively debated
 Levels can vary from 7.0%–8.5% for different
patients, depending on health status, preferences,
and individualized management plan
• Older adults are at higher risk for hypoglycemia, so
choose medications with less risk when possible
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NON-INSULIN AGENTS: ORAL (1 of 2)
Class (Agents)
Percent of
HbA1c Lowering
Biguanide (Metformin)
12
2nd-generation
Sulfonylureas
(Glimepiride, glipizide,
glyburide)
α-Glucosidase Inhibitors
(Acarbose, miglitol)
DPP-4 Enzyme Inhibitors
(Alogliptin, linagliptin,
sitagliptin, saxagliptin)
12
0.5–1
0.5–1
Comments (Metabolism)
Decreases hepatic glucose
production; does not cause
hypoglycemia
Increase insulin secretion; can
cause hypoglycemia and
weight gain
Delay glucose absorption; can
cause hypoglycemia and
weight gain
Protect and enhance
endogenous incretin
hormones; do not cause
hypoglycemia; weight neutral
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NON-INSULIN AGENTS: ORAL (2 of 2)
Class (Agents)
Meglitinides (Nateglinide,
repaglinide)
Thiazolidinediones
(Pioglitazone,
rosiglitazone)
SGLT2 Inhibitors
(Canagliflozin,
dapagliflozin,
empagliflozin)
Other (Bromocriptine,
colesevelam)
Percent of
HbA1c Lowering
12
0.51.5
0.51.5
0.5
Comments (Metabolism)
Increase insulin secretion;
can cause hypoglycemia and
weight gain
Insulin resistance reducers;
increased risk of heart failure;
avoid if NYHA Class III or IV
cardiac status; discontinue if
any decline in cardiac status;
weight gain
Decrease glucose reabsorption
from kidney
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NON-INSULIN AGENTS: INJECTABLE
Class (Agents)
GLP-1 receptor agonists
(Exenatide, liraglutide,
albiglutide, dulaglutide)
Amylin analogue
(Pramlintide)
Percent of
HbA1c Lowering
0.71
0.40.7
Comments (Metabolism)
Less likely to cause
hypoglycemia than insulin or
sulfonylureas; can cause
weight loss; risks include acute
pancreatitis and possibly
medullary thyroid cancer
Nausea common; reduce premeal dose of short-acting
insulin by 50%
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INSULIN PREPARATIONS (1 of 3)
Onset
Peak
Duration
Doses
per day
Insulin glulisine (Apidra)
20 min
0.5–1.5 h
3–4 h
3
Insulin lispro (Humalog)
15 min
0.5–1.5 h
3–4 h
3
Insulin aspart (NovoLog)
30 min
1–3 h
3–5 h
3
Inhaled (Afrezza)a
15 min
1h
3–4 h
3
Preparation
Rapid-acting
a Available
as 4-unit and 8-unit single-use cartridges administered by
inhalation.
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INSULIN PREPARATIONS (2 of 3)
Preparation
Onset
Peak
Duration
Doses
per day
Regular
(eg, Humulin, Novolin)a
0.5–1 h
2–3 h
5–8 h
1–3
1–1.5 h
4–12 h
24 h
1–2
Insulin detemir (Levemir)
3–4 h
6–8 h
6–24 hb
1–2
Insulin glargine (Lantus)
2–4 h
---
24 h
1
Intermediate or long-acting
NPH (eg, Humulin,
Novolin)a
a
Also available as mixtures of NPH and regular in 50:50 proportions.
b Depending on dose.
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INSULIN PREPARATIONS (3 of 3)
Onset
Peak
Duration
Doses
per day
Isophane insulin and
regular insulin injectable
(Novolin 70/30)
See
indiv.
drugs
2–12
24
1–2
Insulin lispro protamine
suspension and insulin
lispro (Humalog mix
50/50; 75/25)
See
indiv.
drugs
Preparation
Combinations
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C H O O S I N G W I S E LY 
• Avoid using medications to achieve hemoglobin A1c <7.5% in most
adults ≥65 years old; moderate control is generally better.
• There is no evidence that using medications to achieve tight glycemic
control in most older adults with type 2 diabetes is beneficial. Among
non-older adults, except for long-term reductions in myocardial
infarction and mortality with metformin, using medications to achieve
glycated hemoglobin levels less than 7% is associated with harms,
including higher mortality rates. Tight control has been consistently
shown to produce higher rates of hypoglycemia in older adults. Given
the long timeframe to achieve theorized microvascular benefits of tight
control, glycemic targets should reflect patient goals, health status, and
life expectancy. Reasonable glycemic targets would be 7.0–7.5% in
healthy older adults with long life expectancy, 7.5–8.0% in those with
moderate comorbidity and a life expectancy <10 years, and 8.0–9.0%
in those with multiple morbidities and shorter life expectancy.
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S U M M A RY
• Both diabetes and pre-diabetes are important to identify
and address
• Because of the great heterogeneity in older population,
treatment goals for diabetes must be individualized
• Although the target is debated, attempts to lower BP, as
tolerated, are important for older hypertensive patients
with diabetes
• Diabetes self-management is an important part of
diabetes care, and annual self-management training is
covered by Medicare Part B
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CASE 1 (1 of 3)
• An 81-year-old man who lives in a nursing home is seen
for a monthly evaluation.
• History: moderate dementia, diabetes mellitus
• Medications: metformin 850 mg three times daily,
glipizide 10 mg twice daily
 This regimen has been stable for several months.
 Values from twice-daily fingerstick monitoring have been between
150 mg/dL and 220 mg/dL for 6 months.
• His most recent hemoglobin A1c value was 8.1%
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CASE 1 (2 of 3)
Which one of the following is the most appropriate next
step?
(A) Stop fingerstick monitoring.
(B) Check fructosamine level.
(C) Increase glipizide to 20 mg twice daily.
(D) Add sitagliptin.
(E) Add insulin glargine at bedtime.
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CASE 1 (3 of 3)
Which one of the following is the most appropriate next
step?
(A) Stop fingerstick monitoring.
(B) Check fructosamine level.
(C) Increase glipizide to 20 mg twice daily.
(D) Add sitagliptin.
(E) Add insulin glargine at bedtime.
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CASE 2 (1 of 4)
• An 82-year-old woman comes to the office, accompanied
by her daughter. The patient lives alone.
• History: diabetes, hypertension, hyperlipidemia
• Medications: lisinopril 20 mg/d, metformin sustainedrelease 1,000 mg/d, atorvastatin 40 mg/d, aspirin 81
mg/d
• The daughter sees her mother most days and notes that
she has been less active recently.
 She seems less interested in her grandchildren and in reading.
 She frequently skips her daily walk.
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CASE 2 (2 of 4)
• Patient’s self-report
 She has been walking less frequently because of poor weather.
 She has no pain with walking and has had no recent falls.
 Her balance has been good and her vision has been stable.
• Retinal screening 18 months ago showed no retinopathy.
• Hemoglobin A1c three months ago was 7.5%.
• Examination
 Blood pressure 145/85 mmHg
 She has lost 1.8 kg (4 lb) since her last visit 6 months ago.
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CASE 2 (3 of 4)
Which one of the following is the most appropriate next
step?
A. Increase lisinopril to 40 mg.
B. Refer for retinal screening.
C. Check hemoglobin A1c level.
D. Screen for depression and cognitive impairment.
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CASE 2 (4 of 4)
Which one of the following is the most appropriate next
step?
A. Increase lisinopril to 40 mg.
B. Refer for retinal screening.
C. Check hemoglobin A1c level.
D. Screen for depression and cognitive impairment.
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GNRS5 Teaching Slides Editor:
Barbara Resnick, PhD, CRNP, FAAN, FAANP, AGSF
GNRS5 Teaching Slides modified from GRS9 Teaching Slides
based on chapter and questions by Sei J. Lee, MD, MAS
Managing Editor:
Andrea N. Sherman, MS
Copyright © 2016 American Geriatrics Society