The message is clear, a high prevalence of our older population is living with diabetes and this number is expected to grow rapidly in the coming decades.

• Over a quarter (25.9%) of Americans age 65 or older have diabetes (diagnosed and undiagnosed). That’s 11.8 million seniors. See more info »
• According to CDC Stats 2011, twenty percent of newly diagnosed cases of diabetes were in the age range 65–79 years.
• Adults 75 years or older, have the highest rates of complications including myocardial infarction, amputations, visual impairment and kidney disease of any other age group.
• The prevalence of diabetes will double in the next 20 years, in part due to the aging population (ADA Consensus Statement)

When does old age start?
As a diabetes specialist working with mainly retirees, I frequently consider this question. I counsel many 60 year olds who perceive themselves as unhealthy and burdened by one or more chronic diseases. On the other hand, I have met with many octogenarians with diabetes and multiple conditions, who report their health as good to excellent.  

According to the World Health Organization, “The aging process is a biological reality which has its own dynamic, largely beyond human control. However, it is also subject to the constructs by which each society makes sense of old age.

In the developed world, chronological time plays a paramount role. The age of 60 or 65, roughly equivalent to retirement age in most developed countries, is said to be the beginning of old age.

In many parts of the developing world, chronological time has little or no importance in the meaning of old age. Old age is seen to begin at the point when active contribution is no longer possible.” (Gorman, 2000).

As with all patients, we first consider the individual, their strengths and limitations, and age is just one aspect of our overall assessment.

The following list highlights the ADA 2016 Standards of Care for Older Adults:

• Start with a thorough assessment – During the initial interview, ask questions to reveal medical, functional, mental and social domains. This will help to provide a framework to determine realistic targets and best treatment approaches.

• Pay special attention to complications and social issues that can quickly and significantly impair functional status – problems such as hypoglycemia, lower extremity complications, visual impairment, dementia and balance issues are paramount to evaluate.

  In addition, the inability to afford diabetes medication, food and shelter, can quickly lead to uncontrolled glucose levels.  Many older patients may be reluctant to share their financial struggles, but some well phrased questions by the interviewer, can provide  opportunities for sharing and collaborative problem solving.

• Treatment Goals – Realizing that older adults have a wide variety of clinical and functional presentations, treatment goals for are adjusted based on:

  • Length of time living with diabetes (new onset, undiagnosed for many years or longer history)

  • Presence or absence of complications

  • Comorbidities

  • Degree of frailty

  • Cognitive function

  • Life expectancy (often longer than expected)

  • Functional status

Treatment Goals Based on Patient Status

Healthy Patients with Good Functional Status

Patients with good cognitive and physical function, who are expected to live long enough to reap the benefits of long term intensive management, can collaborate with providers to set more intensive glucose, blood pressure and cholesterol goals. Ongoing follow-up to evaluate safety is imperative. 

• Reasonable A1c goal <7.5%, 
• Fasting BG 90 – 130 
• Blood Pressure < 140/90 
• Statin unless contraindicated or not tolerated

Patients with Complications and Reduced Functionality –

For patients with advanced diabetes complications, life-limiting illnesses, or substantial cognitive and functional impairment, goals can be less intensive. These groups of patients are less likely to benefit from reduced risk of microvascular complications and are at higher risk of hypoglycemia, hypotension and adverse effects from taking a mountain of pills daily. 

For this group of patients, DE-Intensification of therapy should be considered.

Careful attention is still given to reaching goals, however they are more relaxed and adjusted based on shared decision making and safety.

• Reasonable A1c goal <8.0%, 
• Fasting BG 90 – 150 
• Blood Pressure < 140/90 
• Statin unless contraindicated or not tolerated

Very Complex Patients with Poor Health  

For patients with limited life expectancy and end stage chronic illnesses or moderate-to-severe chronic functional or cognitive issues, the focus is on quality of life and avoidance of hyperglycemic crisis.

• Reasonable A1c goal <8.5%, 
• Fasting BG 100 – 180 
• Blood Pressure < 150/90 
• Consider likely benefit of statin unless contraindicated or not tolerated

View summary chart of goals  >> 

For all these situations, a patient-centered approach and shared decision making can help establish goals and treatment strategies that are reasonable for the patient, family and provider.

You can earn 1.5 CE on our Online University – Older Adults with Diabetes Course >>. 

Further reading:

“Some Older Patients Are Treated Not Wisely, but Too Much,” This 2015 New York Times article raises important concerns about the over treatment of people with diabetes;

Less in More | Appropriate Prescribing for Patients With Diabetes at High Risk for Hypoglycemia – National Survey of Veterans Affairs Health Care Professionals published in JAMA, 2015. In older people with diabetes, for instance, maintaining very low blood sugar — often called “tight control” — can do more harm than good. “People can feel fatigued and weak, get cold sweats, feel like they’re going to pass out,” said Dr. Tanner Caverly, lead author of the Michigan survey.

Rates of Deintensification of Blood Pressure and Glycemic Medication Treatment Based on Levels of Control and Life Expectancy in Older Patients With Diabetes Mellitus – JAMA, December 2015. Conclusions and Relevance  Among older patients whose treatment resulted in very low levels of HbA1c or BP, 27% or fewer underwent deintensification, representing a lost opportunity to reduce overtreatment. Low HbA1c or BP values or low life expectancy had little association with deintensification events. Practice guidelines and performance measures should place more focus on reducing overtreatment through deintensification.

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