From the Adult Diabetes and Clinical Research sections, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts. This guideline was revised and approved May 17, 2017, and updated February 7, 2018.
Objective: The Joslin Guideline for the Care of the Older Adult with Diabetes is designed to assist primary care physicians, specialists, and other healthcare providers in addressing the unique challenges and issues of the older person with diabetes. The guideline should be used in conjunction with Joslin’s Clinical Guideline for Adults with Diabetes as well as Joslin’s Clinical Guideline for Pharmacological Management of Adults with Type 2 Diabetes (T2D).
The primary goal of diabetes management in older adults is to achieve balance between optimal glycemic control to prevent and/or slow the onset and progression of acute and chronic complications, while avoiding hypoglycemia and its consequences. Hypoglycemia can result in worse outcomes in older adults as it can lead to traumatic falls and worsening of chronic conditions such as cognitive dysfunction. Therefore, in many cases, aggressive treatment may not be appropriate if the older adult’s comfort, safety, and overall quality of life are thereby compromised, or if aggressive treatment may not improve outcomes. Recent consensus on the management of diabetes recommends individualization of treatment goals based on coexisting medical conditions, cognitive status, functionality, and available resources. The older adult’s view on illness, health, and aging should also be considered. Appropriate support systems for complex diabetes are not uniformly available nationwide. As a result, treatment decisions become more complex as the capacity to cope with self-care declines.
To assist with self-care, education strategies also require adaptation for aging. Learning new diabetes self-management skills may be difficult for older people, increasing the need for education to proceed in a simple, step-like manner. Cognitive dysfunction, depression, and functional disabilities (such as vision and hearing deficits and a decline in dexterity) are important issues to consider when assessing the older adult’s ability for self-care. Involvement of family members or friends may be required to assure appropriate self-care and adherence to treatment programs.
Portions of this guideline are based upon recommendations of the International Diabetes Federation’s Global Guideline for Managing Older People with Type 2 Diabetes and the American Diabetes Association/American Geriatrics Society Consensus Report on Diabetes in Older Adults.
The table in this guideline (Table 1) lists a group of conditions collectively called geriatric syndrome, which occurs more frequently in older adults with diabetes. These conditions can interfere with a patient’s ability to perform self-care activities and make healthcare more challenging for the older adult and for their caregivers. The table below includes the condition, possible clinical presentations, commonly used short clinical screening tests, and suggested modifications to treatment plans and goals to compensate for the condition.See Joslin’s Clinical Guideline for Adults with Diabetes (Chapter 1) for more details.
CDC data indicate that about half of older adults have prediabetes. It is recommended that all adults >45 years of age be screened for diabetes every 1 to 3 years using a glycated hemoglobin (A1C), fasting glucose, or oral glucose tolerance test. This recommendation should be modified for those with shorter life expectancies and those with multiple comorbidities.See Joslin’s Clinical Guideline for Adults with Diabetes for more details. Treatment goals are modified for health status, based on recommendations from the American Diabetes Association.
Treatment goals for A1C, glucose, blood pressure, and lipid levels should be modified for the older adult based on patient characteristics and on health status. See Table 2 below.Education strategies require adaptation for aging. Simplify and focus programs:
Although diabetes nutritional guidelines for the older adult are no different than for younger adults, unique challenges often exist due to:
4.9.1 Nutritional recommendations:
Consider referral to a dietitian to work with the older adult patient and caregivers to:
4.9.2 Weight loss/potential malnutrition:
4.9.3 Chronic care settings:
4.10.1 Benefits of activity:
Physical activity should be stressed in all older adults as it is crucial in maintaining functionality, independence, and acceptable quality of life.
4.10.3 Challenges to consider:
General principles to consider when prescribing medications to an older adult include:
4.11.1 Overtreatment of diabetes
is common in older adults and should be avoided.
4.11.2 Oral glucose-lowering medications: (Table 3)
Please also refer to Joslin’s Clinical Guideline for Pharmacological Management of Adults With Type 2 Diabetes (Chapter 1) for more detailed information on diabetes medications.
4.11.3 Injectable noninsulin antidiabetic medications (Table 4)
4.11.4 Insulin products (Table 5)
4.12.1 Antihypertensive drugs (Table 6)
4.13.1 Lipid-lowering medications (Table 7)
Recommendations for eye examinations and treatment in older adults with diabetes are the same as those recommended in Joslin’s Clinical Guideline for Adults with Diabetes.