Sponsored by:

Donald W. Reynolds Foundation

Arizona Geriatric Education Center

November 2008 (updated June 2010)

ELDER CARE 
A Resource for Interprofessional Providers

Diabetes – Special Considerations for Older Adults

Barry D. Weiss, MD, College of Medicine, University of Arizona
Diabetes is common in older people. National data show Inexpensive medications with simple dosing schedules,
that at least 1 in 7 older adults has diabetes, and in some short half lives, and few side effects and drug-drug
racial and ethnic groups the rate is as high as 1 in 4. interactions are the best choices for older adults.
Most providers are familiar with practice guidelines for Blood Pressure and Lipid Control
glycemic control in diabetes, but there are many issues in
Research has shown that it takes about 8 years of good
diabetes care that require special considerations when
glycemic control to reduce the rate of diabetes-related
dealing with geriatric patients. The American Geriatrics
vascular complications. It only takes 2-3 years, however,
Society (AGS) has issued guidelines for improving the
to see a similar benefit from blood pressure and lipid
care of older people with diabetes, and this newsletter
control. The AGS guidelines thus emphasize blood
will highlight some of the key points in the AGS and other
pressure and lipid control as a way to reduce vascular
pertinent related guidelines.
complications in people with diabetes (Table 1).
Glycemic Control Blood Pressure Control Current guidelines recommend a
The glycemic control target for otherwise healthy older target blood pressure below 130/80 mm Hg for patients
adults with diabetes is a hemoglobin A1c (A1C) level < with diabetes. Many antihypertensive drugs are
7%. However, the risks of hypoglycemic complications effective, including diuretics, angiotensin-converting
that accompany such tight control outweigh the potential enzyme (ACE) inhibitors, beta-blockers, calcium channel
benefits for frail older adults and people with a life blockers, and angiotensin-receptor blockers (ARBs).
expectancy of less than 5 years. For such individuals, a Because of the renal-protective effective of ACE
less-stringent goal of 8% is more appropriate. inhibitors, many experts recommend that the
antihypertensive medication regimen for diabetic patients
AIC should be measured at least every 6 months for
include these drugs. If ACE inhibitors, ARBs, or diuretics
patients who are not at goal. For those with a stable A1C
are prescribed, the AGS guidelines recommend that renal
level, annual measurements are appropriate. function and potassium levels be checked within 1-2
When prescribing diabetic medications to older adults, weeks after starting therapy. The guidelines also
several specific issues must be considered. Metformin can recommend checking these parameters 1-2 weeks after
cause metabolic acidosis, and is not recommended as a every dose increase, and at least yearly.
routine therapy for people over 80. If a sulfonylurea is
Lipid Control The AGS guidelines set a target low-
used, glipizide is preferable to glyburide because
density lipoprotein (LDL) level for diabetic patients, at
glipizide has a shorter half life. Insulin therapy, the gold
<100 mg/dL. For patients with diabetes or those with
standard for glycemic control, is often not practical for
known coronary disease, the National Cholesterol
older individuals due to vision problems or hand arthritis
Education Program recommends a goal of <70 mg/dL.
that limits the dexterity needed to draw up and inject the
Liver function tests should be measured after 3 months on
drug. Prefilled insulin pens are an excellent option for
starting statin therapy and with dose increases.
older adults, but often are not covered by insurance.
TIPS FOR THE MANAGEMENT OF DIABETES IN OLDER ADULTS
 Emphasize good blood pressure and lipid control. For older adults, good control of blood pressure and lipids has more benefit
for reducing the risk of vascular disease than does tight glycemic control.
 While the goal for glycemic control in most older adults is the same as for younger people (A1C <7%), accept less stringent
glycemic control goals (eg. A1C < 8%) for frail older adults and those with limited life expectancy.
 Unless contraindicated, most older diabetics should be on daily aspirin for cardiac protection, a statin for lipid control, and an
ACE or ARB as part of their blood pressure control regimen.
 Annual foot and eye exams, and screening for microalbuminuria, should be a part of all diabetic preventive care.
Continued from front page ELDER CARE 
Diabetic Education Data from randomized-controlled syndromes than older adults without this disease. Syn-
trials indicates that glycemic control is improved, and dromes include falls, chronic pain, urinary incontinence,
rates of hypoglycemic episodes are reduced, when older cognitive impairment, depression, and polypharmacy.
adults participate in multidisciplinary diabetes education. Table 2 outlines the intervals at which the AGS guidelines
Annual diabetes education is covered under Medicare recommend screening for these syndromes, along with the
Part B. recommended screening tool.
Aspirin The rate of myocardial infarction is reduced in As always in geriatrics, an individualized approach is the
older adults with diabetes if they take a daily dose of key to proper care. Blood pressure and lipid control are
aspirin. The AGS guidelines thus recommend that older paramount. Relatively good control of blood sugar is im-
adults who have diabetes should be offered daily aspirin portant to prevent metabolic abnormalities, reduce infec-
therapy, assuming there are no contraindications to aspi- tion, and hopefully stem the progression of end organ
rin and the patient is not taking anticoagulant therapy. disease. Routine eye and foot exams are vital preventive
The optimal dose is uncertain, but there is no evidence that care. Simple and inexpensive medication regimens should
high doses are more effective than a dose of 81 mg per be the goal for the older patient, who might not be able
day. to afford non-generic drugs or manage insulin. Take some
extra thought with older diabetics—they are worth it.
Monitoring for Geriatric Syndromes Older adults with
diabetes have a higher risk of several common geriatric

Table 1. Glycemic, Lipid, and Blood Pressure Goals for Older Adults who Have Diabetes
< 7% A1C goal for most older adults
< 8% A1C goal for those who are frail or have limited life expectancy
< 130/80 mm Hg Blood pressure goal for all people with diabetes
< 100 mg/dL LDL goal for diabetics with no other heart disease risk factors
< 70 mg/dL LDL goal for diabetes who have heart disease risks factors in addition to diabetes

Table 2. Screening for Geriatric Syndromes in Older Adults with Diabetes

Syndrome When to Screen Recommended Screening Method
Falls Initial evaluation History
Chronic Pain Initial evaluation History
Urinary Incontinence Initial evaluation and annually History
Initial evaluation and also later if there is an unex-
Cognitive Impairment Mini-Mental State Examination
plained decline in status
Initial evaluation and also later if there is an unex-
Depression Geriatric Depression Scale
plained decline in status
If patient experiences new onset of falls, urinary inconti-
Polypharmacy Medication review
nence, cognitive impairment, or depression

References and Resources

California Healthcare Foundation/American Geriatrics Society Panel on Improving Care for Elders with Diabetes. Guidelines for improving the care of the older person
with diabetes. Journal of the American Geriatrics Society. 2003; 51:S265-280.
Grundy SM, et al. Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. Circulation. 2004;110:227-
239. http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3upd04.pdf
Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. 2003. http://www.nhlbi.nih.gov/
guidelines/hypertension/jnc7full.pdf
Wenger, NS, et al. Introduction to the assessing care of vulnerable elders-3 quality indicator measurement set. Journal of the American Geriatrics Society,
2007. 55: p. S247-S252.

ACOVE Quality Indicators

1. IF a vulnerable elder has diabetes, THEN his or her glycated hemoglobin level should be measured at least every 12 months. 2. IF a diabetic, vulnerable elder
does not have established renal disease and is not receiving an ACE inhibitor or ACE receptor blocker, THEN he or she should receive an annual test for proteinuria. 3.
IF a diabetic, vulnerable elder has proteinuria, THEN he or she should be offered therapy with an ACE inhibitor or ACE receptor blocker. 4. IF a diabetic, vulnerable
elder is not blind, THEN he or she should receive an annual dilated eye examination performed by an ophthalmologist, optometrist, or diabetes specialist.

Interprofessional care improves the outcomes of older adults with complex health problems
Editors: Rosemary Browne, MD; Mindy Fain, MD; and Barry D. Weiss, MD
Interprofessional Associate Editors: Karen D’Huyvetter, ND, MS; Carol Howe, MD, MLS; Colleen Keller, PhD, FNP;
Teri Kennedy, PhD, LCSW, MSW; Jeannie Lee, PharmD, BCPS; Jane Mohler, NP, MPH, PhD; Lisa O’Neill, MPH
The University of Arizona, PO Box 245069, Tucson, AZ 85724-5069 | (520) 626-5800 | http://aging.medicine.arizona.edu
Supported by: Donald W. Reynolds Foundation, Arizona Geriatric Education Center and Arizona Center on Aging