2018 Clinical Practice GuidelinesDiabetes in Older People
Introduction
This guideline refers primarily to type 2 diabetes in the older person. There is limited information on the management of type 1 diabetes in the elderly, but this is included wherever appropriate. The definition of “older” varies, with some studies defining the elderly population as ≥60 years of age. Administrative guidelines frequently classify people >65 years of age as older. Although there is no uniformly agreed-upon definition of older, it is generally accepted that this is a concept that reflects an age continuum starting sometime around age 70 and is characterized by a slow, progressive impairment in function that continues until the end of life (1). There are many people with type 2 diabetes who are over the age of 70 who are otherwise well, functionally independent/not frail and have at least a decade of healthy life expectancy. These people should be treated to targets and with therapies described elsewhere in this guideline (see Targets for Glycemic Control chapter, p. S42 and Pharmacologic Glycemic Management of Type 2 Diabetes in Adults chapter, p. S88). This chapter focuses on older people who do not fall into any or all of those categories. Decisions regarding therapy should be made on the basis of age/life expectancy and the person's functional status. Where possible, evidence is based on studies where either the main focus was people over the age of 70 years or where a substantial subgroup, specifically reported, were in this age group.
Section snippets
Diagnosis and Screening
As noted in the Definition, Classification and Diagnosis of Diabetes, Prediabetes and Metabolic Syndrome chapter, p. S10, glycated hemoglobin (A1C) can be used as a diagnostic test for type 2 diabetes in adults. Unfortunately, normal aging is associated with a progressive increase in A1C, and there can be a significant discordance between glucose-based and A1C-based diagnosis of diabetes in this age group, a difference that is accentuated by race and gender (2) (see Monitoring Glycemic Control
Reducing the Risk of Developing Diabetes
Healthy behaviour interventions are effective in reducing the risk of developing diabetes in older people at high risk for the development of the disease (3). Acarbose (4), rosiglitazone (5) and pioglitazone 1, 6 also are effective in preventing diabetes in high-risk elderly. Metformin may not be effective (3). Since several of these drugs have significant toxicity in the older adult (see below) and since there is no evidence that preventing diabetes will make a difference in outcomes in these
Organization of care
As interprofessional interventions specifically designed for older adults have been shown to improve glycemic control, referrals to diabetes health-care (DHC) teams should be facilitated 7, 8, 9. Pay-for-performance programs improve a number of quality indicators in this age group 10, 11. Telemedicine case management and web-based interventions can improve glycemic control, lipids, blood pressure (BP), psychosocial well-being and physical activity; reduce hypoglycemia and ethnic disparities in
Hypertension
Treatment of isolated systolic hypertension or combined systolic and diastolic hypertension in older people with diabetes is associated with a significant reduction in CV morbidity and mortality and microvascular events. The number needed to treat (NNT) reduces with increasing age 194, 195, 196, 197, 198. Treatment of isolated systolic hypertension may also preserve renal function in older people with diabetes (199). Several different classes of antihypertensive agents have been shown to be
Diabetes in Long-Term Care
The prevalence of diabetes is high in institutions and individuals frequently have established microvascular and CV complications, as well as substantial comorbidity 236, 237, 238, 239, 240. Canadian data shows over 25% of residents in long-term care facilities (LTC) have type 2 diabetes (241). Although the number of residents living in LTC with type 1 diabetes is unknown, a growing prevalence is noted as a result of advances of glucose management and adults being diagnosed with type 1 diabetes
Other Relevant Guidelines
Screening for Diabetes in Adults, p. S16
Reducing the Risk of Developing Diabetes, p. S20
Organization of Diabetes Care, p. S27
Self-Management Education and Support, p. S36
Targets for Glycemic Control, p. S42
Glycemic Management in Adults With Type 1 Diabetes, p. S80
Pharmacologic Glycemic Management of Type 2 Diabetes in Adults, p. S88
Hypoglycemia, p. S104
Screening for the Presence of Cardiovascular Disease, p. S170
Dyslipidemia, p. S178
Treatment of Hypertension, p. S186
Sexual Dysfunction and
Relevant Appendix
Appendix 7. Therapeutic Considerations for Renal Impairment
Literature Review Flow Diagram for Chapter 37: Diabetes in Older People
*Excluded based on: population, intervention/exposure, comparator/control or study design.
From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(6): e1000097. doi:10.1371/journal.pmed1000097 (255).
For more information, visit //www.prisma-statement.org
Author Disclosures
Dr. Meneilly reports personal fees from Merck, Novo Nordisk, and grants from Sanofi, outside the submitted work. Dr. Miller reports personal fees from AstraZeneca, Eli Lilly, Novo Nordisk, and Sanofi; grants and personal fees from Boehringer Ingelheim, Janssen, and Merck, outside the submitted work. Dr. Sherifali reports investigator-initiated funding from AstraZeneca. Dr. Tessier has received honoraria from Merck, AstraZeneca, Boehringer Ingelheim, and Elli Lilly. Dr. Zahedi has received
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The Canadian Diabetes Association is the registered owner of the name Diabetes Canada.
Conflict of interest statements can be found on page S290.