The goals of diabetes management in older people (defined by the Guidelines as about age 70 or older) is distinct from diabetes in younger people, especially for those who are frail or dependent on others for care.
One of the highest priorities in the older person with diabetes (as for all people with diabetes) is the avoidance of hypoglycemia (low blood sugars), which can be a side effect of some diabetes medications. Older people are less likely to feel symptoms of low sugars, and their bodies are less able to respond to low sugars (due to reduced glucagon secretion), putting them at even higher risk of severe hypoglycemia.
Many of the recommendations in this chapter of the 2018 Guidelines are focused on the principle of avoiding low sugars in older people with diabetes, upping the emphasis on this even above what was already stated in the last edition of the Guidelines.
NEW: There is now more guidance as to what A1C target may be considered, depending on a patient’s level of independence and frailty.
The recommended targets for older people with diabetes are:
- Functionally independent: A1C 7% or less, premeal sugars 4-7 mmol/L, post meal 5-10
- Functionally dependent: A1C less than 8%, premeal 5-8, post meal less than 12
- Frail and/or with dementia: A1C less than 8.5%, premeal 6-9, post meal less than 14
- End of life: avoid low sugars, and avoid symptomatic high sugars
The 2018 Guidelines continue to advise caution in using sulphonylureas in the elderly because of risk of hypoglycemia. Now, there is a NEW Key Recommendation that DPP4 inhibitors should be used over sulphonlyureas because of a lower risk of hypoglycemia.
Other highlights from the Key Recommendations:
NEW DETAILS: Functionally independent older people with diabetes who have a life expectancy of greater than 10 years should be treated to achieve the same glucose, BP and lipid targets as younger people with diabetes.
BP targets should be individualized for older adults who are functionally dependent, or who have orthostasis, or who have a limited life expectancy. (may wish to target a slightly higher BP than the usual target of less than 130/80)NEW:
In older people with type 2 diabetes with no other complex comorbidities but with clinical cardiovascular disease, and in whom glycemic targets are not met, consider a diabetes medication that decreases the risk of cardiovascular events (same as for the type 2 diabetes population in general, see here
There are new Key Messages For Older People With Diabetes
, which reflect the above points: that every older person with diabetes needs a customized diabetes care plan, and that your diabetes health care team will work with you to set blood sugar control targets, choose appropriate glucose lowering medication, and a program for screening and management of diabetes related complications.Follow me on twitter! @drsuepedersen