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care, fall prevention, and early detection of\ndepression will improve quality of life.\nWhile Table 13.1 provides overall guid-\nance for identifying complex and verycomplex patients, there is not yet globalconsensus on geriatric patient classi fica-\ntion. Ongoing empiric research on the\nclassification of older adults... | [
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classification of older adults with diabetes\nbased on comorbid illness has repeatedly | [
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based on comorbid illness has repeatedly\nfound three major classes of patients: ahealthy, a geriatric, and a cardiovascularclass (9,61,66). The geriatric class has thehighest prevalence of obesity, hyperten-sion, arthritis, and incontinence, and thecardiovascular class has the highest prev-alence of myocardial infarct... | [
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failure, and stroke. Compared with the\nhealthy class, the cardiovascular class hasthe highest risk of frailty and subsequentmortality. Additional research is neededto develop a reproducible classifi cation\nscheme to distinguish the natural history\nof disease as well as differential response\nto glucose management and... | [
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to glucose management and speci fic\nglucose-lowering agents (67).\nVulnerable Older Adults at the End of\nLife\nFor people with diabetes receiving pallia-\ntive care and end-of-life care, the focusshould be to avoid hypoglycemia andsymptomatic hyperglycemia while reduc-ing the burdens of glycemic management.Thus, as or... | [
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agents will have to be deintensi fied or dis-\ncontinued. For a dying person, most agents\nfor type 2 diabetes may be removed (68).There is, however, no consensus for themanagement of type 1 diabetes in thisscenario (69). See the section\nEND-OF-LIFE\nCAREbelow for additional information.\nBeyond Glycemic Management | [
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CAREbelow for additional information.\nBeyond Glycemic Management\nAlthough minimizing hyperglycemia maybe important in older individuals with di-abetes, greater reductions in morbidity\nand mortality are likely to result from a\nclinical focus on comprehensive cardio-vascular risk factor modifi cation. There is | [
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strong evidence from clinical trials of thevalue of treating hypertension in olderadults (70,71), with treatment of hyper-tension to individualized target levels in-dicated in most. There is less evidence\nfor lipid-lowering therapy and aspirin\ntherapy, although the benefi ts of these | [
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therapy, although the benefi ts of these\ninterventions for primary and secondaryprevention are likely to apply to olderTable 13.1 —Framework for considering treatment goals for glycemia, blood pressure, and dyslipidemia in older adults with\ndiabetes\nCharacteristics and\nhealth status of person\nwith diabetes Rational... | [
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with diabetes RationaleReasonable A1C\ngoal*Fasting or\npreprandial\nglucose Bedtime glucoseBlood\npressure Lipids\nHealthy (few coexisting\nchronic illnesses,\nintact cognitive and\nfunctional status)Longer remaining life\nexpectancy<7.0–7.5%\n(<53–58\nmmol/mol)80–130 mg/dL\n(4.4–7.2\nmmol/L)80–180 mg/dL\n(4.4–10.0\nm... | [
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0.... |
mmol/L)80–180 mg/dL\n(4.4–10.0\nmmol/L)<130/80\nmmHgStatin, unless\ncontraindicated\nor not tolerated\nComplex/intermediate\n(multiple coexistingchronic illnesses †or\ntwo or more\ninstrumental ADL\nimpairments ormild to moderate\ncognitive\nimpairment)Variable life\nexpectancy.Individualize goals,considering:\n/C15Sev... | [
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0.02480... |
/C15Severity ofcomorbidities\n/C15Cognitive and\nfunctional limitations\n/C15Frailty\n/C15Risk-to-bene fit ratio\nof diabetes\nmedications\n/C15Individual preference<8.0%\n(<64 mmol/mol)90–150 mg/dL\n(5.0–8.3\nmmol/L)100–180 mg/dL\n(5.6–10.0\nmmol/L)<130/80\nmmHgStatin, unless\ncontraindicated\nor not tolerated\nVery co... | [
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... |
contraindicated\nor not tolerated\nVery complex/poor\nhealth (LTC or\nend-stage chronicillnesses‡ or\nmoderate to severe\ncognitive impairment\nor two or more ADLimpairments)Limited remaining life\nexpectancy makesbene fit minimalAvoid reliance on\nA1C; glucosecontrol decisionsshould be basedon avoiding\nhypoglycemia\na... | [
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0.03... |
hypoglycemia\nand symptomatichyperglycemia100–180 mg/dL\n(5.6–10.0\nmmol/L)110–200 mg/dL\n(6.1–11.1\nmmol/L)<140/90\nmmHgConsider likelihood\nof bene fit with\nstatin | [
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This table represents a consensus framework for considering treatment goals for glycemia, blood pressure, and dyslipidemia in older adultswith diabetes. The characteristic categories are general concepts. Not every individual will clearly fall into a particular category. Considerationof individual and caregiver prefere... | [
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individual and caregiver preferences is an important aspect of treatment individualization. Additionally, an individual ’s health status and | [
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preferences may change over time. ADL, activities of daily living; LTC, long-term care. *A lower A1C goal may be set for an individual ifachievable without recurrent or severe hypoglycemia or undue treatment burden. †Coexisting chronic illnesses are conditions serious enough | [
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to require medications or lifestyle management and may include arthritis, cancer, heart failure, depression, emphysema, falls, hypertension,incontinence, stage 3 or worse chronic kidney disease, myocardial infarction, and stroke. “Multiple ”means at least three, but many individu- | [
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als may have five or more (74). ‡The presence of a single end-stage chronic illness, such as stage 3 –4 heart failure or oxygen-dependent lung\ndisease, chronic kidney disease requiring dialysis, or uncontrolled metastatic cancer, may cause signi ficant symptoms or impairment of func- | [
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tional status and signi ficantly reduce life expectancy. Adapted from Kirkman et al. (3).S248 Older Adults Diabetes Care Volume 47, Supplement 1, January 2024\n©AmericanDiabetesAssociation | [
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adults whose life expectancies equal or\nexceed the time frames of the clinical\ntrials (72). In the case of statins, thefollow-up time of clinical trials rangedfrom 2 to 6 years. While the time frameo ft r i a l sc a nb eu s e dt oi n f o r mt r e a t m e n tdecisions, a more specifi cc o n c e p ti st h e\ntime to ben... | [
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time to bene fit for a therapy. For statins,\na meta-analysis of the previously men-tioned trials showed that the time tobenefiti s2 . 5y e a r s( 7 3 ) .\nLIFESTYLE MANAGEMENT\nRecommendations\n13.12 Optimal nutrition and protein in-\ntake is recommended for older adults | [
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take is recommended for older adults\nwith diabetes; regular exercise, includ-ing aerobic activity, weight-bearing exer-cise, and/or resistance training, shouldbe encouraged in all older adults withdiabetes who can safely engage in suchactivities. B\n13.13 For older adults with type 2 di- | [
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13.13 For older adults with type 2 di-\nabetes, overweight/obesity, and ca-pacity to safely exercise, an intensivelifestyle intervention focused on die-\ntary changes, physical activity, and\nmodest weight loss (e.g., 5 –7%) should\nbe considered for its bene fits on qual- | [
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be considered for its bene fits on qual-\nity of life, mobility and physical func-tioning, and cardiometabolic risk factorcontrol. A\nLifestyle management in older adults\nshould be tailored to frailty status. Dia-\nbetes in the aging population is associ-ated with reduced muscle strength, poormuscle quality, and accele... | [
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muscle mass, which may result in sarco-\npenia and/or osteopenia (74,75). Diabe-tes is also recognized as an independentrisk factor for frailty. Frailty is character-ized by decline in physical performanceand an increased risk of poor health out-comes due to physiologic vulnerability\nand functional or psychosocial str... | [
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and functional or psychosocial stressors.\nInadequate nutritional intake, particularlyinadequate protein intake, can increasethe risk of sarcopenia and frailty in olderadults. Management of frailty in diabetesincludes optimal nutrition with adequateprotein intake combined with an exerciseprogram that includes aerobic, ... | [
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bearing, and resistance training. The ben-\nefits of a structured exercise program (as\nin the Lifestyle Interventions and Inde-pendence for Elders [LIFE] study) in frailolder adults include reducing sedentarytime, preventing mobility disability, and | [
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reducing frailty (76,77). The goal of theseprograms is not weight loss but en-hanced functional status.\nFor nonfrail older adults with type 2\ndiabetes and overweight or obesity, anintensive lifestyle intervention designedto reduce weight is bene ficial across\nmultiple outcomes. The Look AHEAD\n(Action for Health in D... | [
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(Action for Health in Diabetes) trial is\nd e s c r i b e di nS e c t i o n8 , “Obesity and\nWeight Management for the Prevention\nand Treatment of Type 2 Diabetes. ”\nLook AHEAD speci fically excluded indi-\nviduals with a low functional status.\nIt enrolled people between 45 and\n74 years of age and required that they | [
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74 years of age and required that they\nbe able to perform a maximal exercisetest (78,79). While the Look AHEAD trialdid not achieve its primary outcome of\nreducing cardiovascular events, the in-\ntensive lifestyle intervention had multipleclinical bene fits that are important to\nthe quality of life of older adults. B... | [
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the quality of life of older adults. Bene-\nfits included weight loss, improved physi-\ncalfitness, increased HDL cholesterol,\nlowered systolic blood pressure, reducedA1C levels, reduced waist circumference,\nand reduced need for medications (80).Additionally, several subgroups, includingparticipants who lost at least 1... | [
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baseline body weight at year 1, had im-\nproved cardiovascular outcomes (81). Riskfactor management was improved withreduced utilization of antihypertensive\nmedications, statins, and insulin (82). In\nage-strati fied analyses, older adults in the\ntrial (60 to early 70s) had similar bene fits\ncompared with younger peop... | [
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compared with younger people (83,84). In\naddition, lifestyle intervention produced\nbenefits on aging relevant outcomes such\nas reductions in multimorbidity and im-provements in physical function and\nquality of life (85 –88).\nPHARMACOLOGIC THERAPY\nRecommendations\n13.14 In older adults with type 2 di-\nabetes, medi... | [
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abetes, medications with low risk\nof hypoglycemia are preferred, es-\npecially for those with hypoglyce-mia risk factors. B\n13.15 Overtreatment of diabetes is\ncommon in older adults and shouldbe avoided. B\n13.16a In older adults with diabetes, | [
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13.16a In older adults with diabetes,\ndeintensify hypoglycemia-causing med-ications (e.g., insulin, sulfonylureas, ormeglitinides) or switch to a medicationclass with low hypoglycemia risk for\nindividuals who are at high risk for hy-\npoglycemia, using individualized glyce-mic goals. B\n13.16b In older adults with di... | [
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13.16b In older adults with diabetes,\ndeintensify diabetes medications forindividuals for whom the harms and/or\nburdens of treatment may be greater\nthan the bene fits, within individualized\nglycemic goals. E\n13.16c Simpli fication of complex\ntreatment plans (especially insulin)is recommended to reduce the risk\nof ... | [
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of hypoglycemia and polypharmacy\nand decrease the treatment burden\nif it can be achieved using the indi-\nvidualized glycemic goals. B\n13.16d In older adults with type 2\ndiabetes and established or high risk\nof atherosclerotic cardiovascular dis-\nease, heart failure, and/or chronic\nkidney disease, the treatment ... | [
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kidney disease, the treatment plan\nshould include agents that reduce\ncardiorenal risk, irrespective of glyce-\nmia. A\n13.17 Consider costs of care and cov-\nerage when developing treatment\nplans in order to reduce risk of cost-\nrelated barriers to medication taking\nand self-management behaviors. B\nSpecial care i... | [
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Special care is required in prescribing\nand monitoring pharmacologic therapies\nin older adults (89). See Fig. 9.3 for gen-\neral recommendations regarding glucose-lowering treatment for adults with type 2\ndiabetes and Table 9.2 for person- and\ndrug-speci fic factors to consider when | [
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drug-speci fic factors to consider when\nselecting glucose-lowering agents. Costmay be an especially important consider-\nation, as older adults tend to be on\nmany medications and live on fixed\nincomes (90). Accordingly, the costs ofcare and insurance coverage rules should\nbe considered when developing treat-\nment pl... | [
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ment plans to reduce the risk of cost-\nrelated barriers to adherence (91,92).\nSeeTable 9.3 and Table 9.4 for median\nmonthly cost in the U.S. of noninsulin\nglucose-lowering agents and insulin, re-\nspectively. It is important to match com-\nplexity of the treatment plan to the\nself-management ability of older adult... | [
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self-management ability of older adults\nwith diabetes and their available social\nand medical support. Many older adults\nwith diabetes struggle to maintain the\nfrequent blood glucose monitoring and\ninsulin injection plans they previouslydiabetesjournals.org/care Older Adults S249\n©AmericanDiabetesAssociation | [
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followed, perhaps for many decades, as\nthey develop medical conditions that\nmay impair their ability to follow their\ntreatment plan safely. Individualizedglycemic goals should be established\n(Fig. 6.2 and Table 13.1 )a n dp e r i o d i -\ncally adjusted based on coexisting chronicillnesses, cognitive function, and ... | [
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status (2). Intensive glycemic management\nwith medication plans including insulin\nand sulfonylureas in older adults with com-\nplex medical conditions has been identi fied\nas overtreatment and found to be verycommon in clinical practice (93 –97). Ulti-\nmately, the determination of whether aperson is considered overt... | [
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... |
an elicitation of the person ’s perceptions of\nthe current medication burden and prefer-ences for treatments. For those seeking to\nsimplify their diabetes medication plan, de-\nintensi fication of plans in individuals taking\nnoninsulin glucose-lowering medicationscan be achieved by either lowering thedose or disconti... | [
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as long as the individualized glycemic\ngoals are maintained (98). When olderadults are found to have an insulin\nplan with complexity beyond their self-\nmanagement abilities, lowering the dose\nof insulin may not be adequate (99).\nSimpli fication of the insulin plan to match\nan individual ’s self-management abilitie... | [
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an individual ’s self-management abilities\nand their available social and medical sup-\nport in these situations has been shown\nto reduce hypoglycemia and disease-\nrelated distress without worsening glyce-\nmic outcomes (100– 103). Fig. 13.1 de-\npicts an algorithm that can be used tosimplify the insulin plan (102).... | [
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now multiple studies evaluating deinten-\nsification protocols in diabetes as well as\nhypertension, demonstrating that dein-tensification is safe and possibly bene fi-\ncial for older adults (98). Table 13.2provides examples of and rationale for\nsituations where deintensi fication and/or\ninsulin plan simplifi cation may ... | [
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0.04245... |
insulin plan simplifi cation may be appropri-\nate in older adults.\nMetformin\nMetformin is the first-line agent for older\nadults with type 2 diabetes. Recent studieshave indicated that it may be used safelyin individuals with estimated glomerular fil-\ntration rate $30 mL/min/1.73 m\n2(104). | [
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0.06982336938381195,
0.04640554264187813,
0.033042... |
tration rate $30 mL/min/1.73 m\n2(104).\nHowever, it is contraindicated in thosewith advanced renal insuf ficiency and\nshould be used with caution in thosewith impaired hepatic function or heartfailure because of the increased risk oflactic acidosis. Metformin may be tem-porarily discontinued before proceduresincluding... | [
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0.02... |
ated contrast, during hospitalizations, and\nwhen acute illness may compromise renalor liver function. Additionally, metformin\nSimplification of Complex Insulin Therapy\nChange timing from bedtime to morningIndividual on basal (long- or intermediate-acting) * and/or prandial (short- or rapid-acting)† insulins Individua... | [
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0.0... |
Use 70% of total dose as\nbasal only in the morning Prandial insulin Basal insulin\nUsing individual and drug characteristics to guide decision-making, as depicted inFig. 9.3 and Table 9.2, select additional agent(s) as needed:\n/g131/g3Every 2 weeks, adjust insulin dose and/or add glucose-lowering agents based on | [
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0.0628182515501976,
0.12198895215988159,
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0.015239856205880642,
-0.029952920973300934,
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0.00... |
finger-stick glucose testing performed before lunch and before dinner\n/g131/g3Goal: 90–150 mg/dL (5.0–8.3 mmo/L) before meals; may change\n goal based on overall health and goals of care||/g131/g3If 50% of premeal finger-stick values over 2 weeks are above goal, increase the | [
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dose or add another agent/g131/g3If >2 premeal finger-stick values/week are <90 mg/dL (<5.0 mmol/L),\n decrease the dose of medicationTitrate dose of basal insulin based on fasting\nfinger-stick glucose test results over a week\nFasting goal: 90–150 mg/dL (5.0–8.3 mmol/L)\n/g131/g3May change goal based on overall healt... | [
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0.05968598276376724,
0.00896263774484396,
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-0.019... |
/g131/g3May change goal based on overall health\n and goals of care**If mealtime insulin /g10010 units/dose:\n/g131/g3 Discontinue prandial insulin and add\n noninsulin agent(s)§\nAdd noninsulin agents:\n/g131/g3If eGFR is /g11645 mg/dL, start metformin 500 mg\n daily and increase dose every 2 weeks, as\n tolerated | [
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0.04583849012851715,
0.033067841082811356,
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0.022321021184325218,
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-0.... |
daily and increase dose every 2 weeks, as\n tolerated\n/g131/g3If eGFR is <45 mg/dL, patient is already\n taking metformin, or metformin is not tolerated,\n proceed to second-line agentIf prandial insulin >10 units/dose:\n/g131/g3Decrease dose by 50% and add\n noninsulin agent\nTitrate prandial insulin doses down... | [
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0.046225156635046005,
0.11082098633050919,
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-0.014757161028683186,
0.010119047947227955,
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0... |
noninsulin agent\nTitrate prandial insulin doses down as\nnoninsulin agent doses are increasedwith the aim to discontinue prandial insulin\nIf 50% of the fasting finger-stick glucosevalues are over the goal:\n/g131/g3Increase dose by 2 units\nIf >2 fasting finger-stick values/week are <80\nmg/dL (<4.4 mmol/L):\n/g131/g... | [
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-0.027552038431167603,
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-0.03285069018602371,
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0.06475100666284561,
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0.074335478246212,
0.017642103135585785,
-0.047422852367162704,
0.0015... |
mg/dL (<4.4 mmol/L):\n/g131/g3Decrease dose by 2 units\nAdditional Tips\n/g131/g3Do not use rapid- and short-acting insulin at bedtime\n/g131/g3While adjusting prandial insulin, a simplified\n sliding scale may be used, for example:\n/g3/g3\n/g123/g3For premeal glucose >250 mg/dL (>13.9 mmol/L),\n give 2 units of sho... | [
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-0.030927928164601326,
0.0... |
give 2 units of short- or rapid-acting insulin\n/g3/g3 /g123/g3For premeal glucose >350 mg/dL (>19.4 mmol/L),\n give 4 units of short- or rapid-acting insulin/g131/g3Stop sliding scale when not needed daily | [
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0.019504152238368988,
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-0.0... |
Figure 13.1 —Algorithm to simplify insulin plans for older adults with type 2 diabetes. eGFR, estimated glomerular filtration rate. *Basal insulins: glargine\nU-100 and U-300, detemir, degludec, and human NPH. †Prandial insulins: short-acting (regular human insulin) or rapid-acting (lispro, aspart, and gluli- | [
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-0.0022570742294192314,
0.0993230938911438,
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-0.006146141793578863,
0.01931857317686081,
0.013906911015510559,
-0.027332782745361328,
0... |
sine). ‡Premixed insulins: 70/30, 75/25, and 50/50 products. §Examples of noninsulin agents include metformin, sodium –glucose cotransporter 2 inhibi- | [
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0.04680883139371872,
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0.06382394582033157,
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-0.029347434639930725,
0.01277111191302538,
-0.032015610486269,
-0.005036573391407728,
0.0316243... |
tors, dipeptidyl peptidase 4 inhibitors, and glucagon-like peptide 1 receptor agonists. ||SeeTable 13.1 . Adapted with permission from Munshi et al. (102).S250 Older Adults Diabetes Care Volume 47, Supplement 1, January 2024\n©AmericanDiabetesAssociation | [
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0.07365559041500092,
0.04417797923088074,
0.03968063369393349,
0.02204229310154915,
0.06714087724685669,
-0.0420004203915596,
0.05871355... |
Table 13.2 —Considerations for treatment plan simpli fication and deintensi fication/deprescribing in older adults with\ndiabetes\nCharacteristics and\nhealth status of person\nwith diabetesReasonable A1C/\ntreatment goal Rationale/considerationsWhen may medication plan\nsimplification be required?When may treatment\ndei... | [
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0.07236305624246597,
-0.05459814518690109,
-0.009888303466141224,
-0.058118876069784164,
0.07976134866476059,
0.03900787979364395,
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-0.0970524251461029,
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-0.01232218462973833,
0.07257873564958572,
-0.07848704606294632,
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simplification be required?When may treatment\ndeintensification/\ndeprescribing be required?\nHealthy (few coexisting\nchronic illnesses,\nintact cognitive and\nfunctional status)<7.0–7.5%\n(<53–58 mmol/mol)/C15Individuals can generally\nperform complex tasks tomaintain good glycemic\nmanagement when health\nis stable... | [
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0.0005676460568793118,
-0.008418492041528225,
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0.003778506303206086,
0.10935759544372559,
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0.04121287167072296,
-0.014877351000905037,
-0.06294446438550949,
0.0... |
management when health\nis stable\n/C15During acute illness,\nindividuals may be more at\nrisk for administration ordosing errors that canresult in hypoglycemia,\nfalls, fractures, etc./C15If severe or recurrent\nhypoglycemia occurs inindividuals on insulin therapy\n(regardless of A1C)\n/C15If wide glucose excursions\n... | [
-0.0467476025223732,
0.017608482390642166,
-0.022358795627951622,
0.04868020862340927,
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-0.01239149272441864,
0.03857143223285675,
-0.04217715188860893,
0.0143... |
(regardless of A1C)\n/C15If wide glucose excursions\nare observed\n/C15If cognitive or functionaldecline occurs followingacute illness/C15If severe or recurrenthypoglycemia occurs inindviduals on noninsulin\ntherapies with high risk\nof hypoglycemia(regardless of A1C)\n/C15If wide glucoseexcursions are observed\n/C15In... | [
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0.01663975976407528,
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0.02... |
/C15In the presence ofpolypharmacy\nComplex/intermediate\n(multiple coexistingchronic illnesses ortwo or more\ninstrumental ADL\nimpairments or mildto moderate cognitiveimpairment)<8.0%\n(<64 mmol/mol)/C15Comorbidities may affectself-management abilitiesand capacity to avoidhypoglycemia | [
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0.0... |
/C15Long-acting medicationformulations may decreasepill burden and complexityof medication plan/C15If severe or recurrenthypoglycemia occurs inindividuals on insulin therapy(even if A1C is appropriate)\n/C15If unable to managecomplexity of an insulin plan\n/C15If there is a signi ficant\nchange in social\ncircumstances,... | [
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0.033081624656915665,
-0.032553549855947495,
... |
change in social\ncircumstances, such as loss of\ncaregiver, change in livingsituation, or financial\ndifficulties/C15If severe or recurrenthypoglycemia occurs inindividuals on noninsulintherapies with high risk\nof hypoglycemia (even if\nA1C is appropriate)\n/C15If wide glucose\nexcursions are observed\n/C15In the prese... | [
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/C15In the presence ofpolypharmacy\nCommunity-dwelling\nindividuals receivingcare in a skilled\nnursing facility for\nshort-termrehabilitationAvoid reliance on\nA1C, glucose goal100–200 mg/dL\n(5.55 –11.1 mmol/L)/C15Glycemic management isimportant for recovery,wound healing, hydration,\nand avoidance of infections\n/C1... | [
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and avoidance of infections\n/C15Individuals recovering from\nillness may not have\nreturned to baseline\ncognitive function at thetime of discharge\n/C15Consider the type of\nsupport the individual will\nreceive at home/C15If treatment plan increasedin complexity duringhospitalization, it is\nreasonable, in many cases... | [
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reasonable, in many cases, to\nreinstate theprehospitalization medication\nplan during the rehabilitation/C15If the hospitalization for\nacute illness resulted inweight loss, anorexia,\nshort-term cognitive\ndecline, and/or loss ofphysical functioning\nVery complex/poor\nhealth (LTC or end-stage chronic illnessesor mod... | [
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0.03468375653028488,
0.023372597992420197,
0.05791180208... |
impairment or two or\nmore ADLimpairments)Avoid reliance on A1C\nand avoidhypoglycemia andsymptomatichyperglycemia/C15No bene fits of tight\nglycemic management inthis population\n/C15Hypoglycemia should beavoided\n/C15Most important outcomesare maintenance ofcognitive and functionalstatus/C15If on an insulin plan and t... | [
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... |
individual would like to\ndecrease the number ofinjections and finger-stick\nblood glucose monitoring\nevents each day\n/C15If the individual has an\ninconsistent eating pattern/C15If on noninsulin agents\nwith a high\nhypoglycemia risk in thecontext of cognitivedysfunction, depression,\nanorexia, or inconsistent\neatin... | [
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anorexia, or inconsistent\neating pattern\n/C15If taking anymedications without\nclear bene fits\nAt the end of life Avoid hypoglycemia\nand symptomatichyperglycemia/C15Goal is to provide comfort\nand avoid tasks or\ninterventions that cause\npain or discomfort\n/C15Caregivers are important inproviding medical care and | [
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/C15Caregivers are important inproviding medical care and\nmaintaining quality of life/C15If there is pain or discomfort\ncaused by treatment (e.g.,\ninjections or finger sticks)\n/C15If there is excessive caregiver\nstress due to treatmentcomplexity/C15If taking anymedications without\nclear bene fits in\nimproving symp... | [
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clear bene fits in\nimproving symptoms\nand/or comfort\nTreatment plan simpli fication refers to changing strategy to decrease the complexity of a medication plan (e.g., fewer administration times | [
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0.04674115404486656,
0.020519500598311424,
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and fewer blood glucose checks) and decreasing the need for calculations (such as sliding-scale insulin calculations or insulin-carbohydrate ra-tio calculations). Deintensi fication/deprescribing refers to decreasing the dose or frequency of administration of a treatment or discontinuing | [
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0.007214535493403673,
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0.06216394156217575,
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a treatment altogether. Created using information from Munshi et al. 2016 (102) and 2017 (138). ADL, activities of daily living; LTC, long-termcare.diabetesjournals.org/care Older Adults S251\n©AmericanDiabetesAssociation | [
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0.01673797518014908,
0.09234791994094849,
-0.043699175119400024,
-0.0010... |
can cause gastrointestinal side effects and\na reduction in appetite that can be prob-\nlematic for some older adults. Reductionor elimination of metformin may be nec-essary for those experiencing persistentgastrointestinal side effects. For thosetaking metformin long-term, monitoringfor vitamin B12 de ficiency should b... | [
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-... |
considered (105).\nThiazolidinediones\nThiazolidinediones, if used at all, shouldbe used very cautiously in older adults oninsulin therapy as well as in those withor at risk for heart failure, osteoporosis,falls or fractures, and/or macular edema(106,107). Lower doses of a thiazolidine-\ndione in combination therapy ma... | [
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0.05528443679213524,
0.05241074040532112,
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0.094... |
dione in combination therapy may miti-\ng a t et h e s es i d ee f f e c t s .\nInsulin Secretagogues | [
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0.053599968552589417,
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0... |
Sulfonylureas and other insulin secreta-gogues such as the meglitinides (repagli-nide and nateglinide) are associated withh y p o g l y c e m i aa n ds h o u l db eu s e dw i t hcaution. If used, sulfonylureas with a shorterduration of action, such as glipizide, are pre-ferred. Glyburide is a longer-acting sulfonyl-ure... | [
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0.10001856088638306,
-0.05919324606657028,
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Glyburide is a longer-acting sulfonyl-urea and should be avoided in older adults(108). | [
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Incretin-Based Therapies\nOral dipeptidyl peptidase 4 (DPP-4) inhibi-tors have few side effects and minimalrisk of hypoglycemia, but their cost maybe a barrier to some older adults. DPP-4inhibitors do not reduce or increase major\nadverse cardiovascular outcomes (109). | [
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adverse cardiovascular outcomes (109).\nAcross the trials of this drug class, thereappears to be no interaction by age-group(110–112). A challenge of interpreting the\nage-strati fied analyses of this drug class\nand other cardiovascular outcomes trialsis that while most of these analyses wereprespeci fied, they were not... | [
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detect differences.\nGLP-1 receptor agonists have demon-\nstrated cardiovascular bene fits among\npeople with diabetes and established ath-erosclerotic cardiovascular disease (ASCVD)and those at higher ASCVD risk, and newertrials are expanding our understanding\nof their bene fits in other populations\n(109). See Section... | [
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(109). See Section 9, “Pharmacologic\nApproaches to Glycemic Treatment, ”and\nSection 10, “Cardiovascular Disease and\nRisk Management,” for a more extensive\ndiscussion regarding the speci fic indica-\ntions for this class of agents. In asystematic review and meta-analysis of | [
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GLP-1 receptor agonist trials, these agentshave been found to reduce major adverse\ncardiovascular events, cardiovascular\ndeaths, stroke, and myocardial infarction\nto the same degree for people over and\nunder 65 years of age (113). While the ev-idence for this class of agents for older\nadults continues to grow, the... | [
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adults continues to grow, there are a\nnumber of practical issues that should beconsidered speci fically for older people.\nThese drugs are injectable agents (withthe exception of oral semaglutide) (114),\nwhich require visual, motor, and cognitive\nskills for appropriate administration.Agents with a weekly dosing sched... | [
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may however reduce the burden of ad-\nministration. GLP-1 receptor agonists may\nalso be associated with nausea, vomiting,\nand diarrhea. Given the gastrointestinals i d ee f f e c t so ft h i sc l a s s ,G L P - 1r e c e p t o ra g -\nonists may not be preferred in older adults\nwho are experiencing unexplained weight | [
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who are experiencing unexplained weight\nloss or have suspected gastroparesis or re-\ncurrent gastrointestinal problems.\nRecently, tirzepatide, a novel dual-\nacting GIP and GLP-1 receptor coagonist,was approved by the FDA for the treat-ment of type 2 diabetes. Tirzepatide is ad-\nministered as a once-weekly subcutane... | [
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0.0712... |
ministered as a once-weekly subcutaneous\ninjection. In phase 3 trials, tirzepatide de-creased A1C and weight —generally to a\ngreater extent than other glucose-loweringdrugs including semaglutide and insulin —\nwith no signifi cant differences in the safety\nor effi cacy in older compared with younger\nindividuals (115)... | [
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individuals (115).\nSodium –Glucose Cotransporter 2\nInhibitors\nSGLT2 inhibitors are administered orally,\nwhich may be convenient for older adults\nwith diabetes. In those with established\nA S C V D ,t h e s ea g e n t sh a v es h o w nc a r -\ndiovascular benefi ts (109). This class of\nagents has also been found to... | [
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agents has also been found to be bene fi-\ncial for people with heart failure and toslow the progression of chronic kidneydisease. See Section 9, “Pharmacologic\nApproaches to Glycemic Treatment, ”and\nSection 10, “Cardiovascular Disease and\nRisk Management,” for a more extensive | [
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Risk Management,” for a more extensive\ndiscussion regarding the indications forthis class of agents. Strati fied analyses of\nt h et r i a l so ft h i sd r u gc l a s si n d i c a t et h a tolder adults have similar or greater bene-\nfits than younger people (116 –118). While\nunderstanding of the clinical bene fits of | [
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understanding of the clinical bene fits of\nthis class is evolving, side effects such asvolume depletion, urinary tract infections,and worsening urinary incontinence may\nbe more common among older people,\nand these drugs should be used withcaution in individuals who depend oncaregivers for adequate fluid intake | [
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o rw h oh a v er e c u r r e n tu r i n a r yt r a c tinfections.\nInsulin Therapy | [
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The use of insulin therapy requires that in-dividuals or their caregivers have good vi-sual and motor skills and cognitive ability.Insulin therapy relies on the ability of theolder person with diabetes to administer in-s u l i no nt h e i ro w no rw i t ht h ea s s i s t a n c eo fa caregiver. Insulin doses should be t... | [
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