Diabetes In the Elderly

Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association

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Abstract
Diabetes is more common in older adults, has a high prevalence in long-term care (LTC) facilities, and is associated with significant disease burden and higher cost. The heterogeneity of this population with regard to comorbidities and overall health status is critical to establishing personalized goals and treatments for diabetes. The risk of hypoglycemia is the most important factor in determining glycemic goals due to the catastrophic consequences in this population. Simplified treatment regimens are preferred, and the sole use of sliding scale insulin (SSI) should be avoided. This position statement provides a classification system for older adults in LTC settings, describes how diabetes goals and management should be tailored based on comorbidities, delineates key issues to consider when using glucose-lowering agents in this population, and provides recommendations on how to replace SSI in LTC facilities. As these patients transition from one setting to another, or from one provider to another, their risk for adverse events increases. Strategies are presented to reduce these risks and ensure safe transitions. This article addresses diabetes management at end of life and in those receiving palliative and hospice care. The integration of diabetes management into LTC facilities is important and requires an interprofessional team approach. To facilitate this approach, acceptance by administrative personnel is needed, as are protocols and possibly system changes. It is important for clinicians to understand the characteristics, challenges, and barriers related to the older population living in LTC facilities as well as the proper functioning of the facilities themselves. Once these challenges are identified, individualized approaches can be designed to improve diabetes management while lowering the risk of hypoglycemia and ultimately improving quality of life.

Introduction
The epidemic growth of type 2 diabetes in the U.S. has disproportionately affected the elderly. In 2012, the prevalence of diabetes among people aged ≥65 (25.9%) was more than six times that of people aged 20–24 years (4.1%) (1). In the long-term care (LTC) population, the prevalence of diabetes ranges from 25% to 34% across multiple studies (2–4). The high prevalence of diabetes among older adults has contributed to the unsustainable growth of health care costs in the U.S. The estimated total cost of diabetes in 2012 was $245 billion. Average medical expenditures for people with diagnosed diabetes were 2.3 times higher than among people without diabetes. LTC costs for people with diabetes were estimated at $19.6 billion in 2012 (5).
The high prevalence of diabetes in older adults is due to age-related physiological changes, such as increased abdominal fat, sarcopenia, and chronic low-grade inflammation, that lead to increased insulin resistance in peripheral tissues and relatively impaired pancreatic islet function (6). Diabetes increases the risk of cardiovascular and microvascular complications but also increases the risk of common geriatric syndromes, including cognitive impairment, depression, falls, polypharmacy, persistent pain, and urinary incontinence (7,8). The older diabetes population is highly heterogeneous in terms of comorbid illnesses and functional impairments. These characteristics have frequently been used to exclude older individuals from randomized clinical trials. The heterogeneity of the population and the lack of clinical trial data represent challenges to determining standardized intervention strategies that can work for all older adults with diabetes. As the vast majority of the patients with diabetes in LTC facilities have type 2 diabetes, most recommendations in this position statement are directed toward that population. However, we have suggested specific recommendations for patients with type 1 diabetes when appropriate.

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Brenda Schlesinger MSN, APRN, CDE
American Diabetes Education LLC
americandiabeteseducation.net
Brendascde@gmail.com
Office:  215.208.8474

When Diabetes Treatment Goes Too Far

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Excerpt from an article
By Kasia Lipska
New York Times
Jan. 12, 2015

NEW HAVEN – ONE of my elderly patients has Type 2 diabetes and heart disease. He takes a number of medications, including insulin to control his blood sugar levels. A few years ago, he was driving when his blood sugar suddenly dropped. He felt lightheaded for a moment and then ran into a tree.

There are roughly 11 million Americans over age 65 with diabetes. Most of them take medications to reduce their blood sugar levels, The majority reach an average blood sugar target, or “hemoglobin A1C,” of less than 7 percent. Why? Early studies showed that this can reduce the risk of diabetes complications, including eye, kidney and nerve problems. As a result, for more than a decade, medical societies, pharmaceutical companies and diabetes groups have campaigned with a simple concrete message – to get below seven. Many patients carry report cards with their scores to clinic appointments. Doctors are often rewarded based on how many of their patients hit the target.

All of this sounds great. But, at least for older people, there are serious problems with the below-seven paradigm.

To begin with, the health benefits of this strategy are uncertain for older people. Those early studies that were the rationale for going below seven were conducted in people with Type 1 diabetes or with younger patients with newly diagnosed Type 2 diabetes. Subsequent trials of older patients raised doubts about the benefits.

Worse, targeting low blood sugar levels can cause harm. In one instance, investigators actually had to stop a trial early because patients who were targeting hemoglobin A1C levels of six or below had significantly higher rates of death than patients targeting levels in the sevens. We don’t know exactly why this happened. What we do know is that aiming for levels below seven increases the risk of “hypoglycemia,” or low blood sugar reactions. Severe reactions can result in confusion, coma, falls, fractures, abnormal heart rhythms and even death.

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