Diabetes Treatment Considerations in Elderly Patients

About 11 million patients 65 years or older were diagnosed with diabetes in 2012 alone.

About 11 million patients 65 years or older were diagnosed with diabetes in 2012 alone.1

Clinical judgements for a 25-year-old patient will be different than those for a 65-year-old patient because of changes in kidney function, weight distribution, metabolism, and many other age-associated factors. Still, some aspects of diabetes treatment for younger patients remain the same for the elderly.

For instance, all smokers with diabetes are recommended to take smoking cessation measures regardless of age. Meanwhile, hypertension treatment has shown benefit in all patients with diabetes, including those 80 years or older. Plus, the benefits of lipid-lowering statin therapy are similar in older and younger patients with diabetes, but older patients see greater benefits overall.2

As recommended for younger patients, exercise and diet modifications are important for properly managing diabetes in older patients. In terms of pharmacotherapy, the first-line recommendation for type 2 diabetes in elderly patients is metformin.2,3

Elderly patients who lack contraindications like renal impairment or heart failure are able to safely take metformin. For those with a contraindication or intolerance to metformin, a short-acting sulfonylurea like glipizide is recommended as initial therapy.2 Long-acting sulfonylureas like chlorpropamide, glyburide, and glimepiride aren’t recommended for older patients due to increased risk for hypoglycemia.2-4 Other drugs that may be used as initial therapy include repaglinide, dipeptidyl peptidase 4 (DPP-4) inhibitors, or insulin.2

Elderly patients with renal impairment can receive repaglinide because renal adjustments aren’t necessary. Meanwhile, DPP-4 inhibitors have no risk of hypoglycemia and don’t cause a significant change in weight, but they do have a hefty price tag.2 Because many elderly patients are on other medications for various comorbidities, financial factors may play a role in diabetes treatment.

As in younger patients with type 2 diabetes, insulin can also be considered as initial therapy in the elderly. However, injectable forms may be dangerous for older patients with declined motor and visual skills. Therefore, assessment of these skills, along with cognitive function, before initiating insulin is important. The use of sliding-scale insulin in elderly patients isn’t recommended due to increased risk for hypoglycemia.4

It’s also important to screen for microvascular complications like retinopathy, neuropathy, and foot ulcers in all patients with diabetes.2,3 Yearly eye exams by an ophthalmologist and foot exams by a podiatrist are recommended for younger and older diabetes patients alike.

Diabetes can be easily managed with appropriate diet and exercise modifications, along with proper pharmacological therapies. Some aspects of treating diabetes in younger and older patients are similar, but knowing where it can differ will help health care professionals provide better treatment and improve patients’ quality of life.

References

1. CDC. National Diabetes Statistics Report, 2014. cdc.gov/diabetes/pdfs/data/2014-report-estimates-of-diabetes-and-its-burden-in-the-united-states.pdf. Accessed June 30, 2016

2. McCulloch DK, Munshi M, et al. Treatment of type 2 diabetes mellitus in the older patient. UpToDate. uptodate.com/contents/treatment-of-type-2-diabetes-mellitus-in-the-older-patient. Updated May 9, 2016. Accessed June 30, 2016

3. Cefalu WT, Bakris G, Blonde L, et al. American Diabetes Association Standards of Medical Care in Diabetes 2016. Diabetes Care. 2016;39(suppl1).

4. American Geriatrics Society 2015 updated Beers Criteria for potentially inappropriate medication use in older adults. National Guideline Clearinghouse. guideline.gov/content.aspx?id=49933. Accessed June 30, 2016.