As with all persons with diabetes, diabetes self-management education/training (DSME/T) for older adults should be individualized and tailored to the individual’s unique medical, cultural, and social situation. Additionally, for older adults, DSME/T may need to account for possible impairments in sensation (vision, hearing), cognition, and functional/physical status. Care partners—family, friends, or other caregivers—should be involved in DSME/T to increase the likelihood of successful self-care behaviors When communicating with cognitively impaired patients, educators should address the patient by name (even when a caregiver will provide most care), speak in simple terms, use signals (cues) that aid memory (verbal analogies, hands-on experience, demonstrations and models), and utilize strategies such as sequenced visits to build on information. Other tactics include summarizing important points frequently, focusing on one skill at a time, teaching tasks from simple to complex, and providing easy-to-read handouts. Even in the absence of cognitive impairment, educators should consider that many patients may have low health literacy and numeracy skills or may be overwhelmed by the presence of multiple comorbidities.
Physical activity and fitness
Muscle mass and strength decline with age, and these decrements may be exacerbated by diabetes complications, comorbidities, and periods of hospitalization in older adults with diabetes. People with diabetes of longer duration and those with higher A1C have lower muscle strength per unit of muscle mass than BMI- and age-matched people without diabetes and than those whose disease is of shorter duration or under better glycemic control Although age and diabetes conspire to reduce fitness and strength, physical activity interventions improve functional status in older adults with and without diabetes. In the Look AHEAD (Action for Health in Diabetes) study, participants aged 65–76 years had lower gains in fitness with the intensive lifestyle intervention than younger patients, but still improved their measures of fitness by a mean of over 15%. In older adults, even light-intensity physical activity is associated with higher self-rated physical health and psychosocial well-being
Older adults with diabetes who are otherwise healthy and functional should be encouraged to exercise to targets recommended for all adults with diabetes (17). Even patients with poorer health status benefit from modest increases in physical activity. Tactics to facilitate activity for older adults may include referring to supervised group exercise and community resources such as senior centers, YMCAs, the EnhanceFitness program, and the resources of the Arthritis Foundation.
Age-specific aspects of pharmacotherapy
Older patients are at increased risk for adverse drug events from most medications due to age-related changes in pharmacokinetics (in particular reduced renal elimination) and pharmacodynamics (increased sensitivity to certain medications) affecting drug disposition. These changes may translate into increased risk for hypoglycemia, the potential need for reduced doses of certain medications, and attention to renal function to minimize side effects (94,95). The risk for medication-related problems is compounded by the use of complex regimens, high-cost therapies, and polypharmacy or medication burden. Collectively, these factors should be considered and weighed against the expected benefits of a therapy before incorporating it into any therapeutic plan. Attention to the selection of medications with a strong benefit-to-risk ratio is essential to promote efficacy, persistence on therapy, and safety.
Antihyperglycemic medication use in older adults.
Comparative effectiveness studies of medications to treat diabetes in older adult populations are lacking. Type 2 diabetes with onset later in life is characterized by prominent defects in β-cell function, suggesting therapeutic attention to β-cell function and sufficiency of insulin release, as well as the traditional focus on hepatic glucose overproduction and insulin resistance. Understanding the advantages and disadvantages of each antihyperglycemic drug class helps clinicians individualize therapy for patients with type 2 diabetes . Issues particularly relevant to older patients are described for each drug class.
Metformin is often considered the first-line therapy in type 2 diabetes. Its low risk for hypoglycemia may be beneficial in older adults, but gastrointestinal intolerance and weight loss from the drug may be detrimental in frail patients. Despite early concerns, the evidence for an increase in the risk of lactic acidosis with metformin is minimal. The dose should be reduced if estimated glomerular filtration rate (eGFR) is 30–60 mL/min, and the drug should not be used if eGFR is <30 mL/min Metformin’s low cost may be a benefit in those on multiple medications or who are subject to the Medicare Part D “doughnut hole.”
Sulfonylureas are also a low-cost class of medications, but the risk of hypoglycemia with these agents may be problematic for older patients. Glyburide has the highest hypoglycemia risk and should not be prescribed for older adults. Glinides are dosed prior to meals, and their short half-life may be useful for postprandial hyperglycemia. They impart a lower risk for hypoglycemia than sulfonylureas, especially in patients who eat irregularly, but their dosing frequency and high cost may be barriers.
α-Glucosidase inhibitors specifically target postprandial hyperglycemia and have low hypoglycemia risk, making them theoretically attractive for older patients. However, gastrointestinal intolerance may be limiting, frequent dosing adds to regimen complexity, and this class of medications is costly. Thiazolidinediones have associated risks of weight gain, edema, heart failure, bone fractures, and possibly bladder cancer, which may argue against their use in older adults. The use of rosiglitazone is now highly restricted. The class has traditionally been expensive, although the approval of generic pioglitazone may reduce its cost.
Dipeptidyl peptidase-4 inhibitors are useful for postprandial hyperglycemia, impart little risk for hypoglycemia, and are well tolerated, suggesting potential benefits for older patients. However, their high cost may be limiting. Glucagon-like peptide-1 agonists also target postprandial hyperglycemia and impart low risk of hypoglycemia, but their associated nausea and weight loss may be problematic in frail older patients. Injection therapy may add to regimen complexity, and its very high cost may be problematic. For some agents, dose reduction is required for renal dysfunction.
Insulin therapy can be used to achieve glycemic goals in selected older adults with type 2 diabetes with similar efficacy and hypoglycemia risk as in younger patients. However, given the heterogeneity of the older adult population, the risk of hypoglycemia must be carefully considered before using an insulin regimen to achieve an aggressive target for hyperglycemia control. A mean A1C of 7% was achieved and maintained for 12 months with either an insulin pump regimen or multiple daily insulin injections in otherwise healthy and functional older adults (mean age 66 years), with low rates of hypoglycemia (99). The addition of long-acting insulin was similarly effective in achieving A1C goals for older patients with type 2 diabetes (mean age 69 years) in a series of trials with no greater rates of hypoglycemia than in younger patients (mean age 53 years) . However, there are few data on such regimens in people over age 75 years or in older adults with multiple comorbidities and/or limited functional status who were excluded from these trials.
Problems with vision or manual dexterity may be barriers to insulin therapy for some older adults. Pen devices improve ease of use but are more costly than the use of vials and syringes. Hypoglycemia risk (especially nocturnal) is somewhat lower with analog compared with human insulins, but the former are more expensive. Insulin-induced weight gain is a concern for some patients, and the need for more blood glucose monitoring may increase treatment burden.
Other approved therapies for which there is little evidence in older patients include colesevelam, bromocriptine, and pramlintide. An emerging drug class, sodium-glucose cotransporter-2 inhibitors, may require additional study in older adults to assess whether drug-associated genital infections or urinary incontinence is problematic in this population
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