What current guidelines exist for treating diabetes in older adults?

Several organizations have developed diabetes guidelines specific to, or including, older adults. The ADA includes a section on older adults in its annual Standards of Medical Care in Diabetes. The section discusses the heterogeneity of persons aged ≥65 years and the lack of high-level evidence. The overall recommendations, all based on expert opinion, include the following:

• Older adults who are functional, are cognitively intact, and have significant life expectancy should receive diabetes care using goals developed for younger adults.
• Glycemic goals for older adults not meeting the above criteria may be relaxed using individualized criteria, but hyperglycemia leading to symptoms or risk of acute hyperglycemic complications should be avoided in all patients.
• Other cardiovascular risk factors should be treated in older adults with consideration of the timeframe of benefit and the individual patient. Treatment of hypertension is indicated in virtually all older adults, and lipid and aspirin therapy may benefit those with life expectancy at least equal to the timeframe of primary or secondary prevention trials.
• Screening for diabetes complications should be individualized in older adults, but particular attention should be paid to complications that would lead to functional impairment.

The ADA goals for glycemic control do not specifically mention age. The recommendation for many adults is an A1C <7%, but less stringent goals are recommended for those with limited life expectancy, advanced diabetes complications, or extensive comorbid conditions.

In collaboration with the ADA and other medical organizations, the California HealthCare Foundation/American Geriatrics Society panel published guidelines for improving the care of older adults with diabetes in 2003. A significant proportion of the recommendations concerns geriatric syndromes. Highlights of diabetes-specific recommendations include A1C targets of ≤7.0% in “relatively healthy adults,” while for those who are frail or with life expectancy less than 5 years, a less stringent target, such as 8%, was considered appropriate. The guidelines also suggested that the timeline of benefits was estimated to be at least 8 years for glycemic control and 2–3 years for blood pressure and lipid control.

The U.S. Department of Veterans Affairs and the U.S. Department of Defense (VA/DOD) diabetes guidelines were updated in 2010. As with other guidelines, the VA/DOD guidelines do not distinguish by age-group. They highlight the frequency of comorbid conditions in patients with diabetes and stratify glycemic goals based on comorbidity and life expectancy. For glycemic goals, for example, the guidelines have three categories:

• The patient with either none or very mild microvascular complications of diabetes, who is free of major concurrent illnesses and who has a life expectancy of at least 10–15 years, should have an A1C target of <7%, if it can be achieved without risk.
• The patient with longer-duration diabetes (more than 10 years) or with comorbid conditions and who requires a combination medication regimen including insulin should have an A1C target of <8%.
• The patient with advanced microvascular complications and/or major comorbid illness and/or a life expectancy of less than 5 years is unlikely to benefit from aggressive glucose-lowering management and should have an A1C target of 8–9%. Lower targets (<8%) can be established on an individual basis .

The European Diabetes Working Party for Older People recently published guidelines for treating people with diabetes aged ≥70 years. These extensive guidelines recommend that “the decision to offer treatment should be based on the likely benefit/risk ratio of the intervention for the individual concerned, but factors such as vulnerability to hypoglycemia, ability to self-manage, the presence or absence of other pathologies, the cognitive status, and life expectancy must be considered”. There are recommendations to carry out annual evaluations of functional status (global/physical, cognitive, affective) using validated instruments to avoid the use of glyburide due to its high risk of hypoglycemia in this population and to calculate cardiovascular risk in all patients less than 85 years of age. Suggested A1C targets are based on age and comorbidity. A range of 7–7.5% is suggested for older patients with type 2 diabetes without major comorbidities and 7.6–8.5% for frail patients (dependent, multisystem disease, home care residency including those with dementia) where the hypoglycemia risk may be high and the likelihood of benefit relatively low.

Extensive review of the guidelines is beyond the scope of this report, but there are similar themes, which suggest pursuing an individualized approach with a focus on clinical and functional heterogeneity and comorbidities, and weighing the expected time frame of benefit of interventions against life expectancy.