This chapter addresses the following Geriatric Fellowship Curriculum Milestone: #22, #26
Understand the epidemiology of diabetes and the heterogeneity of its complications and comorbidities in older adults, including geriatric conditions.
Describe preventive strategies and initial management strategies for diabetes in the older adult.
Determine appropriate diabetes management goals and regimens for older adults, based on their individual functional status, cognition, and available social support.
Key Clinical Points
Older adults, as a result of interactions among genetics, lifestyle, and aging, are at high risk of developing prediabetes and diabetes.
Intensive lifestyle interventions, including diet and physical activity to achieve weight loss, are effective strategies for prevention of progression from prediabetes to diabetes and for management of diabetes in older adults.
Treatment of diabetes in the older adult, particularly drug therapy, should involve consideration of patient and caregiver preferences, and other coexisting medical and geriatric conditions.
Diabetes mellitus is a common metabolic disorder affecting older people. Although it is recognized by its effects on carbohydrate metabolism to cause hyperglycemia, diabetes usually also affects lipid and protein metabolism. With time, effects of diabetes on the cardiovascular system, the kidneys, the retina, and the peripheral nervous system, often referred to as long-term complications of diabetes, substantially increase mortality and morbidity in older adults. Furthermore, diabetes may accelerate the risk and contribute to worse outcomes for other common age-related conditions, including physical function decline, cognitive impairment, and other geriatric syndromes. Older adults with diabetes are highly heterogeneous in their health and functional status. Many older adults who are relatively healthy and have good functional status may benefit from the same type of diabetes care that is recommended for younger adult diabetes patients. However, the risks of implementing such a diabetes care regimen may lead to more harm than benefit for some older adults who have many comorbidities. Therefore diabetes management and goals of care for older adults should be individualized to address the heterogeneity of this population. More research is needed to identify optimal care for older patients with diabetes that can improve their functional outcomes, so that they can preserve long-term independence.
Diabetes mellitus is a heterogeneous set of disorders affecting multiple body systems; however, diabetes diagnostic criteria are based on documentation of elevated circulating blood glucose levels. While glucose levels vary during the course of the day, the diagnostic criteria for diabetes mellitus are based on standardized values that predict poor outcomes in population studies. The challenge of establishing appropriate diagnostic criteria for older adults is made more difficult by well-described effects of aging on glucose metabolism (summarized later in this chapter in the section on “Effects of Aging”). Table 110-1 summarizes the currently accepted diagnostic criteria published by the American Diabetes Association (ADA) in 2014.
TABLE 110-1THREE METHODS TO DETERMINE DYSGLYCEMIA AND DIAGNOSTIC CRITERIA...