Diabetes mellitus (DM) is very common among persons age 65 and older, particularly among racial and ethnic minorities, and it is on the rise. Although there are many evidence-based guidelines for DM, few are specifically targeted toward the needs of older persons, so few can help clinicians prioritize care for the older adults they may see in their practices.
There are several unique elements of these guidelines. First, throughout the guidelines, an individualized approach to care is emphasized. Older adults with DM are a heterogeneous population, ranging from those who are otherwise very healthy with excellent functional status to those who have several other chronic conditions and significant functional impairment. Assessing a patient's functional status, rather than relying simply on age, is critical to providing appropriate care.
These guidelines emphasize the development of individualized goals and treatment plans and pay special attention to the potential impact of treatment decisions on both immediate and long-term quality of life. Particularly for older persons with diabetes, the benefits gained from treating hypertension and dyslipidemias are potentially great since heart attacks and strokes are the leading causes of disability and death in this group.
There are also important benefits associated with control of blood sugar. These include the immediate benefits of symptom reduction and the longer term benefits of fewer diabetes-related complications, such as blindness and kidney disease.
Another distinctive feature of the guidelines is the inclusion of care recommendations to screen for a number of geriatric syndromes that are more common in older adults who have diabetes. These include depression, injurious falls, urinary incontinence, persistent pain and inappropriate medication use. Evidence suggests that these syndromes may go unrecognized and untreated or undertreated in many clinical settings.
In sum, these guidelines are meant to direct providers not simply to new target numbers or timelines, but instead to an approach to the care of older adults with diabetes that focuses on individualized assessment, planning and decision-making, based on the characteristics of each patient, with the goal of improving both clinical status and quality of life.
The recommendations are divided into diabetes-related topic areas: aspirin use for cardiovascular benefit; smoking cessation; hypertension; glycemic control; lipid management; eye care; foot care; renal disease; diabetes education and lifestyle modification; and the geriatric syndromes, like depression, cognitive impairment, polypharmacy, urinary incontinence, injurious falls and persistent pain. For each section, general recommendations are made, and in some cases, these are followed by specific recommendations on such issues as medication use and monitoring.
The guidelines were developed and written under the auspices of the California Healthcare Foundation American Geriatrics Society (AGS) Panel on Improving Care of Elders with Diabetes and approved by the AGS Board of Directors on February 25, 2003, and published in the May 2003 supplement issue of the Journal of the American Geriatrics Society under the title "Guidelines for Improving the Care of the Older Person with Diabetes Mellitus."
The following organizations with special interest and expertise in the management of diabetes provided peer review of a preliminary draft of the guidelines: the American Academy of Family Physicians; the American College of Physicians; the American College of Consultant Pharmacists; the American College of Clinical Pharmacy; the Society of General Internal Medicine; the American Association of Clinical Endocrinologists; and the American Diabetes Association.
Diabetes Mellitus Recommendations
Summary of Key Recommendations:
- Older persons with diabetes should be offered individualized therapy that takes into consideration life expectancy, functional status, the presence of cognitive impairment, social support and patient preferences.
- Care should be kept simple and inexpensive, wherever possible.
- Older persons with diabetes are likely to benefit greatly from cardiovascular risk reduction, therefore monitor and treat hypertension and dyslipidemias.
- For many older persons, treatment of hypertension may require more than one medication to achieve adequate control. Treatment should be gradual if possible and persons should be monitored for drug interactions and side effects.
- Monitor and treat hyperglycemia, with a target A1C of 7%, but less stringent goals of therapy may be appropriate once patient preferences, diabetes severity, life expectancy and functional status have been considered.
- Encourage diabetes education and make patients and their families aware that it is a covered benefit under Medicare.
- Dilated eye examinations should be performed every two years at a minimum, and more often if there are additional risk factors for diabetic eye disease or evidence of age-related eye disease.
- Maintain an updated medication list and evaluate the patient regularly for adverse medication effects.
- Older persons with diabetes should be screened for depression, and if depression is identified, therapy should be offered and response to therapy monitored.
- Persons should also be screened annually for cognitive impairment, urinary incontinence, injurious falls and persistent pain since these conditions are more prevalent among older persons with diabetes.
Listed below are several brochures on aging and diabetes available from AGS at Living with Diabetes:
- "Medications for Diabetes," a resource on safe use of insulin and other drugs used to treat diabetes and related complications.
- "Diabetes Patient Education Forum," a physician-authored Q&A that answers common questions older patients may have about diabetes.
- "Diabetic Neuropathy," a pamphlet designed to help patients and caregivers understand and manage neuropathic pain.
- "Lifestyle Changes for Living with Diabetes," a brochure that addresses glycemic control, blood sugar monitoring, nutrition, diet, exercise and lifestyle modifications.
- "Managing the Complications of Diabetes," a series of resources addressing management of hypertension, overactive bladder, falls, depression and cognitive impairment.
From the California Healthcare Foundation/American Geriatrics Society (AGS) Panel on Improving Care of Elders with Diabetes. "Guidelines for Improving the Care of the Older Person with Diabetes Mellitus." J Am Geriatr Soc 2003
The development of these guidelines was supported by the California Healthcare Foundation's Program for Elders in Managed Care and an unrestricted educational grant from Aventis Pharmaceuticals.
Source: American Geriatrics Society