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Treatment of type 2 diabetes mellitus in the older patient
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Mar 2014. | This topic last updated: Feb 25, 2014.

INTRODUCTION — The prevalence of type 2 diabetes continues to increase steadily as more people live longer and grow heavier. In the 2005-2006 National Health and Nutrition Examination Survey of community dwelling adults, the prevalence of diabetes increased with age and peaked at age 60 to 74 years (crude prevalence 17.6 percent) [1]. From 1995 to 2004, the overall prevalence of type 2 diabetes in nursing home residents increased from 16 to 23 percent [2].

Older adults with diabetes are at risk of developing a similar spectrum of macrovascular and microvascular complications as their younger counterparts with diabetes. However, their absolute risk for cardiovascular disease is much higher than younger adults. Elderly adults with diabetes suffer excess morbidity and mortality compared with elderly individuals without diabetes [3]. In addition, they are at high risk for polypharmacy, functional disabilities, and common geriatric syndromes that include cognitive impairment, depression, urinary incontinence, falls, and persistent pain [4].

This topic will review diabetes management in elderly patients and how management priorities and treatment choices may differ between elderly and younger patients. The general management of type 2 diabetes is reviewed separately. (See "Overview of medical care in adults with diabetes mellitus" and "Initial management of blood glucose in adults with type 2 diabetes mellitus" and "Management of persistent hyperglycemia in type 2 diabetes mellitus".)

INDIVIDUALIZING MANAGEMENT — Older adults with diabetes are a heterogeneous population that includes persons residing independently in communities, in assisted care facilities, or in nursing homes. Thus older adults with diabetes can be fit and healthy or frail with many comorbidities and functional disabilities.

The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycemia and risk factors. However, in frail elderly patients with diabetes, avoidance of hypoglycemia, hypotension, and drug interactions due to polypharmacy are of even greater concern than in younger patients with diabetes [5]. In addition, management of coexisting medical conditions is important, as it influences their ability to perform self-management.

Glycemic targets — There are few data specifically addressing optimal glycemic goals in elderly patients. Hyperglycemia increases dehydration and impairs vision and cognition [6], all of which contribute to functional decline and an increased risk of falling in elderly diabetic patients. On the other hand, older patients may tolerate relatively higher blood glucose levels before they manifest an osmotic diuresis, owing to their lower glomerular filtration rates and lower load of glucose delivered to the tubules for reabsorption. Furthermore, side effects of diabetes treatment, most notably hypoglycemia, can result in poor outcomes, such as traumatic falls and exacerbation of comorbid conditions. Goals for glycemic control, as well as risk factor management, should be based upon the individual's overall health and projected period of survival, since the risk of complications is duration-dependent.

The appropriate target for hemoglobin A1C (A1C) in fit elderly patients who have a life expectancy of over 10 years should be similar to those developed for younger adults (<7.0 percent). The results of the ACCORD trial suggest that a target A1C of 7.0 to 7.9 percent (achieving a median of 7.5 percent) may be safer than a lower target for patients with long-standing type 2 diabetes who are at high risk for cardiovascular disease [7]. Thus, the goal should be somewhat higher (≤8.0 percent) in frail older adults with medical and functional comorbidities and in those whose life expectancy is less than 10 years. Individualized goals for the very elderly may be even higher and should include efforts to preserve quality of life and avoid hypoglycemia and related complications. These goals are consistent with the American Geriatrics Society, the American Diabetes Association, the International Diabetes Federation, and the European Diabetes Working Party guidelines [4,8-12]. (See "Glycemic control and vascular complications in type 2 diabetes mellitus", section on 'Glycemic targets'.)

The measurement of A1C may not be accurate in several situations that are seen frequently in older adults. These include anemia and other conditions that impact red blood cell life span, chronic kidney disease, recent transfusions and erythropoietin infusions, recent acute illness or hospitalizations, and chronic liver diseases. Biological and patient-specific factors that may cause misleading A1C results are reviewed separately. (See "Estimation of blood glucose control in diabetes mellitus", section on 'Glycated hemoglobin'.)

Avoiding hypoglycemia — The risk of hypoglycemia, which may lead to impaired cognition and function, is substantially increased in the elderly. In addition, older adults may have more neuroglycopenic manifestations of hypoglycemia (dizziness, weakness, delirium, confusion) compared with adrenergic manifestations (tremors, sweating). These symptoms may be missed or misconstrued as primary neurological disease (such as a transient ischemic attack), leading to inappropriate reporting of hypoglycemic episodes by the patients.

Hypoglycemic episodes in elderly individuals may also increase the risk of adverse cardiovascular events and cardiac autonomic dysfunction [13]. In addition, severe hypoglycemia requiring hospitalization has been associated with an increased risk of developing dementia that is higher in patients with repeated episodes, although the direction of causality, if any, is unknown [14].

Even a mild episode of hypoglycemia may lead to adverse outcomes in frail elderly patients. As an example, episodes of dizziness or weakness increase the risk of falls and fracture leading to nursing home placement.

Given the risks, avoidance of hypoglycemia is an important consideration in choosing therapeutic agents and establishing glycemic goals in elderly adults. Insulin secretagogues such as sulfonylurea and meglitinides, as well all types of insulin, should be used with caution in the frail elderly [15].

Lifestyle modification — Diet, weight reduction, and exercise can all be used to improve glycemic control, although the majority of elderly patients with type 2 diabetes will require medication over the course of their diabetes. (See "Initial management of blood glucose in adults with type 2 diabetes mellitus", section on 'Nonpharmacologic therapy'.)

Medical nutrition therapy (MNT) is the process by which the nutrition prescription is tailored for people with diabetes based upon medical, lifestyle, and personal factors and is an integral component of diabetes management and diabetes self-management education. In a randomized trial of medical nutrition intervention in adults ≥65 years of age, patients in the intervention group had significantly greater improvements in fasting plasma glucose (-18.9 versus -1.4 mg/dL) and A1C (-0.5 percentage points versus no change) than control patients [16].

In addition, the oldest age group in the Diabetes Prevention Program (>60 years of age at baseline) had the greatest improvement in glycemia over time, related in part to better adherence to the lifestyle program, compared with the younger age groups [17,18]. These data suggest that older persons can respond well to lifestyle programs. Thus, all elderly patients with diabetes should receive a medical nutrition evaluation. (See "Prevention of type 2 diabetes mellitus", section on 'Lifestyle modification' and "Nutritional considerations in type 2 diabetes mellitus".)

The choice of diet has important clinical considerations:

Obese older adults with diabetes may benefit from caloric restriction and an increase in physical activity with a weight loss goal of approximately 5 percent of body weight [4,19].

The elderly are as much at risk for under-nutrition as for obesity. Weight loss increases the risk of morbidity and mortality in older adults [20]. Thus, an involuntary loss of weight should be addressed in the medical nutrition evaluation.

Drug therapy — There are few data specifically addressing drug therapy in elderly patients [21]. However, most diabetes drug trials included a wide range of patients, including those >65 years of age. All of the types of oral hypoglycemic drugs and insulin are safe in older patients, although each has some limitations. Pharmacologic therapy must be individualized based upon patient abilities and comorbidities. "Start low and go slow" is a good principle to follow when starting any new medications in an elderly adult.

The following recommendations are based upon trials carried out in the general population and from clinical experience. They are consistent with the American Geriatrics Society, the American Diabetes Association, the International Diabetes Federation, and the European Diabetes Working Party guidelines [4,8-12].

For elderly patients who do not have contraindications to metformin (eg, renal impairment or severe heart failure), we prefer to initiate therapy with metformin (see "Metformin in the treatment of adults with type 2 diabetes mellitus", section on 'Lactic acidosis'). However in patients with contraindications and/or intolerance to metformin, a short-acting sulfonylurea (eg, glipizide) is an alternative option. In a patient with chronic kidney disease who is intolerant of sulfonylureas, repaglinide could be considered as initial therapy. (See "Initial management of blood glucose in adults with type 2 diabetes mellitus".)

After a successful initial response to oral therapy, many patients fail to maintain target A1C levels. If glycemic goals are not met with a single agent, the elderly patient should be evaluated for contributing causes, such as difficulty adhering to the medication, side effects, or poor understanding of the nutrition plan [4,11]. In elderly patients who require more than one agent, pill-dosing dispensers may help improve adherence. As an alternative, family members or caregivers may be required to help administer medication.

Indications for a second agent and therapeutic options for patients who fail initial therapy with lifestyle intervention and metformin or a sulfonylurea are similar in the elderly and in younger patients (table 1). This topic is reviewed separately. (See "Management of persistent hyperglycemia in type 2 diabetes mellitus".)

Metformin — Metformin is an attractive agent to use in the elderly due to a low risk of hypoglycemia. However, it should be given with caution in older diabetic patients because of the risk of lactic acidosis. Elderly patients often have impaired renal function despite an apparently normal serum creatinine concentration. They are also at increased risk for developing other conditions that reduce renal function further or cause lactic acidosis (eg, myocardial infarction, stroke, cardiac failure, pneumonia). A calculated (or estimated) GFR >30 mL/min has been suggested as a safe level of kidney function for the use of metformin.

Weight loss and gastrointestinal side effects may also be limiting factors in older adults taking metformin. Therefore, metformin should be used with caution in older patients. Contraindications to its use are reviewed elsewhere. (See "Metformin in the treatment of adults with type 2 diabetes mellitus", section on 'Lactic acidosis'.)

Any elderly patient treated with metformin should be cautioned to stop taking the drug immediately if they become ill for any reason, or if they are to undergo a procedure requiring the use of iodinated contrast material.

Sulfonylurea drugs — Sulfonylurea drugs are usually well-tolerated. Hypoglycemia is the most common side effect and is more common with long-acting sulfonylurea drugs (eg, chlorpropamide, glyburide, and glimepiride). Thus, we avoid the use of long-acting sulfonylureas in elderly adults. We prefer to use a short-acting sulfonylurea, such as glipizide. (See "Sulfonylureas and meglitinides in the treatment of diabetes mellitus" and "Management of hypoglycemia during treatment of diabetes mellitus", section on 'Type 2 diabetes'.)

The reported frequency of sulfonylurea-related hypoglycemia in the elderly is variable. In one observational study, the frequency in patients over age 65 treated with either glyburide or chlorpropamide was similar (16.6 episodes per 1000 person-years) [22]. In contrast, in another study of 52 elderly patients treated with glyburide or the glipizide gastrointestinal therapeutic system (GITS), no episodes of hypoglycemia occurred during a 23-hour fast [23].

Drug-induced hypoglycemia is most likely to occur in the following circumstances in older patients and may be a limiting factor for use of these drugs in older adults:

After exercise or missed meals

When they eat poorly or abuse alcohol

When they have impaired renal or cardiac function or intercurrent gastrointestinal disease

During therapy with salicylates, sulfonamides, fibric acid derivatives (such as gemfibrozil), and warfarin [24]

After being in the hospital [22]

These issues may arise when there is a change in overall health status in older adults with diabetes. In patients who are using sulfonylurea drugs, the presence and frequency of hypoglycemia should be evaluated at each visit.

Thiazolidinediones — The thiazolidinediones (rosiglitazone and pioglitazone) improve insulin resistance. They also may increase insulin secretion in response to glucose, at least in patients with impaired glucose tolerance [25].

The thiazolidinediones may be considered for some older patients, particularly those with lower initial A1C values, if there are specific contraindications to sulfonylureas or if they are not able or willing to consider insulin. They can be given to patients who have impaired renal function, are well tolerated in older adults, and do not cause hypoglycemia. However, thiazolidinediones should not be used in patients with class III or IV heart failure. In addition, limited experience, high cost, and concerns regarding fluid retention, congestive heart failure, MI, and fractures limit their usefulness, particularly in the elderly. If a thiazolidinedione is to be used as therapy, pioglitazone is preferred because of the greater concern about atherogenic lipid profiles and a potential increased risk for cardiovascular events with rosiglitazone. In 2010, the European Medicines Agency suspended sales of rosiglitazone. In the United States, rosiglitazone is only available through a Risk Evaluation and Mitigation Strategy program. New concerns regarding increased risk for bladder cancer with pioglitazone, in addition to fluid retention and bone loss, have led to decreased enthusiasm for its use. (See "Thiazolidinediones in the treatment of diabetes mellitus", section on 'Cardiovascular Effects' and "Thiazolidinediones in the treatment of diabetes mellitus", section on 'Safety' and "Heart failure in diabetes mellitus".)

Meglitinides — Repaglinide and nateglinide are short-acting glucose-lowering drugs that act similarly to the sulfonylureas and have similar or slightly less efficacy in decreasing glycemia. Meglitinides are pharmacologically distinct from sulfonylureas and may be used in patients who have allergy to sulfonylurea medications. They have a similar risk for weight gain as sulfonylureas but possibly less risk of hypoglycemia [26]. Unlike nateglinide, repaglinide is principally metabolized by the liver, with less than 10 percent renally excreted. Dose adjustments with this agent do not appear to be necessary in patients with renal insufficiency. In addition, repaglinide is somewhat more effective in lowering A1C than nateglinide. Thus, repaglinide could be considered as initial therapy in a patient with chronic kidney disease who is intolerant of metformin and sulfonylureas. (See "Sulfonylureas and meglitinides in the treatment of diabetes mellitus".)

Alpha-glucosidase inhibitors — Acarbose and miglitol inhibit the gastrointestinal alpha-glucosidases that convert dietary starch and other complex carbohydrates into monosaccharides, thereby slowing the absorption of glucose, which results in a slower rise in postprandial blood glucose concentrations. These drugs may be used alone, or in combination with insulin, a sulfonylurea, and metformin.

Acarbose and miglitol have not been widely tested in elderly diabetic patients, but are likely to be fairly safe and effective. The main side effects that limit their use are flatulence and diarrhea, which are very common. (See "Alpha-glucosidase inhibitors and lipase inhibitors for treatment of diabetes mellitus".)

DPP-IV inhibitors — Dipeptidyl peptidase IV (DPP-IV) is a ubiquitous enzyme that deactivates a variety of other bioactive peptides, including glucagon-like peptide-1 (GLP-1) and glucose dependent insulinotropic polypeptide (GIP); therefore, its inhibition could potentially affect glucose regulation through multiple effects. DPP-IV inhibitors have been shown to be moderately effective as monotherapy or when used in combination with metformin, sulfonylureas, or thiazolidinediones. They are relatively weak agents and usually lower A1C levels by only 0.6 percent. (See "Glucagon-like peptide-1-based therapies for the treatment of type 2 diabetes mellitus", section on 'DPP-4 inhibitors'.)

DPP-IV inhibitors have no risk of hypoglycemia and are weight-neutral, when used as monotherapy, and therefore may be attractive agents to use in the elderly. However, the long-term safety with this class of drug has not been established, and they are relatively expensive. The dose of DPP-IV inhibitors should be adjusted in patients with renal insufficiency. (See "Glucagon-like peptide-1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Side effects'.)

GLP-1 therapies — The role of gastrointestinal peptides in glucose homeostasis is illustrated by the incretin effect, in which oral glucose has a greater stimulatory effect on insulin secretion than intravenous glucose. This effect is mediated by several gastrointestinal peptides, particularly GLP-1. Exenatide and liraglutide are GLP-1 analog agents available for use as monotherapy as an adjunct to diet and exercise or in combination with oral agents in adults with type 2 diabetes. Exenatide is administered twice daily and liraglutide once daily by subcutaneous injection. (See "Glucagon-like peptide-1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Exenatide' and "Glucagon-like peptide-1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Liraglutide'.)

There is no risk of hypoglycemia with the use of GLP-1 analogs alone. Both drugs are sometimes associated with significant reduction in weight. The most common adverse events are nausea, vomiting, and diarrhea, occurring in 10 to 40 percent of treated patients. There have been postmarketing reports of acute pancreatitis and deterioration in renal function in patients taking GLP-1 therapies. However, there are insufficient data to know if there is a causal relationship. Due to concerns about renal toxicity, exenatide should not be used in patients with a creatinine clearance below 30 mL/min. (See "Glucagon-like peptide-1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Exenatide' and "Glucagon-like peptide-1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Liraglutide'.)

Pramlintide — Pramlintide is a synthetic analog of amylin that is administered by mealtime subcutaneous injection with insulin. It is available for the treatment of both type 1 and insulin-treated type 2 diabetes. It requires multiple subcutaneous injections and, therefore, its role in the management of diabetes in the elderly is limited. (See "Amylin analogs for the treatment of diabetes mellitus", section on 'Pramlintide'.)

Insulin — Insulin is sometimes underutilized in the elderly because of fear (by the clinician, patient, or family) that it is too complicated or dangerous. With the availability of long-acting insulins, it has become easier to use once daily long-acting insulin as monotherapy or add once daily insulin to oral hypoglycemic medications in older patients who have suboptimal glycemic control. Patients may wrongly assume that their symptoms of fatigue are due to "old age" rather than hyperglycemia. However, in many older patients, quality of life improves substantially when they take one or two daily doses of intermediate- or long-acting insulin. (See "General principles of insulin therapy in diabetes mellitus".)

Before beginning insulin therapy, it is important to evaluate whether or not the patient is physically and cognitively capable of using an insulin pen or drawing up and giving the appropriate dose of insulin (using syringes and vials), monitoring blood glucose, and recognizing and treating hypoglycemia. For elderly patients taking a fixed daily dose of insulin and who are capable of giving the insulin shot but not of drawing it up, a pharmacist or family member may prepare a week's supply of insulin in syringes and leave them in the refrigerator. Such a plan may allow an elderly patient to remain living independently at home.

Insulin metabolism is altered in patients with chronic renal failure, so that less insulin is needed when the glomerular filtration rate is below 50 mL/min.

Specifics of insulin therapy are discussed in detail elsewhere. (See "General principles of insulin therapy in diabetes mellitus" and "Insulin therapy in type 2 diabetes mellitus".)

Monitoring of blood glucose — Monitoring is usually necessary to achieve glycemic goals. We typically monitor A1C twice yearly in elderly patients who are meeting treatment goals and who have stable glycemic control, and quarterly in patients whose therapy has changed or who are not meeting glycemic goals. (See "Estimation of blood glucose control in diabetes mellitus", section on 'Glycated hemoglobin'.)

Blood glucose concentrations can also be monitored at home by the patient or a caregiver. The effectiveness of self monitoring of blood glucose (SMBG) in terms of improving glycemic control in patients with type 2 diabetes is less clear than for type 1 diabetes. (See "Blood glucose self-monitoring in management of adults with diabetes mellitus", section on 'Type 2 diabetes'.)

SMBG may be helpful in elderly patients with type 2 diabetes who take medications that can cause hypoglycemia (eg, insulin). SMBG may also be useful for some patients who would take action to modify eating patterns or exercise, as well as be willing to intensify pharmacotherapy, based on SMBG results. However, self-monitoring of glucose may not be necessary at all, or only in unusual circumstances, for elderly patients with type 2 diabetes who are diet-treated or who are treated with oral agents not associated with hypoglycemia.

Thus, SMBG can be considered in select elderly patients, depending upon medications and functional and cognitive abilities [4,11].

SCREENING FOR MICROVASCULAR COMPLICATIONS — Retinopathy, nephropathy, and foot problems are all important complications of diabetes mellitus in elderly patients. Monitoring recommendations for elderly patients with diabetes are similar to those in younger patients (table 2).

Retinopathy — The prevalence of retinopathy increases progressively with increasing duration of diabetes (figure 1). (See "Diabetic retinopathy: Classification and clinical features".)

Regular eye examinations are extremely important for elderly diabetic patients because poor vision can lead to social isolation, an increased risk of accidents, and impaired ability to measure blood glucose and draw up insulin doses. A complete ophthalmologic examination should be performed by a qualified ophthalmologist or optometrist at the time of diagnosis and at least yearly thereafter. The purpose is to screen not only for diabetic retinopathy but also for cataracts and glaucoma, which are more common in elderly diabetic compared with nondiabetic subjects. Cataracts are over twice as common in people over age 65 years with diabetes compared with similarly aged nondiabetic subjects (38.4 percent versus 16.6 percent), while glaucoma is almost three times more common (11.2 percent versus 3.8 percent) [27].

Nephropathy — The availability of effective therapy for diabetic nephropathy with angiotensin-converting enzyme (ACE) inhibitors has led to the recommendation that all patients with diabetes be screened for increased urinary albumin excretion annually. (See "Moderately increased albuminuria (microalbuminuria) in type 1 diabetes mellitus" and "Moderately increased albuminuria (microalbuminuria) in type 2 diabetes mellitus".)

However, the prevalence of increased urinary albumin excretion increases in the elderly population for reasons unrelated to diabetic nephropathy. For elderly patients who are already taking an ACE inhibitor or ACE receptor blocker, it may not be necessary or helpful to continue testing for increased urinary albumin excretion on an annual basis.

Foot problems — Foot problems are an important cause of morbidity in patients with diabetes, and the risk of them is much higher in older patients. Both vascular and neurologic disease contribute to foot lesions. It is estimated, for example, that the prevalence of diabetic neuropathy in patients with type 2 diabetes is 32 percent overall and more than 50 percent in patients over age 60 years [28,29]. (See "Treatment of diabetic neuropathy".)

In addition to the increasing prevalence of neuropathy with age, more than 30 percent of older diabetic patients cannot see or reach their feet, and may therefore be unable to perform routine foot inspections.

We recommend that elderly diabetic patients have their feet examined at every visit; this examination should include an assessment of the patient's ability to see and reach his or her feet, and inquiry about other family members or friends who could be trained to do routine foot inspections. Visits to a podiatrist on a regular basis should also be considered. A detailed neurologic examination and assessment for peripheral artery disease should be performed at least yearly. It is also important that prophylactic advice on foot care be given to any patient whose feet are at high risk. (See "Evaluation of the diabetic foot".)

CARDIOVASCULAR RISK REDUCTION — Both diabetes and age are major risk factors for coronary heart disease. It is therefore not surprising that coronary heart disease is by far the leading cause of death in elderly patients with diabetes, and that the effect of most interventions is more pronounced in them.

Risk reduction should be focused upon the following areas:

Smoking cessation

Treatment of hypertension

Treatment of dyslipidemia

Aspirin therapy

Exercise

Smoking cessation — Smoking in patients with diabetes mellitus is an independent risk factor for all-cause mortality, due largely to cardiovascular disease. Therefore, smoking cessation should be vigorously promoted. (See "Smoking and cardiovascular risk in diabetes mellitus".)

Treatment of hypertension — Treatment of hypertension in elderly patients is clearly beneficial, including patients over age 80. Recommended therapeutic goals and drug options for patients with diabetes and the elderly are reviewed in detail elsewhere. (See "Treatment of hypertension in patients with diabetes mellitus" and "Treatment of hypertension in the elderly patient, particularly isolated systolic hypertension".)

Treatment of dyslipidemia — Several abnormalities in lipid metabolism may contribute to the increase in atherosclerosis associated with diabetes. The beneficial effects of lipid lowering therapy may be evident in as early as six months [30]. In addition, the relative reduction of cardiovascular disease with serum LDL reduction is similar in elderly and younger patients with diabetes [31,32]. (See "Prevalence of and risk factors for coronary heart disease in diabetes mellitus".)

We recommend use of a statin drug (unless contraindicated) to lower cholesterol in all elderly diabetics with a persistent LDL cholesterol value above 100 mg/dL (2.6 mmol/L), with a goal of reducing LDL below 100 mg/dL (2.6 mmol/L). In patients with diabetes who already have cardiovascular disease, a goal LDL of 70 to 80 mg/dL (1.8 to 2.1 mmol/L) is warranted, particularly in very high-risk patients. We also recommend drug therapy in those with a serum HDL cholesterol concentration below 35 mg/dL (0.9 mmol/L) or marked hypertriglyceridemia (≥400 mg/dL [4.5 mmol/L]). More detailed information on the use of lipid-lowering drugs for secondary prevention of CHD is found elsewhere. (See "Intensity of lipid lowering therapy in secondary prevention of cardiovascular disease" and "Clinical trials of cholesterol lowering in patients with cardiovascular disease or diabetes", section on 'Heart Protection Study' and "Clinical trials of cholesterol lowering in patients with cardiovascular disease or diabetes", section on 'ACCORD Lipid trial'.)

As with the goal for glycemic control, goals for risk factor management (hypertension, hyperlipidemia) should be adjusted based upon elderly patients' life expectancy, comorbidities, cognitive status, and personal preferences.

Aspirin — The value of daily aspirin therapy in patients with known macrovascular disease (secondary prevention) is widely accepted (see "Benefits and risks of aspirin in secondary and primary prevention of cardiovascular disease"). A meta-analysis of a large number of secondary prevention trials found that the absolute benefit of aspirin was greatest in those over age 65 years with diabetes or diastolic hypertension [33].

The role of aspirin for the primary prevention of cardiovascular events in patients with diabetes is less certain. These trials and recommendations for aspirin therapy are reviewed elsewhere. (See "Overview of medical care in adults with diabetes mellitus", section on 'Aspirin'.)

Exercise — Exercise is beneficial to help maintain physical function, reduce cardiac risk, and improve insulin sensitivity in patients with diabetes. In older adults, exercise also improves body composition and arthritic pain, reduces falls and depression, increases strength and balance, enhances the quality of life, and improves survival [34-37]. Studies of frail elderly people have shown that weight training should be included in addition to aerobic exercises [38]. Patients with deconditioning at risk for falls should be referred to an exercise physiologist and/or physical therapist for muscle strengthening and balance training in a safe environment. (See "Effects of exercise in diabetes mellitus in adults".)

COMMON GERIATRIC SYNDROMES ASSOCIATED WITH DIABETES

Cognitive impairment — Diabetes is associated with increased risk of dementia (see "Risk factors for dementia", section on 'Diabetes mellitus'). Many older patients with dementia remain undiagnosed, particularly in the early stages. Elderly patients with diabetes and cognitive dysfunction may have difficulty performing self-management and following complicated treatment regimens. Cognitive function should be assessed in elderly diabetic patients when there is:

Nonadherence with therapy

Frequent episodes of hypoglycemia

Deterioration of glycemic control without obvious explanation (see "Evaluation of cognitive impairment and dementia")

Depression — Depression occurs at a higher rate in older patients with diabetes compared with age-matched controls [39,40]. Depression is frequently undiagnosed and remains untreated in this high risk population [41].

Depression has been associated with poor glycemic control and with accelerated rates of coronary heart disease in diabetic patients [42]. Early identification with a short screening tool (such as a geriatric depression scale) and treatment may help achieve better glycemic control [43].

Polypharmacy — Use of multiple drugs is common in older adults. Management of hyperglycemia and its associated risk factors often increases the number of medications even more in the elderly with diabetes. Side effects may exacerbate comorbidities and impede the patient's ability to manage his/her diabetes. Therefore, the medication list should be kept current and reviewed at each visit [4,11].

Falls — The increased risk of falls in older adults with diabetes is multifactorial. Presence of peripheral and/or autonomic neuropathy, reduced renal function, muscle weakness, functional disability, loss of vision, polypharmacy, comorbidities like osteoarthritis, and even mild hypoglycemia may contribute to falls in frail older adults. (See "Falls in older persons: Risk factors and patient evaluation".)

While good glycemic control prevents progression of some diabetes complications and therefore may decrease the risk of falls, hypoglycemia that occurs as a result of intensive glycemic control may increase the risk of falls. In a prospective observational study of 446 elderly adults with diabetes (mean age 74 years), intensive glycemic control (A1C ≤6 versus >8 percent) was associated with an increased risk of falls in insulin users (odds ratio 4.4, 95% CI 1.3-14.5) but not in those treated with oral agents (OR 1.3, 95% CI 0.7-2.5) [44]. Potential reasons for the discrepancy include a greater duration or severity of diabetes or a greater number of hypoglycemic episodes in patients treated with insulin versus oral agents, possibilities which were not rigorously explored in this observational study.

Nevertheless, the benefits of improved glycemic control to reduce diabetes-related complications (and decrease risk of falls) must be balanced with the possible increased risk of falls with intensive insulin therapy. These findings support the use of less rigorous glycemic goals in the elderly (see 'Glycemic targets' above). In addition, identifying the causes of falls and initiating exercise programs may reduce the risk of falls in these individuals.

Urinary incontinence — Diabetes increases a woman's risk of developing urinary incontinence. Risk factors include urinary tract infection, vaginal infection, autonomic neuropathy (resulting in either neurogenic bladder or fecal impaction) and polyuria due to hyperglycemia. Although there is no direct evidence to suggest deleterious effect of incontinence on diabetes control, identification and treatment are recommended to improve quality of life in women. (See "Treatment and prevention of urinary incontinence in women".)

Nursing home patients — There are few studies and guidelines directed at care of older adults with diabetes residing in nursing homes. Life expectancy, quality of life, severe functional disabilities and other co-existing conditions mentioned above affect goal setting and management plans. Exercise as tolerated in any form continues to be important for all patients. Regular diet without concentrated sweets may improve quality of life and prevent weight loss.

Treatment regimens should be chosen to achieve maximal glycemic control possible, with a focus on avoidance of hypoglycemia and control of hyperglycemic symptoms.

SUMMARY AND RECOMMENDATIONS

The appropriate target for hemoglobin A1C (A1C) in fit elderly patients who have a life expectancy of over 10 years should be similar to those developed for younger adults (<7.0 percent). The goal should be somewhat higher (≤8.0 percent) in frail older adults with multiple medical and functional comorbidities and in those whose life expectancy is less than 10 years. Individualized goals for the very elderly may be even higher and should include efforts to preserve quality of life and avoid hypoglycemia and related complications. (See 'Glycemic targets' above.)

The risk of hypoglycemia, which may lead to impaired cognition and function, is substantially increased in the elderly. Thus, avoidance of hypoglycemia is an important consideration in establishing goals and choosing therapeutic agents in elderly adults. (See 'Avoiding hypoglycemia' above.)

Elderly patients with diabetes should receive individualized counseling regarding lifestyle modification, including a medical nutrition evaluation. The nutrition prescription is tailored for elderly people with diabetes based upon medical, lifestyle, and personal factors. (See 'Lifestyle modification' above.)

In the absence of specific contraindications, we suggest metformin as initial therapy for elderly patients with diabetes (Grade 2B). In patients with contraindications and/or intolerance to metformin, a short-acting sulfonylurea (eg, glipizide) is an alternative option. (See 'Drug therapy' above.)

In patients who are intolerant of or are not candidates for metformin or sulfonylureas, repaglinide is a reasonable alternative, particularly in a patient with chronic kidney disease at risk for hypoglycemia. DPP4-inhibitors can also be considered as monotherapy in elderly patients who are intolerant of or have contraindications to metformin, sulfonylureas, or repaglinide. Since they are relatively weak agents and usually lower HbA1c levels by only 0.6 percent, DPP-4 inhibitors should only be used as monotherapy when the HbA1c level is relatively close to the goal level. DPP-4 inhibitors have no risk of hypoglycemia and are weight-neutral, when used as monotherapy. However, the long-term safety with this class of drug has not been established, and they are relatively expensive.

If glycemic goals are not met with a single agent, the elderly patient should be evaluated for contributing causes, such as difficulty adhering to the medication, side effects, or poor understanding of the nutrition plan. (See 'Drug therapy' above.)

Indications for a second agent and therapeutic options for patients who fail initial therapy with lifestyle intervention and metformin or a sulfonylurea are similar in the elderly and in younger patients (table 1). This topic is reviewed separately. (See "Management of persistent hyperglycemia in type 2 diabetes mellitus".)

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