Annals of Long-Term Care: Clinical Care and Aging. 2013;21(11):10.
In the United States, individuals aged 65 years and older have a higher prevalence of diabetes mellitus than those in all other age groups, and a significant number of these older adults are in long-term care (LTC) settings. According to a 2008 report in Diabetes Care, roughly 25% of all older people in LTC have a diabetes diagnosis.1 These older adults are at a higher risk of a range of complications of diabetes, including cardiovascular disease, stroke, and kidney damage. They are also more likely to have geriatric syndromes, such as depression, persistent pain, polypharmacy, cognitive impairment, and injurious falls, than those who do not have the disease.2
Over the last decade, high-quality evidence has shed new light on the management of diabetes in later life. In light of this, the American Geriatrics Society (AGS) recently updated its guidelines for older patients, which were originally published in 2003 in collaboration with the California HealthCare Foundation. A complete version of the new AGS guidelines is available on the AGS portal, GeriatricsCareOnline.org, and an abridged version—The American Geriatrics Society Guidelines for Improving the Care of Older Adults with Diabetes Mellitus: 2013 Update—appears in the November issue of the Journal of the American Geriatrics Society.3
The new guidelines are the work of a panel of experts in medicine, nursing, and pharmacy, and they differ from the previous editions in a number of ways. The updated guidelines no longer recommend aspirin for the primary prevention of cardiovascular disease among older adults with diabetes. To support this recommendation, the guidelines cite new, well-designed studies that found that the increased risk of bleeding outweighs the reduction in cardiovascular events. The guidelines, however, recognize that there is strong evidence that aspirin may be effective in secondary prevention for older patients who both have diabetes and a history of stroke or myocardial infarction.
The new guidelines also reemphasize the importance of treating elevated cholesterol with statins, but not necessarily treating to specific target levels. In addition, they encourage healthy older adults with diabetes to exercise and lose excess weight, if recommended, using an exercise regimen tailored to their functional status. This recommendation is based on increased evidence that supports the importance of exercise among this population.
The guidelines also recommend that blood glucose control be tailored to each patient’s functional status, taking his or her health and life expectancy into consideration. If control is too aggressive it may lead to hypoglycemia and complications, such as falls or loss of consciousness.
“There can be risks in lowering glycated hemoglobin (HbA1c),” notes former AGS president Barbara Resnick, PhD, CRNP, a professor at the University of Maryland School of Nursing who has a clinical/faculty position as a gerontological nurse practitioner at Maryland’s Roland Park Place, a continuing care retirement community offering independent and assisted living as well as comprehensive skilled nursing care.
Throughout, the new guidelines emphasize that treatment of older adults with diabetes should be individualized and patient-focused. Therefore, healthcare providers, patients, family members, and other informal caregivers should work together to identify personalized treatment goals.
“Treatment planning and implementation should optimize quality of life and the individual patient’s physical and cognitive function,” Dr. Resnick adds. “In addition, goals should be altered—again, in consultation with the patient and informal caregivers—when health status changes. At all times, the focus should be on avoiding and preventing acute events, such as hypoglycemia and hyperglycemia, and associated problems, such as urinary frequency, infections, and slow wound healing.”
1. Resnick HE, Heineman J, Stone R, et al. Diabetes in U.S. nursing homes, 2004. Diabetes Care. 2008;31(2):287-288.
2. Sue Kirkman M, Briscoe VJ, Clark N, et al; Consensus Development Conference on Diabetes and Older Adults. Diabetes in older adults: a consensus report. J Am Geriatr Soc. 2012;60(12):2342-2356.
3. American Geriatrics Society Expert Panel on the Care of Older Adults with Diabetes Mellitus. Guidelines Abstracted from the American Geriatrics Society Guidelines for Improving the Care of Older Adults with Diabetes Mellitus: 2013 Update. J Am Geriatr Soc. 2013;61(11):2020-2026.