DIABETES IN THE ELDERLY 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada

ELDERLY  It is generally agreed that there is no clear definition of “elderly” and that it reflects an age continuum starting somewhere in the 60s and is characterized by a slow, progressive frailty that continues until the end of life.

ELDERLY  Elderly patients with diabetes should be referred to a diabetes healthcare team.  The same glycemic, blood pressure and lipid targets apply to the otherwise healthy elderly. In people with multiple comorbidities, a high level of functional dependency and/or limited life expectancy, the goals should be more conservative. In these latter groups, symptoms of hyperglycemia and hypoglycemia should be avoided.

LIFESTYLE  Nutrition education programs can improve metabolic control in ambulatory older people with diabetes.  Physical training programs can be successfully implemented in older people with diabetes, although comorbid conditions may prevent aerobic physical training in many patients.  Resistance (weight) training has been shown to result in modest improvements in glycemic control as well as an increase in strength.

ORAL AGENTS  In lean elderly patients with type 2 diabetes, the principal metabolic defect is an impairment in glucose-induced insulin secretion. Initial therapy for these patients should involve agents that stimulation insulin secretion.  In obese elderly patients with type 2 diabetes, the principal metabolic defect is resistance to insulin-mediated glucose disposal. Initial therapy for these patients should involve agents that improve insulin resistance.

ORAL AGENTS  The incidence of hypoglycemia associated with the use of sulfonylureas increases with age and appears to be highest with glyburide. Gliclazide and glimepiride are preferred over glyburide in the elderly.

COMPLICATIONS  Treatment of isolated systolic hypertension or combined systolic and diastolic hypertension in elderly patients with diabetes is associated with a significant reduction in CV morbidity and mortality.  Treatment of hypercholesterolemia with statins for both primary and secondary prevention significantly reduces cardiovascular morbidity and mortality in older people with diabetes.

COMPLICATIONS  Type 5 phosphodiesterase inhibitors (e.g. sildenafil, tadalafil, vardenafil) appear to be effective for the treatment of erectile dysfunction in carefully selected elderly patients with diabetes.

DIABETES IN THE ELDERLY - RECOMMENDATIONS  Lifestyle interventions, including nutritional therapy and exercise, should be considered as therapeutic interventions to prevent type 2 diabetes in elderly patients at risk [Grade A, Level 1A].  Otherwise healthy elderly people with diabetes should be treated to achieve the same glycemic, blood pressure and lipid targets as younger people with diabetes [Grade D, Consensus]. In people with multiple comorbidities, high level of functional dependency or limited life expectancy, the goals should be more conservative [Grade D, Consensus].

DIABETES IN THE ELDERLY - RECOMMENDATIONS  As interdisciplinary interventions have been shown to improve glycemic control in elderly people with diabetes, these patients should be referred to a DHC team [Grade C, Level 3].  Either aerobic exercise or resistance training may benefit elderly people with type 2 diabetes and should be recommended for those individuals in whom it is not contraindicated [Grade B, Level 2].

DIABETES IN THE ELDERLY - RECOMMENDATIONS  Insulin sensitizers (TZDs) are effective in elderly patients with type 2 diabetes, but should be used with caution in elderly patients at risk for fluid retention [Grade D, Consensus].  Alpha-glucosidase inhibitors are modestly effective in the elderly with type 2 diabetes [Grade A, Level 1A].

DIABETES IN THE ELDERLY - RECOMMENDATIONS  In elderly people with type 2 diabetes, sulfonylureas should be used with caution because the risk of hypoglycemia increases exponentially with age [Grade D, Level 4].  In general, initial doses of sulfonylureas in the elderly should be half those used for younger people, and doses should be increased more slowly [Grade D, Consensus].  Gliclazide [Grade B, Level 2] and glimepiride [Grade C, Level 3] are the preferred sulfonylureas, as they are associated with a reduced frequency of hypoglycemic events compared with glyburide.

DIABETES IN THE ELDERLY - RECOMMENDATIONS  In elderly people, the use of premixed insulins and prefilled insulin pens as an alternative to mixing insulins should be encouraged to reduce dosage errors and potentially improve glycemic control [Grade B, Level 2].

DIABETES IN THE ELDERLY - RECOMMENDATIONS  Isolated systolic hypertension or combined systolic and diastolic hypertension in elderly patients with diabetes should be treated to reduce CV morbidity and mortality [Grade A, Level 1A].