Diagnosing type 2 diabetes in older people
Many of the symptoms of type 2 diabetes in older people are the same as in younger people; however, they can often be overlooked or mistakenly attributed to ‘old age’. It is important to be alert to the clinical features of diabetes in older patients, such as:
- lethargy
- urinary incontinence as part of polyuria
- recurrent infections
- slow wound healing
- cognitive changes.
GPs should also be aware that type 1 diabetes does occur in older people; clear identification of diabetes type is therefore vital.
For more information, refer to The McKellar guidelines for managing older people with diabetes in residential and other care settings.
Assessment
The following additional assessment should be undertaken in elderly patients with type 2 diabetes:1
- full assessment of physical, mental and social health, including falls risk, nutrition and immunisation status
- careful screening and monitoring for cognitive impairment.
The NO TEARS tool7,8 can be useful to review medications and can be tailored to the individual practitioner's consultation style:
- Need and indication
- Open questions
- Tests and monitoring
- Evidence and guidelines
- Adverse events
- Risk reduction or prevention
- Simplification and switches
Additional tools as outlined in the RACGP aged care clinical guide (Silver Book) to help identify medication-related safety concerns and potential medication to deprescribe or reintroduce include:
- Screening Tool of Older People’s Prescriptions (STOPP)
- Screening Tool to Alert to Right Treatment (START).
An accredited pharmacist may be helpful in initiating any such changes.
For information about frailty screening, assessment and management, see:
Management and care planning
Care planning is vitally important in older people with diabetes. It can provide clarity regarding aims of care and help avoid reactive management to problems. Care planning should include up-to-date care plans, regular reviews, documented sick-day management plans and hyper- and hypoglycaemia risk assessment.
Management of diabetes in elderly patients should take into account quality of life, life expectancy and functioning (Figure 1). In some patients, strict glycaemic management may be less important than risk minimisation and maintaining quality of life. Blood glucose targets may therefore be higher than for younger adults with type 2 diabetes (see ‘Considerations in management ’ below).
Figure 1. Consensus framework for individualising targets and therapeutic approach to glycaemic management across the continuum of care for older people with type 2 diabetes.9
However, optimising glycaemia might help prevent acute symptoms of diabetes such as polyuria, weight loss, confusion and falls.9 Note that HbA1c levels greater than 8–8.5% (64–69 mmol/mol) are associated with greater morbidity and mortality in older patients.10,11 Older people with diabetes have higher rates of conditions that might impair their ability to self-manage diabetes compared with younger people. These include functional disability, accelerated muscle loss, osteoporosis, cognitive impairment, urinary incontinence, injurious falls and persistent pain.1
Refer to the section ‘Managing multimorbidity in people with type 2 diabetes ’ for approaches to managing comorbidities, including cognitive decline.
Possible strategies to manage diabetes in some clinical presentations are described in table 3 in the American Diabetes Association publication Management of diabetes in long-term care and skilled nursing facilities.12
Considerations in management
Older people are at higher risk of hypoglycaemia, so medication regimens should aim to avoid hypoglycaemia.1 Where needed, individualised targets should be redefined, and treatment regimens deintensified (if possible) to reduce the risk of hypoglycaemia and avoid polypharmacy.1
Older people with diabetes should have an individualised hypoglycaemia management plan.
Glycaemic targets for some elderly people may be higher than for the non-elderly (eg an HbA1c target of 8% [64 mmol/mol] rather than 7% [53 mmol/mol]). Intensive glycaemic management reduces microvascular but not macrovascular complications, and may increase adverse events and mortality. However, optimising glycaemia might help prevent acute symptoms of diabetes such as polyuria, weight loss, confusion and falls.9 Note that HbA1c levels greater than 8–8.5% (64–69 mmol/mol) are associated with greater morbidity and mortality in older patients.10,11
Consideration of the use of insulin to reduce symptoms of hyperglycaemia in combination with other glucose-lowering medications is still possible in the elderly. Complex regimens should be avoided, and prefilled insulin pens can reduce dosing errors.13 Nursing or carer support may be needed to administer injections; however, older people who have been self-injecting their insulin at home should be enabled to continue to do so in a residential aged care facility, subject to their capability.
Insulin regimens and the time/frequency of blood glucose monitoring should be reviewed regularly, including a review of doses and timing of administration relative to food intake, activity, frailty or clinical changes and glycaemic profile. There should not be a ‘set and forget’ approach. Technology such as continuous glucose monitoring (CGM) may need specific management plans from a credentialled diabetes educator to provide support and advice for appropriate nursing support while in residential care.
Reduce polypharmacy after discussion with clinical staff and family. Very often medications are listed as ‘prn’, but could be stopped.14 Consider fixed-dose combinations where available to assist ‘pill burden’.
Table 1 presents prescribing considerations of different glucose-lowering medications in elderly patients.
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Table 1: Considerations for selecting, monitoring and deintensifying glucose-lowering medications in elderly people with type 2 diabetes9
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Medication
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Considerations for elderly populations
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Metformin
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- May cause weight loss and gastrointestinal upset
- Cease if diarrhoea continues for a few days after starting, even after dose reduction
- Extended-release form has fewer gastrointestinal side effects and may reduce regimen complexity; however, cannot be crushed
- In renal impairment, cease if at risk of further decline in renal function
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Sulfonylureas
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- Efficacy may reduce over time as β-cell function is lost
- Long-acting sulfonylureas (glimepiride, glibenclamide and slow-release gliclazide) have a higher risk of hypoglycaemia. Avoid in frail people or when eating patterns are irregular
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DPP-4i
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- Given once daily, except vildagliptin (once or twice daily)
- Dose reduction is required in renal impairment, except linagliptin (excreted unchanged in bile)
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GLP-1RAs
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- May cause weight loss. Need to consider issues of malnutrition and sarcopenia and avoid in people who are frail and underweight
- Gastrointestinal effects are more common in older people
- Liraglutide is not recommended in people aged ≥75 years and in end-stage renal disease (no experience in these groups)
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Acarbose
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- Limited role because of gastrointestinal side effects and inferior glycaemic effect compared with metformin and sulfonylureas
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Thiazolidinediones
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- May worsen heart failure, oedema and bone fracture risk
- Change in glycaemic management may take up to 12 weeks after initiation, dose changes or cessation
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| SGLT2i |
- Watch for increased urinary frequency or incontinence, genitourinary infections and dehydration, which can contribute to delirium
- Not recommended with loop diuretics, due to volume depletion concerns
- May be problematic in people with urinary incontinence and those who require assistance getting to the toilet
- Care should be taken with use in people aged ≥75 years and in end-stage renal disease (limited experience in these groups)
- May be prescribed primarily for the treatment of heart failure and/or chronic kidney disease even when limited glycaemic efficacy is indicated
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Insulin
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- Appropriate meal planning is essential
- Basal insulin may have a lower hypoglycaemia risk than premixed insulin in some cases
- Administration by syringe increases the risk of overdose; a pen device is preferred in residential aged care facilities
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DPP-4i, dipeptidyl peptidase-4 inhibitors; GLP-1RAs, glucagon-like peptide-1 receptor agonists; SGLT2i, sodium–glucose cotransporter 2 inhibitors.
Source: Adapted from Stasinopoulos et al.9
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Lifestyle interventions
Diet
Nutritional interventions can help reduce the risk of adverse diabetes events in older people, such as hypoglycaemia, undesired weight loss, frailty and falls.1,15 It is important to consider the different nutritional needs of elderly people compared with younger people, including the healthy weight range in people aged >65 years.
Elderly people may lack awareness of thirst, and can experience reduced appetite. Adequate hydration and nutrition can therefore be a problem. Consideration of the use of an accredited practicing dietitian and supplementing nutrition with diabetes specific formulas may assist with nutritional problems. Other areas to assess and monitor include constipation, oral hygiene and the ability to cook or shop for food.
Refer also to the National Diabetes Services Scheme (NDSS) booklet Healthy eating: A guide for older people living with diabetes.16
Physical activity
Even in older adults with multiple chronic diseases, the risks associated with exercise are considered to be less than those of inactivity. Targeted exercise programs (aerobic, resistance, balance training or a combination) have been shown to provide clinically significant symptom relief for osteoarthritis, peripheral vascular disease, mobility impairment, peripheral neuropathy and elevated fall risk, depression and cognitive impairment.17
Therefore, exercise training is an essential component of any treatment plan for all elderly people who have, or are at risk of, type 2 diabetes.17 An accredited exercise physiologist can safely prescribe exercise programs. For more information, refer to ‘Lifestyle interventions for management of type 2 diabetes ’.
Sick-day management
Sick days should be planned for as usual, with the additional inclusion of advice for nurses or carers. Refer to ‘Managing risks and other impacts of type 2 diabetes ’.
Diabetes management in residential aged care facilities
The McKellar guidelines for managing older people with diabetes in residential and other care settings provide comprehensive and detailed information about managing older patients with type 2 diabetes in aged care facilities, including hyperglycaemia management guidelines (pp 25–28) and hypoglycaemia management guidelines and a risk tool (pp 29–33). Medical considerations for care plans are also presented in Appendix 5.
The key considerations in residential care are the same as for other elderly patients; however, optimising care will necessarily involve collaboration with health professionals such as nurses, aged care staff, pharmacists, dietitians, credentialled diabetes educators and residential-based allied health teams.
Staff clinical knowledge and communication is critical. Page 15 of The McKellar guidelines for managing older people with diabetes in residential and other care settings outlines to residential care staff how to consult with GPs in terms of care context and preparation for a GP consultation. Refer to the ‘Resources ’ list at the end of this section for links to guidebooks specifically for residential care staff.
In addition to the considerations listed above, medication management in residential aged care facilities requires management of the complex processes that underpin prescription, supply, administration and monitoring of glucose-lowering medication in residential aged care facilities.
- Consider residents’ goals of care and susceptibility to adverse drug events.9
- Aim for optimisation of care, deprescribing, reducing polypharmacy and avoiding hypoglycaemia.
- Conduct medication reviews with facility pharmacists and nurses.9
- Appropriate training for nursing staff (preferably annually) will help with care, and should include the safe management of insulin, understanding insulin profiles, monitoring blood glucose levels and when to increase monitoring.
For more information about medicine management, deprescribing and polypharmacy, refer also to the RACGP aged care clinical guide (Silver Book).