Treatment of Diabetes in Older Adults: An Endocrine Society Clinical Practice Guideline

Derek LeRoith; Geert Jan Biessels; Susan S Braithwaite; Felipe F Casanueva; Boris Draznin; Jeffrey B Halter; Irl B Hirsch; Marie E McDonnell; Mark E Molitch; M Hassan Murad; Alan J Sinclair

doi:10.1210/jc.2019-00198

. 2019 Mar 23;104(5):1520–1574. doi: 10.1210/jc.2019-00198

Treatment of Diabetes in Older Adults: An Endocrine Society^{^*}^{Clinical Practice Guideline}

Derek LeRoith ^1,^✉, Geert Jan Biessels ², Susan S Braithwaite ^3,⁴, Felipe F Casanueva ⁵, Boris Draznin ⁶, Jeffrey B Halter ^7,⁸, Irl B Hirsch ⁹, Marie E McDonnell ¹⁰, Mark E Molitch ¹¹, M Hassan Murad ¹², Alan J Sinclair ¹³

PMCID: PMC7271968 PMID: 30903688

Abstract

Objective

The objective is to formulate clinical practice guidelines for the treatment of diabetes in older adults.

Conclusions

Diabetes, particularly type 2, is becoming more prevalent in the general population, especially in individuals over the age of 65 years. The underlying pathophysiology of the disease in these patients is exacerbated by the direct effects of aging on metabolic regulation. Similarly, aging effects interact with diabetes to accelerate the progression of many common diabetes complications. Each section in this guideline covers all aspects of the etiology and available evidence, primarily from controlled trials, on therapeutic options and outcomes in this population. The goal is to give guidance to practicing health care providers that will benefit patients with diabetes (both type 1 and type 2), paying particular attention to avoiding unnecessary and/or harmful adverse effects.

Screening, treatment, and management of diabetes mellitus and complications in older patients.

List of Recommendations

Role of the endocrinologist and diabetes care specialist

1.1 In patients aged 65 years and older with newly diagnosed diabetes, we advise that an endocrinologist or diabetes care specialist should work with the primary care provider, a multidisciplinary team, and the patient in the development of individualized diabetes treatment goals. (Ungraded Good Practice Statement)
1.2 In patients aged 65 years and older with diabetes, an endocrinologist or diabetes care specialist should be primarily responsible for diabetes care if the patient has type 1 diabetes, or requires complex hyperglycemia treatment to achieve treatment goals, or has recurrent severe hypoglycemia, or has multiple diabetes complications. (Ungraded Good Practice Statement)

Screening for diabetes and prediabetes, and diabetes prevention

2.1 In patients aged 65 years and older without known diabetes, we recommend fasting plasma glucose and/or HbA1c screening to diagnose diabetes or prediabetes. (1|⊕⊕⊕⊕)
Technical remark: The measurement of HbA1c may be inaccurate in some people in this age group because of comorbidities that can affect the lifespan of red blood cells in the circulation. Although the optimal screening frequency for patients whose initial screening test is normal remains unclear, the writing committee advocates repeat screening every 2 years thereafter. As with any health screening, the decision about diabetes and prediabetes screening for an individual patient depends on whether some action will be taken as a result and the likelihood of benefit. For example, such screening may not be appropriate for an older patient with end-stage cancer or organ system failure. In these situations, shared decision-making with the patient is recommended.
2.2 In patients aged 65 years and older without known diabetes who meet the criteria for prediabetes by fasting plasma glucose or HbA1c, we suggest obtaining a 2-hour glucose post–oral glucose tolerance test measurement. (2|⊕⊕⊕O)
Technical remark: This recommendation is most applicable to high-risk patients with any of the following characteristics: overweight or obese, first-degree relative with diabetes, high-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander), history of cardiovascular disease, hypertension (≥140/90 mm Hg or on therapy for hypertension), high-density lipoprotein cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L), sleep apnea, or physical inactivity. Shared decision-making is advised for performing this procedure in frail older people or in those for whom it may be overly burdensome. Standard dietary preparation for an oral glucose tolerance test is advised.
2.3 In patients aged 65 years and older who have prediabetes, we recommend a lifestyle program similar to the Diabetes Prevention Program to delay progression to diabetes. (1|⊕⊕⊕⊕)
Technical remark: Metformin is not recommended for diabetes prevention at this time, as it is not approved by the Food and Drug Administration for this indication. As of 2018, a Diabetes Prevention Program–like lifestyle intervention is a covered benefit for Medicare beneficiaries in the United States who meet the criteria for prediabetes.

Assessment of older patients with diabetes

3.1 In patients aged 65 years and older with diabetes, we advise assessing the patient’s overall health (see Table 2) and personal values prior to the determination of treatment goals and strategies (see Table 3). (Ungraded Good Practice Statement)
3.2 In patients aged 65 years and older with diabetes, we suggest that periodic cognitive screening should be performed to identify undiagnosed cognitive impairment. (2|⊕⊕OO)
Technical remark: Use of validated self-administered tests is an efficient and cost-effective way to implement screening (see text). Alternative screening test options, such as the Mini-Mental State Examination or Montreal Cognitive Assessment, are widely used. An initial screening should be performed at the time of diagnosis or when a patient enters a care program. Screening should be repeated every 2 to 3 years after a normal screening test result for patients without cognitive complaints or repeated 1 year after a borderline normal test result. Always evaluate cognitive complaints and assess cognition in patients with complaints.
3.3 In patients aged 65 years and older with diabetes and a diagnosis of cognitive impairment (i.e., mild cognitive impairment or dementia), we suggest that medication regimens should be simplified (see recommendation 3.1) and glycemic targets tailored (i.e., be more lenient; see recommendation 4.1) to improve compliance and prevent treatment-related complications. (2|⊕⊕OO)
Technical remark: Medical and nonmedical treatment and care for cognitive symptoms in people with diabetes and cognitive impairment are no different from those in people without diabetes and cognitive impairment. Depending on the situation and preferences of the patient, a primary caregiver can be involved in decision-making and management of medication.

Table 2.

Clinical Care of Older People

General Health Assessment^a	General Health Tests^b	Diabetes-Specific Health^c
Functional status (ADLs/IADLs^d)	ECG	Retinopathy
Depression	Lipid panel	Nephropathy
Cognition	Bone mineral density	Neuropathy
Fall risk	AAA ultrasound	Medical nutrition therapy
Weight (kg)/height (m)² = BMI	Diabetes screening (for nondiabetic persons)	Diabetes management
Blood pressure		Diabetes self-management training
Tobacco use
Alcohol use
Medication review
Cancer screening
Hearing
Comorbid conditions
Visual acuity
Frailty/physical performance

Open in a new tab

Abbreviations: AAA, abdominal aortic aneurysm; ADL, activity of daily living; BMI, body mass index; IADL, instrumental activity of daily living.

^{^a}

All items are required services to qualify for Medicare coverage of annual wellness examinations for people in the United States >65 y of age, except for frailty/physical performance (33). These are generally conducted by primary care providers.

^{^b}

All items are services covered by Medicare for people in the United State >65 y of age as part of annual wellness examinations at intervals varying from annually to once per lifetime (33).

^{^c}

All items are services covered by Medicare for people in the United States >65 y of age as part of standard diabetes care (33). These are covered annually except for diabetes management visits, which are covered as recommended by the diabetes care team.

^{^d}

Functional status is based on assessment of independence or dependency (having difficulty and receiving assistance) of five ADLs (bathing, dressing, eating, toileting, and transferring) and five IADLs (preparing meals, shopping, managing money, using the telephone, and managing medications) (34).

Table 3.

Conceptual Framework for Considering Overall Health and Patient Values in Determining Clinical Targets in Adults Aged 65 y and Older

graphic file with name jc.2019-00198fx1.jpg

Open in a new tab

Treatment of hyperglycemia

Setting glycemic targets and goals

4.1 In patients aged 65 years and older with diabetes, we recommend that outpatient diabetes regimens be designed specifically to minimize hypoglycemia. (1|⊕⊕⊕O)
Technical remark: Although evidence for specific targets is lacking, glycemic targets should be tailored to overall health and management strategies (e.g., whether a medication that can cause hypoglycemia is used) (see Table 3).

Assessing glycemia in older adults with diabetes

4.2 In patients aged 65 years and older with diabetes who are treated with insulin, we recommend frequent fingerstick glucose monitoring and/or continuous glucose monitoring (to assess glycemia) in addition to HbA1c. (1|⊕⊕OO)

Lifestyle interventions for older adults with diabetes

Lifestyle modifications

4.3 In patients aged 65 years and older with diabetes who are ambulatory, we recommend lifestyle modification as the first-line treatment of hyperglycemia. (1|⊕⊕⊕⊕)

Nutrition

4.4 In patients aged 65 years and older with diabetes, we recommend assessing nutritional status to detect and manage malnutrition. (1|⊕⊕⊕⊕)
Technical remark: Nutritional status can be assessed using validated tools such as the Mini Nutritional Assessment and Short Nutritional Assessment Questionnaire.
4.5 In patients aged 65 years and older with diabetes and frailty, we suggest the use of diets rich in protein and energy to prevent malnutrition and weight loss. (2|⊕⊕OO)
4.6 In patients aged 65 years and older with diabetes who cannot achieve glycemic targets with lifestyle modification, we suggest avoiding the use of restrictive diets and instead limiting consumption of simple sugars if patients are at risk for malnutrition. (2|⊕OOO)
Technical remark: Patients’ glycemic responses to changes in diet should be monitored closely. This recommendation applies to both older adults living in the community and those in nursing homes.

Drug therapy for hyperglycemia

Glycemic management of diabetes in older adults with diabetes

4.7 In patients aged 65 years and older with diabetes, we recommend metformin as the initial oral medication chosen for glycemic management in addition to lifestyle management. (1|⊕⊕⊕O)
Technical remark: This recommendation should not be implemented in patients who have significantly impaired kidney function (estimated glomerular filtration rate <30 mL/min/1.73 m²) or have a gastrointestinal intolerance.
4.8 In patients aged 65 years and older with diabetes who have not achieved glycemic targets with metformin and lifestyle, we recommend that other oral or injectable agents and/or insulin should be added to metformin. (1|⊕⊕⊕⊕)
Technical remark: To reduce the risk of hypoglycemia, avoid using sulfonylureas and glinides, and use insulin sparingly. Glycemic treatment regimens should be kept as simple as possible.

Treating complications of diabetes

Management of hypertension in older adults with diabetes

5.1 In patients aged 65 to 85 years with diabetes, we recommend a target blood pressure of 140/90 mm Hg to decrease the risk of cardiovascular disease outcomes, stroke, and progressive chronic kidney disease. (1|⊕⊕⊕O)
Technical remark: Patients in certain high-risk groups could be considered for lower blood pressure targets (130/80 mm Hg), such as those with previous stroke or progressing chronic kidney disease (estimated glomerular filtration rate <60 mL/min/1.73 m² and/or albuminuria). If lower blood pressure targets are selected, careful monitoring of such patients is needed to avoid orthostatic hypotension. Patients with high disease complexity (group 3, poor health, Table 3) could be considered for higher blood pressure targets (145 to 160/90 mm Hg). Choosing a blood pressure target involves shared decision-making between the clinician and patient, with full discussion of the benefits and risks of each target.
5.2 In patients aged 65 years and older with diabetes and hypertension, we recommend that an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker should be the first-line therapy. (1|⊕⊕⊕O)
Technical remark: If one class is not tolerated, the other should be substituted.

Management of hyperlipidemia in older adults with diabetes

5.3 In patients aged 65 years and older with diabetes, we recommend an annual lipid profile. (1|⊕⊕OO)
5.4 In patients aged 65 years and older with diabetes, we recommend statin therapy and the use of an annual lipid profile to achieve the recommended levels for reducing absolute cardiovascular disease events and all-cause mortality. (1|⊕⊕⊕⊕)
Technical remark: The Writing Committee did not rigorously evaluate the evidence for specific low-density lipoprotein cholesterol targets in this population, so we refrained from endorsing specific low-density lipoprotein cholesterol targets in this guideline. For patients aged 80 years old and older or with short life expectancy, we advocate that low-density lipoprotein cholesterol goal levels should not be so strict.
5.5 In patients aged 65 years and older with diabetes, we suggest that if statin therapy is inadequate for reaching the low-density lipoprotein cholesterol reduction goal, either because of side effects or because the low-density lipoprotein cholesterol target is elusive, then alternative or additional approaches (such as including ezetimibe or proprotein convertase subtilisin/kexin type 9 inhibitors) should be initiated. (2|⊕OOO)
5.6 In patients aged 65 years and older with diabetes and fasting triglycerides >500 mg/dL, we recommend the use of fish oil and/or fenofibrate to reduce the risk of pancreatitis. (1|⊕⊕OO)

Management of congestive heart failure in older adults with diabetes

5.7 In patients aged 65 years and older who have diabetes and congestive heart failure, we advise treatment in accordance with published clinical practice guidelines on congestive heart failure. (Ungraded Good Practice Statement)
5.8 In patients aged 65 years and older who have diabetes and congestive heart failure, the following oral hypoglycemic agents should be prescribed with caution to prevent worsening of heart failure: glinides, rosiglitazone, pioglitazone, and dipeptidyl peptidase-4 inhibitors. (Ungraded Good Practice Statement)

Management of atherosclerosis in older adults with diabetes

5.9 In patients aged 65 years and older with diabetes and a history of atherosclerotic cardiovascular disease, we recommend low-dosage aspirin (75 to 162 mg/d) for secondary prevention of cardiovascular disease after careful assessment of bleeding risk and collaborative decision-making with the patient, family, and other caregivers. (1|⊕⊕OO)

Eye complications in older adults with diabetes

5.10 In patients aged 65 years and older with diabetes, we recommend annual comprehensive eye examinations to detect retinal disease (1|⊕⊕⊕⊕).
Technical remark: Screening and treatment should be conducted by an ophthalmologist or optometrist in line with present-day standards.

Neuropathy, falls, and lower extremity problems in older adults with diabetes

5.11 In patients aged 65 years and older with diabetes and advanced chronic sensorimotor distal polyneuropathy, we suggest treatment regimens that minimize fall risk, such as the minimized use of sedative drugs or drugs that promote orthostatic hypotension and/or hypoglycemia. (2|⊕OOO)
5.12 In patients aged 65 years and older with diabetes and peripheral neuropathy with balance and gait problems, we suggest referral to physical therapy or a fall management program to reduce the risk of fractures and fracture-related complications. (2|⊕OOO)
5.13 In patients aged 65 years and older with diabetes and peripheral neuropathy and/or peripheral vascular disease, we suggest referral to a podiatrist, orthopedist, or vascular specialist for preventive care to reduce the risk of foot ulceration and/or lower extremity amputation. (2|⊕⊕OO)

Chronic kidney disease in older adults with diabetes

5.14 In patients aged 65 years and older with diabetes who are not on dialysis, we recommend annual screening for chronic kidney disease with an estimated glomerular filtration rate and urine albumin-to-creatinine ratio. (1|⊕⊕⊕⊕)
5.15 In patients aged 65 years and older with diabetes who are in group 3 (poor health, see Table 3) of the framework and have a previous albumin-to-creatinine ratio of <30 mg/g, we suggest against additional annual albumin-to-creatinine ratio measurements. (2|⊕⊕OO)
5.16 In patients aged 65 years and older with diabetes and decreased estimated glomerular filtration rate, we recommend limiting the use or dosage of many classes of diabetes medications to minimize the side effects and complications associated with chronic kidney disease. (1|⊕⊕OO)
Technical remark: Specific use/dosing guidance on each class of diabetes medication is provided in Table 7.

Table 7.

Medications Used to Treat Hyperglycemia and Special Concerns With Use in Older Patients With CKD and CVD

Medication Class	Use in Older Patients	Use in Patients With CKD  (Stages 3 to 5)	Use in Patients With CVD
Insulin	Can cause hypoglycemia	Decreased clearance. Increased risk of hypoglycemia. Dosages may need adjusting. Consider giving rapid-acting insulin postprandially because of gastroparesis.	May worsen fluid retention when used with thiazolidinediones. Hypoglycemia to be avoided because of potential arrhythmias and stroke
Metformin	Can cause gastrointestinal intolerance	Reduce dosage to 1000 mg/d if eGFR <45^a; do not start if eGFR <45^a	May be beneficial in patients with coronary artery disease. Avoid use in patients with severe CHF to avoid lactic acidosis
	Does not cause hypoglycemia	Stop if eGFR <30^a
	May cause vitamin B12 deficiency	Stop if increased risk of acute kidney injury (radiocontrast dye, hypotension, sepsis, shock, hypoxia).
SUs	Can cause hypoglycemia	Glyburide: avoid if eGFR <60^a	Can cause hypoglycemia, which is to be avoided because of potential arrhythmias and stroke
	Can cause weight gain	Glimepiride: avoid if eGFR <30^a
	Avoid glyburide	Glipizide: use with caution if eGFR < 30^a
Glinides	Can cause hypoglycemia	Nateglinide: stop if eGFR <60^a but can use if patient is on dialysis	Can cause hypoglycemia, which is to be avoided because of potential arrhythmias and stroke
Glinides	May be useful for individuals who skip meals	Repaglinide: use with caution if eGFR <30^a
Thiazolidinediones	Does not cause hypoglycemia	No dosage adjustment needed. Can cause fluid retention. Can increase fractures.	Pioglitazone has been shown to reduce CVD mortality. Can cause fluid retention with potential to worsen heart failure
	Can increase fracture risk
	Can cause fluid retention
	Can cause weight gain
α-Glucosidase inhibitors	Does not cause hypoglycemia	Avoid if serum creatinine >2.0 mg/dL because of lack of studies in such patients
α-Glucosidase inhibitors	Gastrointestinal side effects may cause nonadherence
DPP-4 inhibitors	Does not cause hypoglycemia	Sitagliptin:	Saxagliptin has been shown to increase the risk of heart failure
		eGFR >50^a: 100 mg/d
		eGFR 30–50^a: 50 mg/d
		eGFR <30^a: 25 mg/d
		Saxagliptin:
		eGFR >50^a: 2.5 or 5 mg daily
		eGFR ≤50^a: 2.5 mg daily
		Alogliptin:
		eGFR >60^a: 25 mg daily
		eGFR 30–60^a: 12.5 mg daily
		eGFR <30^a: 6.25 mg daily
		Linagliptin:
		No dosage adjustment needed
SGLT2 inhibitors	Does not cause hypoglycemia	Canagliflozin: eGFR 45–60^a: 100 mg/d; eGFR <45^a: avoid use	Empagliflozin and canagliflozin have been demonstrated to reduce major adverse cardiovascular events and CHF
	Empagliflozin can reduce cardiovascular events and progression of CKD	Dapagliflozin: eGFR <60^a: avoid use
	Volume depletion adverse effects more common in older patients	Empagliflozin: eGFR <45^a: avoid use
		Ertugliflozin: eGFR <60^a: avoid use
	Canagliflozin may increase fracture risk; has also been associated with an increased risk of toe and foot amputations	Canagliflozin and dapagliflozin have been associated with acute kidney injury
	May rarely cause ketoacidosis	Empagliflozin and canagliflozin can reduce progression of CKD
GLP-1 receptor agonists	Does not cause hypoglycemia	Exenatide: eGFR <30^a: avoid use	Liraglutide and semaglutide have been demonstrated to reduce major adverse CVD events
	May cause gastrointestinal side effects	Liraglutide, dulaglutide, semaglutide: no dosage adjustment needed
		Lixisenatide: avoid if eGFR <15^a
Bromocriptine	May cause nausea	Use with caution. Not studied in CKD.
Bromocriptine	Does not cause hypoglycemia	Use with caution. Not studied in CKD.
Colesevelam	May cause gastrointestinal side effects	No dosage adjustment needed, but limited data are available
Colesevelam	Does not cause hypoglycemia	No dosage adjustment needed, but limited data are available

Open in a new tab

^{^a}

eGFR levels are all in mL/min/1.73 m².

Special settings and populations

Management of diabetes away from home—in hospitals and long-term care facilities—and transitions of care

6.1 In patients aged 65 years and over with diabetes in hospitals or nursing homes, we recommend establishing clear targets for glycemia at 100 to 140 mg/dL (5.55 to 7.77 mmol/L) fasting and 140 to 180 mg/dL (7.77 to 10 mmol/L) postprandial while avoiding hypoglycemia. (1|⊕⊕OO)
Technical remark: An explicit discharge plan should be developed to reestablish long-term glycemic treatment targets and glucose-lowering medications as the patient transitions to posthospital care.
6.2 In patients aged 65 years and older with diabetes and a terminal illness or severe comorbidities, we recommend simplifying diabetes management strategies. (1|⊕OOO)
6.3 In patients aged 65 years and older without diagnosed diabetes, we suggest routine screening for HbA1c during admission to the hospital to ensure detection and treatment where needed (see the technical remark in recommendation 2.1). (2|⊕⊕OO)

Introduction

Scope of guideline

In recognition of the broad nature of the topic, the Writing Committee has identified topics deemed to have the greatest impact on the overall health and quality of life of older individuals (defined here as age 65 years or older) with diabetes. The Writing Committee has chosen to use the American Diabetes Association (ADA) definitions for diabetes and prediabetes (see section 2 on “Screening for Diabetes and Prediabetes, and Diabetes Prevention”). We discuss pathophysiology and epidemiology unique to older adults, evidenced-based treatment strategies, such as lifestyle management and drug therapy, and the identification and management of common comorbidities and diabetes-related complications, such as hypertension, hyperlipidemia, congestive heart failure (CHF), retinopathy, neuropathy, and chronic kidney disease (CKD). We also discuss special settings and type 1 diabetes (T1D). Some topics, such as a detailed discussion on the use of devices and technology, are identified as being important for the care of patients with diabetes but are beyond the scope of the guideline. Furthermore, we emphasize the heterogeneity of the older adult population with diabetes and provide guidance for individualization of treatment plans by creating a conceptual framework that suggests three categories of overall health (see “Assessment of Older Patients With Diabetes”). This framework is discussed in detail in section 3 and referenced in specific recommendations wherever relevant. Lastly, members of the Writing Committee sought to incorporate the patient’s voice into this guideline by developing and administering a brief survey in collaboration with patient advocacy organizations/community organizers who helped us identify individuals with diabetes for participation. The results of this survey are reported in a designated section in Appendix B.

Epidemiology

Among older adults with diabetes, >90% have type 2 diabetes (T2D), and in one study, this value was 96% (1). T2D is an age-related disease with a prevalence of 33% in the US population aged 65 years or older, and nearly 50% of older people meet the criteria for prediabetes (2). The incidence of newly diagnosed diabetes is highest among those aged 65 to 79 years. The reported duration of T2D among older people is illustrated in Fig. 1 (3). Although nearly half of those with diabetes aged 60 to 69 years report having had the disease for >10 years, ∼20% of individuals over the age 80 years report a duration of <5 years. However, the duration of T2D may be underestimated unless individuals are screened regularly. The prevalence of diabetes in the United States is projected to increase dramatically during the next 3 decades; as the population ages, the numbers of higher-risk minority groups increase, and people with diabetes live longer because of decreasing rates of cardiovascular deaths (4). Moreover, older adults are susceptible to all of the usual complications of diabetes [reviewed in Refs. (3) and (5)]. The prevalence rates of end-stage renal disease, loss of vision, myocardial infarction, stroke, peripheral vascular disease, and peripheral neuropathy are increased by the presence of diabetes, as illustrated in Fig. 2 for cardiovascular diseases (CVDs) and in Fig. 3 for microvascular complications (3).

Figure 1. — Duration of diabetes among adults aged ≥60 y, by age, United States, 2009–2010 (3). [Reproduced from Laiteerapong N, Huang ES. Chapter 16: Diabetes in older adults. In Cowie CC, Casagrande SS, Menke A, *et al.*, eds. Diabetes in America, 3rd ed. Bethesda, MD: National Institutes of Health, NIH Pub No. 17-1468, 2017; pp 16-1 to 16-26.]

Figure 2. — Cardiovascular complications among adults age ≥65 y, by diabetes status, United States, 2007–2010. Data are self-reported. Error bards represent 95% CIs. [Reproduced from Laiteerapong N, Huang ES. Chapter 16: Diabetes in older adults. In Cowie CC, Casagrande SS, Menke A, *et al.*, eds. Diabetes in America, 3rd ed. Bethesda, MD: National Institutes of Health, NIH Pub No. 17-1468, 2017; pp 16-1 to 16-26.]

Figure 3. — Microvascular complications among adults age ≥65 y, by diabetes status, United States, 2005–2010. Diabetes status is self-reported. Error bars represent 95% CIs. *Retinopathy detected by nonmydriatic digital fundus photography. Based on 2005–2008 data. †Microalbuminuria defined as an albumin-to-creatinine ratio of 30 to 300 mg/g. Based on 2007–2010 data. ‡Decreased kidney function based on eGFR <60 mL/min/1.73 m² determined using the CKD-EPI equation and serum creatinine. ¹Estimate is too unreliable to present; one case (or no cases) or relative SE >50%. [Reproduced from Laiteerapong N, Huang ES. Chapter 16: Diabetes in older adults. In Cowie CC, Casagrande SS, Menke A, *et al.*, eds. Diabetes in America, 3rd ed. Bethesda, MD: National Institutes of Health, NIH Pub No. 17-1468, 2017; pp 16-1 to 16-26.]

The dramatic effect of age on the incidence of major diabetes complications is illustrated in Fig. 4 (6). As summarized in Halter et al. (7), ∼50% of individuals over age 65 years with diabetes have diabetic nephropathy, which manifests as albuminuria, impaired glomerular filtration rate (GFR), or both. Diabetic kidney disease accounts for nearly half of all cases of end-stage renal disease in the United States, and the rate is highest among those aged ≥75 years. The risk for lower extremity amputation is 10-fold greater in older people with diabetes than in those without diabetes.

Figure 4. — Incidence (per 1000) of major diabetes complications according to age among adults with diabetes, 2009 (6). ER, emergency room; ESRD, end-stage renal disease; IHD, ischemic heart disease. [Reproduced from the National Diabetes Surveillance System at http://www.cdc.gov/diabetes]

Pathophysiology of hyperglycemia

A detailed discussion of the pathophysiology of T2D and its relationship to aging is beyond the scope of this report. As summarized recently (8), T2D occurs in the older population as a result of a complex interaction among genetic, lifestyle, and aging influences [see Fig. 5 (9)]. This complexity means that there is substantial heterogeneity in the pathophysiology, clinical features, and rate of progression of the disease among older people. A recent review summarizes the effects of aging on glucose tolerance and insulin secretion (8). Notably, consistent declines in β cell function and insulin secretion are hallmarks of aging in rodents and humans (10–18). These impairments limit the response to lifestyle-induced insulin resistance, resulting in progression to prediabetes and T2D. Glucose toxicity from chronic exposure to hyperglycemia can worsen insulin resistance and further impair pancreatic β cell function (19). Thus, hyperglycemia in diabetes may drive further worsening of age-related impairments of both β cell function and proliferation. Lipotoxicity from exposure to products of fat cell lipolysis may also contribute to this vicious cycle (20), as do visceral obesity and intramyocellular fat. The heterogeneity of T2D likely reflects the varying contributions of multiple factors to the development of hyperglycemia in a given individual or family. Understanding these factors for an individual patient may provide a basis for the selection of glucose-lowering interventions (8).

Figure 5. — Model for age-related hyperglycemia (9). [Adapted with permission from Chang AM, Halter JB. Aging and insulin secretion. Am J Physiol Endocrinol Metab 2003;284:E7–E12.]

Systematic Review and Meta-Analyses

The Writing Committee commissioned two systematic reviews to support this guideline. Both reviews focused on individuals aged 65 years and older. Although the target population of this guideline is individuals with diabetes, concerns about not identifying sufficient evidence necessitated that the two systematic reviews summarize evidence on individuals with and without diabetes (presented separately).

The first review attempted to answer the following question: In older individuals, does treatment with antihypertensive pharmacologic therapy lead to improvement in patient-important outcomes? The review identified 19 randomized trials. Antihypertensive therapy was associated with a reduction in all-cause mortality, cardiovascular mortality, myocardial infarction, heart failure, stroke, and CKD. Older patients with diabetes treated with antihypertensive therapy had lower risk of CKD without a significant reduction in other outcomes; however, there was no significant difference in estimates of beneficial effects between those with and without diabetes.

The second review attempted to answer the following question: In older individuals, does treatment with lipid-lowering pharmacologic therapy lead to improvement in patient-important outcomes? The review identified 23 randomized trials. For primary prevention, statins reduced the risk of coronary artery disease and myocardial infarction, but not all-cause or cardiovascular mortality or stroke. These effects were imprecise in patients with diabetes, but there was no significant interaction between diabetes status and the intervention effect. For secondary prevention, statins reduced all-cause mortality, cardiovascular mortality, coronary artery disease, myocardial infarction, and revascularization. Intensive (vs less intensive) statin therapy reduced the risk of coronary artery disease and heart failure.

In both of the systematic reviews, the quality of evidence, or certainty in the estimates, was high for most outcomes when evaluated in all older patients. When the evaluation was restricted to those with diabetes, the estimates of beneficial effects were generally similar to those observed in all older patients, but the CIs were relatively wide, indicating imprecision. Accordingly, the corresponding quality of evidence was considered to be moderate for older patients with diabetes. There was also no significant difference in estimates (interaction) between those with and without diabetes, suggesting that extrapolation of data from the older population at large to older individuals with diabetes is reasonable.

1. Role of the Endocrinologist and Diabetes Care Specialist

1.1 In patients aged 65 years and older with newly diagnosed diabetes, we advise that an endocrinologist or diabetes care specialist should work with the primary care provider, a multidisciplinary team, and the patient in the development of individualized diabetes treatment goals. (Ungraded Good Practice Statement)
1.2 In patients aged 65 years and older with diabetes, an endocrinologist or diabetes care specialist should be primarily responsible for diabetes care if the patient has T1D, or requires complex hyperglycemia treatment to achieve treatment goals, or has recurrent severe hypoglycemia, or has multiple diabetes complications. (Ungraded Good Practice Statement)

Evidence

Given the heterogeneity of the population of older adults with diabetes, the role of the endocrinologist or the diabetes care specialist in the care of an individual patient may vary considerably during the course of the disease. Decision-making about this role requires active participation and good lines of communication among the endocrinologist or diabetes care specialist, the primary care physician, and the patient. Because of the high burden of diabetes and its complications on overall health status (21, 22), many older patients benefit from care by an interdisciplinary team. The endocrinologist or diabetes care specialist functions as the leader of the diabetes care team, which includes a nurse educator, dietician, and others (e.g., pharmacist, psychologist, social worker). The endocrinologist or diabetes care specialist may also serve the medical community by providing up-to-date training in the care of older patients with diabetes. Possible roles of the endocrinologist or diabetes care specialist include the following.

No role.

Diabetes care is provided by the patient’s primary care team, which has received up-to-date training in the care of older patients with diabetes. An endocrinologist or diabetes care specialist may not be needed for patients whose hyperglycemia and CVD prevention treatment goals are easily achieved with lifestyle alone or with simple oral agent therapy (one or two medications). Application of the Chronic Disease Model can facilitate diabetes quality care in the primary care setting (23).

Consultant-only collaborative care.

Overall diabetes care is provided by the patient’s primary care team. The endocrinologist or diabetes care specialist assists in assessing the patient’s diabetes status and related complications and setting treatment goals with recommendations for specific interventions. Consultation may occur at the time of original diabetes diagnosis or when there is a change in the patient’s diabetes status (e.g., treatment goals no longer being achieved, recurrent hypoglycemia, development of one or more diabetes complications). Consultation may involve only a member (not all) of the diabetes care team (e.g., nurse educator or dietician). The endocrinologist or diabetes care specialist may be asked to initiate insulin therapy for a patient and then send the patient back to the primary care provider once stable, or they may consult to assist with glycemic management when a patient is hospitalized.

Overall diabetes management.

For selected patients, the endocrinologist or diabetes care specialist and the diabetes care team are primarily responsible for diabetes care and collaborate with providers who manage the patient’s other health problems and comorbidities. This situation may occur by default if the patient has no primary care provider or if the patient is already under the care of the endocrinologist or diabetes care specialist for long-standing T1D or other endocrine conditions. Specific indications for the endocrinologist or diabetes care specialist to assume control of overall diabetes management for an older patient include complex hyperglycemia treatment (use of three or more glucose-lowering agents; the addition of insulin, especially multiple types or injections), recurrent severe hypoglycemia, multiple diabetes complications, and a long history of diabetes.

2. Screening for Diabetes and Prediabetes, and Diabetes Prevention

2.1 In patients aged 65 years and older without known diabetes, we recommend fasting plasma glucose and/or HbA1c screening to diagnose diabetes or prediabetes. (1|⊕⊕⊕⊕)
Technical remark: The measurement of HbA1c may be inaccurate in some people in this age group because of comorbidities that can affect the lifespan of red blood cells in the circulation. Although the optimal screening frequency for patients whose initial screening test is normal remains unclear, the writing committee advocates repeat screening every 2 years thereafter. As with any health screening, the decision about diabetes and prediabetes screening for an individual patient depends on whether some action will be taken as a result and the likelihood of benefit. For example, such screening may not be appropriate for an older patient with end-stage cancer or organ system failure. In these situations, shared decision-making with the patient is recommended.
2.2 In patients aged 65 years and older without known diabetes who meet the criteria for prediabetes by fasting plasma glucose or HbA1c, we suggest obtaining a 2-hour glucose post–oral glucose tolerance test measurement. (2|⊕⊕⊕O)
Technical remark: This recommendation is most applicable to high-risk patients with any of the following characteristics: overweight or obese, first-degree relative with diabetes, high-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander), history of CVD, hypertension (≥140/90 mm Hg or on therapy for hypertension), high-density lipoprotein cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L), sleep apnea, or physical inactivity. Shared decision-making is advised for performing this procedure in frail older people or in those for whom it may be overly burdensome. Standard dietary preparation for an oral glucose tolerance test is advised.
2.3 In patients aged 65 years and older who have prediabetes, we recommend a lifestyle program similar to the Diabetes Prevention Program to delay progression to diabetes. (1|⊕⊕⊕⊕)
Technical remark: Metformin is not recommended for diabetes prevention at this time, as it is not approved by the Food and Drug Administration for this indication. As of 2018, a Diabetes Prevention Program–like lifestyle intervention is a covered benefit for Medicare beneficiaries in the United States who meet the criteria for prediabetes.

Evidence

The ADA defines diabetes and prediabetes based on glucose measures (24). Importantly, individuals with prediabetes are at increased risk for progression to diabetes and development of CVDs; Table 1 (24) lists the ADA criteria for prediabetes and diabetes. The fasting plasma glucose and HbA1c categories allow easy identification of both diabetes and prediabetes. However, many people over the age of 60 years affected with diabetes and prediabetes are not diagnosed unless an oral glucose tolerance test is performed (2). Importantly, individuals with prediabetes are at increased risk for progression to diabetes and development of CVDs. Population screening demonstrates a high rate of detection of newly diagnosed diabetes. Additionally, modeling such studies suggests that early detection and treatment of diabetes can reduce long-term complications (25). Furthermore, diabetes and prediabetes criteria predict risk for subsequent diabetes and CVD similarly in both older and younger people. The prevalence of disorders of sleep increases with age, and such disorders have been associated with the development or exacerbation of diabetes and risks of cardiovascular events. Therefore, assessment for sleep disorders and their treatment should be considered in older patients at risk for and with diabetes (26).

Table 1.

ADA Criteria for Prediabetes and Diabetes

Prediabetes^a	Diabetes^b
FPG 100 mg/dL (5.6 mmol/L) to 125 mg/dL (6.9 mmol/L) = IFG	FPG ≥126 mg/dL (7.0 mmol/L)
OR	OR
2-h PG during 75-g OGTT 140 mg/dL (7.8 mmol/L) to 199 mg/dL (11.0 mmol/L) = IGT	2-h PG ≥200 mg/dL (11.1 mmol/L) during OGTT^c
OR	OR
A1C 5.7%–6.4% (39–47 mmol/mol)^d	A1C ≥6.5% (48 mmol/mol)^d
	OR
	In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random PG ≥200 mg/dL (11.1 mmol/L).

Open in a new tab

[Data from American Diabetes Association. 2. Classification and diagnosis of diabetes: standards of medical care in diabetes-2019. Diabetes Care. 2019;42:S13–s28].

Abbreviations: FPG, fasting PG; IFG, impaired fasting glucose; IGT, impaired glucose tolerance; OGTT, oral glucose tolerance test; PG, plasma glucose.

^{^a}

For all three tests, risk is continuous, extending below the lower limit of the range and becoming disproportionately greater at the higher end of the range.

^{^b}

In the absence of unequivocal hyperglycemia, diagnosis requires two abnormal test results from the same sample or in two separate test samples.

^{^c}

The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75-g anhydrous glucose dissolved in water.

^{^d}

The test should be performed in a laboratory using a method that is National Glycohemoglobin Standardization Program certified and standardized to the Diabetes Control and Complications Trial assay.

Progression from prediabetes to diabetes can be slowed substantially (27–30). Evidence supporting this observation includes recent meta-analyses involving nearly 50,000 subjects (31, 32). In people over the age of 60 years in the Diabetes Prevention Program, lifestyle intervention to reduce body weight and increase physical activity reduced the rate of progression to diabetes by 71% during 4 years (estimated number needed to treat to prevent one person progressing to diabetes, 5.6). The reduced rate of progression to diabetes was maintained during 15 years of follow-up, although the lifestyle intervention was much less intense during the last 10 years (28, 29). Notably, the impact of this intervention is cost-effective (27). Additionally, metformin was less effective in people over the age of 60 years (estimated number needed to treat, 39.2) in the Diabetes Prevention Program, and the meta-analyses suggest that drug treatment tends to have transitory effects on diabetes prevention.

3. Assessment of Older Patients With Diabetes

Overall health framework

3.1 In patients aged 65 years and older with diabetes, we advise assessing the patient’s overall health (see Table 2) and personal values prior to the determination of treatment goals and strategies (see Table 3). (Ungraded Good Practice Statement)

Evidence

The treatment strategies and goals developed for older adults depend on overall patient health, including medical complexity and functional status. Table 2 (33, 34) provides a guide for the comprehensive assessment of the older adult, including the general medical assessment and diabetes-focused evaluations. Functional status refers to a person’s ability to perform normal daily activities required to meet basic needs, fulfill usual roles, and maintain health and well-being (35). Both aging and diabetes are independent risk factors for impaired functional status, and the interaction of these two factors is highly complex and unique for each patient. For this reason, recent diabetes guidelines have generally concluded that care of the aging patient with diabetes requires an individualized, rather than purely algorithmic, approach (36–38). However, there is no standard tool recommended for the assessment and documentation of how effectively older adults function in their lives. Functional status is most often documented using subsets of specific activities that are necessary for living independently. They include activities of daily living (ADLs), that is, bathing, dressing, eating, toileting, and transferring, as well as instrumental ADLs (IADLs), that is, preparing meals, shopping, managing money, using the telephone, and managing medications (Table 2) (34). In patients with diabetes, deficits in IADLs identified during routine evaluation should trigger a more in-depth evaluation of the patient, including a detailed assessment of hypoglycemia and hyperglycemia, microvascular and macrovascular complications, and cognition, as discussed in depth in this guideline.

Overall health in older adults has been described in terms of frameworks or categories that guide the clinician to consider multiple factors when assessing the health of an adult over the age of 65 years. One such framework was developed by Blaum et al. (35) and was incorporated into the 2012 ADA consensus report on the care of older adults with diabetes. The Blaum framework suggests considering chronic diseases (fewer than three vs three or more), cognitive or visual impairment (none, mild, moderate to severe), and IADL dependencies (none vs two or more) to define functional status. This framework was used to identify three classes of patients corresponding to increasing levels of mortality risk and was thus validated as a tool for determining the likelihood of benefit of a treatment strategy based on life expectancy (39). Using this evidence, the Blaum categories and the 2012 ADA consensus report as guides, we developed a conceptual framework for overall health that categorizes patients into good health (group 1), intermediate health (group 2), and poor health (group 3) groups [Table 3 (39, 40) and “Setting glycemic targets and goals” under section 4 on “Treatment of Hyperglycemia”].

Frailty

Frailty can be defined as a state of increased vulnerability to physical or psychological stressors because of decreased physiological reserves in multiple organ systems that cause a limited capacity to maintain homeostasis. Moreover, it represents a predisability condition that can be responsive to intervention (41).

Screening for geriatric syndromes, including frailty, should be part of a stepped-care approach in older people with diabetes, particularly in primary and community care settings. Where there is evidence of moderate to severe physical or cognitive impairment or functional loss, referral to geriatricians or other skilled clinicians for a comprehensive assessment is needed. The importance of detecting frailty lies in the opportunity to consider targeted interventions that reduce functional decline and risk of disability.

Any report of a change in mobility, presence of falls, noticeable decrease in IADLs after recent discharge from a hospital, or presence of continuing fatigue should prompt the clinician to screen for functional loss and/or frailty [Table 4 (42–45)]. An initial screen for physical impairment can be obtained by using the following commonly employed measures in geriatric practice (46) [Table 5 (47–51)].

Table 4.

Tools to Detect Frailty

Assessment Tool	Comments
Fried score	Well-established physical frailty tool based on data from the Cardiovascular Health Study; often seen as a reference frame for studies of frailty in community-dwelling older adults; requires two procedures/measures (gait speed and grip strength) and answers to three questions (relating to weight loss, level of exhaustion, and amount of physical activity); can identify “prefrail” individuals (42).
Clinical Frailty Scale (Note: A larger 70-item assessment tool called the Frailty Index is also available.)	Based on data from the Canadian Study of Health and Aging; seven-point scale; predictive of future events including mortality; easy to employ in routine clinical practice (43).
FRAIL score	Well-validated in multiple population groups; sensitivity and specificity similar to that of the Fried scale. Comprises only five questions (no procedures) covering fatigue, climbing stairs, walking, number of illnesses, and weight loss (44).

Open in a new tab

[Reproduced with permission from Sinclair AJ, Abdelhafiz A, Dunning T, Izquierdo M, Rodriguez Manas L, Bourdel-Marchasson I, Morley JE, Munshi M, Woo J, Vellas B. An international position statement on the management of frailty in diabetes mellitus: summary of recommendations 2017. J Frailty Aging 2018;7:10–20.] (45)

Table 5.

Commonly Employed Measures to Screen for Physical Impairment

Measure	Comments
Timed “get-up and go” test	Most adults can complete this test. Good correlation with gait speed, Barthel Index, and measures of balance (47, 48).
4-m Gait speed	Robust, clinically friendly measure. Easy to perform. Can be used to measure functional status in older adults and to predict future health and well-being. Population norms available (49, 50).
Grip strength	Requires a dynamometer for objective measurement; normative ranges in older people available. Predictive of increased future functional limitations and disability, increased fracture risk, and increased all-cause mortality (51).

Open in a new tab

Screening for sarcopenia

Sarcopenia is an age-related loss of muscle mass that has now been linked to progressive loss of muscle strength and reduced physical performance (52). Sarcopenia is accelerated in the presence of diabetes. Clinicians can refer patients with possible sarcopenia for a dual-energy X-ray absorptiometry scan, but this procedure is expensive and may not be convenient. Bioelectrical impedance analysis is an alternative method for the assessment of lean muscle mass and may be considered in place of dual-energy X-ray absorptiometry scanning. Alternatively, a rapid screening test for sarcopenia in a clinical setting can be obtained using a simple five-question instrument called the Sarc-F, which looks at fall history, ability to lift objects, and difficulties with mobility. This scale has been validated extensively and has been shown to be highly predictive of future disability and hospitalization (53).

Cognitive impairment in older adults with diabetes

In the general population, the prevalence of dementia increases from 1% to 2% at ages 60 to 64 years to 6% to 9% at ages 75 to 79 years to well above 35% in those who are 90 years and older (54). The population burden of cognitive impairment in older individuals is even larger if predementia stages of cognitive dysfunction, such as mild cognitive impairment (MCI), are also considered.

Epidemiological studies have found clear associations between diabetes and dementia risk (55). A meta-analysis including over 1 million individuals presented a pooled overall relative risk (RR) for dementia in people with diabetes of 1.73 (95% CI, 1.65 to 1.82) compared to people without diabetes (56). This increased risk was present in both Alzheimer’s disease (RR, 1.56; 95% CI, 1.41 to 1.73) and vascular dementia (RR, 2.27; 95% CI, 1.94 to 2.66) (56); notably, however, Alzheimer’s disease generally was not diagnosed with biomarker support in these epidemiological studies. Neuropathological studies indicate that diabetes is primarily associated with an increase in the burden of vascular pathologies rather than plaques and tangles, the neuropathological hallmarks of Alzheimer’s disease (57). Moreover, diabetes is associated with an increased risk of MCI (RR, 1.21; 95% CI, 1.02 to 1.45) (58) and an increased rate of conversion from MCI to dementia (OR, 1.65; 95% CI, 1.12 to 2.43) (59). Of note, these numbers primarily apply to patients with T2D because data on older individuals with T1D are still scarce.

With the aging of the population and trends in diabetes prevalence, the combination of cognitive impairment and diabetes is likely to become more common, having implications for diabetes care. Clearly, cognitive impairment in patients with diabetes is associated with poorer diabetes self-management and glycemic control (60, 61), an increased frequency of hospital admissions and occurrence of severe hypoglycemic episodes (62, 63), and an increased occurrence of major cardiovascular events and death (64). Early identification of individuals with cognitive impairment may avoid some of these poor outcomes (65–67). Of note, the relationship between some of these “outcomes” and cognitive impairment may be bidirectional: there are clear indications that CVD, but also occurrence of hypoglycemic episodes (68), increase the risk of developing cognitive impairment in older patients with diabetes.

Detection and diagnosis

3.2 In patients aged 65 years and older with diabetes, we suggest that periodic cognitive screening should be performed to identify undiagnosed cognitive impairment. (2|⊕⊕OO)
Technical remark: Use of validated self-administered tests is an efficient and cost-effective way to implement screening (see text). Alternative screening test options, such as the Mini-Mental State Examination or Montreal Cognitive Assessment, are widely used. An initial screening should be performed at the time of diagnosis or when a patient enters a care program. Screening should be repeated every 2 to 3 years after a normal screening test result for patients without cognitive complaints or repeated 1 year after a borderline normal test result. Always evaluate cognitive complaints and assess cognition in patients with complaints.

Evidence

In the general population, screening for cognitive impairment and dementia is currently not recommended because of insufficient evidence on the balance of benefits and harms of screening (69). This ratio may be different in people with diabetes because the harm of unrecognized cognitive impairment (e.g., risks related to diabetes treatment) might be larger than that in people without diabetes. The benefit of screening is that this harm might be at least partially avoided (67). Therefore, an active approach to the detection of cognitive impairment (i.e., screening) has been advocated for older adults with diabetes (65, 67). However, the evidence base upon which screening procedures can be operationalized (i.e., which target groups, type of test, frequency of testing) is limited. With regard to the target group, the chance of encountering cognitive impairment should be sufficiently high to warrant screening. At this stage, we therefore suggest that screening should be limited to those over the age of 65 years; in younger patients, actively responding to cognitive complaints should be sufficient.

The purpose of screening is to identify marked clinically relevant stages of cognitive impairment (i.e., MCI or dementia) likely to interfere with diabetes management. A positive screening test should be complemented by an appropriate diagnostic evaluation, starting with history taking, to formally diagnose or rule out these conditions. With regard to the choice of screening test, brief widely used tests such as the Mini-Mental State Examination or Montreal Cognitive Assessment may be suitable, although administering these tests still requires ∼10 minutes, and currently no strong evidence supports the choice of one particular test over another (70, 71). Notably, self-administered cognitive screening tools are becoming available and might offer an efficient alternative (72), greatly facilitating widespread implementation.

With regard to the timing and frequency of screening, performing an initial assessment at the time of diabetes diagnosis or when a patient enters a care program would be appropriate. Screening could then be repeated annually, or even less frequently, depending on the perceived risk. In patients without cognitive complaints, screening should be repeated 2 to 3 years after an initial normal screening test result or 1 year after a borderline normal test result. Cognitive complaints should always be evaluated.

Thus far, no evidence supports a benefit of intensive glycemic treatment to preserve cognitive function in patients with diabetes (68). However, further trials are underway, and cognition is increasingly considered an (secondary) outcome measure in drug trials in diabetes.

Management and treatment

3.3 In patients aged 65 years and older with diabetes and a diagnosis of cognitive impairment (i.e., MCI or dementia), we suggest that medication regimens should be simplified (see recommendation 3.1) and glycemic targets tailored (i.e., be more lenient; see recommendation 4.1) to improve compliance and prevent treatment-related complications. (2|⊕⊕OO)
Technical remark: Medical and nonmedical treatment and care for cognitive symptoms in people with diabetes and cognitive impairment is no different from those in people without diabetes and cognitive impairment. Depending on the situation and preferences of the patient, a primary caregiver can be involved in decision-making and management of medication.

Evidence

No randomized controlled trials (RCTs) have shown that simplified glucose-lowering treatment regimens improve adherence in patients with diabetes and cognitive impairment or that tailored glycemic targets reduce the risk of treatment-related adverse events, particularly hypoglycemic episodes. However, patients with impaired cognition are known to have lower adherence and an increased risk of adverse events (60, 61, 63). Furthermore, more stringent control increases the risk of hypoglycemia (see “Balancing risks and benefits of lower glycemic targets” under section 4 on “Treatment of Hyperglycemia”). Therefore, the assumption that simplifying treatments and tailoring targets improve compliance and prevent treatment-related complications in patients with impaired cognition is reasonable. HbA1c levels <8.0% (64 mmol/mol) have been proposed for mild-to-moderate cognitive impairment, and those below 8.5% (69 mmol/mol) for moderate to severe cognitive impairment (66).

With regard to patient care and management in those with cognitive impairment, regular review of the patient’s ability to self-manage diabetes and the need for appropriate support is essential. Providing support for caregivers and involving them in all aspects of care are also important.