2016 ADA Guidelines for the Elderly

ADA terms us Older Adults and I use elderly. Maybe I am not politically correct, but I use the term(s) I am comfortable with and I don't always worry about being politically correct.

Diabetes is an important health condition for the aging population. The ADA says 26 percent of patients over the age of 65 years have diabetes and this number is expected to increase rapidly in the coming decades. Older individuals with diabetes have higher rates of premature death, functional disability, and coexisting illnesses, such as hypertension, coronary heart disease, and stroke, than those without diabetes – and the list goes on. Older adults with diabetes have more geriatric syndromes, such as polypharmacy, cognitive impairment, urinary incontinence, injurious falls, and persistent pain.

Screening for diabetes complications in older adults also should be individualized and periodically revisited, since the results of screening tests may impact therapeutic approaches and targets. Older adults are at increased risk for depression and should therefore be screened and treated accordingly. Diabetes management may require assessment of medical, functional, mental, and social domains. This may provide a framework to determine targets and therapeutic approaches. Particular attention should be paid to complications that can develop over short periods of time and/or that would significantly impair functional status, such as visual and lower-extremity complications.

Diabetes increases the incidence of all-cause dementia, Alzheimer disease, and vascular dementia when compared with rates in people with normal glucose tolerance. The effects of hyperglycemia and hyperinsulinemia on the brain are areas of intense research interest. Poor glycemic control is associated with a decline in cognitive function, and longer duration of diabetes worsens cognitive function. Older adults with diabetes should be carefully screened and monitored for cognitive impairment.

It is important to prevent hypoglycemia to reduce the risk of cognitive decline and to carefully assess and reassess patients’ risk for worsening of glycemic control and functional decline. Older adults are at higher risk of hypoglycemia for many reasons, including insulin deficiency and progressive renal insufficiency. In addition, older adults tend to have higher rates of unidentified cognitive deficits, causing difficulty in complex self-care activities - glucose monitoring, adjusting insulin doses, etc.. These deficits have been associated with increased risk of hypoglycemia and with severe hypoglycemia linked to increased dementia. Therefore, it is important to routinely screen older adults for cognitive dysfunction and discuss findings with the caregivers. Hypoglycemic events should be diligently monitored and avoided, whereas glycemic targets and pharmacological interventions may need to be adjusted to accommodate for the changing needs of the older adult.

At least they do make the following statements. For patients with advanced diabetes complications, life-limiting comorbid illness, or substantial cognitive or functional impairment, it is reasonable to set less intensive glycemic target goals. These patients are less likely to benefit from reducing the risk of microvascular complications and more likely to suffer serious adverse effects from hypoglycemia. However, patients with poorly controlled diabetes may be subject to acute complications of diabetes, including dehydration, poor wound healing, and hyperglycemic hyperosmolar coma. Glycemic goals at a minimum should avoid these consequences.

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