Is there a “smarter” medication regimen that lowers the risk of hypoglycemia?Over 29% of people over the age of 65 years of age had diabetes according to a 2024 report from the Centers for Disease Control & Prevention. As Americans continue to live longer, this number is expected to rise. With the increasing prevalence of diabetes in older adults comes an increased concern with increased risk of complications and healthcare management unique to this age group.
Type 2 diabetes continues to be the most common diabetes in those 65 years of age and older. With advancing age comes a higher risk of diabetes due to factors like insulin resistance, impaired pancreatic function, and age-related conditions. Additionally, improvements in diabetes management have also increased the number of people living with Type 1 diabetes into advanced age.
While managing diabetes demands a personalized approach, in older adults a personalized approach to successful management must include overall health, other medical conditions, and individual needs.
Key Aspects of Diabetes in Older Adults:
Increased Risk and Prevalence
Being 45 years of age or older increases the risk of developing pre-diabetes and type 2 diabetes.
Age-Related Factors
With advancing age comes increased risk of impaired pancreatic function, loss of muscle mass and strength, and a reduced level of physical activity. All of these contribute to the development of diabetes.
Comorbidities and Complications
Older adults with diabetes often have other health conditions, which can complicate management and require a more holistic approach to care. Additionally, people who have an extended history of diabetes are at increased risk for diabetes-related complications such as heart disease, kidney disease, vision impairment or loss, and nerve damage.
Medication Management
Older adults with other health conditions may have complicated medication management regimens due to interactions between drugs. Additionally, multiple medication regimens can be complicated and difficult to adhere to. Strategies to simplify medication regimens should be regularly assessed.
Geriatric Syndromes
Geriatric syndromes are health conditions that often involve multiple factors and systems of the body that lead to a decline in functional abilities and quality of life. These multi-organ conditions are complex health challenges that require regular assessment of cognitive impairment, depression, falls, and frailty
While it’s easy to discount these challenges as a normal part of aging, they can significantly affect the quality of life for many older adults. The inability to actively take part in self-care practices like a regular healthy eating style, routine physical activity, and medication adherence can lead to depression, fear of living alone, social isolation, and ultimately reduced independence. Treatment plans should be designed with each individual’s unique situation and health needs.
How to Proceed
Diabetes management for adults 65 and older should be based on an assessment of overall health and other medical conditions; general health tests (EKG, lipid panel, bone mineral density, and more); hearing test; mental health or depression screen; cognitive impairment and dementia screen; balance assessment; and more. Success depends on meeting patients where they are and helping them make realistic, sustainable changes they can maintain over time. If not, consider options and resources that support success.
Assessments and medical exams
Assessment also includes a review of medical exams in health areas of greatest concern when diagnosed with diabetes. These include:
- Checkups with a primary care physician. The primary care physician can deal with many of the routine health issues people face and can facilitate referrals to specialists when recommended.
- Annual eye exams to screen for retinopathy.
- Annual kidney function checks. These checks watch kidney estimated Glomerular Filtration Rates (eGFR) and check for albuminuria (protein in the urine).
- Annual foot exams for early detection or prevention of foot problems.
- Annual review with a Diabetes Care and Education Specialist (DCES). DCES’s can provide educational support and guidance on living with diabetes in the presence of other conditions. Additionally, many DCES are part of a system that provides a peer support group that can share experiences that keep people with diabetes from feeling isolated in the day-to-day struggles of living with diabetes and other conditions.
- Twice a year for dental checkups. Diabetes can increase the risk of gum disease (periodontitis) and other oral health problems. Regular dental checkups are crucial for early detection and prevention of these issues, which can affect overall health.
Age-adjusted diabetes management considerations
What is the target blood glucose?
The more complicated the patient’s health status, the less strict glucose targets. Additionally, patients treated with insulin, should perform fingerstick glucose monitoring and/or continuous glucose monitoring (to assess glycemia) in addition to HbA1c. There is evidence supporting an HbA1c may be inaccurate in some people in older age groups because of comorbidities that can affect the lifespan of red blood cells in the circulation (note: HbA1c measurements are based on a 90-day red blood cell life expectancy).
Is there a “smarter” medication regimen that lowers the risk of hypoglycemia?
Can the medication regimen be simplified to reduce low glucose risk? Any source of hypoglycemia must be considered in an older age group. Older adults with hypoglycemia are more prone to falls, cognitive impairment, increased disability and mortality. Hypoglycemia unawareness (hypoglycemia without symptoms) is also more common in older adults. Additionally, older adults often take multiple medications for multiple health conditions that affect response to hypoglycemia and/or increase the risk of medication-related hypoglycemia.
Could lifestyle modification reduce hyperglycemia?
Older patients with high glucose levels can often change the diet or activity level with positive outcomes. A registered dietitian can assess the older patient for gaps and/or excesses in nutrition. Choose a balanced, sustainable eating pattern rather than a highly restrictive diet, and focus on improving targeted problem areas.
Could management of comorbidities affect management of older adults with diabetes?
The Endocrine Society recommends a target blood pressure of 140/90 mmHg to decrease risk of cardiovascular system and progressive chronic kidney disease complications. Patients with a history of past heart and/or kidney complications may have lower blood pressure targets.
Organizations that serve as a resource for diabetes and other medical conditions include:
- American Diabetes Association
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
- Centers for Disease Control and Prevention (CDC)
Additionally, you can download the Endocrine Society’s (endocrine.org) Diabetes and Older Adults Patient Guide.
There are few things as intimate as one’s health. All decisions in healthcare should be a shared decision-making process between the healthcare provider and the patient and/or a patient advocate. Decisions should be made with benefits, risks, and concerns discussed. Special considerations should be addressed to support the patient’s overall health status and quality of life.