We typically begin with mg daily and increase the dose slowly over several weeks to minimize gastrointestinal side effects. Extended-release formulations of metformin may be tolerated better in patients who are unable to tolerate immediate-release metformin due to gastrointestinal side effects.

While these recommendations are reasonable, few studies have established the therapeutic efficacy or safety of these reduced doses. See "Metformin in the treatment of adults with type 2 diabetes mellitus", section on 'Dosing'.

Therefore, metformin should be used with caution in older patients. Older patients treated with metformin should be cautioned to stop taking the drug immediately if they become seriously ill for any reason or if they are to undergo a procedure requiring the use of iodinated contrast material.

In addition, kidney function measurement of serum creatinine and eGFR should be monitored every three to six months rather than annually. See "Metformin in the treatment of adults with type 2 diabetes mellitus", section on 'Contraindications'.

This approach is reviewed in detail separately. See "Initial management of hyperglycemia in adults with type 2 diabetes mellitus", section on 'Contraindications to or intolerance of metformin' and "Initial management of hyperglycemia in adults with type 2 diabetes mellitus", section on 'Established cardiovascular or kidney disease' and "Management of hyperglycemia in patients with type 2 diabetes and advanced chronic kidney disease or end-stage kidney disease".

Evaluation — If glycemic goals are not met with a single agent, older patients should be evaluated for contributing causes similar to younger adults, such as difficulty adhering to the medication, side effects, or adherence to the nutrition plan [ 1,6 ].

If hyperglycemia above the individualized target persists, an additional agent is needed. In older patients who require more than one agent, pill-dosing dispensers may help improve adherence. As an alternative, family members or caregivers may be required to help administer medication.

Additional nutritional counseling and diabetes self-management education and support programs, when available, should be offered to patients. Choice of second drug — For older patients who have persistent hyperglycemia above their individualized glycemic target despite treatment with lifestyle intervention and metformin , a second agent should be selected.

The choice of a second agent should be individualized based upon efficacy, the patient's underlying comorbidities, risk of hypoglycemia, impact on body weight, side effects, and cost figure 1. See "Management of persistent hyperglycemia in type 2 diabetes mellitus", section on 'Indications for a second agent' and "Management of persistent hyperglycemia in type 2 diabetes mellitus", section on 'Our approach'.

The individual agents are discussed in more detail in the individual topic reviews. See "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus" and "Sodium-glucose cotransporter 2 inhibitors for the treatment of hyperglycemia in type 2 diabetes mellitus" and "Dipeptidyl peptidase 4 DPP-4 inhibitors for the treatment of type 2 diabetes mellitus" and "Sulfonylureas and meglitinides in the treatment of type 2 diabetes mellitus" and "Thiazolidinediones in the treatment of type 2 diabetes mellitus" and "Alpha-glucosidase inhibitors for treatment of diabetes mellitus".

Insulin is sometimes underutilized in older adults because of fear by the clinician, patient, or family that it is too complicated or dangerous. Addition of once-daily basal insulin to a non-insulin agent usually metformin is a low-complexity regimen with a relatively lower risk of hypoglycemia compared with regimens using multiple daily insulin doses [ 44 ].

Before beginning insulin therapy, it is important to evaluate whether the patient is physically and cognitively capable of using an insulin pen or drawing up and injecting the appropriate dose of insulin using syringes and vials , monitoring blood glucose, and recognizing and treating hypoglycemia.

For older patients taking a fixed daily dose of insulin who are capable of injecting insulin but not of drawing it into the syringe, a pharmacist or family member may prepare a week's supply of insulin in syringes and leave them in the refrigerator.

Such a plan may allow an older patient to remain living independently at home. Insulin pens, when available and affordable, are an alternative for patients who have difficulty administering insulin using vials and syringes due to vision or motor limitations.

Morning administration reduces the risk of nocturnal hypoglycemia, and fasting hyperglycemia is less of a concern in older patients [ 45 ]. See "Management of hyperglycemia in patients with type 2 diabetes and advanced chronic kidney disease or end-stage kidney disease", section on 'Treatment'.

Insulin therapy is discussed in detail elsewhere. See "General principles of insulin therapy in diabetes mellitus" and "Insulin therapy in type 2 diabetes mellitus". History of cardiovascular or kidney disease — Sodium-glucose co-transporter 2 SGLT2 inhibitors empagliflozin or canagliflozin or glucagon-like peptide 1 GLP-1 receptor agonists liraglutide or semaglutide are reasonable second agents for patients with established cardiovascular or kidney disease [ 46,47 ].

All of these drugs confer low risk of hypoglycemia on their own or in combination with other drugs that do not usually cause hypoglycemia.

GLP-1 receptor agonists should be titrated slowly, with monitoring for gastrointestinal GI side effects, which could precipitate dehydration and acute kidney injury AKI. We avoid use of SGLT2 inhibitors in patients with frequent bacterial urinary tract infections or genitourinary yeast infections, low bone density and high risk for falls and fractures, foot ulceration, and factors predisposing to diabetic ketoacidosis eg, pancreatic insufficiency, drug or alcohol abuse disorder because of increased risk while using these agents.

See "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Cardiovascular effects' and "Sodium-glucose cotransporter 2 inhibitors for the treatment of hyperglycemia in type 2 diabetes mellitus", section on 'Cardiovascular effects'.

Avoidance of hypoglycemia — In older adults at increased risk of hypoglycemia, GLP-1 receptor agonists, SGLT2 inhibitors, and dipeptidyl peptidase 4 DPP-4 inhibitors are options as they are associated with a low hypoglycemia risk.

DPP-4 inhibitors are useful only to improve mild hyperglycemia since they are relatively weak agents and usually lower A1C levels by only 0. However, in frail older adults with late-onset diabetes, particularly patients at high risk of hypoglycemia and impaired awareness of hypoglycemia, a DPP-4 inhibitor can be a useful agent to lower glycemia to the individualized target.

See "Dipeptidyl peptidase 4 DPP-4 inhibitors for the treatment of type 2 diabetes mellitus", section on 'Glycemic efficacy'. Avoidance of weight gain — GLP-1 receptor agonists may be appropriate to use when avoidance of weight gain is a primary consideration and cost is not a major barrier.

SGLT2 inhibitors are also associated with weight loss. However, in the absence of cardiovascular or kidney disease, the risks of SGLT2 inhibitors in older individuals eg, dehydration, falls, fractures may outweigh the benefits. DPP-4 inhibitors, which are weight neutral, also may be a reasonable option.

Cost concerns — If cost is a concern, adding a short- or intermediate-acting sulfonylurea with a relatively lower rate of hypoglycemia, such as glipizide , glimepiride , or gliclazide gliclazide not available in the United States , remains a reasonable alternative.

Choosing a sulfonylurea balances glucose-lowering efficacy, universal local availability, and low cost with risk of hypoglycemia and weight gain. Short- or intermediate-acting sulfonylureas can also be used cautiously in patients with impaired kidney function when other classes are contraindicated.

Generic pioglitazone is also inexpensive. However, we tend not to use pioglitazone in older adults due to risks of fluid retention, weight gain, heart failure, macular edema, and osteoporotic fracture. See "Sulfonylureas and meglitinides in the treatment of type 2 diabetes mellitus", section on 'Hypoglycemia' and "Thiazolidinediones in the treatment of type 2 diabetes mellitus", section on 'Safety'.

A typical starting dose of a sulfonylurea is as follows see "Sulfonylureas and meglitinides in the treatment of type 2 diabetes mellitus", section on 'Dosing and monitoring' :. In patients who are using sulfonylureas, the presence and frequency of hypoglycemia should be evaluated at each visit.

All blood glucose monitoring BGM or continuous glucose monitoring CGM data that are available should be reviewed and the frequency and details of any recognized episodes of hypoglycemia determined.

See 'Monitoring of glycemia' below and "Sulfonylureas and meglitinides in the treatment of type 2 diabetes mellitus", section on 'Hypoglycemia'. The reported frequency of sulfonylurea-related hypoglycemia in older adults is variable. In an analysis of adverse event data from a drug surveillance project, oral hypoglycemic agents accounted for 10 percent of hospitalizations for adverse drug events [ 49 ].

Long-acting sulfonylureas eg, glyburide should be avoided in older adults due to higher risk of hypoglycemia, especially in individuals with inconsistent timing or content of their meals or those with cognitive decline that prevents prompt recognition or treatment of hypoglycemic episodes [ 50 ].

Drug-induced hypoglycemia may be a limiting factor for sulfonylurea use in older adults and is most likely to occur in the following circumstances:. These issues may arise when there is a change in overall health status in older adults with diabetes.

Dual agent failure — For patients who do not achieve A1C goals with two agents eg, metformin plus sulfonylurea or another agent , we suggest starting or intensifying insulin therapy see "Insulin therapy in type 2 diabetes mellitus", section on 'Designing an insulin regimen'.

In patients on sulfonylureas and metformin who are starting insulin therapy, sulfonylureas are generally tapered and discontinued, while metformin is continued. Another option is two oral agents and a GLP-1 receptor agonist.

It is reasonable to try a GLP-1 agonist before starting insulin in patients who are near glycemic goals, those who prefer to avoid insulin, and those in whom weight loss or avoidance of hypoglycemia is a primary consideration.

A once-weekly GLP-1 agonist formulation is particularly attractive for patients and caregivers. However, this option often increases costs and contributes to the problem of polypharmacy in older adults see 'Polypharmacy and deintensification' below. The management of persistent hyperglycemia is reviewed in more detail separately.

See "Management of persistent hyperglycemia in type 2 diabetes mellitus", section on 'Dual agent failure'. Polypharmacy and deintensification — Use of multiple drugs is common in older adults. Management of hyperglycemia and its associated risk factors often increases the number of medications even more in the older adult with diabetes.

Side effects may exacerbate comorbidities and impede patients' ability to manage their diabetes. Therefore, the medication list should be kept current and reviewed at each visit [ 1,6 ]. Overtreatment and complicated regimens should be avoided. Complex regimens that may have been required in the past can often be simplified to be consistent with the modified glycemic targets of an older patient [ 53,54 ].

See 'Controlling hyperglycemia' above. It is important to look for any conditions that interfere with A1C measurement eg, anemia, recent infections, kidney failure, erythropoietin therapy, etc.

In these settings or when unexpected or discordant A1C values are encountered, medication adjustments should be based on glucose readings from a glucose meter or continuous glucose monitoring CGM rather than A1C. See "Measurements of chronic glycemia in diabetes mellitus", section on 'Glycated hemoglobin A1C '.

However, infrequent or no BGM may be adequate for older patients with type 2 diabetes who are diet treated or who are treated with oral agents not associated with hypoglycemia. The effectiveness of BGM in terms of improving glycemic management in patients with type 2 diabetes is less clear than for type 1 diabetes.

See "Glucose monitoring in the ambulatory management of nonpregnant adults with diabetes mellitus", section on 'Type 2 diabetes'. CGM use also should be considered for older patients with impaired awareness of hypoglycemia, those taking other medications that confer higher risk of hypoglycemia eg, sulfonylureas , and those who have difficulty performing BGM through fingerstick checks due to cognitive or physical limitations.

Advances in CGM have made it possible to use the technology in older and even frail patients. Professional CGM devices, applied like a patch on a patient's arm or abdomen depending on the CGM model , measure interstitial glucose levels every 5 to 15 minutes for 10 to 14 days.

These devices provide patterns of glucose excursions that can be the foundation for choosing or adjusting insulin doses in patients on multiple daily insulin regimens. These CGM devices are covered by Medicare in qualifying patients. See "Glucose monitoring in the ambulatory management of nonpregnant adults with diabetes mellitus", section on 'CGM systems'.

Retinopathy, nephropathy, and foot problems are all important complications of diabetes mellitus in older patients. Monitoring recommendations for older patients with diabetes are similar to those in younger patients table 3. In particular, complications that impair functional capacity eg, retinopathy, foot problems should be identified and treated promptly [ 12 ].

Retinopathy — The prevalence of retinopathy increases progressively with increasing duration of diabetes figure 2. See "Diabetic retinopathy: Classification and clinical features".

Regular eye examinations are extremely important for older patients with diabetes because poor vision can lead to social isolation, an increased risk of accidents, and impaired ability to measure blood glucose and draw up insulin doses.

A complete ophthalmologic examination should be performed by a qualified ophthalmologist or optometrist at the time of diagnosis and at least yearly thereafter.

The purpose is to screen not only for diabetic retinopathy, but also for cataracts and glaucoma, which are approximately twice as common in older individuals with diabetes compared with those without diabetes [ 55,56 ]. See "Diabetic retinopathy: Screening".

Nephropathy — The availability of effective therapy for diabetic nephropathy with angiotensin-converting enzyme ACE inhibitors, angiotensin receptor blockade agents ARBs , mineralocorticoid receptor antagonists, and sodium-glucose co-transport 2 SGLT2 inhibitors has led to the recommendation that all patients with diabetes be screened for increased urinary albumin excretion annually.

See "Moderately increased albuminuria microalbuminuria in type 1 diabetes mellitus" and "Moderately increased albuminuria microalbuminuria in type 2 diabetes mellitus". However, the prevalence of increased urinary albumin excretion increases in the older population for reasons unrelated to diabetic nephropathy.

For older patients who are already taking an ACE inhibitor or ARB and have progressive decline in glomerular filtration rate GFR or increase in albuminuria, referral to a nephrologist for further evaluation and treatment is warranted.

Foot problems — Foot problems are an important cause of morbidity in patients with diabetes, and risk is much higher in older patients. Both vascular and neurologic disease contribute to foot lesions. See "Management of diabetic neuropathy". In addition to the increasing prevalence of neuropathy with age, more than 30 percent of older patients with diabetes cannot see or reach their feet, and they may therefore be unable to perform routine foot inspections.

We recommend that older patients with diabetes have their feet examined at every visit; this examination should include an assessment of the patient's ability to see and reach his or her feet and inquiry about other family members or friends who could be trained to do routine foot inspections.

Visits to a podiatrist on a regular basis should also be considered if feasible. A detailed neurologic examination and assessment for peripheral artery disease should be performed at least yearly. It is also important that prophylactic advice on foot care be given to any patient whose feet are at high risk.

See "Evaluation of the diabetic foot". In addition, they are at high risk for polypharmacy, functional disabilities, and other common geriatric syndromes that include cognitive impairment, depression, urinary incontinence, mobility impairment, falls, and persistent pain [ 1 ].

See "Comprehensive geriatric assessment". All older adults should undergo screening for mild cognitive impairment or dementia at initial evaluation and, thereafter, annually or as appropriate for the individual patient [ 12 ]. Despite limited treatment options, identification of underlying cognitive impairment is critical for assessing a patient's capacity to self-manage diabetes treatment and care.

In particular, cognitive function and the possibility of depression should be assessed in older patients with diabetes when any of the following are present see "Evaluation of cognitive impairment and dementia" and "Screening for depression in adults" :.

Nursing home patients — Few studies have focused on management of older adults with diabetes residing in nursing homes [ 4 ]. Life expectancy, quality of life, severe functional disabilities, and other coexisting conditions affect goal setting and management plans.

See 'Controlling hyperglycemia' above and 'Avoiding hypoglycemia' above. Treatment regimens should be chosen with a focus on avoidance of hypoglycemia and control of hyperglycemic symptoms [ 17 ].

For patients requiring insulin, metformin combined with once-daily basal insulin is an effective, relatively simple regimen. If prandial insulin is necessary, it can be administered immediately after a meal to better match the meal size and minimize hypoglycemia.

Sliding scale insulin should not be used as a sole means of providing insulin. If a patient is temporarily managed with sliding scale insulin to determine the requisite dose s of insulin therapy, a more physiologic glucose control strategy should be implemented within a few days table 4.

End-of-life care — Management of patients with diabetes at the end of life must be tailored to individual needs and the severity of the illness. In general, the risks and consequences of hypoglycemia are greater than those of hyperglycemia in patients at the end of life.

The goal is to avoid extreme hyperglycemia and dehydration as well as excessive treatment burdens such as multiple insulin injections or intensive monitoring. For patients with type 2 diabetes who are no longer taking anything by mouth, discontinuation of diabetes medications is reasonable [ 59 ].

This is in contrast to patients with type 1 diabetes, in whom continuing a small amount of basal insulin is required to prevent iatrogenic acute hyperglycemia and ketoacidosis.

See "Palliative care: The last hours and days of life", section on 'Eliminating non-essential medications' and "Deprescribing", section on 'Glucose-lowering medications'. SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately.

See "Society guideline links: Diabetes mellitus in adults". Older adults with diabetes are a heterogeneous population that includes persons residing independently in communities, in assisted care facilities, or in nursing homes.

They can be fit and healthy, or frail with many comorbidities and functional disabilities. Therefore, older adults in particular require individualized goals for diabetes management, keeping in mind their limited life expectancy and comorbidities.

See 'Goals' above. Thus, avoidance of hypoglycemia is an important consideration in establishing goals and choosing therapeutic agents in older adults. See 'Avoiding hypoglycemia' above and "Hypoglycemia in adults with diabetes mellitus", section on 'Strategies to manage hypoglycemia'.

See 'Cardiovascular risk reduction' above. The nutrition prescription is tailored for older people with diabetes based upon medical, lifestyle, and personal factors. Exercise is beneficial to help maintain physical function, reduce cardiac risk, and improve body composition and insulin sensitivity in older patients with diabetes.

See 'Lifestyle modification' above. Because of concern for hypoglycemia, some clinicians use insulin only for a short time to ameliorate glucose toxicity. Once insulin secretion and sensitivity are improved, it may be possible to lower the dose or replace insulin with metformin or another oral hypoglycemic agent with lower risk of hypoglycemia.

See 'Choice of initial drug' above. Metformin will likely reduce glycemia safely at any level of hyperglycemia and further may reduce progression of hyperglycemia or the risk of developing diabetes-related complications. See 'Metformin' above. An alternative option for patients who present with A1C near their medication-treated target and who prefer to avoid medication is a three- to six-month trial of lifestyle modification before initiating metformin.

The approach to choosing alternative therapy in metformin-intolerant patients is similar in older and younger adults. See 'Contraindications to metformin' above and "Initial management of hyperglycemia in adults with type 2 diabetes mellitus", section on 'Contraindications to or intolerance of metformin'.

The therapeutic options for patients who do not reach glycemic goals with lifestyle intervention and metformin are similar in older and younger patients. All of the medications have advantages and disadvantages table 2. The choice of a second agent should be individualized based upon efficacy, risk of hypoglycemia, the patient's underlying comorbidities, the impact on weight, side effects, and cost figure 1.

See 'Persistent hyperglycemia' above and "Management of persistent hyperglycemia in type 2 diabetes mellitus". Another option is two oral agents and a glucagon-like peptide 1 GLP-1 receptor agonist. See 'Dual agent failure' above. In particular, complications that impair functional capacity eg, retinopathy, foot problems should be identified and treated promptly.

See 'Screening for microvascular complications' above. Cognitive function should be assessed routinely in older adults with diabetes. Unexplained deterioration in glycemia or nonadherence to diabetes care may reflect underlying depression.

See 'Common geriatric syndromes associated with diabetes' above. Why UpToDate? Product Editorial Subscription Options Subscribe Sign in. Learn how UpToDate can help you.

Select the option that best describes you. View Topic. Font Size Small Normal Large. Treatment of type 2 diabetes mellitus in the older patient.

Formulary drug information for this topic. No drug references linked in this topic. Find in topic Formulary Print Share. View in. Language Chinese English. Author: Medha Munshi, MD Section Editors: David M Nathan, MD Kenneth E Schmader, MD Deputy Editors: Katya Rubinow, MD Jane Givens, MD, MSCE Contributor Disclosures.

All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Jan This topic last updated: Jan 04, Diabetes in older adults: a consensus report.

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Diabetes Care ; Lipska KJ, Krumholz H, Soones T, Lee SJ. Polypharmacy in the Aging Patient: A Review of Glycemic Control in Older Adults With Type 2 Diabetes. JAMA ; Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycaemia in type 2 diabetes, a patient-centred approach.

Update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetologia ; Sinclair AJ, Paolisso G, Castro M, et al. European Diabetes Working Party for Older People clinical guidelines for type 2 diabetes mellitus.

Executive summary. Diabetes Metab ; 37 Suppl 3:S Kirkman MS, Briscoe VJ, Clark N, et al. Diabetes in older adults. International Diabetes Federation. pdf Accessed on February 24, American Geriatrics Society Expert Panel on Care of Older Adults with Diabetes Mellitus, Moreno G, Mangione CM, et al.

Guidelines abstracted from the American Geriatrics Society Guidelines for Improving the Care of Older Adults with Diabetes Mellitus: update. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee, Meneilly GS, Knip A, Tessier D.

Diabetes in the elderly. Can J Diabetes ; 37 Suppl 1:S Qaseem A, Wilt TJ, Kansagara D, et al. Hemoglobin A1c Targets for Glycemic Control With Pharmacologic Therapy for Nonpregnant Adults With Type 2 Diabetes Mellitus: A Guidance Statement Update From the American College of Physicians.

Ann Intern Med ; LeRoith D, Biessels GJ, Braithwaite SS, et al. J Clin Endocrinol Metab ; American Diabetes Association Professional Practice Committee. Older Adults: Standards of Care in Diabetes Diabetes Care ; S Action to Control Cardiovascular Risk in Diabetes Study Group, Gerstein HC, Miller ME, et al.

Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med ; Riddle MC, Ambrosius WT, Brillon DJ, et al. Epidemiologic relationships between A1C and all-cause mortality during a median 3.

Riddle MC, Gerstein HC. Comment on Hempe et al. The hemoglobin glycation index identifies subpopulations with harms or benefits from intensive treatment in the ACCORD trial.

Diabetes Care ; Diabetes Care ; e Wei N, Zheng H, Nathan DM. Empirically establishing blood glucose targets to achieve HbA1c goals. Munshi MN, Florez H, Huang ES, et al. Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association.

Matyka K, Evans M, Lomas J, et al. Although attention has rightly been paid to the risks of overtreatment of hyperglycemia in older adults hypoglycemia, treatment burden, possibly increased mortality , untreated or undertreated hyperglycemia also has risks, even in patients with life expectancy too short to be impacted by the development of chronic complications.

Hyperglycemic hyperosmolar syndrome is a particularly severe complication of unrecognized or undertreated hyperglycemia in older adults. Although it is appropriate to relax glycemic targets for older patients with a history of hypoglycemia, a high burden of comorbidities, and limited life expectancy, goals that minimize severe hyperglycemia are indicated for almost all patients.

A central concept in geriatric diabetes care guidelines is that providers should base decisions regarding treatment targets or interventions on life expectancy 2 , 17 , 56 , Patients whose life expectancy is limited e.

An observation supporting this concept is that cumulative event curves for the intensive and conventional glycemic control arms of the UKPDS separated after the 9-year mark. National Vital Statistics life table estimates of average life expectancy for adults of specific ages, sexes, and races may not apply to older adults with diabetes, who have shorter life expectancies than the average older adult.

Mortality prediction models that account for variables such as comorbidities and functional status can serve as the basis for making more refined life expectancy estimates — Mortality prediction models specific to diabetes exist but were not designed to inform treatment decisions , A limitation of existing mortality models is that they can help to rank patients by probability of death, but these probabilities must still be transformed into a life expectancy for a particular older diabetic patient.

Simulation models can help transform mortality prediction into a usable life expectancy. One such model estimated the benefits of lowering A1C from 8.

A combination of multiple comorbid illnesses and functional impairments was a better predictor of limited life expectancy and diminished benefits of intensive glucose control than age alone. This model suggests that life expectancy averages less than 5 years for patients aged 60—64 years with seven additional index points points due to comorbid conditions and functional impairments , aged 65—69 years with six additional points, aged 70—74 years with five additional points, and aged 75—79 years with four additional points.

An example of comorbid illnesses is the diagnosis of cancer, which confers two points, whereas an example of a functional impairment is the inability to bathe oneself, conferring two points. In light of the paucity of data for diabetes care in older adults, treatment decisions are frequently made with considerable uncertainty.

Shared decision making has been advocated as an approach to improving the quality of these so-called preference-sensitive medical decisions , Key components of the shared decision-making approach are 1 establishing an ongoing partnership between patient and provider, 2 information exchange, 3 deliberation on choices, and 4 deciding and acting on decisions When asked about their health care goals, older diabetic patients focus most on their functional status and independence A key component of improving communication in the clinical setting may be finding congruence between patient goals and the biomedical goals on which clinicians tend to focus.

Thus, providers must first educate patients and their caregivers about what is known about the role of risk factors in the development of complications and then discuss the possible harms and benefits of interventions to reduce these risk factors.

Equally important is discussing the actual medications that may be needed to achieve treatment goals because patients may have strong preferences about the treatment regimen. In a study of patient preferences regarding diabetes complications and treatments, end-stage complications had the greatest perceived burden on quality of life; however, comprehensive diabetes treatments had significant negative perceived quality-of-life effects, similar to those of intermediate complications Preferences for each health state varied widely among patients, and this variation was not related to health status , implying that the preferences of an individual patient cannot be assumed to be known based on health status.

Many older adults rely on family members or friends to help them with their treatment decisions or to implement day-to-day treatments. In the case of the older person with cognitive deficits, the family member or friend may in fact be serving as a surrogate decision maker.

Among older adults, African Americans and Hispanics have higher incidence and prevalence of type 2 diabetes than non-Hispanic whites, and those with diagnosed diabetes have worse glycemic control and higher rates of comorbid conditions and complications The Institute of Medicine found that although health care access and demographic variables account for some racial and ethnic disparities, there are persistent, residual gaps in outcomes attributed to differences in the quality of care received There is clearly a need for more research into the disparities in diabetes, particularly to understand the full impact of quality improvement programs and culturally tailored interventions among vulnerable older adults with diabetes.

Long-term care LTC facilities include nursing homes, which provide h nursing care for patients in either residential care or rehabilitative care, and adult family homes where the level of care is not as acute. LTC residents with diabetes have more falls , higher rates of CVD and depression, more functional impairment, and more cognitive decline and dependency than residents without diabetes The LTC facility resident may have irregular and unpredictable meal consumption, undernutrition, anorexia, and impaired swallowing.

Therapeutic diets may inadvertently lead to decreased food intake and contribute to unintentional weight loss and undernutrition. Vulnerable older adults, particularly those with cognitive dysfunction, may have impaired thirst sensation, contributing to the risk of volume depletion and hyperglycemic crises.

Precipitating situations include illness, institutional settings LTC or hospital , aversion to drinking water, dysphasia requiring thickened liquids, and some medications Fluid intake should be encouraged and monitored in an institutional setting.

A major issue in LTC facilities is frequent staff turnover with resultant unfamiliarity with vulnerable residents There is often inadequate oversight of glycemic control related to infrequent review of glycemic trends, complex and difficult-to-read glucose logs, and lack of specific diabetes treatment algorithms including glycemic parameters for provider notification Excessive reliance on sliding-scale insulin SSI has been documented.

Evidence-based policies for glycemic control, use of insulin, and treatment of hypoglycemia have the potential to improve the care of residents with diabetes, alleviate some of the burden caused by frequent staff turnover, and even lead to more staff satisfaction.

Older adults are more apt to require hospitalization than younger adults, and those with diabetes are at very high risk of requiring hospitalization. There is a dearth of studies addressing older adults with diabetes, particularly more frail older adults, in the hospital. Many guidelines that apply to hospitalized adults with hyperglycemia can probably be extrapolated to older adults , Less stringent glycemic targets may be appropriate for patients with multiple comorbidities and reduced life expectancy—criteria that could be applicable to many hospitalized older adults.

Studies of glycemic control targets in critically ill patients did include older adults, and therefore the recommendations for insulin infusions and glycemic goals of the ADA 17 are reasonable for older adults in intensive care units.

Other recommendations for all adults, such as avoiding the use of sliding scale—only regimens and noninsulin antihyperglycemic drugs, are also reasonable for hospitalized older adults. Transitions from hospital to home or to short- or long-term care facilities are times of risk for patients with diabetes, and probably more so for older patients.

Older patients on insulin may need to increase or decrease their dose as they recuperate from their acute illness and their diet improves. Delirium acute decline in cognitive function is a common complication seen in older adults during and after hospitalization and may require more supervision to avoid errors in dosing.

Medication reconciliation, patient and caregiver education, and close communication between inpatient and outpatient care teams, are critically important to ensure patient safety and reduce readmission rates. After review of the available evidence and consideration of issues that might influence treatment decisions in older adults with diabetes, the authors have developed recommendations in a number of areas.

Table 1 provides a framework for considering treatment goals for glycemia, blood pressure, and dyslipidemia. This framework is based on the work of Blaum et al.

The three classes correspond with increasing levels of mortality risk The observation that there are three major classes of older diabetic patients is supported by other research The framework is an attempt to balance the expected time frame of benefit of interventions with anticipated life expectancy.

Table 2 provides additional consensus recommendations beyond goals of treatment of glycemia, blood pressure, and dyslipidemia. A framework for considering treatment goals for glycemia, blood pressure, and dyslipidemia in older adults with diabetes.

The exclusion of older, and especially frail older, participants from most traditional randomized controlled trials of diabetes interventions has left us with large gaps in our knowledge of how best to address diabetes in the age-group with the highest prevalence rates.

Future research should allow and account for the complexity and heterogeneity of older adults. Studies will need to include patients with multiple comorbidities, dependent living situations, and geriatric syndromes in order to advance our knowledge about these populations. Suggested research questions and topics are listed in Table 3.

The ADA thanks the following individuals for their excellent presentations at the Consensus Development Conference on Diabetes and Older Adults: Edward Gregg, PhD; Nicolas Musi, MD; M. Miller, PhD; R. Harsha Rao, MD, FRCP; Craig Williams, PharmD, BCPS, FNLA; Barbara Resnick, PhD, CRNP, FAAN, FAANP; Carol M.

Mangione, MD, MSPH; Jill P. Crandall, MD; Caroline S. Blaum, MD, MS; Jeff D. Williamson, MD, MHS; John M. Jakicic, PhD; Tamara Harris, MD, MS; and Naushira Pandya, MD, CMD. The authors thank Bobbie Alexander, Monique Lindsy, and Earnestine Walker for their assistance with the consensus development conference.

The consensus development conference was supported by a planning grant from the Association of Subspecialty Professors though a grant from the John A. Hartford Foundation , by educational grants from Lilly USA, LLC and Novo Nordisk, and sponsorships from the Medco Foundation and Sanofi.

Sponsors had no influence on the selection of speakers or writing group members, topics and content presented at the conference, or the content of this report. Pepper Older Americans Independence Center P30 AG receives speaking honoraria from Sanofi. chairs a Data Monitoring Committee for Takeda Global Research and Development for studies of a new dipeptidyl peptidase-4 inhibitor.

receives grant support from Sanofi and has served as a consultant to Regeneron. receives grant support from Sanofi. No other potential conflicts of interest relevant to this article were reported.

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Haas, PHC, RN, CDE. Jeffrey B. Halter, MD ; Jeffrey B. Halter, MD. Elbert S. Huang, MD, MPH ; Elbert S. Huang, MD, MPH. Mary T. Korytkowski, MD ; Mary T. Korytkowski, MD. Medha N. Munshi, MD ; Medha N. Munshi, MD. Peggy Soule Odegard, BS, PHARMD, CDE ; Peggy Soule Odegard, BS, PHARMD, CDE. Richard E.

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Table 2 Additional consensus recommendations for care of older adults with diabetes. Table 3 Consensus recommendations for research questions about diabetes in older adults. disclosed no conflicts of interest.

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METHODS We analyzed the clinical data of patients who were diagnosed DKA for the first time from July, to June, at Hallym Univ. Sacred Heart Hospitals. We divided our patients into 3 groups according to the age at the first DKA and compared the clinical characteristics of DKA patients aged 65 or over with those of under 30 of age.

RESULTS Forty-four patients were under 30 of age and 8 patients were 65 or over of age. The duration of DM prior to DKA was Common geriatric syndromes occur frequently in older adults with diabetes that include cognitive impairment, depression, urinary incontinence, injurious falls, polypharmacy, and chronic pain [ 20 ].

Some of these syndromes have subtle presentations which are rarely identified if not specifically looked for [ 21 ]. Therefore, elderly diabetic patients have complex medical, psychosocial, and functional problems with cognitive impairment than non-diabetics [ 21 — 23 ].

They may lack the typical symptoms of hyperglycemia such as polyuria, polydipsia, and polyphagia [ 24 ]. In the present study, hyperglycemia or poor hyperglycemic control was the second most common reason for hospital admission.

Of the patients admitted for hyperglycemia or poor hyperglycemic control, Frequently, these symptoms go unnoticed or are attributed to old age [ 25 ]. In fact, the typical symptoms of hyperglycemia are less common in elderly patients because the renal threshold for glycosuria increases with age and the thirst mechanisms are more likely to be impaired [ 27 ].

Diabetes mellitus is a chronic, progressive disorder that affects virtually every organ of the body. One of the problems associated with this condition is infection [ 28 ]. It has been reported that individuals with diabetes are at increased risk of various infection conditions [ 29 — 31 ] and infection-related hospitalization [ 32 ].

In the present study, infection was also a frequent cause of hospitalization, in fact, infections of the respiratory and urinary tracts together accounted for more than half of these hospital admissions.

Moreover, we found that respiratory tract infection was significantly more common in men than women, whereas urinary tract infection was more frequently encountered in women. These findings may be explained by gender differences in anatomy, lifestyle, behavior, and socioeconomics [ 33 ].

In a systematic review by Falagas et al. Gender-based differences in response to infection have also been reported in other studies, which reported that women have higher levels of plasma immunoglobulin Ig and are more resistant to exogenous antigens [ 34 ]. In addition, estrogens are generally immune enhancing, whereas androgens exert suppressive effects on both humoral and cellular immune responses [ 35 ].

In general, the risk of developing urinary tract infections is higher for patients with type 2 diabetes compared with those without diabetes [ 36 ].

Several factors are thought to predispose to urinary tract infections in diabetic patients, including older age, history of urinary tract infections, a longer history of diabetes, and increased HbA1c levels [ 30 , 37 ].

The range of patient signs and symptoms can vary from classic to atypical in elderly patients [ 38 ]. In the elderly population with diabetes, autonomic neuropathy can reduce sensitivity and alter distensibility of the urinary bladder, leading to recurrent urinary tract infections or asymptomatic bacteriuria [ 30 , 39 ].

Moreover, glycosuria enhances bacterial growth and impairs phagocytosis, which probably has a role in the increased incidence of urinary tract infections in diabetic patients, especially in the elderly.

Vaginitis and renal microangiopathy, which occur more frequently in the elderly, may also be associated with urinary tract infections [ 39 ].

Diabetic ketoacidosis is a major, life-threatening hyperglycemic emergency [ 40 ]. Although the ratio of men to women afflicted with diabetes is roughly equal, women may be more likely than men to develop diabetic ketoacidosis [ 41 ].

Barski et al. However, in that study hospitalized men and women with diabetic ketoacidosis were statistically similar for rates of in-hospital mortality and complications [ 42 ].

This study provides new data regarding reasons for hospitalization among elderly patients with diabetes. However, the results of the study should be generalized with caution in other geographic areas and hospitals.

The study is retrospective and was performed at a single center, which led to unavoidable selection bias. Another limitation is that we did not conduct a subgroup analysis of those patients who were admitted more than once, because most of these patients were readmitted for the same reason.

This retrospective study highlighted some of the characteristics of hospitalized elderly diabetic patients and the gender differences in causes of hospital admission. The most frequent reason reported for hospitalization of elderly diabetic patients was chronic complications of diabetes, seconded by hyperglycemia, and then infection.

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Diabetes and aging: epidemiologic overview. DKA was associated with a high burden of disease reflected by high rates of intensive care unit admission, prolonged hospital stay and high mortality rates, especially in elderly. Diabetic ketoacidosis DKA and hyperglycemic hyperosmolar state are life-threatening complications occurring at states of metabolic decompensation or at primary diagnosis of diabetes mellitus 1 — 3.

While patients with type 1 diabetes are known to be susceptible to DKA particularly under stressful conditions such as infection, trauma, or surgery, ketoacidosis may also occur in patients with poorly controlled or newly diagnosed type 2 diabetes 4 , 5. Especially in recent years, the broader use of sodium—glucose cotransporter 2 SGLT2 inhibitors has raised awareness of DKA in type 2 diabetes, since this modern antidiabetic drug class precipitates euglycemic DKA 6.

There are disparities in occurrence of DKA, in that patients from disadvantaged socioeconomic backgrounds or with poor mental health have a higher incidence rates of DKA 7 , 8.

Although management of diabetes and its associated complications has significantly improved over the past decades 9 , 10 , DKA remains a significant health burden with high morbidity 11 , mortality 12 — 14 , and relevant utilization of health-care resources 15 — While recent data indicate that the population incidence for DKA has been increasing dramatically over the past years 18 , data on risks throughout lifetime and granular characteristics of individuals at highest risk of DKA are scarce.

Most published data about the epidemiology of DKA were either derived from longitudinal cohort studies that do not reveal population-based estimates or they were focused on either pediatric or adult patient populations, lacking an entire picture.

Hence, in this nationwide cohort study, we first aimed to investigate the risk of DKA in patients with type 1 and type 2 diabetes mellitus throughout lifespan and to assess sex-specific differences, time trends and relevant clinical outcomes. This was a nationwide retrospective cohort study in pediatric, adolescent, and adult patients who were hospitalized with DKA in Switzerland between and Hospitalization data were obtained from population-based administrative claims data provided by the Swiss Federal Office for Statistics Bundesamt für Statistik, Neuchâtel, Switzerland.

The database includes all Swiss inpatient discharge records from acute care-, general-, and specialty hospitals in Switzerland for both pediatric and adult patients.

Individual-level data on patient demographics, healthcare utilization, hospital typology, medical diagnoses, diagnostic tests, clinical procedures, and in-hospital patient outcomes were provided for all hospitalized patients in Switzerland.

The data were unidentifiable due to a multiple-step pseudonymization procedure. Each hospitalization in this database was identified uniquely so that re-hospitalizations could be tracked. Ethics committee Northwest and Central Switzerland EKNZ approved this study and granted a waiver of informed consent Req Eligible individuals included pediatric, adolescent, and adult persons up to an age of 90 years hospitalized with DKA and the diagnosis of either type 1 or type 2 diabetes mellitus, respectively.

Cases with DKA were identified by applying the ICDGM codes E The diagnosis of diabetes mellitus was identified by the codes E xx for type 1 diabetes and E xx for type 2 diabetes, respectively. This study followed the Strengthening The Reporting of OBservational studies in Epidemiology STROBE reporting guideline Data on the population size per age and year were obtained from census data from the Swiss Federal Office for Statistics.

Secondary outcomes comprised assessment of time trends in DKA incidence and occurrence of clinical endpoints: intensive care unit ICU admission rate, intubation rate, length of ICU stay, incidence of cerebral edema, total length of hospital stay LOS — defined as days spent in the hospital during the hospitalization, all-cause in-hospital mortality, day, 1-year, and 2-year all-cause hospital readmission rates.

These analyses were stratified by age categories, sex, and type of diabetes mellitus. Unless stated otherwise, categorical variables are expressed as number percentage and continuous variables as mean standard deviation, SD.

The denominator for all incidence rates was the standard population per year. Exposure time began on January 1st and ended on December 31st of the cohort year Incidence rates were reported in five age categories: children years , adolescents years , and adults , , and years , respectively.

Graphical depiction of incidence rates over age was performed using locally estimated scatterplot smoothing LOESS. To assess whether incidence rates of DKA changed with time, we used a mixed method linear regression model for three time periods , and All statistical analyses were performed using STATA, version From January 1 st to December 31 st , a total of 5, hospital admissions for DKA were identified in Switzerland, yielding in an average total incidence rate of 7.

Of those, 3, DKA events occurred in patients with type 1 diabetes and 1, events in patients with type 2 diabetes. The clinical characteristics of the study population are outlined in Table 1.

Among children, adolescents, and younger adults up to an age of 29 years, nearly all cases While in middle-aged adults years , Microvascular complications of diabetes were rare among children and adolescents 0.

Psychiatric disorders were seen in While in adolescents anxiety, stress-related and somatoform disorders were most prevalent, in adults the main cause of psychiatric disorder was dementia. The total incidence of DKA was highest among patients with type 1 diabetes, for both sexes incidence rates of DKA showed a steep rise from childhood to adolescence with a peak at an age of 16 years in females with a maximum of There was a significant incidence rate difference between female and male adolescents aged years of Figure 1 Lifetime Incidence Rates of Diabetic Ketoacidosis by Sex.

Incidence rates per , person-years for male blue and female red patients. Figure 2 Incidence Rates of Diabetic Ketoacidosis.

Incidence rates for diabetic ketoacidosis per , person-years for A female or B male patients with type 1 or type 2 diabetes, respectively.

For both sexes, highest incidences for patients with type 1 diabetes occur within the adolescence and remain low from the age of 30 years. In patients with type 2 diabetes, incidences for ketoacidosis are lower and slowly increase with age from 30 with a peak around the age of 85 years.

There were no clinically relevant differences in in-hospital outcomes between sexes or type of diabetes.

Hospitalization with DKA - irrespective of type of diabetes - was associated with a high burden of disease and utilization of health-care, reflected by a high rate of ICU admission of DKA was associated with cerebral edema in 0.

During the study period, among children aged below 9 years only one boy with DKA died. In this case, cerebral edema was observed and could be the underlying cause of death. These patients were also at high risk for hospital readmission within 1 year at a rate of In adults aged 20 years or older, DKA was associated with a mean in-hospital mortality rate of 3.

Length of hospital stay was long in patients with DKA, with longest hospitalizations among the oldest age group years of Incidence rates of DKA increased from 7. Figure 3 Trends of Ketoacidosis Incidence by Age, Sex, and Type of Diabetes. Shown are incidence rates per , person-years for an event of diabetic ketoacidosis for three time periods: light blue ; dark blue ; orange.

This population-based cohort study has three key findings: First, while among patients with type 1 diabetes the risk for DKA was highest among adolescents at around 15 years of age, in patients with type 2 diabetes the lifetime risk for DKA steadily increased with age.

Second, in adolescence, females were predominantly prone to develop DKA, however in adults there was a switch towards higher rates in males.

Third, incidence rates for DKA were increasing over time, especially among the elderly with relevant health-care burden. So far, few data exist about the lifetime risks for DKA among patients with diabetes.

While patients with diabetes are usually managed in an outpatient care setting, DKA is a life-threatening condition and requires emergency admission and most often relies on inpatient acute care. Therefore, incidence rates and in-hospital mortality rates reflect the real-world data with high certainty using nationwide hospital claims data.

A previous meta-analysis investigating the incidences of DKA among patients with type 1 diabetes mellitus reported a very wide range in incidence rates of DKA ranging from 0 to 26, events per , person-years, however, almost all included studies were susceptible to potential selection bias or were of limited generalizability We found that in type 1 diabetes, the risks for the development of DKA were most pronounced during adolescence and in particular among girls.

This finding is in line with previous data on HbA1c trajectories among youth with type 1 diabetes. Several longitudinal studies have shown that worsening of glycemic control during puberty is common and that girls were more likely to have significant deterioration of their glycemic control 21 — Underlying factors for this gender disparity have been discussed extensively.

Potential contributors to poor glucose control during puberty being more predominant in females include poorer diabetes acceptance, psychiatric disorders e.

depression, personality disorders , eating disorders e. patients omitting inulin to induce weight loss , cognitive problems e. attention deficit , binge alcohol consumption, and hazardous and risk-taking behavior inherent to adolescence 1 , 25 — In addition, increased autonomy in the management of diabetes with refusal of further parental support and the strong need to be accepted outside the family, especially by the peer group, result in less stringent diabetes treatment.

Finally, somatic factors such as increased insulin requirements due to changing insulin sensitivity during puberty have an impact on glycemic control and differ between females and males 28 — In addition, previous DKA episodes are well known risk factors for repeated DKA events in adolescents 1.

Transition from pediatric to adult care during this sensitive developmental phase might further increase the risk for DKA by disengagement for clinical care of diabetes, while structured transition programs and young adult diabetes clinics show in some studies the potential to improve metabolic control and psychosocial well-being during the intervention 31 — In summary, the DKA peak between years reflects the multifactorial difficulties in chronic disease acceptance and management during this vulnerable developmental time window and underlines the importance of awareness for age specific multidisciplinary patient care In comparison, higher rates of DKA among males in adult age may be reflected by higher prevalence of type 2 diabetes with worse metabolic control and higher rates of obesity in men when compared with women DKA no longer can be considered pathognomonic of type 1 diabetes, since a substantial number of DKA episodes especially in adult patients occur with a history of type 2 diabetes.

In type 2 diabetes, DKA is known to occur commonly among patients with low social status from urban populations with high rates of obesity Previous studies identified risk factors for DKA such as lack of adherence to therapy, low socioeconomic status, substance abuse, and low education It has been shown that in patients with type 2 diabetes DKA is more severe with worse outcomes and higher mortality 36 , It can only be speculated whether in older patients hospitalized with DKA the high rate of organic mental disorders, i.

various forms of dementia, may be related to the fact that patients with dementia more often forget their insulin application or if patients with recurrent DKA episodes and possibly worse glycemic control are at higher risk to develop dementia. It is well established that cognitive impairment is a long-term comorbidity of diabetes mellitus In addition, it has been demonstrated that in adults with type 1 diabetes, recurrent DKA events were associated with lower global cognitive function Hence, approaches to prevent, early diagnose and to manage diabetes-associated cognitive impairments become increasingly important with longevity and ageing of populations.

During the 9-year study period, the population-based incidence rate of DKA increased over time. This is an intriguing finding. It may be explained by the epidemic rise in cases with type 2 diabetes or it could as well be associated with the increasing prescription rate of SGLT2 inhibitors that are widely recommended in current guidelines but are known to increase the risk of euglycemic ketoacidosis 40 , On the other hand, incidence rates of type 1 diabetes in children have been also increasing over time There is a significant global variation in rates of DKA, being highest in developing countries 24 , 43 — 49 , which may be explained by lower disease awareness, and as a consequence delayed diagnosis Our data confirm the high in-hospital burden of DKA with a high utilization of health-care resources.

While length of hospital stay might be influenced by other co-morbidities among adults, rates of ICU admissions among children may even have been underestimated since many Swiss hospitals do not provide pediatric intensive care, but rather intermediate care that was not captured in the hospital claims dataset.

Our data must be interpreted in the context of the study design. First and foremost, in Switzerland, having a decentralized health-care system steered by their 26 cantons federal states , there is a strong need for improved completeness, accessibility, and linkability of health-care data.

For instance, there is minimal information on the incidence of type 1 and of type 2 diabetes within the Swiss population, hence incidence rates in our study were calculated in the general population and not in patients with diabetes only.

Second, our study is based on administrative hospital claims data that do neither contain information on the duration of diabetes - thus DKA events may have occurred in newly diagnosed as well as in established disease — nor do they contain medication data e.

insulin pump usage. Unfortunately, in Switzerland there is no national database on utilization of medications. Third, data on causes of ICU admission, mechanical ventilation, and death were not available.

Fourth, data on laboratory parameters such as glycemic control were likewise not available, therefore associations of DKA with poor glycemic control cannot be assessed in our study.

Finally, we cannot exclude a certain risk of misclassification and underreporting since administrative data were used in our analyses and we were not able to validate diagnoses, as a consequence it is possible that patients with latent autoimmune diabetes in adults LADA may have been misclassified.