Ch37 Elderly

Canadian Diabetes Association
Clinical Practice Guidelines

Diabetes in the Elderly
Chapter 37
(Updated March 2016)
Graydon S. Meneilly, Daniel Tessier, Aileen Knip
2016
Diabetes in the Elderly Checklist
2013
ASSESS for level of functional dependency (frailty)

INDIVIDUALIZE glycemic targets based on the above
(A1C 8.5% for frail elderly) but if otherwise healthy,
use the same targets as younger people
AVOID hypoglycemia in cognitive impairment
SELECT antihyperglycemic therapy carefully
Caution with sulfonylureas or thiazolidinediones
Basal analogues instead of NPH or human 30/70 insulin
Premixed insulins instead of mixing insulins separately
GIVE regular diets instead of diabetic diets or

nutritional formulas in nursing homes
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright 2013 Canadian Diabetes Association
Frailty is a widely used term associated with

aging that denotes a multidimensional
syndrome that gives rise to increased
vulnerability


Moorhouse P, Rockwood K.
J R Coll Physicians Edinb 2012;42:333-340.
Consider A1C 7.1-8.5% if
2013
Limited life expectancy

High level of functional dependency
Extensive coronary artery disease at high risk of
ischemic events
Multiple co-morbidities
History of recurrent severe hypoglycemia
Hypoglycemia unawareness
Longstanding diabetes for whom is it difficult to
achieve an A1C 7%, despite effective doses of
multiple antihyperglycemic agents, including
intensified basal-bolus insulin therapy

Individualizing A1C Targets
2013
Consider 7.1-8.5% if:
which must
be balanced
against the
risk of
hypoglycemi
guidelines.diabetes.ca
| 1-800-BANTING (226-8464)
a
| diabetes.ca
Among Frail Elderly
2013
Parameter
Target
A1C
8.5%
FPG or
preprandial glucose
5.0-12.0 mmol/L
(depending on level of
frailty)
AVOID HYPOGLYCEMIA
FPG= Fasting Plasma Glucose

Autonomic
symptoms
Older Patients have Less Perception of Hypoglycemia

14
12
10
8
6
4
2
0
**
Middle-aged
(39-64 years)
Older
(65 years)
Baseline
Hypo
Recovery
Neuroglycopenic
symptoms
12
*
10
8
6
4
2
0
Baseline

Hypo
Recovery
Bremer JP et al. Diabetes Care. 2009; 32 (8):1513-17
AT DIAGNOSIS OF TYPE 2 DIABETES

Start lifestyle intervention (nutrition therapy and physical activity) +/- Metformin
L
I
F
E
S
T
Y
L
E
2016
A1C <8.5%
If not at glycemic
target (2-3 mos)
Start / Increase
metformin
A1C 8.5%
Symptomatic hyperglycemia with

metabolic decompensation
Start metformin immediately

Consider initial combination with
another antihyperglycemic agent
Initiate
insulin +/metformin
If not at glycemic targets

Add another agent best suited to the individual by prioritizing patient characteristics:
PATIENT CHARACTERISTIC
PRIORITY:
Clinical Cardiovascular Disease
CHOICE OF AGENT
SGLT2 inhibitor with demonstrated CV

outcome benefit
Degree of hyperglycemia
Risk of hypoglycemia
Overweight or obesity
Cardiovascular disease or multiple risk factors
Comorbidities (renal, CHF, hepatic)
Preferences & access to treatment
Consider relative A1C lowering

Rare hypoglycemia
Weight loss or weight neutral
Effect on cardiovascular outcome
See therapeutic considerations, consider eGFR
See cost column; consider access
See next page
From prior page
L
I
F
E
S
T
Y
L
E
If not at glycemic target
2016
Add another agent from a different

class
Add/Intensify insulin regimen
Make timely adjustments to attain target A1C within 3-6 months

May use detemir or glargine instead of NPH or

human 30/70 for less hypos
Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing errors
CAUTION in the elderly

Initial doses = HALF of usual dose
Avoid glyburide
Use gliclazide, gliclazide MR, glimepiride,
nateglinide or repaglinide instead
CAUTION with renal dysfunction
CAUTION in the elderly

Increased risk of fractures
Increased risk of heart failure
2016
If Choosing to Use Insulin
2013
Clock drawing test can be used to predict who is

likely to have problems with insulin therapy
Write numbers on the blank clock face and draw

hands on the clock to show 10 minutes past 11
oclock
Trimble LA et al. Can J Diabetes 2005;29(2):102-104.

Diabetes in Nursing Homes
2013
Under nutrition is a problem in people with diabetes

living in nursing homes
Regular diets may be used in nursing homes

instead of diabetic diets or diabetic nutritional
formulas
Mooradian AD et al. J Am Geriatr Soc 1988;36:391-396

Coulston AM et al. Am J Clin Nutr 1990;51:67-71.
Recommendation 1
1. Healthy, elderly people with diabetes should be
treated to achieve the same glycemic, blood
pressure, and lipid targets as younger people with
diabetes [Grade D, Consensus].

Recommendation 2
2013
2. In the frail elderly, while avoiding symptomatic

hyperglycemia, glycemic targets should be an A1C
of 8.5% and FPG or pre-prandial PG of
5.0-12.0 mmol/L, depending on the level of frailty.
Avoidance of hypoglycemia should take priority over
attainment of glycemic targets because the risks of
hypoglycemia are magnified in this patient
population [Grade D, Consensus].

Recommendations 3 and 4
3. In elderly people with cognitive impairment,
strategies should be employed to strictly avoid
hypoglycemia, which include the choice of
antihyperglycemic therapy and less stringent A1C
target [Grade D, Consensus].
4. Elderly people with type 2 diabetes should perform
aerobic exercise and/or resistance training, if not
contraindicated, to improve glycemic control [Grade B,
Level 2].

Recommendation 5
5. In elderly people with T2DM, sulfonylureas should
be used with caution because the risk of
hypoglycemia increases exponentially with age
[Grade D, Level 4].
In general, initial doses of sulfonylureas in the elderly

should be half of those used for younger people, and
doses should be increased more slowly [Grade D, Consensus].
Gliclazide and gliclazide MR [Grade B, Level 2] and
glimepiride [Grade C, Level 3] should be used instead of
glyburide, as they are associated with a reduced frequency
of hypoglycemic events.
Meglitinides may be used instead of glyburide to reduce
the risk of hypoglycemia [Grade C Level 2 for repaglinide; Grade C,
Level 3 for nateglinide], particularly in patients with irregular
eating habits [Grade D, Consensus].
Recommendation 6
6. In elderly people, thiazolidinediones should be used
with caution due to the increased risk of fractures
and heart failure [Grade D, Consensus].

7. Detemir and glargine may be used instead of NPH
or human 30/70 insulin to lower the frequency of
2013
hypoglycemic events [Grade B, Level 2].
8. In elderly people, if insulin mixture is required,

premixed insulins and prefilled insulin pens
2013
should be used instead of mixing insulins to
reduce dosing errors, and to potentially improve
glycemic control [Grade B, Level 2].
2013
9. The clock drawing test may be used to predict

which elderly subjects will have difficulty learning to
inject insulin [Grade D, Level 4].
10. In elderly nursing home residents, regular diets may
be used instead of diabetic diets or nutritional
formulas [Grade D, Level 4].

CDA Clinical Practice Guidelines

www.guidelines.diabetes.ca for professionals
1-800-BANTING (226-8464)
www.diabetes.ca for patients

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Canadian Diabetes Association

Clinical Practice Guidelines

Graydon S. Meneilly, Daniel Tessier, Aileen Knip

Diabetes in the Elderly Checklist

ASSESS for level of functional dependency (frailty)

GIVE regular diets instead of diabetic diets or

Frailty is a widely used term associated with

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Consider A1C 7.1-8.5% if

Limited life expectancy

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Individualizing A1C Targets

Consider 7.1-8.5% if:

Among Frail Elderly

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Older Patients have Less Perception of Hypoglycemia

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

AT DIAGNOSIS OF TYPE 2 DIABETES

Symptomatic hyperglycemia with

Start metformin immediately

If not at glycemic targets

Clinical Cardiovascular Disease

SGLT2 inhibitor with demonstrated CV

Consider relative A1C lowering

See next page

From prior page

If not at glycemic target

Add another agent from a different

Make timely adjustments to attain target A1C within 3-6 months

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

May use detemir or glargine instead of NPH or

CAUTION in the elderly

CAUTION with renal dysfunction

CAUTION in the elderly

If Choosing to Use Insulin

Clock drawing test can be used to predict who is

Write numbers on the blank clock face and draw

Trimble LA et al. Can J Diabetes 2005;29(2):102-104.

Diabetes in Nursing Homes

Under nutrition is a problem in people with diabetes

Regular diets may be used in nursing homes

Mooradian AD et al. J Am Geriatr Soc 1988;36:391-396

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

2. In the frail elderly, while avoiding symptomatic

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

In general, initial doses of sulfonylureas in the elderly

Copyright 2013 Canadian Diabetes Association

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

hypoglycemic events [Grade B, Level 2].

8. In elderly people, if insulin mixture is required,

9. The clock drawing test may be used to predict

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

CDA Clinical Practice Guidelines

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