12. Older Adults: Standards of Medical Care in Diabetes—2021

• 12.1 Consider the assessment of medical, psychological, functional (self-management abilities), and social geriatric domains in older adults to provide a framework to determine targets and therapeutic approaches for diabetes management. B

• 12.2 Screen for geriatric syndromes (i.e., polypharmacy, cognitive impairment, depression, urinary incontinence, falls, and persistent pain) in older adults, as they may affect diabetes self-management and diminish quality of life. B

Diabetes is a highly prevalent health condition in the aging population. Over one-quarter of people over the age of 65 years have diabetes and one-half of older adults have prediabetes (1,2), and the number of older adults living with these conditions is expected to increase rapidly in the coming decades. Diabetes management in older adults requires regular assessment of medical, psychological, functional, and social domains. Older adults with diabetes have higher rates of premature death, functional disability, accelerated muscle loss, and coexisting illnesses, such as hypertension, coronary heart disease, and stroke, than those without diabetes. Screening for diabetes complications in older adults should be individualized and periodically revisited, as the results of screening tests may impact targets and therapeutic approaches (3–5). At the same time, older adults with diabetes are also at greater risk than other older adults for several common geriatric syndromes, such as polypharmacy, cognitive impairment, depression, urinary incontinence, injurious falls, and persistent pain (1). These conditions may impact older adults' diabetes self-management abilities and quality of life if left unaddressed (2,6,7). See Section 4 “Comprehensive Medical Evaluation and Assessment of Comorbidities” (https://doi.org/10.2337/dc21-S004), for the full range of issues to consider when caring for older adults with diabetes.

The comprehensive assessment described above may provide a framework to determine targets and therapeutic approaches (8–10), including whether referral for diabetes self-management education is appropriate (when complicating factors arise or when transitions in care occur) or whether the current regimen is too complex for the patient's self-management ability or the caregivers providing care. Particular attention should be paid to complications that can develop over short periods of time and/or would significantly impair functional status, such as visual and lower-extremity complications. Please refer to the American Diabetes Association (ADA) consensus report “Diabetes in Older Adults” for details (2).

• 12.3 Screening for early detection of mild cognitive impairment or dementia should be performed for adults 65 years of age or older at the initial visit and annually as appropriate. B

Older adults with diabetes are at higher risk of cognitive decline and institutionalization (11,12). The presentation of cognitive impairment ranges from subtle executive dysfunction to memory loss and overt dementia. People with diabetes have higher incidences of all-cause dementia, Alzheimer disease, and vascular dementia than people with normal glucose tolerance (13). The effects of hyperglycemia and hyperinsulinemia on the brain are areas of intense research. Poor glycemic control is associated with a decline in cognitive function (14,15), and longer duration of diabetes is associated with worsening cognitive function. There are ongoing studies evaluating whether preventing or delaying diabetes onset may help to maintain cognitive function in older adults. However, studies examining the effects of intensive glycemic and blood pressure control to achieve specific targets have not demonstrated a reduction in brain function decline (16,17).

Clinical trials of specific interventions—including cholinesterase inhibitors and glutamatergic antagonists—have not shown positive therapeutic benefit in maintaining or significantly improving cognitive function or in preventing cognitive decline (18). Pilot studies in patients with mild cognitive impairment evaluating the potential benefits of intranasal insulin therapy and metformin therapy provide insights for future clinical trials and mechanistic studies (19–21).

Despite the paucity of therapies to prevent or remedy cognitive decline, identifying cognitive impairment early has important implications for diabetes care. The presence of cognitive impairment can make it challenging for clinicians to help their patients reach individualized glycemic, blood pressure, and lipid targets. Cognitive dysfunction makes it difficult for patients to perform complex self-care tasks (22), such as monitoring glucose and adjusting insulin doses. It also hinders their ability to appropriately maintain the timing of meals and content of diet. When clinicians are managing patients with cognitive dysfunction, it is critical to simplify drug regimens and to facilitate and engage the appropriate support structure to assist the patient in all aspects of care.

Older adults with diabetes should be carefully screened and monitored for cognitive impairment (2). Several simple assessment tools are available to screen for cognitive impairment (23,24), such as the Mini Mental State Examination (25), Mini-Cog (26), and the Montreal Cognitive Assessment (27), which may help to identify patients requiring neuropsychological evaluation, particularly those in whom dementia is suspected (i.e., experiencing memory loss and decline in their basic and instrumental activities of daily living). Annual screening is indicated for adults 65 years of age or older for early detection of mild cognitive impairment or dementia (4,28). Screening for cognitive impairment should additionally be considered when a patient presents with a significant decline in clinical status due to increased problems with self-care activities, such as errors in calculating insulin dose, difficulty counting carbohydrates, skipped meals, skipped insulin doses, and difficulty recognizing, preventing, or treating hypoglycemia. People who screen positive for cognitive impairment should receive diagnostic assessment as appropriate, including referral to a behavioral health provider for formal cognitive/neuropsychological evaluation (29).

• 12.4 Because older adults with diabetes have a greater risk of hypoglycemia than younger adults, episodes of hypoglycemia should be ascertained and addressed at routine visits. B

• 12.5 For older adults with type 1 diabetes, continuous glucose monitoring should be considered to reduce hypoglycemia. A

Older adults are at higher risk of hypoglycemia for many reasons, including insulin deficiency necessitating insulin therapy and progressive renal insufficiency (30). As described above, older adults have higher rates of unidentified cognitive impairment and dementia, leading to difficulties in adhering to complex self-care activities (e.g., glucose monitoring, insulin dose adjustment, etc.). Cognitive decline has been associated with increased risk of hypoglycemia, and conversely, severe hypoglycemia has been linked to increased risk of dementia (31,32). Therefore, as discussed in Recommendation 12.3, it is important to routinely screen older adults for cognitive impairment and dementia and discuss findings with the patients and their caregivers.

Patients and their caregivers should be routinely queried about hypoglycemia (e.g., selected questions from the Diabetes Care Profile) (33) and hypoglycemia unawareness (34). Older patients can also be stratified for future risk for hypoglycemia with validated risk calculators (e.g., Kaiser Hypoglycemia Model) (35). An important step to mitigating hypoglycemia risk is to determine whether the patient is skipping meals or inadvertently repeating doses of their medications. Glycemic targets and pharmacologic regimens may need to be adjusted to minimize the occurrence of hypoglycemic events (2). This recommendation is supported by observations from multiple randomized controlled trials, such as the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study and the Veterans Affairs Diabetes Trial (VADT), which showed that intensive treatment protocols targeting A1C <6.0% with complex drug regimens significantly increased the risk for hypoglycemia requiring assistance compared with standard treatment (36,37). However, these intensive treatment regimens included extensive use of insulin and minimal use of glucagon-like peptide 1 (GLP-1) receptor agonists, and they preceded the availability of sodium–glucose cotransporter 2 (SGLT2) inhibitors.

For older patients with type 1 diabetes, continuous glucose monitoring (CGM) may be another approach to reducing the risk of hypoglycemia. In the Wireless Innovation in Seniors with Diabetes Mellitus (WISDM) trial, patients over 60 years of age with type 1 diabetes were randomized to CGM or standard blood glucose monitoring (BGM). Over 6 months, use of CGM resulted in a small but statistically significant reduction in time spent with hypoglycemia (glucose level <70 mg/dL) compared with routine finger-stick monitoring using standard BGM (adjusted treatment difference, −1.9% [−27 min per day]; 95% CI −2.8% to −1.1% [−40 to −16 min per day]; P < 0.001) (38,39). While the current evidence base for older adults is primarily in type 1 diabetes, CGM may be an option for older patients with type 2 diabetes using multiple daily injections of insulin (see Section 7 “Diabetes Technology,” https://doi.org/10.2337/dc21-S007).

• 12.6 Older adults who are otherwise healthy with few coexisting chronic illnesses and intact cognitive function and functional status should have lower glycemic goals (such as A1C <7.0–7.5% [53–58 mmol/mol]), while those with multiple coexisting chronic illnesses, cognitive impairment, or functional dependence should have less stringent glycemic goals (such as A1C <8.0–8.5% [64–69 mmol/mol]). C

• 12.7 Glycemic goals for some older adults might reasonably be relaxed as part of individualized care, but hyperglycemia leading to symptoms or risk of acute hyperglycemia complications should be avoided in all patients. C

• 12.8 Screening for diabetes complications should be individualized in older adults. Particular attention should be paid to complications that would lead to functional impairment. C

• 12.9 Treatment of hypertension to individualized target levels is indicated in most older adults. C

• 12.10 Treatment of other cardiovascular risk factors should be individualized in older adults considering the time frame of benefit. Lipid-lowering therapy and aspirin therapy may benefit those with life expectancies at least equal to the time frame of primary prevention or secondary intervention trials. E

The care of older adults with diabetes is complicated by their clinical, cognitive, and functional heterogeneity. Some older individuals may have developed diabetes years earlier and have significant complications, others are newly diagnosed and may have had years of undiagnosed diabetes with resultant complications, and still other older adults may have truly recent-onset disease with few or no complications (40). Some older adults with diabetes have other underlying chronic conditions, substantial diabetes-related comorbidity, limited cognitive or physical functioning, or frailty (41,42). Other older individuals with diabetes have little comorbidity and are active. Life expectancies are highly variable but are often longer than clinicians realize. Multiple prognostic tools for life expectancy for older adults are available (43), including tools specifically designed for older adults with diabetes (44). Providers caring for older adults with diabetes must take this heterogeneity into consideration when setting and prioritizing treatment goals (9,10) (Table 12.1). In addition, older adults with diabetes should be assessed for disease treatment and self-management knowledge, health literacy, and mathematical literacy (numeracy) at the onset of treatment. See Fig. 6.2 for patient- and disease-related factors to consider when determining individualized glycemic targets.

A1C is used as the standard biomarker for glycemic control in all patients with diabetes but may have limitations in patients who have medical conditions that impact red blood cell turnover (see Section 2 “Classification and Diagnosis of Diabetes,” https://doi.org/10.2337/dc21-S002, for additional details on the limitations of A1C) (45). Many conditions associated with increased red blood cell turnover, such as hemodialysis, recent blood loss or transfusion, or erythropoietin therapy, are commonly seen in older adults and can falsely increase or decrease A1C. In these instances, plasma blood glucose fingerstick and sensor glucose readings should be used for goal setting (Table 12.1).

There are few long-term studies in older adults demonstrating the benefits of intensive glycemic, blood pressure, and lipid control. Patients who can be expected to live long enough to reap the benefits of long-term intensive diabetes management, who have good cognitive and physical function, and who choose to do so via shared decision-making may be treated using therapeutic interventions and goals similar to those for younger adults with diabetes (Table 12.1).

As with all patients with diabetes, diabetes self-management education and ongoing diabetes self-management support are vital components of diabetes care for older adults and their caregivers. Self-management knowledge and skills should be reassessed when regimen changes are made or an individual's functional abilities diminish. In addition, declining or impaired ability to perform diabetes self-care behaviors may be an indication that a patient needs a referral for cognitive and physical functional assessment, using age-normalized evaluation tools, as well as help establishing a support structure for diabetes care (3,29).

For patients with advanced diabetes complications, life-limiting comorbid illnesses, or substantial cognitive or functional impairments, it is reasonable to set less-intensive glycemic goals (Table 12.1). Factors to consider in individualizing glycemic goals are outlined in Fig. 6.2. 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 should, at a minimum, avoid these consequences.

For patients receiving palliative care and end-of-life care, the focus should be to avoid hypoglycemia and symptomatic hyperglycemia while reducing the burdens of glycemic management. Thus, when organ failure develops, several agents will have to be deintensified or discontinued. For the dying patient, most agents for type 2 diabetes may be removed (46). There is, however, no consensus for the management of type 1 diabetes in this scenario (47). See the section end-of-life care below, for additional information.

Although hyperglycemia control may be important in older individuals with diabetes, greater reductions in morbidity and mortality are likely to result from control of other cardiovascular risk factors rather than from tight glycemic control alone. There is strong evidence from clinical trials of the value of treating hypertension in older adults (48,49), with treatment of hypertension to individualized target levels indicated in most. There is less evidence for lipid-lowering therapy and aspirin therapy, although the benefits of these interventions for primary prevention and secondary intervention are likely to apply to older adults whose life expectancies equal or exceed the time frames of the clinical trials.

• 12.11 Optimal nutrition and protein intake is recommended for older adults; regular exercise, including aerobic activity, weight-bearing exercise, and/or resistance training, should be encouraged in all older adults who can safely engage in such activities. B

• 12.12 For older adults with type 2 diabetes, overweight/obesity, and capacity to safely exercise, an intensive lifestyle intervention focused on dietary changes, physical activity, and modest weight loss (e.g., 5–7%) should be considered for its benefits on quality of life, mobility and physical functioning, and cardiometabolic risk factor control. A

Diabetes in the aging population is associated with reduced muscle strength, poor muscle quality, and accelerated loss of muscle mass, which may result in sarcopenia and/or osteopenia (51,52). Diabetes is also recognized as an independent risk factor for frailty. Frailty is characterized by decline in physical performance and an increased risk of poor health outcomes due to physiologic vulnerability and functional or psychosocial stressors. Inadequate nutritional intake, particularly inadequate protein intake, can increase the risk of sarcopenia and frailty in older adults. Management of frailty in diabetes includes optimal nutrition with adequate protein intake combined with an exercise program that includes aerobic and resistance training (53,54).

Many older adults with type 2 diabetes also have overweight or obesity and will benefit from an intensive lifestyle intervention. The Look Action for Health in Diabetes (Look AHEAD) trial is described in Section 8 “Obesity Management for the Treatment of Type 2 Diabetes” (https://doi.org/10.2337/dc21-S008). The trial enrolled patients between 45 and 74 years of age and required that patients be able perform a maximal exercise test (55,56). While the Look AHEAD trial did not achieve its primary outcome of reducing cardiovascular events, the intensive lifestyle intervention had multiple clinical benefits that are important to the quality of life of older patients. Benefits included weight loss, improved physical fitness, increased HDL cholesterol, lowered systolic blood pressure, reduced A1C levels, and reduced waist circumference (57). Additionally, several subgroups, including participants who lost at least 10% of baseline body weight at year 1, had improved cardiovascular outcomes (58). Risk factor control was improved with reduced utilization of antihypertensive medications, statins, and insulin (59). In age-stratified analyses, older patients in the trial (60 to early 70s) had similar benefits compared with younger patients (60,61). In addition, lifestyle intervention produced benefits on aging-relevant outcomes like better physical function and quality of life (62–65).

• 12.13 In older adults with type 2 diabetes at increased risk of hypoglycemia, medication classes with low risk of hypoglycemia are preferred. B

• 12.14 Overtreatment of diabetes is common in older adults and should be avoided. B

• 12.15 Deintensification (or simplification) of complex regimens is recommended to reduce the risk of hypoglycemia and polypharmacy, if it can be achieved within the individualized A1C target. B

• 12.16 Consider costs of care and insurance coverage rules when developing treatment plans in order to reduce risk of cost-related nonadherence. B

Special care is required in prescribing and monitoring pharmacologic therapies in older adults (66). See Fig. 9.1 for general recommendations regarding glucose-lowering treatment for adults with type 2 diabetes and Table 9.1 for patient- and drug-specific factors to consider when selecting glucose-lowering agents. Cost may be an important consideration, especially as older adults tend to be on many medications and live on fixed incomes (67). Accordingly, the costs of care and insurance coverage rules should be considered when developing treatment plans to reduce the risk of cost-related nonadherence (68,69). See Table 9.2 and Table 9.3 for median monthly cost in the U.S. of noninsulin glucose-lowering agents and insulin, respectively. It is important to match complexity of the treatment regimen to the self-management ability of older patients and their available social and medical support. Many older adults with diabetes struggle to maintain the frequent blood glucose monitoring and insulin injection regimens they previously followed, perhaps for many decades, as they develop medical conditions that may impair their ability to follow their regimen safely. Individualized glycemic goals should be established (Fig. 6.2) and periodically adjusted based on coexisting chronic illnesses, cognitive function, and functional status (2). Tight glycemic control in older adults with multiple medical conditions is considered over treatment and is associated with an increased risk of hypoglycemia; overtreatment is unfortunately common in clinical practice (50,70–73). Deintensification of regimens in patients taking noninsulin glucose-lowering medications can be achieved by either lowering the dose or discontinuing some medications, as long as the individualized glycemic targets are maintained. When patients are found to have an insulin regimen with complexity beyond their self-management abilities, lowering the dose of insulin may not be adequate (74). Simplification of the insulin regimen to match an individual's self-management abilities and their available social and medical support in these situations has been shown to reduce hypoglycemia and disease-related distress without worsening glycemic control (75–77). Figure 12.1 depicts an algorithm that can be used to simplify the insulin regimen (75). There are now multiple studies evaluating deintensification protocols that, in general, demonstrate that deintensification is safe and possibly beneficial for older adults (78). Table 12.2 provides examples of and rationale for situations where deintensification and/or insulin regimen simplification may be appropriate in older adults.

Metformin is the first-line agent for older adults with type 2 diabetes. Recent studies have indicated that it may be used safely in patients with estimated glomerular filtration rate ≥30 mL/min/1.73 m² (81). However, it is contraindicated in patients with advanced renal insufficiency and should be used with caution in patients with impaired hepatic function or congestive heart failure because of the increased risk of lactic acidosis. Metformin may be temporarily discontinued before procedures, during hospitalizations, and when acute illness may compromise renal or liver function. Additionally, metformin can cause gastrointestinal side effects and a reduction in appetite that can be problematic for some older adults. Reduction or elimination of metformin may be necessary for patients experiencing persistent gastrointestinal side effects.

Thiazolidinediones, if used at all, should be used very cautiously in those patients on insulin therapy as well as those patients with or at risk for congestive heart failure, osteoporosis, falls or fractures, and/or macular edema (82,83).

Sulfonylureas and other insulin secretagogues are associated with hypoglycemia and should be used with caution. If used, sulfonylureas with a shorter duration of action, such as glipizide or glimepiride, are preferred. Glyburide is a longer-acting sulfonylurea and should be avoided in older adults (84).

Oral dipeptidyl peptidase 4 (DPP-4) inhibitors have few side effects and minimal risk of hypoglycemia, but their cost may be a barrier to some older patients. DPP-4 inhibitors do not increase major adverse cardiovascular outcomes (85). Across the trials of this drug class, there appears to be no interaction by age-group (86–88). A challenge of interpreting the age-stratified analyses of this drug class and other cardiovascular outcomes trials is that while most of these analyses were prespecified, they were not powered to detect differences.

GLP-1 receptor agonists have demonstrated cardiovascular benefits among patients with established atherosclerotic cardiovascular disease (CVD), and newer trials are expanding our understanding of their benefits in other populations (85). See Section 9 “Pharmacologic Approaches to Glycemic Treatment” (https://doi.org/10.2337/dc21-S009) and Section 10 “Cardiovascular Disease and Risk Management” (https://doi.org/10.2337/dc21-S010) for a more extensive discussion regarding the specific indications for this class. The stratified analyses of several of the trials of this drug class indicate a complex interaction with age. In the Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results (LEADER) trial with liraglutide, those aged ≥50 years with CVD at baseline had a reduction in primary outcome (n = 7,598; hazard ratio [HR] 0.83), whereas those aged ≥60 years with no established CVD had a significantly adverse outcome (n = 1,742; HR 1.20, P = 0.04), except in a small subgroup of those aged ≥75 years (89,90). A similar trend was seen in the Harmony Outcomes trial with albiglutide, comparing participants aged <65 years to those aged 65–75 years and a smaller group aged ≥75 years (91). While the evidence for this class for older patients continues to grow, there are a number of practical issues that should be considered for older patients. These drugs are injectable agents (with the exception of oral semaglutide) (92), which require visual, motor, and cognitive skills for appropriate administration. They may also be associated with nausea, vomiting, and diarrhea. Given the gastrointestinal side-effects of this class, GLP-1 receptor agonists may not be preferred in older patients who are experiencing unexplained weight loss.

SGLT2 inhibitors are administered orally, which may be convenient for older adults with diabetes. In patients with established atherosclerotic CVD, these agents have shown cardiovascular benefits (85). This class of agents has also been found to be beneficial for patients with heart failure and to slow the progression of chronic kidney disease. See Section 9 “Pharmacologic Approaches to Glycemic Treatment” (https://doi.org/10.2337/dc21-S009) and Section 10 “Cardiovascular Disease and Risk Management” (https://doi.org/10.2337/dc21-S010) for a more extensive discussion regarding the indications for this class of agents. The stratified analyses of the trials of this drug class indicate that older patients have similar or greater benefits than younger patients (93–95). While understanding of the clinical benefits of this class is evolving, side effects such as volume depletion may be more common among older patients.

The use of insulin therapy requires that patients or their caregivers have good visual and motor skills and cognitive ability. Insulin therapy relies on the ability of the older patient to administer insulin on their own or with the assistance of a caregiver. Insulin doses should be titrated to meet individualized glycemic targets and to avoid hypoglycemia.

Once-daily basal insulin injection therapy is associated with minimal side effects and may be a reasonable option in many older patients. Multiple daily injections of insulin may be too complex for the older patient with advanced diabetes complications, life-limiting coexisting chronic illnesses, or limited functional status. Figure 12.1 provides a potential approach to insulin regimen simplification.

The needs of older adults with diabetes and their caregivers should be evaluated to construct a tailored care plan. Impaired social functioning may reduce these patients' quality of life and increase the risk of functional dependency (7). The patient's living situation must be considered as it may affect diabetes management and support needs. Social and instrumental support networks (e.g., adult children, caretakers) that provide instrumental or emotional support for older adults with diabetes should be included in diabetes management discussions and shared decision-making.

Older adults in assisted living facilities may not have support to administer their own medications, whereas those living in a nursing home (community living centers) may rely completely on the care plan and nursing support. Those receiving palliative care (with or without hospice) may require an approach that emphasizes comfort and symptom management, while de-emphasizing strict metabolic and blood pressure control.

Due in part to the success of modern diabetes management, patients with type 1 diabetes are living longer, and the population of these patients over 65 years of age is growing (96–99). Many of the recommendations in this section regarding a comprehensive geriatric assessment and personalization of goals and treatments are directly applicable to older adults with type 1 diabetes; however, this population has unique challenges and requires distinct treatment considerations (100). Insulin is an essential life-preserving therapy for patients with type 1 diabetes, unlike for those with type 2 diabetes. To avoid diabetic ketoacidosis, older adults with type 1 diabetes need some form of basal insulin even when they are unable to ingest meals. Insulin may be delivered through an insulin pump or injections. CGM is approved for use by Medicare and can play a critical role in improving A1C, reducing glycemic variability, and reducing risk of hypoglycemia (101) (see Section 7 “Diabetes Technology,” https://doi.org/10.2337/dc21-S007, and Section 9 “Pharmacologic Approaches to Glycemic Treatment,” https://doi.org/10.2337/dc21-S009). In the older patient with type 1 diabetes, administration of insulin may become more difficult as complications, cognitive impairment, and functional impairment arise. This increases the importance of caregivers in the lives of these patients. Many older patients with type 1 diabetes require placement in long-term care (LTC) settings (i.e., nursing homes and skilled nursing facilities), and unfortunately these patients encounter providers that are unfamiliar with insulin pumps or CGM. Some providers may be unaware of the distinction between type 1 and type 2 diabetes. In these instances, the patient or the patient's family may be more familiar with diabetes management than the providers. Education of relevant support staff and providers in rehabilitation and LTC settings regarding insulin dosing and use of pumps and CGM is recommended as part of general diabetes education (see Recommendations 12.17 and 12.18).

• 12.17 Consider diabetes education for the staff of long-term care and rehabilitation facilities to improve the management of older adults with diabetes. E

• 12.18 Patients with diabetes residing in long-term care facilities need careful assessment to establish individualized glycemic goals and to make appropriate choices of glucose-lowering agents based on their clinical and functional status. E

Management of diabetes in the LTC setting is unique. Individualization of health care is important in all patients; however, practical guidance is needed for medical providers as well as the LTC staff and caregivers (102). Training should include diabetes detection and institutional quality assessment. LTC facilities should develop their own policies and procedures for prevention and management of hypoglycemia.

Staff of LTC facilities should receive appropriate diabetes education to improve the management of older adults with diabetes. Treatments for each patient should be individualized. Special management considerations include the need to avoid both hypoglycemia and the complications of hyperglycemia (2,103). For more information, see the ADA position statement “Management of Diabetes in Long-term Care and Skilled Nursing Facilities” (102).

An older adult residing in an LTC facility may have irregular and unpredictable meal consumption, undernutrition, anorexia, and impaired swallowing. Furthermore, therapeutic diets may inadvertently lead to decreased food intake and contribute to unintentional weight loss and undernutrition. Diets tailored to a patient's culture, preferences, and personal goals may increase quality of life, satisfaction with meals, and nutrition status (104). It may be helpful to give insulin after meals to ensure that the dose is appropriate for the amount of carbohydrate the patient consumed in the meal.

Older adults with diabetes in LTC are especially vulnerable to hypoglycemia. They have a disproportionately high number of clinical complications and comorbidities that can increase hypoglycemia risk: impaired cognitive and renal function, slowed hormonal regulation and counterregulation, suboptimal hydration, variable appetite and nutritional intake, polypharmacy, and slowed intestinal absorption (105). Oral agents may achieve glycemic outcomes in LTC populations similar to basal insulin (70,106).

Another consideration for the LTC setting is that, unlike in the hospital setting, medical providers are not required to evaluate the patients daily. According to federal guidelines, assessments should be done at least every 30 days for the first 90 days after admission and then at least once every 60 days. Although in practice the patients may actually be seen more frequently, the concern is that patients may have uncontrolled glucose levels or wide excursions without the practitioner being notified. Providers may make adjustments to treatment regimens by telephone, fax, or in person directly at the LTC facilities provided they are given timely notification of blood glucose management issues from a standardized alert system.

The following alert strategy could be considered:

1. Call provider immediately in cases of low blood glucose levels (<70 mg/dL [3.9 mmol/L]).

2. Call as soon as possible when

   • a) glucose values are 70–100 mg/dL (3.9–5.6 mmol/L) (regimen may need to be adjusted),

   • b) glucose values are >250 mg/dL (13.9 mmol/L) within a 24-h period,

   • c) glucose values are >300 mg/dL (16.7 mmol/L) over 2 consecutive days,

   • d) any reading is too high for the glucometer, or

   • e) the patient is sick, with vomiting, symptomatic hyperglycemia, or poor oral intake.

• 12.19 When palliative care is needed in older adults with diabetes, providers should initiate conversations regarding the goals and intensity of care. Strict glucose and blood pressure control may not be necessary E, and reduction of therapy may be appropriate. Similarly, the intensity of lipid management can be relaxed, and withdrawal of lipid-lowering therapy may be appropriate. A

• 12.20 Overall comfort, prevention of distressing symptoms, and preservation of quality of life and dignity are primary goals for diabetes management at the end of life. C

The management of the older adult at the end of life receiving palliative medicine or hospice care is a unique situation. Overall, palliative medicine promotes comfort, symptom control and prevention (pain, hypoglycemia, hyperglycemia, and dehydration), and preservation of dignity and quality of life in patients with limited life expectancy (103,107). In the setting of palliative care, providers should initiate conversations regarding the goals and intensity of diabetes care; strict glucose and blood pressure control may not be consistent with achieving comfort and quality of life. In a multicenter trial, withdrawal of statins among patients in palliative care was found to improve quality of life, while similar evidence for glucose and blood pressure control are not yet available (108–110). A patient has the right to refuse testing and treatment, whereas providers may consider withdrawing treatment and limiting diagnostic testing, including a reduction in the frequency of blood glucose monitoring (111,112). Glucose targets should aim to prevent hypoglycemia and hyperglycemia. Treatment interventions need to be mindful of quality of life. Careful monitoring of oral intake is warranted. The decision process may need to involve the patient, family, and caregivers, leading to a care plan that is both convenient and effective for the goals of care (113). The pharmacologic therapy may include oral agents as first line, followed by a simplified insulin regimen. If needed, basal insulin can be implemented, accompanied by oral agents and without rapid-acting insulin. Agents that can cause gastrointestinal symptoms such as nausea or excess weight loss may not be good choices in this setting. As symptoms progress, some agents may be slowly tapered and discontinued.

Different patient categories have been proposed for diabetes management in those with advanced disease (47).

• 1. A stable patient: Continue with the patient's previous regimen, with a focus on the prevention of hypoglycemia and the management of hyperglycemia using blood glucose testing, keeping levels below the renal threshold of glucose. There is very little role for A1C monitoring and lowering.

• 2. A patient with organ failure: Preventing hypoglycemia is of greater significance. Dehydration must be prevented and treated. In people with type 1 diabetes, insulin administration may be reduced as the oral intake of food decreases but should not be stopped. For those with type 2 diabetes, agents that may cause hypoglycemia should be reduced in dose. The main goal is to avoid hypoglycemia, allowing for glucose values in the upper level of the desired target range.

• 3. A dying patient: For patients with type 2 diabetes, the discontinuation of all medications may be a reasonable approach, as patients are unlikely to have any oral intake. In patients with type 1 diabetes, there is no consensus, but a small amount of basal insulin may maintain glucose levels and prevent acute hyperglycemic complications.