Diabetes in Older People Practice Exam: Diabetes Chapter 37

Managing diabetes in older adults requires a fundamental shift from a “one-size-fits-all” approach to highly personalized care. The 2018 Clinical Practice Guidelines emphasize that this population is incredibly heterogeneous—ranging from robust, functionally independent individuals to those with frailty and dementia. Consequently, treatment goals must balance the benefits of glycemic control against the heightened risks of hypoglycemia, falls, and cognitive decline.

This practice exam tests your ability to stratify risk, select appropriate glycemic targets based on functional status, and safely de-intensify therapy when necessary.

Key Concepts Covered in This Exam:

Personalized Targets: Distinguishing between functionally independent older adults (who may aim for an A1C $\le$ 7.0%) and frail individuals (where an A1C of 7.1%–8.5% is appropriate to prioritize safety).
Hypoglycemia & Cognition: Understanding the bidirectional relationship between severe hypoglycemia and dementia, where each increases the risk of the other, necessitating regular cognitive screening.
De-intensification: Recognizing when to simplify complex insulin regimens or stop high-risk oral agents (such as sulfonylureas) to reduce the risk of adverse events without compromising quality of life.
Safe Pharmacotherapy: Identifying glyburide as a medication to avoid in older adults due to its prolonged risk of hypoglycemia, and selecting safer alternatives like DPP-4 inhibitors.
Institutional Care: Applying specific management strategies for residents in long-term care facilities, where the primary goal is symptom management and preservation of comfort rather than strict metabolic control.

1. An 82-year-old patient with type 1 diabetes who is highly functional (Clinical Frailty Scale 2) asks about insulin pump therapy. Based on the evidence, what can you advise?

Only basal insulin delivery is possible with pumps in older adults
Insulin pumps provide no benefit over multiple daily injections in older adults
Insulin pumps are contraindicated in people over 75
People with type 1 diabetes <75 years who are highly functional may have improved glycemic control and reduced hypoglycemia with CSII

2. A 72-year-old patient with type 2 diabetes, established cardiovascular disease, and eGFR of 45 mL/min/1.73 m² is not at glycemic target. According to the guideline, which medication could be added for CV outcome benefit?

Glyburide
Saxagliptin
Pioglitazone
Empagliflozin

3. An 84-year-old nursing home resident with diabetes has an A1C of 5.8% on glyburide and metformin. She has moderate dementia and multiple comorbidities. According to the guideline, what is the most appropriate action?

Intensify therapy to prevent complications
Add a DPP-4 inhibitor to further reduce A1C
Consider deprescribing
Continue current therapy as A1C is well controlled

4. In the management of diabetes in LTC facilities, which statement best reflects guideline recommendations?

Complex insulin regimens are preferred over simplified regimens
A1C <6.0% should be targeted to prevent complications
Sliding scale insulin is the preferred management approach
Tight glycemic control with A1C <6.0% is associated with higher mortality

5. A 75-year-old patient with diabetes has cognitive dysfunction. According to the guideline, cognitive dysfunction has been identified as a significant risk factor for:

Development of diabetic retinopathy
Development of severe hypoglycemia
Development of diabetic nephropathy
Development of peripheral neuropathy

6. In an older person with diabetes considering SGLT2 inhibitor therapy, which concern should be discussed?

Potential for dehydration and fractures
Significant weight gain
High risk of lactic acidosis
Increased risk of severe hypoglycemia

7. If a sulfonylurea must be used in an older patient, which of the following should be avoided due to higher risk of hypoglycemia?

Gliclazide MR
Glimepiride
Glyburide
Gliclazide

8. A 79-year-old patient with diabetes is started on pioglitazone. Which adverse effect is of particular concern in this population?

Lactic acidosis
Edema and congestive heart failure
Severe gastrointestinal upset
Hypoglycemia

9. To reduce the frequency of hypoglycemia in an older patient currently on NPH insulin, which of the following basal insulins should be considered?

Insulin glargine U-100
Regular insulin
Human 30/70 insulin
Lispro mix 75/25

10. A 76-year-old patient with type 2 diabetes has been on metformin for 5 years. Which monitoring should be considered in this patient?

Vitamin B12 levels
Iron studies
Serum folate levels
Vitamin D levels

11. A 74-year-old patient with type 2 diabetes has irregular eating habits. Which medication class may be considered to reduce hypoglycemia risk compared to glyburide?

Thiazolidinediones
Meglitinides
Alpha-glucosidase inhibitors
Basal insulin

12. A 78-year-old obese patient with type 2 diabetes requires second-line therapy after metformin. Which medication class is preferred over sulfonylureas because of lower hypoglycemia risk?

DPP-4 inhibitors
Thiazolidinediones
Alpha-glucosidase inhibitors
Meglitinides

13. According to cohort studies, the best survival in elderly people with diabetes is associated with an A1C range of:

7.0% to 8.0%
6.0% to 6.5%
6.5% to 7.0%
8.0% to 9.0%

14. A 71-year-old obese patient with type 2 diabetes needs initial therapy. According to the guideline, the principal metabolic defect in obese elderly patients is:

Resistance to insulin-mediated glucose disposal
Complete beta-cell failure
Impaired glucose-induced insulin secretion
Increased hepatic gluconeogenesis only

15. Which statement regarding A1C and aging is correct?

A1C remains stable throughout the lifespan in non-diabetic individuals
A1C is more accurate for diagnosis in older adults than younger adults
Normal aging is associated with a progressive decrease in A1C
Normal aging is associated with a progressive increase in A1C

16. Why should DPP-4 inhibitors be used as second-line therapy in older adults with diabetes over SGLT2 inhibitors?

SGLT2 inhibitors are less effective at lowering A1C
There is much larger body of evidence with DPP-4 inhibitors in this age group
DPP-4 inhibitors have proven CV mortality benefit
SGLT2 inhibitors cause more hypoglycemia

17. An 85-year-old patient with dementia (Clinical Frailty Scale 7) is on insulin and metformin. What is the appropriate postprandial glucose target?

<10 mmol/L
5–10 mmol/L
<14 mmol/L
<12 mmol/L

18. Which of the following insulin regimens was shown to result in equivalent glycemic control with reduced hypoglycemia risk when used to simplify complex regimens in older people with multiple comorbidities?

Twice-daily premixed insulin
Basal-bolus regimen
Once-daily glargine U-100
Sliding scale insulin alone

19. The increased risk of hypoglycemia in older adults appears to be due to all of the following EXCEPT:

Altered psychomotor performance
Increased hepatic glucose output
Age-related reduction in glucagon secretion
Impaired awareness of hypoglycemic warning symptoms

20. A CGM study in older adults revealed which surprising finding about those with higher A1C targets?

They had no episodes of hypoglycemia
Their A1C accurately reflected mean glucose
They still had frequent episodes of prolonged asymptomatic hypoglycemia
They had fewer complications than those with lower targets

21. A 73-year-old patient with type 2 diabetes asks about the preferred injection site for insulin. According to the guideline, which site is preferred because it is easier for older people to landmark?

Thigh
Abdomen
Arm
Buttocks

22. An 80-year-old patient at end of life has diabetes. What is the recommended approach to A1C monitoring?

Target A1C <7.0%
Target A1C <8.5%
Continue regular A1C monitoring every 3 months
A1C measurement not recommended

23. Which approach to diabetes self-management education has been shown to result in greater A1C reductions in older adults ≥65 years?

Review and feedback monitoring only
Group-setting education alone
Medical management alone without education
Programs emphasizing tailored education and support

24. A 75-year-old functionally independent patient with diabetes has a life expectancy greater than 10 years. According to the guidelines, what A1C target is appropriate if using antihyperglycemic agents with low risk of hypoglycemia?

≤7.0%
<8.5%
≤6.5%
<8.0%

25. The Clinical Frailty Scale developed by Rockwood et al is a:

9-point scale from 1 (very fit) to 9 (terminally ill)
5-point scale from 1 (very frail) to 5 (very fit)
7-point scale from 1 (very fit) to 7 (severely frail)
10-point scale from 0 (no frailty) to 10 (complete dependence)

26. Which cognitive assessment can be used to predict which elderly people are likely to have problems with insulin therapy?

Mini-Mental State Examination (MMSE)
Trail Making Test
Clock drawing test
Montreal Cognitive Assessment (MoCA)

27. A 77-year-old woman with type 2 diabetes has been on a thiazolidinedione for 3 years. According to the guideline, she is at increased risk for:

Fractures
Hypoglycemia
Diabetic ketoacidosis
Pancreatic cancer

28. According to Fried’s Frailty Phenotype, a person is considered frail when how many of the specified criteria are present?

3 or more
4 or more
2 or more
1 or more

29. Treatment of hypertension in older people with diabetes is associated with:

Significant reduction in CV morbidity and mortality
No change in CV outcomes
Increased CV morbidity and mortality
Worse renal outcomes

30. Which of the following is NOT one of the criteria in Fried’s Frailty Phenotype?

Cognitive impairment
Slow walking speed
Unintentional weight loss (>4.5 kg in the past year)
Self-reported exhaustion

31. According to the guideline, diabetes screening is unlikely to be beneficial in most people over the age of:

70
75
85
80

32. A 78-year-old patient with diabetes in a long-term care facility is on sliding scale insulin as the sole glycemic management. According to the guideline, what should be done?

Add oral agents to the sliding scale regimen
Transition to scheduled insulin or oral agents
Continue sliding scale insulin as it is effective
Increase the frequency of blood glucose monitoring

33. What percentage of residents in long-term care facilities in Canada have type 2 diabetes?

Over 15%
Over 25%
Over 10%
Over 40%

34. An 80-year-old patient with diabetes is starting insulin therapy. Which insulin delivery method is recommended to minimize dosing errors?

Jet injectors
Prefilled insulin pens
Insulin vials with standard syringes
Insulin pump therapy

35. An 81-year-old frail patient with diabetes (Clinical Frailty Scale 7) and limited life expectancy is on atorvastatin and multiple other medications. According to deprescribing principles, what action is most appropriate?

Continue all medications to prevent complications
Add additional medications for diabetes complications
Switch to a more potent statin
Consider stopping statin therapy

36. According to Diabetes Canada guidelines, the concept of “older” in diabetes management generally reflects an age continuum starting around:

75 years
65 years
60 years
70 years

37. A nursing home requests guidance on dietary management for residents with diabetes. According to the guideline, which statement is correct?

Only diabetic nutritional formulas should be used
Carbohydrate counting is mandatory for all residents
Strict diabetic diets must be followed
Regular diets may be used instead of diabetic diets or nutritional formulas

38. In older people with type 2 diabetes, which type of exercise has been shown to result in modest improvements in glycemic control as well as improvements in strength and mobility?

Flexibility exercises only
Resistance training
Balance training only
Aerobic exercise only

39. An 82-year-old patient with diabetes who is functionally dependent (Clinical Frailty Scale 4–5) is currently on glyburide. What is the recommended preprandial capillary blood glucose target for this patient?

6–9 mmol/L
7–10 mmol/L
4–7 mmol/L
5–8 mmol/L

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