1. Overview & Philosophy
Management of diabetes in older adults requires a paradigm shift from the approach used in younger adults. The focus shifts from strict prevention of long-term complications to preservation of function, quality of life, and safety (avoidance of hypoglycemia).
- Heterogeneity: The “older person” category (generally age 70) includes a spectrum from robust/fit individuals to those who are frail or at the end of life.
- Frailty: A multidimensional syndrome of increased vulnerability. It is a better predictor of complications and death than chronological age.
- The “Clock Drawing Test”: A simple cognitive tool that can predict which older individuals will have difficulty learning to inject insulin.
2. Diagnosis and Screening
- A1C Limitations: Normal aging is associated with a progressive increase in A1C. There is often discordance between glucose-based and A1C-based diagnosis in this age group.
- Recommendation: Screen with BOTH a Fasting Plasma Glucose (FPG) and an A1C, as they are complementary.
- Over Age 80: Screening is unlikely to be beneficial in most people over age 80; decisions should be individualized.
3. Glycemic Targets (The Functional Status Approach)
This is the most critical section for the CDE exam. Targets are stratified by health status.
| Functional Status | Description / Frailty Score | A1C Target |
| Functionally Independent | Robust, life expectancy > 10 years. | 7.0% |
| Functionally Dependent | Loss of autonomy, intermediate health. | 7.1% – 8.0% |
| Frail and/or Dementia | Multiple comorbidities, high vulnerability. | 7.1% – 8.5% |
| End of Life | Life expectancy < 6 months. | Avoid symptomatic hyperglycemia and any hypoglycemia. A1C measurement not recommended. |
4. Pharmacotherapy Considerations
Older adults are highly susceptible to hypoglycemia due to reduced glucagon secretion and impaired awareness.
- Metformin: First-line. Monitor Vitamin B12 levels as deficiency is associated with long-term use.
- Sulfonylureas (Caution):
- Glyburide: Avoid. High risk of severe hypoglycemia.
- Gliclazide/Glimepiride: Preferred over glyburide if a sulfonylurea must be used.
- Dosing: Start at half the regular dose.
- DPP-4 Inhibitors: Preferred as second-line therapy over sulfonylureas due to lower risk of hypoglycemia and weight neutrality.
- SGLT2 Inhibitors: Use with caution. High risk of dehydration (volume depletion) and potential fracture risk. Benefits for CV outcomes seen in empagliflozin/canagliflozin trials for older cohorts.
B. Insulin Therapy
- Basal Analogues: Glargine (U-100/U-300), Detemir, and Degludec are preferred over NPH or Humulin 30/70 because they cause less hypoglycemia.
- Simplification: In frail elderly, complex regimens (e.g., MDI/Basal-Bolus) should be simplified to once-daily basal insulin to reduce error and hypoglycemia risk.
- Delivery: Use pre-filled pens instead of syringes to improve dosing accuracy.
C. Deprescribing
- In people with limited life expectancy or frailty, agents that cause hypoglycemia (sulfonylureas, insulin) or have long-term preventive goals (statins) should be considered for discontinuation.
5. Long-Term Care (LTC) Management
- Diet: “Diabetic diets” or specialized formulas are generally not recommended. A regular diet is preferred to prevent undernutrition and improve quality of life.
- Sliding Scale Insulin: Should be avoided. It is associated with worse control and higher hypoglycemia risk.
- Overtreatment: Many LTC residents are overtreated (A1C < 7.0%), putting them at dangerous risk for falls and cognitive decline.
6. Diabetes Canada 2018 Clinical Practice Guidelines Recommendations
Key takeaways from the “Recommendations” section (Page 5289).
Targets:
Independent: Same as young (usually 7.0%) [Grade D].
Dependent: 7.1–8.0% [Grade D].
Frail/Dementia: 7.1–8.5% [Grade D].
End of Life: Avoid symptoms, no A1C [Grade D].
Education: Tailor diabetes education to the individual; focus on psychological support [Grade A, Level 1A].
Exercise: Resistance training and/or aerobic exercise should be performed if not contraindicated [Grade B, Level 2].
Sulfonylureas:
Use with caution [Grade D].
DPP-4 inhibitors should be used over sulfonylureas because of lower hypoglycemia risk [Grade B, Level 2].
Gliclazide/Glimepiride preferred over Glyburide [Grade B/C].
Insulin:
Basal analogues (Detemir, Glargine, Degludec) preferred over NPH to reduce hypoglycemia [Grade B, Level 2].
Use pre-filled pens [Grade B, Level 2].
LTC: Avoid sliding scale insulin [Grade C, Level 3]. Use regular diets [Grade D, Level 4].