Journal of Gerontological Nursing

Geropharmacology 

Update on Type 2 Diabetes Mellitus and Older Adults

Taylor Kaminsky, BS; Stephanie M. Ozalas, PharmD, BCPS, BCGP; Nicole J. Brandt, PharmD, MBA, BCGP, BCPP, FASCP

Abstract

In 2020, the American Diabetes Association released an update to their standards of care guideline, which included special considerations for older adults. Care of older adults with type 2 diabetes mellitus needs to be individualized and incorporate patient preferences. Guideline updates provide specific goals for older adults based on their ability to perform activities of daily living, comorbidities, and health prognosis. The current article aims to illustrate updates through an older adult case and key medication-related considerations. [Journal of Gerontological Nursing, 46(4), 7–12.]

Abstract

In 2020, the American Diabetes Association released an update to their standards of care guideline, which included special considerations for older adults. Care of older adults with type 2 diabetes mellitus needs to be individualized and incorporate patient preferences. Guideline updates provide specific goals for older adults based on their ability to perform activities of daily living, comorbidities, and health prognosis. The current article aims to illustrate updates through an older adult case and key medication-related considerations. [Journal of Gerontological Nursing, 46(4), 7–12.]

The prevalence of type 2 diabetes mellitus increases as one ages and is as high as 25% in the older adult population (Centers for Disease Control and Prevention, 2020). Type 2 diabetes mellitus is associated with many comorbid conditions, such as cardiovascular morbidity/mortality, chronic kidney disease, depression, neuropathy, and retinopathy. Furthermore, older adults who are ≥75 years old experience hypoglycemia at twice the rate of older adults aged 65 to 74 years (Lipska et al., 2014). For patients who are age >74, their risk of fall is significantly increased when hemoglobin A1c (HbA1c) is <7% (Chiba et al., 2015). Given these alarming statistics, it is necessary that the treatment goals for older adults with type 2 diabetes mellitus change to incorporate their risks. The American Diabetes Association (ADA; 2020) has been advocating to address less strict glycemic targets for older adults with diabetes for many years and continues to do so in the 2020 update to its Standards of Medical Care in Diabetes. This updated guideline will be illustrated through a case scenario, which highlights considerations for practitioners caring for older adults across the care continuum.

Case Scenario

Mr. Scott is an 89-year-old man with type 2 diabetes mellitus, chronic obstructive pulmonary disease (Gold Class C), and history of multiple strokes. He was living at home prior to this hospitalization and relied on a family member for management of medications and finances. He presented to the hospital following a mechanical fall, which resulted in a hip fracture. While at the hospital, he received a partial hip replacement and is now ready for discharge to a skilled nursing facility (SNF) for short-term rehabilitation. This facility will administer all of Mr. Scott's medications for him (Table 1).

Mr. Scott's Medications

Table 1:

Mr. Scott's Medications

Patient-Specific Treatment Goals

When identifying patient-specific treatment goals, it is important to take into consideration what matters to the patient (e.g., cost of medications, willingness to use injections). In addition, it is important to consider their day-to-day function and activities, level of care needs, coexisting illnesses, and prognosis (Table 2). This information tailors the individualized approach as well as realistic goals of care. In addition to clarifying goals for different subgroups of older adults, the 2020 ADA guideline also offers examples where it may be reasonable to deprescribe and simplify a medication regimen for each subgroup. It is important to understand that these categories are dynamic, and patients should be continually evaluated to ensure goals are appropriate and realistic.

Treatment Goals in Older Adults

Table 2:

Treatment Goals in Older Adults

Goals for Healthy Older Adults

For patients who have few chronic illnesses and intact cognitive and functional status, the recommended target HbA1c is <7.5%. This target is the strictest goal for older adults because it is reasonable for this group to complete difficult medication regimens, which would allow for a stricter glycemic control. For this group, providers may consider simplification or deprescribing if the patient is experiencing severe or recurrent hypoglycemia or if there is a change in his/her cognitive or functional status. At this stage, medications that potentiate hypoglycemia, such as sulfonylureas or insulin products, should be evaluated.

Goals for Older Adults With Complex/Intermediate Health

This category provides recommendations for older adults with many chronic illnesses or impairments in their cognitive or functional status (e.g., two or more instrumental activities of daily living [ADL] impairments, mild-to-moderate cognitive impairment). A realistic HbA1c goal in this subcategory is <8%. This goal is slightly more lenient because it may be more difficult for this group to maintain complex regimens. If the patient's HbA1c is above this target, providers can take advantage of this higher threshold through deprescribing antidiabetic medications such as sulfonylureas (Strain et al., 2018). This group may benefit from once per week formulations, which are less complex and easier to manage. Similar to the previous subgroup, providers should consider deprescribing if the patient is experiencing severe hypoglycemic episodes. Providers should also consider simplification if there is a change in functional status, cognitive status, or living situation (e.g., loss of a caregiver, financial stresses).

Goals for Community-Dwelling Older Adults Receiving Care in a SNF for Short-Term Rehabilitation

This subgroup is a unique addition, as most guidelines do not recognize patients in SNFs. For patients who are in this transition period, there is no target HbA1c; instead, providers should focus on a glucose target between 100 mg/dL and 200 mg/dL. The priority for patients in this stage is maintaining glycemic control to prevent infections and promote recovery, wound healing, and hydration. Simplification may be necessary if the patient's medication regimen became overly complex during his/her hospital stay. If this is the case, the authors of the ADA guideline recommend reinitiating the patient's pre-hospitalization regimen. Furthermore, when evaluating the patient's medication regimen, it is essential to take into consideration the type of support the patient will receive at home and the feasibility of the regimen being suggested.

Goals for Older Adults With Very Complex/Poor Health

This subcategory includes patients in long-term care (LTC) or with end-stage chronic illnesses or moderate to severe functional and cognitive impairments. The HbA1c goal in this group is <8.5%. This goal is less strict than the other groups, as it is more important to avoid hypoglycemia. For this group, the priority is to prevent further decline of the patient's cognitive and functional status. Although glycemic control remains important, it is not at the forefront of care in this population, unless the patient is experiencing hypoglycemia or symptomatic hyperglycemia. At this stage, there are many opportunities for simplification and deprescribing of the patient's medication regimen.

Goals for Older Adults at End of Life

In this population, the goals of care are to prevent discomfort and promote comfort. With respect to these goals, there are no targets for HbA1c. Rather, the goals are to avoid hypoglycemia and symptomatic hyperglycemia. For these patients, tasks that may cause un-warranted pain, such as frequent glucose finger sticks or insulin injections, should be avoided. This is also an opportunity for providers to remove any medications that do not have benefits in symptom management for the patient. The immediate benefit or harm that may come from each medication or task should always be considered prior to continuing or adding on for patients at this stage of life.

Individualized Goals

The first step in determining goals for Mr. Scott is to determine the subgroup in which he falls. Mr. Scott had previously been living at home but has transitioned to a SNF for short-term care; thus, he would be in the subgroup of those receiving care at a SNF. In the ADA (2020) guideline, this group has the strictest requirements with regard to glycemic control to promote healing and prevent infections. Mr. Scott's fasting blood glucose (FBG) during his hospital stay was well-managed and may continue to remain managed on the same regimen. However, there are important considerations for glyburide in older adults, especially ones who have a recent fall history and multiple comorbidities. It is reasonable for Mr. Scott to discontinue glyburide in favor of a medication with less hypoglycemia implications. Given this patient's atherosclerotic cardiovascular disease (ASCVD) history, a once-weekly GLP-1 receptor agonist may be a good option for him. The SNF staff should have the capability to administer this medication.

Simplifying Insulin Regimens

One of the most important jobs for providers of older adults is understanding when and how to simplify medication regimens. The authors of the ADA (2020) guideline offer recommendations for doing just that. For patients on insulin who may need a simpler medication regimen, the updates have provided a flowchart for guidance. This chart should be used if a patient is experiencing recurrent hypoglycemia or is unable to manage his/her insulin regimen.

Basal Insulin

The recommendations for basal insulin begin with moving the timing of the injection from bedtime to morning and titrating the dose based on FBG readings measured over 1 week. The titration should use the goals specific to the patient's subgroup mentioned above. If one half of the FBG measurements are above the patient's goal, the basal insulin should be increased by two units. If more than two FBG values are <80 mg/dL, the basal insulin dose should be reduced by two units (ADA, 2020).

Mealtime Insulin

Recommendations for simplification of mealtime insulin are based on the dose the patient is currently receiving. For patients whose mealtime insulin is >10 units per dose, the dose should be reduced by 50% and a non-insulin agent should be added. As the non-insulin agent is titrated, mealtime doses should be tapered. For patients whose mealtime insulin is ≤10 units per dose, this medication should be discontinued, and a non-insulin agent added to the regimen (ADA, 2020).

Premixed Insulin

For patients who are using pre-mixed insulin products, the recommendation is to use 70% of the total dose as a basal only dose in the morning. There is also a recommendation to add a non-insulin product. These changes will reduce the likelihood of hypoglycemia (ADA, 2020).

Adding a Non-Insulin Agent

The first-choice non-insulin agent for patients with diabetes is metformin, if the patient has an estimated glomerular filtration rate (eGFR) ≥45 mg/dL. For patients with eGFR <45 mg/dL or who cannot tolerate metformin, providers should choose an agent that incorporates patient-related variables, such as chronic kidney disease, ASCVD, and compelling need to reduce hypoglycemia or cost. There is a flowchart in the ADA (2020) guideline that should be used to choose an appropriate agent.

During his 4-week stay, it was determined that Mr. Scott is not fit to live independently and will be transferring to a LTC facility, where he will receive advanced care. At the SNF, his average FBG was 90 mg/dL to 100 mg/dL. His goals of care, as well as his medications, need to be re-evaluated for his transfer to LTC (Table 3).

Mr. Scott's Scheduled Medications at the Skilled Nursing Facility

Table 3:

Mr. Scott's Scheduled Medications at the Skilled Nursing Facility

Mr. Scott has multiple comorbid conditions, is dependent for multiple ADL, and resides in a LTC facility— for these reasons, it is appropriate to now consider him in the very complex subgroup. His goals are less strict while in LTC compared to when he was actively healing at the SNF. Priorities for Mr. Scott are to maintain his cognitive and functional status; a reasonable HbA1c goal is 8.5%. The level of care he will receive upon transferring will decline, thus his medication regimen may need to be simplified.

With the understanding that Mr. Scott's regimen is too complex to stay the same, there are modifications that can be done immediately to simplify his regimen without knowing specific values. First, the long-acting insulin glargine can be moved to the morning, reducing the variability of glucose throughout the day and decreasing the likelihood of hypoglycemic episodes (Gradiser et al., 2015). Second, the insulin lispro dose can be reduced to five units three times per day before meals with the goal of complete discontinuation. If the patient's insurance allows, liraglutide should be changed to semaglutide, which is a once per week dosing. Reducing the frequency will be less injections for the patient and be easier on facility staff. Finally, after looking over Mr. Scott's average FBG values at the SNF, the insulin glargine dose can be reduced to 12 units daily. Table 4 provides considerations regarding various pharmacological classes when working with older adults.

Pharmacological Classes to Consider for Older Adults With Type 2 Diabetes Mellitus

Table 4:

Pharmacological Classes to Consider for Older Adults With Type 2 Diabetes Mellitus

Clinical Implications and Conclusion

Nurses are an integral part of the interdisciplinary team (particularly in long-term care facilities) for patients with diabetes through the monitoring of blood glucose, rapid detection and treatment of hyper- and hypoglycemia, and reinforcement of recommended diets. Nursing leadership should be encouraged to implement protocols for the prompt treatment of hypoglycemia (ADA, 2016).

A collaborative, interprofessional team approach, including consultant pharmacists, can optimize medication use and monitoring especially for older adults with type 2 diabetes mellitus. Agents with a high risk for hypoglycemia (e.g., sulfonylureas, basal/bolus insulin therapy) should be carefully evaluated for appropriateness and the potential to switch to a lower risk agent. The following should be considered when caring for older adults, especially during transitions in care.

  • Individualized patient goals and plans should include consideration of challenges that may occur based on various discharge settings. Patients should be seen by their diabetes provider within 1 to 2 weeks of discharge if diabetes medications were changed during hospitalization.

  • Medication reconciliation prior to discharge is vital to ensure that medically necessary chronic medications were not unintentionally discontinued, no drug–drug interactions exist, new medications are safe and effective, and discharge medications are consistent with outpatient formulary coverage. Older adults with multiple comorbidities may require more detailed discharge plans with close monitoring to prevent medication-related adverse effects, such as hypoglycemia.

  • All patients and those who care for them should receive discharge counseling prior to leaving the institution (e.g., hospital, nursing home). Counseling should include the name and address of the outpatient diabetes provider and the date of their first follow-up appointment, explanation regarding their diagnosis, patient self-management, diet and meal preparation, blood glucose goals, medication administration, sick day management of blood glucose, and disposal of needles and syringes.

  • It is important that blood glucose targets and the diabetes regimen be re-evaluated during transitions of care, as this represents a change in health status and a time when patients are at high risk of complications related to their diabetes care.

For more than 15 years, the ADA has been recommending lighter glycemic control in older adults; however, the rates of older adults with hypoglycemic episodes are rising. The newest guideline update (ADA, 2020) provides explicit examples of when and how to de-escalate antidiabetic therapies to help aid in reducing harm to older adult patients.

References

  • American Diabetes Association. (2016). Management of diabetes in long-term care and skilled nursing facilities: A position statement of the American Diabetes Association. https://care.diabetesjournals.org/content/39/2/308
  • American Diabetes Association. (2019). 12. Older adults: Standards of medical care in diabetes–2019https://care.diabetesjournals.org/content/42/Supplement_1/S139
  • American Diabetes Association. (2020). 12. Older adults: Standards of medical care in diabetes–2020. https://care.diabetesjournals.org/content/43/Supplement_1/S152
  • Centers for Disease Control and Prevention. (2020). National diabetes statistics report, 2020. https://www.cdc.gov/diabetes/data/statistics/statistics-report.html.
  • Chiba, Y., Kimbara, Y., Kodera, R., Tsuboi, Y., Sato, K., Tamura, Y., Mori, S., Ito, H. & Araki, A. (2015). Risk factors associated with falls in elderly patients with type 2 diabetes. Journal of Diabetes and Its Complications, 29(7), 898–902 doi:10.1016/j.jdiacomp.2015.05.016 [CrossRef]
  • Gradiser, M., Bilic-Curcic, I., Djindjic, B. & Berkovic, M. C. (2015). The effects of transition from bedtime to morning glargine administration in patients with poorly regulated type 1 diabetes mellitus: Croatian pilot study. Diabetes Therapy, 6(4), 643–648 doi:10.1007/s13300-015-0130-2 [CrossRef]
  • Lipska, K. J., Ross, J. S., Wang, Y., Inzucchi, S. E., Minges, K., Karter, A. J., Huang, E. S., Desai, M. M., Gill, T. M. & Krumholz, H. M. (2014). National trends in US hospital admissions for hyperglycemia and hypoglycemia among Medicare beneficiaries, 1999 to 2011. JAMA Internal Medicine, 174(7), 1116–1124 doi:10.1001/jamainternmed.2014.1824 [CrossRef]
  • Munshi, M. N., Florez, H., Huang, E. S., Kalyani, R. R., Mupanomunda, M., Pandya, N., Swift, C. S., Taveira, T. H. & Haas, L. B. (2016). Management of diabetes in long-term care and skilled nursing facilities: A position statement of the American Diabetes Association. Diabetes Care, 39(2), 308–318 doi:10.2337/dc15-2512 [CrossRef] PMID:26798150
  • Strain, W. D., Hope, S. V., Green, A., Kar, P., Valabhji, J. & Sinclair, A. J. (2018). Type 2 diabetes mellitus in older people: A brief statement of key principles of modern day management including the assessment of frailty. A national collaborative stakeholder initiative. Diabetic Medicine, 35(7), 838–845 doi:10.1111/dme.13644 [CrossRef]

Mr. Scott's Medications

Medications Prior to HospitalizationMedications During HospitalizationLaboratory Values to Consider
Metformin 100 mg BIDMetformin 100 mg BIDHbA1c 7.5%
Glyburide 10 mg dailyGlyburide 10 mg dailyAverage FBG 120 mg/dL
Insulin glargine 14 units at bedtimeInsulin glargine 14 units at bedtimeSCr 1.2 mg/dL
Insulin lispro 5 units TID before mealsInsulin lispro low dose sliding scale TID before mealsaWeight 82 kg
Atorvastatin 80 mg dailyAtorvastatin 80 mg dailyHeight 182 cm
Apixaban 5 mg BIDApixaban 5 mg BID
Fluticasone/salmeterol 250/50 1 puff BIDFluticasone/salmeterol 250/50 1 puff BID
Albuterol HFA 2 puffs every 4 hours as neededAlbuterol HFA 2 puffs every 4 hours as needed
Vitamin D3 1,000 units dailyVitamin D3 1,000 units daily

Treatment Goals in Older Adults

Health StatusReasonable HbA1c Goal (%)Fasting/Preprandial Glucose (mg/dL)Bedtime Glucose (mg/dL)Blood Pressure (mmHg)Lipids
Healthya<7.5 ≥7%b90 to 130 90 to 150b90 to 150 100 to 180b<140/90Statin unless contraindicated or not tolerated
Complex/intermediatec<8 ≥7.5%b90 to 150 100 to 150b100 to 180 150 to 180b<140/90Statin unless contraindicated or not tolerated
Very complex/poor healthd<8.5 ≥8b100 to 180 100 to 180b110 to 200 150 to 250b<150/90Consider likelihood of benefit with statin (secondary prevention preferred over primary)
Acute rehabilitation/post-acute careAvoid100 to 200N/AN/AN/A

Mr. Scott's Scheduled Medications at the Skilled Nursing Facility

MedicationDose
Metformin100 mg twice daily
Liraglutide1.2 mg daily
Insulin glargine14 units at bedtime
Insulin lispro10 units three times daily before meals
Atorvastatin80 mg daily
Apixaban5 mg t wice daily
Fluticasone/salmeterol 250/50One puff twice daily
Albuterol HFATwo puffs every 4 hours as needed
Vitamin D31,000 units daily

Pharmacological Classes to Consider for Older Adults With Type 2 Diabetes Mellitus

Pharmacological Class and Medication ExamplesUtilize When…Potential Issues
GLP-1RA
  Dulaglutide (Trulicity®)   Exenatide (Bydureon ®, Byetta®)   Liraglutide (Victoza®)   Lixisenatide (Lyxumia®)

ASCVD predominates

Compelling need to minimize hypoglycemia

Compelling need to minimize weight gain or promote weight loss

Injectable only

Higher costs

GI tolerability issues

Renal dose adjustments

SGLT2i
  Canagliflozin (Invokana®)   Dapagliflozin (Farxiga®)   Empagliflozin (Jardiance®)

ASCVD predominates

HF or CKD predominates

Compelling need to minimize hypoglycemia

Compelling need to minimize weight gain or promote weight loss

Increased genitourinary infections due to increased glucose secretion through urine

Renal dose adjustments

Sulfonylurea
  Glyburide (DiaBeta®)   Glimepiride (Amaryl®)   Glipizide (Glucotrol®)

Cost is a major issue

Weight gain

Increased incidence of hypoglycemia

TZD
  Pioglitazone (Actos®)   Rosiglitazone (Avandia®)

Cost is a major issue

Compelling need to minimize hypoglycemia

Black box warning for patients with congestive HF

Fluid retention can occur

Risk of bone fractures

DPP-4i
Alogliptin (Nesina®) Linagliptin (Tradjenta®) Saxagliptin (Onglyza®) Sitagliptin (Januvia®)

Compelling need to minimize hypoglycemia

Renal dose adjustment required

Authors

Ms. Kaminsky is PharmD Candidate 2020, Dr. Ozalas is Clinical Assistant Professor, and Dr. Brandt is Professor, Geriatric Pharmacotherapy, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland. Dr. Ozalas is also Long Term Care Clinical Pharmacy Specialist, PGY-2 Geriatric Pharmacy Residency Program Coordinator, VA Maryland Health Care System, and Dr. Brandt is also Executive Director, Peter Lamy Center on Drug Therapy and Aging, Baltimore, Maryland.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Nicole J. Brandt, PharmD, MBA, BCGP, BCPP, FASCP, Professor, Geriatric Pharmacotherapy, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, and Executive Director, Peter Lamy Center on Drug Therapy and Aging, 220 Arch Street, 12th Floor, Baltimore, MD 21201; e-mail: nbrandt@rx.umaryland.edu.

10.3928/00989134-20200310-01

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