Managing Diabetes in

Older Adults

Anar Dossa, BSc Pharm, Pharm D, CDE

Jodi Crawford, RD
The opinions expressed in this presentation are that of the presenter
and do not necessarily reflect those of Dietitians of Canada. Further,
this presentation should not be reproduced in full or in part without
the express written consent of the presenter.

Les opinions exprimées dans cette présentation sont celles du

présentateur ou de la présentatrice et ne reflètent pas
nécessairement celles des Diététistes du Canada. Par ailleurs, cette
présentation ne devrait pas être reproduite, que ce soit en partie ou
dans son intégralité, sans le consentement écrit exprès du
présentateur ou de la présentatrice.
Financial Interest Disclosure
(over the past 24 months)

No relevant financial relationships with any commercial

interests
New 2018 Clinical Practice Guidelines
for Diabetes
Definition of “Older Adult”
• No uniform definition for “older adult”
• Generally accepted to reflect the age around 70 years
and is characterized by slow progressive impairment in
function that continues to the end of life.
• Decisions regarding therapy should be made on the
basis of age/life expectancy and the person’s functional
status.
Targets for
Glycemic
Control
Glycemic targets in older people with DM
Comparison of Clinical Outcomes
2012
Clinical
Frailty
Scale
http://diabetescare.nshealth.ca/sites/default/files/files/LTCPresentationFinal.pdf
Diabetes Care
Program of
Nova Scotia
Revised November 2016

http://diabetescare.nshealth.ca/sites/default/files/LTCPocketRefNOV2016_0.pdf
Targets for
Glycemic
Control
Medications:
What do the guidelines say?
Avoid hypoglycemia
• Reconsider need for sulfonylureas
§ Will depend on how high the blood sugars are
• Reconsider A1c target
§ To reduce the risk of hypoglycemia
Why avoid hypoglycemia?
• Asymptomatic in this patient population
• Age related reduction in glucagon secretion
• Altered psychomotor performance limits ability to treat
hypoglycemia
Medications
• DPP-4 inhibitors should be used over sulfonylureas as second
line therapy to metformin, because of a lower risk of
hypoglycemia

• Initial doses of sulfonylureas in the older person should be half

of those used for younger people, and doses should be
increased more slowly

• Meglitinides may be used instead of glyburide to reduce the

risk of hypoglycemia in individuals with irregular eating habits
What about the newer agents in the older
adult with diabetes?

Add SGLT-2 inhibitors or GLP-1 analogues if patient has no

other complex comorbidities and has cardiovascular
disease and A1c is not at target
• More experience with DPP-IV inhibitors to date
• Dehydration is a concern especially if the person is on
diuretics and SGLT-2
What about Insulin?
• Detemir, glargine U-100 and U-300 and degludec may
be used instead of NPH or human 30/70 insulin to lower
the frequency of hypoglycemic events

• In older people, premixed insulins and prefilled insulin

pens should be used to reduce dosing errors and to
potentially improve glycemic control

• Sliding scale and correction insulin protocols should be

avoided in elderly LTC diabetes residents
Simplification
• switching multiple-dose insulin regimens to once-a-day
glargine U-100 with or without noninsulin
antihyperglycemic agents results in equivalent glycemic
control and a reduced risk of hypoglycemia
Deprescribing
• Anyone with A1c of less than 6% and on diabetes
medications should be reassessed for deprescribing
• Statins – lack of benefit in the elderly with limited life
expectancy
Where I care
• Alberta Health – licensing authority, set the standards
• Alberta Health Services – guides policy, practice and
procedures
What’s on the menu?
Alberta Health Services diet guidelines.
• A special menu is not necessary, but some
considerations are needed.
• Sugar substitutes
• Reduced sugar or no sugar added condiments
• Lower sugar beverages
• Sugar reduced dessert options
Looking at the CPG in Practice
• My “Petri Dish”
• LTC facility with 270 beds
• Review of 2012 – present
Looking at the CPG in Practice
21.1 – 24.4% of LTC % of LTC residents with T2DM
270 bed Calgary Facility
residents with type 2 25.0%

diabetes 24.0%

23.0%

Canadian data show over 25% of 22.0%

resident in LTC have type 2 diabetes. 21.0%

Canadian Diabetes Association. Diabetes in Ontario; An
ICES practice atlas. Toronto: Institute for Clinical 20.0%
Evaluation Sciences (ICES), 2003
http://www.ices.on.ca/~/media/Files/Atlases- 19.0%
Reports/2003/Diabetes-in-Ontario/Full%20report.ashx.

Feb-13

Feb-14

Feb-15

Feb-16

Feb-17

Feb-18
Oct-12

Jun-13
Oct-13

Jun-14
Oct-14

Jun-15
Oct-15

Jun-16
Oct-16

Jun-17
Oct-17
Looking at the CPG in Practice
• We typically target Clinical Frailty Scale for 59 T2DM
Residents - March 2018
HbA1c <8.5, as 60.0%

majority are at least 50.0%

40.0%
moderately frail (>6). 30.0%

20.0%

10.0%
Diabetes in Older People. Graydon S. Meneilly MD, FRCPC, MACP,
Aileen Knip RN, MN, CDE, David B. Miller MD, FRCPC, Diana
0.0%
Sherifali RN, PhD, CDE, Daniel Tessier MD, MSc, FRCPC, Afshan
Zahedi BASc, MD, FRCPC. Table 1 & Figure 1 pages Canadian 5 6 7 8 9
Journal of Diabetes April 2018; 42: S284-S286. Mildly Frail Moderately Severely Very Terminally Ill
Frail Frail Severely
Frail
 they
treated?
How are

10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%

0.0%
Oct-12
Jan-13
Apr-13
Jul-13
Oct-13
Jan-14
Apr-14
Jul-14
Oct-14
Jan-15
Apr-15
Jul-15
Oct-15
Jan-16
Apr-16
Jul-16
Looking at the CPG in Practice

Oct-16
Jan-17
Apr-17
Jul-17
Oct-17
Jan-18
% Ins
% diet

% O&I
% OHA
Considerations: Intake
• Menu & food service operations
• Recreation Therapy!! They get to have all the fun!
• “Cheating”, “Treats” & food in room
• Family & friends: compassionate treats
• Varied intake
• Resident choice
Considerations: Health Condition
• Frailty Score / Dependence
• Goals of Care / Level of Care
• LTC Medication Formulary
• Cognitive impairment
• Infection, colonization
• Wound healing
• Supplementation
Considerations: Health Condition

• Degree of hyperglycemia
• Hypoglycemia risk
• Cost
• Adherence
• Comorbidities
Considerations: Medications
Medication Characteristics
• How effective is it at lowering blood glucose?
• What outcomes have been achieved?
• How long has the medication been around?
• What is the safety profile?
• Cost
• Adherence
Monitoring Outcomes
• Lab ordering practices by lab or region: Limited or no
values for comparison
• HbA1c vs RBG
• Goals of Care: Often no blood work or RBG for QOL
• Weight management: stability, planned weight change
• Physical Function and independence
• Other indicators: wounds, infections, comorbidities
We heard you.
• Case studies and practice questions submitted by
members.
Carb Overload

Many clients live at home and get Meals on Wheels or take

out from health care institutions. Some of the meals are
loaded with carbohydrates resulting in RBG of >20 for
people on structured insulin doses. I don’t disagree with
“let our diabetics eat cake”, but it the rolls, potatoes and
corn with it that makes it a challenge.
Variety and Choice
• Older LTC gentleman on insulin with unstable blood
sugars resulting from eating large amounts of fruit in his
room and refusing to eat much of anything from the
menu.
Choice and Flexibility
• 85 y.o. with prediabetes for many years was diagnosed
with Parkinson’s. Diet was changed to soft, moist
texture with thickened fluids, resulting in weight loss
from fatigue and early satiety. Much difficulty to
convince him and his wife to be more flexible with his
diet.
• Older woman living in the community who is fairly mobile
and was recently diagnosis with prediabetes. She
doesn’t tolerate the medications and she chooses to try
manage blood sugars with diet alone. She has a very
“black and white” approach which may indicate a
significant history of restrictive dieting.
Medication and Monitoring
• How important are snacks for glycemic control and
avoiding hypoglycemia?
Medication and Monitoring

• How can we support others with implementation CPG for

older adults? I feel our nurses would struggle with giving
insulin if RBG is not checked.
References
Diabetes Canada 2018 Clinical Practice Guidelines
• http://guidelines.diabetes.ca/news/2018-cpg

Diabetes Care Program of Nova Scotia

• http://diabetescare.nshealth.ca/guidelines-
resources/professionals/guidelines/special-populations
• http://diabetescare.nshealth.ca/sites/default/files/files/LTCPresentationFinal.pdf

Guidelines for Monitoring A1C for the Frail Elderly with Known Diabetes in or
Awaiting Long-Term Care (LTC)
• http://diabetescare.nshealth.ca/sites/default/files/files/Phase2LTCDraftMay2016.
pdf