ENDO 2019: 101st Annual Meeting of the Endocrine Society:

Focus Turns to Need for Better Diabetes Management in Older Adults

With Anders L. Carlson, MD, Derek LeRoith, MD, PhD, and Mark Molitch, MD

Turning our attention to the specific diabetes management needs of our aging population Stepping up treatment Simpler Care, better Screening, Different Approaches Needed to Improve Glycemic Control

Many seniors with diabetes are unaware that they are hypoglycemic.

Hypoglycemia is common in older adults who have type 1 diabetes (T1D) who are not aware of their poor diabetes control,1 according to data presented in an oral poster presentation at ENDO 2019, the 101st annual meeting of the Endocrinology Society in New Orleans, Louisiana.

This alarming lack of awareness regarding their blood glucose status put them at significant risk of serious and severe medical complications, given that they typically spend 7% of the time, or more than 70 minutes (P = 0.01) daily below their target glycemic range (< 70 mg/dL),1 said lead author Anders L. Carlson, MD, assistant professor of medicine at the University of Minnesota Medical School, and medical director of the International Diabetes Center in Minneapolis, Minnesota.

These insights were derived from baseline review of blinded data (n = 203; 52% female, 93% non-Hispanic white) from the Wireless innovation for Seniors with Diabetes Mellitus (WISDM) trial of adults—a randomized clinical trial over age 59 years­— who were being managed for T1D on a continuous glucose monitor (CGM) for nearly three weeks.1

Dr. Carlson indicated that there were three common factors among patients whose hypoglycemia unawareness was twofold higher, and not achieving the glucose in-range targets, appearing in a U-shape curve—employment, income, insulin need:

  • Retired individuals spent the greatest time in-range for serum glucose
  • Patients earning $30k – $70k spent the most time below their target range
  •  Lower daily insulin needs per kg body weight achieved best glucose control

The authors concluded that new approaches are needed to improve time-in-range and reduce hypoglycemic unawareness,1 which dovetailed nicely with the announcement of first-ever Endocrine Society diabetes management recommendations for the older population.2

More Directed Care Needed in Older Adults with Type 2 Diabetes

 For many decades, the need to manage diabetes in the older patient was considered unnecessary. This arose from the perspective that they had a limited lifespan so their long-term risks were of limited consequence. Times have changed—an anticipated 50% of individuals age 65 or older are estimated to have prediabetes and another one in four seniors is believed to have diabetes4—many of whom may live well into their 80s and 90s.  

In introducing the new guidelines,5 Derek LeRoith, MD, PhD, professor of Medicine at the Icahn School of Medicine at Mount Sinai in New York, who was chairman of the guidelines writing committee, said: “people are living longer with diabetes so the approach to management needs to evolve from a position that we do not need to worry about their age to a multidisciplinary approach that is patient-centered and individualized to optimize their health for the longer term.

The significance of delaying the progression of diabetes in older ages is now considered urgent since this segment of the population would otherwise experience exaggerated micro- and macro complications. That is the basis for the Treatment of Diabetes in Older Adults: An Endocrine Society Clinical Practice Guideline, introduced at ENDO 2019, the 101st annual meeting of the Endocrine Society,5 and published in the Journal of Clinical Endocrinology & Metabolism.6

Dr. LeRoith shares some insights with EndocrineWeb regarding what's new about these guidelines.

"We found that the characteristics such as financial and cognitive abilities affected patients health, requiring treatment to be tailored to individuals based on their comorbidities," said Mark E. Moltich MD, professor of medicine at Northwestern University Feinberg School of Medicine, and a member of the guideline writing committee, at a press conference. The best way forward needs to be a team approach in order to best address potential complications of cardiovascular disease, renal, and cognitive.

Key Recommendations for the Older Patient with Diabetes

There wasn't much difference the clinical recommendations for diagnosing type 1 diabetes in the older population but the guideline reinforces the need to avoid complex treatment regimens, taking into account level of cognitive function and financial means," Dr. LeRoith told EndocrineWeb.

The treatment recommendations regarding the use of insulin were merged for older adults with either type 1 or type 2 diabetes.  Measuring serum glucose will depend upon the patient's cognitive status, treatment demands, and overall wellbeing. 

"We tried to bring about a discussion about what type of care should be given to an older patient," he said.  "We hope that all decisions are made with input from the patient, family and their caregiver(s)."

"One important difference in the older age group is that they are more prone to problems of sarcopenia, frailty, and falling so clinicians will want to proceed carefully when intensifying therapy that we don’t cause an increase in hypoglycemia,” said Dr. LeRoith. “This can lead to these individuals falling, for example, fracturing bones, and reducing their quality of life.” Therefore,  blood pressure management, for example, should not be too aggressive to lessen the risk of falls. 

Key strategies in the guidance  included

  • Simplify medication regimens to facilitate adherence among patients who are likely to be taking five or more medications.
  • Determine the frequency of glucose measures depending on the individual
  • Choice of diabetes medication should be selected with cardiovascular risks (et, blood pressure, lipids), renal disease, and other comorbidities, in mind.
  • Annual lipids profile should be done to improve blood cholesterol.
  • A comprehensive yearly eye exam is recommended to check for diabetic retinopathy.
  • Establish glycemic goals with institutional fasting blood glucose targets of 100-140 mg/dL and 140-180 mg/dL after meals.
  • Each diabetes plan must be personalized, taking into account the patient’s cognitive capability, health complications, and devising a complete medication regime

Know the Multiple Medical Challenges Often Faced By Older Adults

We need to start with regular screening for diabetes in older patients so clinicians are better positioned to intervene, said lead author Dereck LeRoith, MD, PhD, professor of Medicine at the Icahn School of Medicine at Mount Sinai in New York, taking into account the factors that commonly affect the overall health of those who are 65 years of age and older

“We found that characteristics and values such as finances and cognitive abilities impacted patients’ health, necessitating that treatment be tailored to the individual with consideration to any and all comorbidities,” said Mark E. Moltich MD, professor of medicine at Northwestern University Feinberg School of Medicine, and a member of the guideline writing committee, at a press conference to introduce the guideline.

The authors suggest avoiding complex treatment regimens, seeking a simplified diabetes care plan that utilizes a multidisciplinary team approach; this is the best way to help older adults achieve good glucose control that supports their quality of life.

“It is critical to avoid hypoglycemia in order to lessen the risk of falls and fractures,” said Dr. Motlich, since this is heightened concern in patients who are also at risk for sarcopenia. Take a 70-year-old, for example, whose blood pressure management may be too aggressive and whose serum glucose is poorly managed. The result may be a fall, leading to hip fracture.

“There wasn’t much difference the clinical recommendations for diagnosing type 1 diabetes in the older population but the guideline reinforces the need to avoid complex treatment regimens, taking into account level of cognitive function and financial means,” Dr. LeRoith told EndocrineWeb. However, it is preferable to rely on glucose tolerance testing rather than hemoglobin A1c (HbA1c) in making a differential diagnosis, given the inaccuracies in the A1c testing, including dilutional effects.

The treatment recommendations regarding insulin were merged for older adults with either type 1- or type 2 diabetes. Frequency schedule for measuring serum glucose will depend upon the patient’s status, treatment demands, and overall wellbeing.

“We haven’t really made major changes to the level at which each of these treatment measurements should be affected,” he said. “We have emphasized that treatment choices should be appropriate for that particular patient so it’s a personalized patient-centered approach and we hope that these guidelines will be utilized by primary care physicians, as well as other healthcare providers.”

Development of this guidance was entirely underwritten with funds from the Endocrine Society.

This diabetes guideline for older adults was endorsed by the European Society of Endocrinology, the Gerontological Society of American, and the Obesity Society.

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