CONTINUING EDUCATION

Type 2 Diabetes Care in the

Elderly
April Bigelow, PhD, ANP-BC, and Barbara Freeland, DNP, ACNS-BC

ABSTRACT
Type 2 diabetes mellitus is a major chronic disease worldwide. Over the next decade, the largest increase in
diabetes prevalence is expected to be in those > 75 years old. Diabetes self-care and prevention of
complications can be challenging, but, when combined with the demands of self-care for other chronic
conditions, it can become overwhelming to patients and caregivers. The glycemic targets and treatment
options are unique to older adults. Clinicians should treat elderly patients with diabetes based on comorbid
conditions, functional status, and life expectancy using a person-centered, team-based approach.

Keywords: diabetes, elderly, management, older adults

Ó 2016 Elsevier Inc. All rights reserved.

Both authors are affiliated with the School of Nursing at the University of Michigan in Ann Arbor. April Bigelow, PhD, ANP-BC,
AGPCNP-BC, is a clinical associate professor. She can be reached at aballard@med.umich.edu. Barbara Freeland, DNP, ACNS-
BC, CDE, is a clinical assistant professor. In compliance with national ethical guidelines, the authors report no relationships with business
or industry that would pose a conflict of interest.

INTRODUCTION elderly when up to half of them are also dealing with

T ype 2 diabetes mellitus (T2DM) is a major
chronic disease throughout the world. In the
aging population, 1 in 4 adults over age 65
have been diagnosed with T2DM and another 50%
have prediabetes, putting them a greater risk of
developing diabetes in the future.1,2 Aging is
considered a major risk factor for diabetes.1 Over the
next decade, the largest increase in diabetes
prevalence is expected to be in those > 75 years old.
Diabetes self-care and prevention of complications
can be challenging, but, when combined with the
demands of self-care for other chronic conditions, it
can become overwhelming to patients and caregivers.
Diabetes self-care presents specific challenges in the
2 or more other chronic conditions and about 40%
have chronic pain as a further complication.3 The
purpose of this study is to present special
considerations for the care of diabetes in the elderly.
SCREENING AND DIAGNOSIS
Insulin production decreases with age while insulin
resistance increases. Add to this impaired hepatic
glucose metabolism and it is not surprising that
T2DM prevalence increases with aging.4 The
textbook signs and symptoms of new-onset T2DM
can be subtle in the elderly. Unfortunately, overt
symptoms of diabetes in the older adult are often
absent. Traditionally, polyphagia, polydipsia, and

This CE learning activity is designed to augment the knowledge, skills, and attitudes of nurse practitioners and assist in their understanding unique factors involved in
caring for elderly patients with Type 2 diabetes.
At the conclusion of this activity, the participant will be able to:
A. Describe the screening and diagnosis of diabetes in older adults
B. Identify barriers to glucose control and self-management in the older adult
C. Explain treatment strategies for the older adult with diabetes
The authors, reviewers, editors, and nurse planners all report no financial relationships that would pose a conflict of interest.
The authors do not present any off-label or non-FDA-approved recommendations for treatment.

This activity has been awarded 1.0 Contact Hours of which 0.5 credits are in the area of Pharmacology. The activity is valid for CE credit until April 1, 2019.

www.npjournal.org The Journal for Nurse Practitioners - JNP 181

polyuria have been considered the classic triad of
symptoms for T2DM in adults. Unfortunately, these
symptoms may not be as pronounced in the older
population due to an impaired thirst mechanism and
an increasing renal threshold for glucose increases
with age.5 Symptoms may be mistakenly attributed
another chronic condition or go on unrecognized.
Fatigue and failure to thrive may be attributed to
aging. Patients may present with other vague
symptoms, such as urinary incontinence,
dehydration, or confusion. Nocturia, especially in
men, is sometimes seen as “normal” or related to an
enlarging prostate. Poor wound healing and
neuropathy may also be part of peripheral vascular
disease and can further delay diagnosis. In addition,
the thirst threshold is decreased in older adults,
making the classic signs of hyperglycemia, namely
increased thirst and urination, less remarkable in the
elderly, and thus putting them at greater risk for
dehydration and non-ketotic hyperosmolar state.5
Likewise, the signs and symptoms of hypo- and
hyperglycemia may be masked by other conditions
and medications, or even misinterpreted by both
patients and providers. Because of the complex
symptomology, many older patients receive a
diagnosis of diabetes that results from routine
screening or is delayed until the identification of
diabetic complications.
The American Diabetes Association (ADA) rec-
ommends that routine screening for diabetes begin at
age 45 for all individuals, regardless of weight; earlier
testing for those overweight or obese with one or
more risk factor.1 Certain medications, such as
thiazide diuretics, glucocorticoids, antiphychotics,
and even statins, in the condition of prediabetes are
known to increase the risk of diabetes.6 People may
spend years with elevated glucose before developing
even subtle symptoms. About one quarter of people
with diabetes in the United States are undiagnosed.
Almost half the Asian and Hispanic Americans are
undiagnosed.1
The diagnosis of diabetes in the older adult is
consistent with its younger counterparts. Fasting
plasma glucose (FPG), 2-hour plasma glucose after
75-g oral glucose tolerance test, and hemoglobin A1c
(HbA1c, a reflection of estimated average glucose
182 The Journal for Nurse Practitioners - JNP
over the previous 2-3 months; see Table) are all
assessment options for diagnosis.1 Although no one
test is preferred, it is often more convenient in older
adults to obtain HbA1c, as fasting is not required.7
Using FPG will not readily identify those with
impaired glucose tolerance or prediabetes. It is
important to note, however, that interpretation of
HbA1c may be difficult if the patient has chronic
anemia or chronic kidney disease.8 HbA1c levels vary
with race and ethnicity and “normal” for African
Americans, for example, may be higher than for
Caucasians.1 Thus, clinicians should select the
diagnostic test appropriate to their patient’s comorbid
conditions. It is important to note that confirming
the diagnosis with the same test and a new blood
sample on a subsequent day is required. Point-of-care
testing methods are not appropriate for diagnostic
testing.
Criteria for diagnosis include all of the following:
FPG
126 mg/dL (7.0 mmol/dL); 2-hour plasma
glucose
200 mg/dL (11.1 mmol/dL); HbA1c
6.5%
(48 mmol/mol); or classic symptoms of hyperglycemia
and a random plasma glucose  200 mg/dL.1
ON-GOING MANAGEMENT
Glucose Control and Self-monitoring
Both the American Diabetes Association (ADA) and
the American Geriatric Society (AGS) recommend
that glucose targets be individualized. Measuring
HbA1c gives providers a gauge for overall glucose
control. The AGS guidelines generally recommend
an HbA1c target of 7.5%-8%, depending on the
patient’s characteristics, health status, life expectancy,
and other chronic diseases.9 Lower targets of
Table. HgA1C to Average Glucose Conversion
HbA1c Estimated Average Glucose
6.5% 140 mg/dL
7% 154 mg/dL
7.5% 169 mg/dL
8% 183 mg/dL
8.5% 197 mg/dL
9% 212 mg/dL
Refer to: http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-
glucose-control/a1c/?referrer¼https://www.google.com/.
Volume 13, Issue 3, March 2017
7%-7.5% may be used if safely achievable in those with
good functional status and few comorbidities. Higher
targets of 8%-9% are recommended for those with
poor health, multiple comorbidities, or limited life
expectancy. The ADA guidelines are slightly more
stringent, but also allow for individualization based
on patient status.1 In very stable adults, HbA1c
testing can be done annually. More frequent testing
should be done when health status or drug
therapy changes.
Self-monitoring of blood glucose is recommended
for all those with diabetes, but it is important to assess a
person’s ability to carry out this procedure and un-
derstand the implications of the results before making
recommendations. Functional status and cognition, as
well as individual goals, must be taken into consider-
ation when planning glucose monitoring.10 Dexterity,
adequate circulation in the extremities, and sufficient
vision or hearing are needed to obtain the results.
Cognitive skills are necessary to understand and act on
the results. In many elderly people with diabetes, one
or more of these areas need support. Asking patients to
demonstrate the use of the meter can reveal errors in
technique, appropriate storage of supplies, and results
in the memory. It is also important to determine
whether the patient has understanding about the
significance of the result, what is considered a high or
low reading, and what action should be taken. Careful
assessment can help direct selection of a glucose meter
that best meets individual needs for larger display of
results, voiced results, or simplicity of use. In addition,
because the cost of monitoring can be a barrier, the
ability to obtain affordable supplies must be known.
Testing supplies are a covered Medicare benefit.11
It may not be necessary for every patient to check
a capillary blood glucose level multiple times per day
or at all. If monitoring cannot be carried out accu-
rately or consistently, or the patient does not gain
insight from the results, there is little value to overall
care. Home glucose monitoring in the elderly should
be individualized based on patient dexterity, cogni-
tion, comorbidities, caregiver support, glycemic
goals, and type of management.
LIFESTYLE CHANGES AND OBESITY MANAGEMENT
Lifestyle changes and weight reduction or obesity
management comprise the primary first-line therapy
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for adults with T2DM, including the elderly. Healthy
diet, increased physical activity, and weight loss have
been pivotal in not only managing HbA1c but
improving cardiovascular risk profiles.10 Lifestyle
changes can also assist in the management of other
potential comorbidities. Healthy eating is the
cornerstone of treatment of T2DM, but older adults
have formed lifetime habits that may be challenging
or resistant to change. Older adults are at greater risk
for poor nutritional and fluid intake. Aging can
decrease sensations of taste and smell, which in turn
may decrease the appeal of eating. Dentures that do
not fit well, loss of teeth, or general poor dentition
may also contribute to poor intake. Socioeconomic
factors can influence access to good nutrition.
Depression and isolation can also contribute to the
problem. With these risk factors in mind, an
individualized meal plan is very important. In
addition to glucose control, the diet may need to be
adjusted for comorbid conditions such as
hypertension, obesity, failure to thrive, or
hyperlipidemia. Medical nutrition therapy is a
covered benefit through Medicare for all those with
diabetes. A dietitian can best evaluate the needs of an
individual. The goals of medical nutrition therapy
include providing patients with a variety of foods that
meet personal and cultural needs in appropriate
portions to improve overall health.1 Clinicians can
assist by helping implement the plan and supporting
education around understanding the relationship
between food intake and glucose levels. Minimally,
patients with diabetes should be able to identify food
items in their diet that contain carbohydrates and will
most affect their glucose levels.
Physical activity or exercise is another first-line
therapy in the treatment of adults with T2DM. The
current recommendation for exercise is 150 minutes
of moderate-intensity aerobic activity per week.1
This may not be practical for many older adults, and
comorbidities may preclude participation in intensive
lifestyle interventions.3 Strong consideration must be
given to safety, including decreasing the risk of
hypoglycemia. It is necessary to understand the
relationship between activity and glucose levels.
Teaching should include risks for hypoglycemia as
well as use of safety equipment, such as properly
fitting shoes for walking or helmets for bike riding.
The Journal for Nurse Practitioners - JNP 183
As with younger adults, a successful approach to
discussion of diet and activity begins with
motivational interviewing and determining the
patient’s readiness and/or ability to make the
necessary changes.
Healthy eating, physical activity, and weight
reduction have been shown to assist in glycemic
control and decrease the need for medications to
lower blood glucose.1 Whereas 5% weight loss is
often recommended in adults, even modest weight
loss that is sustained will provide some benefit for
cardiovascular risk and glycemic goals. Assisting
patients with lifestyle changes also helps to achieve
blood pressure goals, lipid goals, and may delay or
prevent complications. Finally, smoking cessation
should be encouraged at every clinic visit to further
decrease cardiovascular risk.2
PHARMACOLOGIC THERAPY
Although lifestyle changes and obesity management
comprise the cornerstone of treatment, as the disease
progresses, pharmacologic therapy may be necessary,
depending on individualized patient glycemic targets.
The overall goal should be to achieve the best gly-
cemic control without exposing the patient to the
risk of hypoglycemia and its consequences.5 The
American Association of Clinical Endocrinologists
and American College of Endocrinologists published
goals and recommendations for glycemic control,
including a profile of antidiabetic medications.12 This
may serve as an excellent resource for clinicians, yet
several factors complicate pharmacologic therapy in
older adults. One must consider declining renal and
hepatic function, increased risk for polypharmacy,
increased risk for hypoglycemia or other harms, and
limited clinical trials in older adults.7 Ultimately,
the clinician must evaluate the patient’s functional
status, cognitive status, cardiovascular risks and
comorbidities, glycemic targets, and life expectancy
before making a pharmacologic choice.
The preferred first-line agent for oral therapy in an
older adult is metformin, due to its lower risk for
hypoglycemia.10,12 Recently, the US Food and Drug
Administration updated warnings related to use of
metformin, stating it is safe to use in mild to moderate
renal impairment and recommending that monitoring
include estimated glomerular filtration rate and
184 The Journal for Nurse Practitioners - JNP
hepatic function.13 Thiazolidinediones must be used
with caution in the geriatric population. Patients with
preexisting heart failure, edema, or hepatic failure
should not take thiazolidinediones. These agents have
also been implicated in increased fracture risk.14
Medications that introduce a heightened risk
of hypoglycemia, such as insulin and insulin
secretagogues, should be used with caution in the
elderly, and glycemic goals should be less strict.6
Sulfonylureas must also be used with caution and have
been strongly associated with hypoglycemia.
Glyburide in particular should be avoided.1,5 Use
of warfarin and sulfonylurea has been shown to lead to
significant hypoglycemia,15 and many of these agents
are considered contraindicated in older adults.
Newer classes of drugs, including glucose-like
peptide 1 receptor agonists and dipeptidylpeptidase-4
inhibitors, have been known to have fewer side
effects, are generally well tolerated, have a low risk
of hypoglycemia, and do not cause weight gain.
However, their cost may be a limiting factor. Sodium
glucose cotransport 2 inhibitors, the newest class of
medication for T2DM, should be considered. They
present minimal to no risk of hypoglycemia, have
minimal drug-drug interactions, and provide an
osmotic diuresis, which has a modest blood pressuree
lowering effect. Disadvantages of the sodium glucose
cotransport 2 inhibitors include their higher cost, lack
of long-term-use data, and high incidence of geni-
tourinary infections, especially in women.16
Insulin therapy may also be added for additional
glycemic control or used as a solo agent, depending
on the patient’s ability to administer and monitor
for symptoms. It is recommended that patients
and/or caregivers have formal diabetes education
and ongoing cognitive assessment throughout the
treatment plan.1
With each change in medication therapy, it is
important to monitor the patient’s response and
modify the regimen every 3 months until goals are
achieved and the patient is stable. T2DM is a pro-
gressive condition and it is expected that therapy will
change over time.
POLYPHARMACY
Unique to older adults is the increased risk for pol-
ypharmacy, as many have one or more chronic illness
Volume 13, Issue 3, March 2017
in addition to T2DM. It is essential that the provider
maintain an accurate medication list. Such a list
should include all medications that the patient takes
on a regular and as-needed basis, including prescribed
and over-the-counter medications, herbal remedies,
vitamins, and nutritional supplements. Health care
providers should review medications at least annually
to evaluate potential interactions, eliminate unnec-
essary medications, and look for ways to improve
adherence and meet disease targets.10 The Beers
Criteria is an excellent resource for clinicians and may
provide information for providers on potential
inappropriate medications in the older T2DM
population.17 Polypharmacy increases the risk of side
effects and interactions with other medications, and
may also lead to confusion in some patients with
regard to dosing and frequency, depending on the
number of medications prescribed.9 It is important to
assess the degree of medication adherence, continued
medication indication, and any side effects or
interactions at each visit. Reducing the complexity of
the regimen and considering the use of extended-
release products rather than multiple doses per day
should be considered.
PREVENTION OF COMPLICATIONS
Hypoglycemia is a serious risk for older adults as they
may be lacking autonomic warning symptoms.
Confusion, delirium, dizziness, weakness, and falls are
more common symptoms in older adults and reflect
neuroglycopenic manifestations. It is easy to under-
stand how these symptoms may be attributed to other
conditions. In addition, symptoms may not occur
until glucose is much lower as compared with
younger adults.5 Likewise, progression of vague
hypoglycemic symptoms to symptoms requiring
intervention from a third-party can progress rapidly,
and seizures may occur, making the older adult pa-
tient more at risk for serious or even life-threatening
episodes of hypoglycemia. Avoiding hypoglycemia
should be a major goal of therapy. In 2011, hypo-
glycemia was responsible for 282,000 emergency
room visits and hyperglycemia was responsible for
175,000 emergency room visits.2 In recent years, the
danger associated with hypoglycemia, especially in
the elderly, has gained recognition.
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In addition to the standard risk factors for hypo-
glycemia, which include use of insulin or other
medications that may lower glucose, irregular meals,
unpredictable exercise patterns, and older age carry
additional risk factors, including decreased renal
function, polypharmacy, hospitalization, or coexist-
ing comorbidities.5 All patients taking glucose-
lowering drugs must be aware of the risk factors and
signs and symptoms of hypoglycemia as well as the
immediate treatment options. Clinicians should
provide extensive teaching to patients and caregivers
regarding hypoglycemia for those at risk and should
consider referrals to diabetes nutritionists or educa-
tors. Each office visit should include assessment of
hypoglycemic events.
Hyperglycemia and T2DM may lead to multiple
complications. Clinicians must be aware of and screen
for complications. Diabetes has been linked to neu-
ropathies, nonalcoholic fatty liver disease, depression,
periodontal disease, erectile dysfunction, and other
diseases.2 Because of this strong association, both the
ADA and AGS have recommended annual
evaluation and screening for complications.
Specifically, the ADA recommends management of
atherosclerotic cardiovascular disease consistent with
the guidelines for younger adults, with consideration
given to the patient’s comorbidities and life
expectancy. Also, annual evaluation for kidney
disease and neuropathies is recommended.1 Further,
the ADA and AGS specifically recommend dilated
eye examinations every 1-3 years, depending on risk
and symptoms, and evaluation of the feet at least
annually.1,10 A yearly influenza vaccine is
recommended as well as a pneumococcal vaccine.
COPING AND COGNITION
People with diabetes are at least 1.5 times more likely
to have cognitive decline or frank dementia.3,10
Because of the suspected link between diabetes and
depression, the ADA and AGS recommend regular
screening as well as prompt treatment.1,10 A recent
study of > 22,000 adults with diabetes (mean age 65)
suggested a link between depressive symptoms, stress,
and cardiovascular mortality.18 Furthermore, patients
should be screened for symptoms of depression if
there is any unexplained decline in clinical status.10
The Journal for Nurse Practitioners - JNP 185
Standardized screening tools include the Geriatric
Depression Scale, the Patient Health Questionnaire-2
or -9, and either the Diabetes Distress Scale or the
Problem Areas in Diabetes Scale.1 It is recommended
that older adults who have either a new onset or a
recurrence of depressive symptoms be treated or
referred within 2 weeks of identification or
presentation. It is imperative to evaluate for risk or
harm to themselves or others; it should not be
assumed that older patients are less likely to have
suicidal or homicidal ideation.
Likewise, older adults are at risk for declining
cognition related to a variety of factors. This decline
has the potential to impact attitude about themselves,
their disease, and their quality of life.10 Patient
support systems, financial support, and community
resources should be evaluated and discussed at each
visit. In addition, use of a standardized tool for
cognitive screenings, such as the Montreal Cognitive
Assessment tool or the Mini-Mental State Examination,
are recommended.1
CONCLUSION
Both the ADA and AGS promote person-centered
care in which the patient is supported by a health care
team to provide culturally specific and individualized
care.1,10 Due to the lack of data and clinical studies
that include older adults, team-based care that
informs the patient while enabling choice and
autonomy is preferred.
Management of TDM2 in older adults is complex
and benefits from the use of guidelines, but each
clinician must individualize care to specific patient
needs and abilities. Providers must critically examine
the patient and develop strategies for care that
incorporate the patient’s unique circumstances as an
older adult. Using a team-based approach that is
patient-centered and outcome- and prevention-
focused, the treatment plan can be individualized,
despite the limitations in mobility, decreased appetite,
decreased liver and renal function, and complex
186 The Journal for Nurse Practitioners - JNP
comorbidities. T2DM care and management in the
older adult is multifaceted. Advanced training in the
care of vulnerable populations may direct clinicians in
the care of this complex population.
References
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Diabetes Care. 2016;39(Suppl 1):S1-S111.
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diabetes/statistics/prevalence_national/. Accessed June 2015.
3. Lee P, Cigolle C, Ha J, et al. Physical function and limitations among middle-
aged and older adults with diabetes. Diabetes Care. 2013;36:3076-3082. http://
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11. US Centers for Medicare and Medicaid Services. http://www.medicare.gov/
Pubs/pdf/11022.pdf/. Accessed June 2016.
12. AACE/ACE comprehensive diabetes management algorithm 2015. Endocr
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patients with reduced kidney function. 2016. http://www.fda.gov/Drugs/
DrugSafety/ucm493244.htm/. Accessed July 30, 2016.
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management algorithm. Endocr Pract. 2013;19:327-336.
15. Romley JA, Gong C, Jena AB, et al. Association between use of warfarin with
common sulfonylureas and serious hypoglycemic events: retrospective
cohort analysis. BMJ. 2015;351:h6223. http://dx.doi.org/10.1136/bmj.h6223.
16. Abdul-Ghani M, Norton L, DeFronzo R. Sodium-glucose cotransporter-2
inhibitors and type 2 diabetes. In: Umpierrez G, ed. Therapy for Diabetes
Mellitus and Related Disorders. 6th ed. Alexandria, Va: American Diabetes
Association; 2014:445-460.
17. American Geriatrics Society. 2012 Beers Criteria Update Expert Panel.
American Geriatrics Society updated Beers Criteria for potentially
inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60:
616-631.
18. Cummings D, Kirinal M, Howard K, et al. Consequences of comorbidity of
elevated stress and/or depressive symptoms and incident cardiovascular
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Differences in Stroke (REGARDS) study. Diabetes Care. 2015;38:101-109.
1555-4155/16/$ see front matter
© 2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.nurpra.2016.08.010
Volume 13, Issue 3, March 2017