The American Diabetes Association (ADA) Standards of Care define different categories of older adults, including those with good functional status and no complications and those with complications and reduced functionality.
According to the most recent Centers for Disease Control and Prevention (CDC) statistics, there are 29.4 million adults with diabetes and 97.6 million adults with prediabetes. When looking at people 65 years and older, over half (16.5 million) have diabetes, and nearly a third (27.2 million) have prediabetes (CDC 2022).
When managing diabetes in the older adult population, it is important to take into account disease duration, complications from diabetes, risk and incidence of hypoglycemia, treatment goals, and patient preferences as well as populationspecific challenges. Older adults with diabetes have increased rates of premature death, functional disability, accelerated muscle loss, and comorbidities, such as hypertension, heart disease, and stroke. Older adults are also at a higher risk of polypharmacy, cognitive impairment, depression, urinary incontinence, falls, pain, and frailty, all of which can impact diabetes treatment plans and self-management ability (American Diabetes Association Professional Practice Committee [ADA PPC] 2024b).
Because of these concerns and other factors, such as life expectancy and treatment burden, A1C goals may need to be relaxed for some individuals. However, older adults with good functional status and a longer life expectancy may benefit from tighter glucose control. This article highlights overall diabetes management considerations in older adults, but it is important for the diabetes care and education specialist (DCES) to keep in mind that everyone ages differently. The DCES can play an important role in assessing medicationtaking behaviors, medication concerns, and selfmanagement abilities.
The American Diabetes Association (ADA) Standards of Care define different categories of older adults, including those with good functional status and no complications and those with complications and reduced functionality (Table 1). Those with good functional status have a longer life expectancy and would benefit from tighter glucose control.
It is important to utilize shared decisionmaking when determining treatment goals and plans. Monitoring for a decline in selfmanagement knowledge and skills is also key. When reduced functionality and complications come into play, it is important to adjust glycemic goals and be less stringent. There is a fine balance of preventing hypoglycemia and minimizing side effects while still preventing acute complications, such as poor wound healing and hyperglycemia hyperosmolar coma (ADA PPC 2024b).
Although medications may be clinically needed, polypharmacy is a concern in the older adult population. The World Health Organization defines polypharmacy as “the administration of many drugs at the same time or the administration of an excessive number of drugs.” Using 5 or more medications at once is the typically accepted threshold.
Polypharmacy has been associated with poor health outcomes, including increased risk of death, falls, drug interactions, nonadherence, and hospitalizations (Delara et al 2022). Similar to having a patient-specific A1C goal, medication recommendations should also be individualized.
Decreasing the risk of hypoglycemia is a major goal of diabetes management of the older adult. Older adults are at a higher risk of experiencing hypoglycemia due to a longer disease duration, requiring insulin, renal decline and insufficiency, and cognitive impairment.
The ADA Standards of Care recommend simplifying complex treatment plans to decrease the risk of hypoglycemia, polypharmacy, and disease burden when possible (ADA PPC 2024b). The DCES can assess and assist in developing a simpler medication plan and making sure appropriate patient education is provided.
Sulfonylureas, meglitinides, thiazolidinediones (TZDs), and prandial insulin all pose safety concerns in the older adult population. According to the Geriatric Society Beers Criteria, glimepiride, glipizide, and glyburide can increase the risk of cardiovascular events, all-cause mortality, and hypoglycemia. These guidelines suggest avoiding the use of these medications as monotherapy or add-on therapy unless there are substantial barriers to using safer and more effective medications, such as metformin, glucagonlike peptide 1 receptor agonists (GLP1-RA), and sodium-glucose cotransporter 2 inhibitors (SGLT2i). If this medication class must be used, a short-acting agent, such as glipizide, should be used over the longer acting agents, glimepiride and glyburide (2023 American Geriatrics Society [AGS] Beers Criteria Update Expert Panel 2023). The ADA guidelines are in line with this recommendation as well (ADA PPC 2024a, 2024b). Similar to sulfonylureas, the ADA Standards of Care also highlight that meglitinides should be used with caution, especially in older adults, due to increased risk of hypoglycemia (ADA PPC 2024a, 2024b).
TZDs, such as pioglitazone and rosiglitazone, should be used very cautiously, if at all, in patients with or at risk of heart failure, osteoporosis, falls, fractures, or macular edema. TZDs can cause fluid retention, which can worsen heart failure; therefore, they should be avoided in anyone with symptomatic heart failure, and caution should be used in those with asymptomatic heart failure. Although heart failure is not exclusive to the older adult population, people over the age of 65 are at greater risk of developing and having this condition, especially because diabetes is a risk factor (Roger 2021). If TZDs are used, they should be used in the lowest possible dose. The DCES can also review the patient’s medication list for furosemide, torsemide, and bumetanide because these medications are all used for fluid retention and could show that TZD use may not be appropriate. Prolonged use of TZDs can cause bone loss, which is a concern for those with osteopenia, osteoporosis, or a high risk of falling (2023 AGS Beers Criteria Update Expert Panel 2023; ADA PPC 2024b; LeRoith et al 2019).
The ADA Standards of Care recommend simplifying complex treatment plans to decrease the risk of hypoglycemia, polypharmacy, and disease burden when possible.
Any type of prandial insulin can pose safety concerns for the older adult. Prandial insulin without use of long-acting insulin is not recommended due to risk of hypoglycemia (2023 AGS Beers Criteria Update Expert Panel 2023). Multiple daily injections may become too complex for older adults due to the potential to mix up insulin types or give the incorrect dose. Carbohydrate counting and an insulin sensitivity factor calculation may be difficult, depending on functional status. Giving insulin injections may also be cumbersome due to physical limitations, such as neuropathy and arthritis, and may require a caregiver to assist with injections.
The ADA Standards of Care offer an algorithm on how to simplify insulin regimens. The following are some suggestions: Do not use bolus insulin at bedtime, use a simplified sliding scale or none at all, use prandial insulin at lower doses, and replace prandial insulin with noninsulin agents. The DCES can assess a person’s ability to safely use insulin, make suggestions on how to simplify the regimen, educate on continuous glucose monitors, review hypoglycemia history and treatment, and offer a glucagon product if the individual is going to remain on insulin (ADA PPC 2024b).
The GLP1-RA and SGLT2i medication classes are considered to be safe to use in older adults; however, there are some extra concerns and considerations that should be taken into account when using these agents in this population.
Older adults may have preexisting gastrointestinal conditions, such as constipation, diarrhea, fecal incontinence, Crohn’s disease, ulcerative colitis, irritable bowel syndrome (IBS), and others. These conditions can happen at any age but might be more symptomatic and/or bothersome as one ages. Although having these conditions is not a contraindication, the DCES may need to ask the person with diabetes (PWD) more probing questions to see how well the condition is controlled and get a good idea of their baseline symptoms. For example, a person with constipation who has a bowel movement every 3 days may be willing to make lifestyle changes or try medications for constipation and could still use a GLP1-RA. On the other hand, for a person with diarrhea-predominant IBS who has 6 loose stools per day and fecal incontinence overnight requiring a diaper, a GLP1-RA would not be a good choice. Older adults starting GLP1-RA may require more education, slower dose titrations, and trialing another agent in the class in order to tolerate it (Wharton et al 2022).
Another potential concern with the GLP1-RA class is weight loss. Not all older adults are interested in weight loss or need weight loss, and some may be experiencing unintentional weight loss. In this group, GLP1-RA should be used with caution. Body mass index (BMI) in the older adult (≥65 years old) has been studied, and it has been shown that there is an increased mortality risk in those with a BMI less than 23 kg/m2. The lowest risk of mortality is between 24 and 30.9 kg/m2, with the ideal being between 27 and 27.9 kg/m2 (Winter et al 2014).
In addition to weight and BMI, the DCES needs to be concerned with nutritional and fluid intake and making sure muscle mass is being retained. Because GLP1-RAs decrease appetite, it is important to ensure that good nutritional intake is still being consumed to avoid malnourishment concerns. Decreased appetite may also cause a decrease in fluid intake, which could lead to dehydration, weakness, acute kidney injury, and falls. Sarcopenia, age-related loss of muscle mass, is accelerated in PWD (LeRoith et al 2019). Maintaining muscle mass is also important for bone health, overall health, minimizing the risk of falls, and decreasing risk of death (Tufts University 2014). The DCES can encourage resistance training to minimize muscle mass loss, taking into account any physical limitations the PWD may have (ADA PPC 2024b).
GLP1-RA Side Effect Education
Discuss expectations of side effects
Most side effects are mild to moderate
Slowly go away over time as your body adjusts
Encourage smaller meals
Eat slower
Don’t eat when you’re not hungry
Stop eating when full (mindful eating)
Eat without distractions to enjoy eating
Avoid laying down after eating
Minimize fried, fatty, greasy foods
Keep a food log to look for changes in diet because older adults may not be able to recall their meals due to cognitive impairment
Stay hydrated—drink plenty of fluids
When to call the office with concerns (Gorgojo-Martínez et al 2023; Wharton et al 2022)
Older adults are at an increased risk of having underlying urinary issues, such as urinary incontinence, urge incontinence, overactive bladder, lower urinary tract symptoms (LUTS) or benign prostatic hyperplasia (BPH), a history of urinary tract infections (UTIs), or volume depletion, which can be a concern with the SGLT2i medication class (ADA PPC 2024b).
Again, although these are not absolute contraindications, it is important for the DCES to investigate these conditions further. LUTS is often concurrent with BPH and includes urinary frequency and urgency and nocturia. When adding an SGLT2i, these symptoms may worsen (Krepostman and Kramer 2021). Having multiple UTIs recently or a UTI requiring hospitalization is more concerning than having a UTI several years ago. Similarly, having controlled BPH is less of an issue than urge incontinence requiring pad or diaper use.
The DCES can provide the following education tips to those being started on an SGLT2i: maintaining good genital hygiene; signs and symptoms of UTI and yeast infections; signs of low blood pressure; signs, symptoms, and treatment of euglycemic diabetic ketoacidosis; when to call the office with concerns; and maintaining adequate hydration (Morris 2023). Starting an SGLT2i when A1C is lower can also help decrease risk of side effects (Wilding et al 2018).
As of 2023, there are approximately 65 million people who have Medicare. Of those, just over 50 million have drug coverage, whether that be through Part D or a Medicare Advantage plan. Prior to the Inflation Reduction Act of 2023, insulin of any kind may have been cost-prohibitive. Now, insulin products are capped at $35 per month supply for Medicare recipients who have prescription coverage (KFF 2023). However, both GLP1-RA and SGLT2i remain expensive medications, even with Medicare coverage. Cost can be a barrier for patient use, especially when they are in the coverage gap or “donut hole.” Insurance coverage and requirements should be taken into account when recommending these medications for patients.
Anticipating and addressing cost-related barriers can help improve patient satisfaction and adherence with the therapy. Older adults may live on a fixed income, so cost tends to be a priority and comes into play regarding their treatment preferences. The DCES can see if there are any safety concerns with prescribed diabetes medications and recommend stopping them, which would address the safety concern and decrease costs as well (ADA PPC 2024b). More information about helping PWD with cost of medications can be found through Association for Diabetes Care & Education Specialists (ADCES) Cost-Saving Resources for insulin and noninsulin medications, which discusses patient assistance programs and other offerings (ADCES 2023a, 2023b).
Cost and concerns about side effects can be barriers to older adults taking GLP1-RA and SGLT2i medications. Other barriers could include lack of understanding or knowledge about diabetes, skepticism about medication use, lack of trust in their care team or health care system, cultural differences, and differences in health beliefs. For some, diabetes is not a priority.
Utilizing shared decision making (SDM), motivational interviewing (MI), and the teach back method are some strategies that the DCES can use to assess and potentially overcome barriers to taking medications.
Accounting for functional status, presence of complications and comorbidities, and life expectancy will aid the DCES in developing an optimal treatment plan as the PWD ages.
According to LeRoith et al 2019, “SDM is a collaborative, patient-directed decision-making process that that helps the patient set goals and priorities with input from their health care team, family, and other caregivers. The objective is for the patient to make choices that meet his/her needs while honoring personal values and preferences.”
It is particularly important to involve the PWD in their own treatment plan to improve adherence and patient satisfaction. When discussing medication changes with patients, it is important to assess their beliefs, needs, and concerns. Older adults may have many concerns about taking another medication or how they will feel once they take it.
If the PWD is resistant to medication or lifestyle changes, consider using MI. MI is a patient-centered counseling style that helps patients explore and resolve ambivalence with a goal of changing behaviors. MI is not meant to be confrontational or “preachy.” Rather, it is meant to be nonjudgmental, open, accepting, and compassionate. The guiding principles of MI include resisting the urge to correct the patient, understanding the patient’s motivations, listening with empathy, and empowering the patient to find their own motivation to engage in positive behaviors. Using open-ended questions, reflective listening, and affirmations can help facilitate the conversation.
Training to help learn and practice MI is widely available. A few additional helpful tips include communicating with respect and acceptance, giving advice only if it is asked for, helping PWD become aware of discrepancies between their goals and current behaviors, and supporting self-efficacy by referring to their previous achievements and strengths (Duff and Latchford 2016; Hawkins 2022).
After providing education, using the teach back method is also a helpful strategy to make sure the PWD understands the information. Consider having close follow-up with the older adult to address any questions or concerns that arise. This would also give another opportunity to teach, repeat, or reinforce topics so the PWD is not overwhelmed with too much information at once.
There are many factors to take into account when evaluating medication use in the older adult. Diabetes goals and management should always be individualized, especially in the older adult population, because the aging process is different from person to person. Accounting for functional status, presence of complications and comorbidities, and life expectancy will aid the DCES in developing an optimal treatment plan as the PWD ages. Evaluating for declining selfmanagement behaviors is also an important part of care.
The DCES is well positioned to provide education about medications, screen for potential issues, be a patient advocate, and provide recommendations on how to manage side effects. The DCES can usually spend more time with the older adult to make sure they understand the risks and benefits of their diabetes medications and talk through the concerns that they may have. SDM and MI are both great strategies that the DCES can use to facilitate these conversations.
Christina Inteso, PharmD, BCACP, CDCES, is with Corewell Health in Grand Rapids, MI.
The author declares having no professional or financial association or interest in an entity, product, or service related to the content or development of this article.
The author declares having received no specific grant from a funding agency in the public, commercial, or not-for-profit sectors related to the content or development of this article.
Christina Inteso https://orcid.org/0009-0009-5677-8800
2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-2081. doi:10.1111/jgs.18372
American Diabetes Association Professional Practice Committee. American Diabetes Association. 6. Glycemic goals and hypoglycemia: Standards of Care in Diabetes—2024. Diabetes Care. 2024[a];47(Suppl 1):S111-S125. doi:10.2337/dc24-S006
American Diabetes Association Professional Practice Committee. American Diabetes Association. 13. Older adults: Standards of Care in Diabetes—2024. Diabetes Care. 2024[b];47(Suppl 1):S244-S257. doi:10.2337/dc24-S013
Association of Diabetes Care and Education Specialists. Insulin cost-savings resource guide. Updated September 8, 2023[a]. Accessed March 16, 2024. https://www.adces.org/docs/default-source/handouts/costsavingsresources/ehandout_hcp_costsaving_insulincostsavingresource2023.pdf?Status=Master&sfvrsn=1e56359_15
Association of Diabetes Care and Education Specialists. Noninsulin diabetes medication cost-savings resources. Updated September 8, 2023[b]. Accessed December 16, 2023. https://www.adces.org/docs/default-source/handouts/costsavingsresources/ehandout_hcp_costsaving_noninsulindiabetesmeds2023.pdf?Status=Master&sfvrsn=38e56359_11
Centers for Disease Control and Prevention. National diabetes statistics report. Published 2022. Accessed December 16, 2023. https://www.cdc.gov/diabetes/data/statistics-report/index.html
Delara M, Murray L, Jafari B, et al. Prevalence and risk factors associated with polypharmacy: a systematic review and meta-analysis. BMC Geriatrics. 2022;22:601. doi:10.1186/s12877-022-03279-x
Duff A, Latchford G. Using motivational interviewing to improve medicines adherence. Pharm J. 2016;296(7889). doi:10.1211/PJ.2016.20200954
Gorgojo-Martínez JJ, Mezquita-Raya P, Carretero-Gómez J, et al. Clinical recommendations to manage gastrointestinal adverse events in patients treated with GLP-1 receptor agonists: a multidisciplinary expert consensus. J Clin Med. 2023;12(1):145. doi:10.3390/jcm12010145
Hawkins C. Supporting medication adherence with motivational interviewing. Pharmacy Times. Published September 23, 2022. Accessed December 16, 2023. https://www.pharmacytimes.com/view/supporting-medication-adherence-with-motivational-interviewing
KFF. An overview of the Medicare Part D prescription drug benefit. Published October 2023. Accessed March 16, 2024. https://www.kff.org/medicare/fact-sheet/an-overview-of-the-medicare-part-d-prescription-drug-benefit/
Krepostman N, Kramer H. Lower urinary tract symptoms should be queried when initiating sodium glucose co-transporter 2 inhibitors. Kidney360. 2021;2(4):751-754. doi:10.34067/KID.0000472021
LeRoith D, Biessels GJ, Braithwaite SS, et al. Treatment of diabetes in older adults: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2019;104(5):1520-1574. doi:10.1210/jc.2019-00198
Morris D. Avoiding and managing side effects of type 2 diabetes treatments. J Prescr Pract. 2023;5(4). doi:10.12968/jprp.2023.5.4.158
Roger VL. Epidemiology of heart failure. Circ Res. 2021;128(10):1421-1434. doi:10.1161/CIRCRESAHA.121.318172
Tufts University. Rethinking BMI for older adults. Published July 2014. Updated September 2019. Accessed December 16, 2023. https://www.nutritionletter.tufts.edu/healthy-eating/weight-mgmt/rethinking-bmi-for-older-adults/
Wharton S, Davies M, Dicker D, et al. Managing the gastrointestinal side effects of GLP-1 receptor agonists in obesity: recommendations from clinical practice. Postgrad Med J. 2022;134(1):14-19. doi:10.1080/00325481.2021.2002616
Wilding J, Fernando K, Milne N, et al. SGLT2 inhibitors in type 2 diabetes management: key evidence and implications for clinical practice. Diabetes Ther. 2018;9:1757-1773. doi:10.1007/s13300-018-0471-8
Winter J, MacInnis RJ, Wattanapenpaiboon N, et al. BMI and all-cause mortality in older adults: a meta-analysis. Am J Clin Nutr. 2014;99:875-890. doi:10.3945/ajcn.113.068122
