Building Competency in Diabetes Education THE ESSENTIALS

TREATMENT MODALITIES: PHARMACOLOGICAL THERAPIES | 6-51

• a person with limited life expectancy • a frail elderly individual and/or with dementia

o In cohort studies, an A1C of 7.0 to 8.0% is associated with the best survival rate in the elderly with diabetes; increased mortality is seen with lower and higher A1C results (23). o Moderate to severe hypoglycemia could precipitate a fall, injury, CV event, seizure or coma for A1C of <6.5% (23). o A1C of <6.5% or >8.0 is associated with increased risk of fractures (23). Studies have shown intensive glycemic control reduces the risk of microvascular events, but does not reduce macrovascular events or mortality in older individuals that have diabetes complications. However, improved glycemic control has been linked to better function and less disability (23). The diabetes health-care (DHC) teammust weigh the benefits of optimal glycemic control with the risks associated with hypoglycemia and impact on comorbid conditions. For many older adults, the above risks often outweigh the benefits of tight glycemic control. • The risk of severe hypoglycemia and hypoglycemia unawareness increases with age. Older adults with diabetes are at an increased risk for hypoglycemia due to an age-related decrease in glucagon production, impaired recognition of autonomic symptoms of hypoglycemia (reduced neurogenic symptoms), delayed psychomotor response to treatment and impaired cognition (117). • Older adults are also at an increased risk of drug interactions, as they are often taking multiple medications to treat numerous comorbid conditions. Increased age is also associated with a decrease in renal and hepatic function and increased risk for drug accumulation (118). The liver’s ability to metabolize specific drugs is diminished due to decreased blood flow to the liver. Creatinine clearance is often decreased in the older adult; the kidney’s ability to excrete medications may be reduced by 50% or more (117). Determining the best treatment option in the older person with diabetes (23,43, 100) The choice of agent needs to be individualized in the older person with diabetes. The priority is to use agents not associated with hypoglycemia and weight gain. Complicated treatment regimens and overtreatment should be minimized. Baseline serum creatinine levels and eGFR (or calculated creatinine clearance) should be assessed in the older adult as they can have impaired renal function despite a normal serum creatinine level (38).