AGS Updates Its Guidelines for Managing Diabetes in Older Adults

Roughly 11 million Americans aged 65 and older have diabetes mellitus, making this the largest age group in the United States with the disease. The prevalence of diabetes among older people is expected to increase further in coming years, and with it, the number of seniors at risk of serious complications of diabetes, including cardiovascular disease (CVD) and kidney failure. Further complicating care, diabetes is associated with geriatric syndromes such as depression, polyuria, cognitive impairment, and falls.

In light of this clinical complexity, it’s essential that healthcare professionals provide up-to-date, evidence-based, individualized, and patient-centered care for their older patients with diabetes. To help healthcare professionals deliver high-quality and high-value care, the American Geriatrics Society (AGS) recently updated its diabetes guidelines.
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An abridged version of the full guidelines, titled The American Geriatrics Society Guidelines for Improving the Care of Older Adults with Diabetes Mellitus: 2013 Update, appears in this month’s Journal of the American Geriatrics Society. The complete guidelines are available on GeriatricsCareOnline.org. The new guidelines update a 2003 edition published by the AGS and the California Health Care Foundation, and are the work of an expert panel of clinicians and researchers in the fields of medicine, nursing, and pharmacy.

Reflecting a decade of new research, the 2013 guidelines cover the prevalence and incidence of the disease among older people today. They also report the latest findings regarding complications and syndromes associated with diabetes, and updated, evidence-based treatment recommendations for these patients.

Those familiar with the 2003 edition will find some significant changes. The new version no longer recommends the use of aspirin for the primary prevention of CVD among older people with diabetes. This shift is informed by recent, well-designed studies finding that increased risks of bleeding outweigh potential reductions in cardiovascular events. The guidelines, however, note “strong evidence” that aspirin may be effective in secondary prevention for older adults with diabetes who have already had a stroke or heart attack.

The new guidelines also renew the emphasis on treating elevated cholesterol with statins – but not necessarily treating to specific target levels. The guidelines advise that blood sugar control be tailored to each older adult’s functional status, comorbidities, and life expectancy. This is important because, they note, if control is too aggressive it may lead to hypoglycemia, and serious complications such as falls or loss of consciousness. In addition, the guidelines recommend lifestyle modification for healthy older adults with diabetes, given additional evidence of the important of exercise and, when necessary, weight loss.

The self-monitoring of blood glucose (SMBG) should also be individualized and questioned. Many older adults with type 2 diabetes do not need SMBG and there is little evidence of any positive impact on desired outcomes, especially for those without changes in their therapy. And they are unnecessarily sampling blood glucose multiple times a day when the value of this monitoring may, at best, be questionable.

Incorporating the new guidelines into practice will require the involvement of patients— and family members, or other informal caregivers, if appropriate—not only in identifying their treatment goals, but also in reaching those goals. Ensuring that patients are counseled about their important role in collaborating with their providers, and getting the support they need is essential as well.

To help patients and their caregivers learn to better manage their diabetes, Medicare Part B covers outpatient training for both those at risk of complications of diabetes, and those recently diagnosed with the disease. The cost is 20% of the Medicare-approved amount after the yearly Part B deductible. A healthcare professional must provide a written order to a certified diabetes self-management education program for a patient to qualify. Under the Affordable Care Act, older adults also qualify for free annual wellness visits aimed at identifying health risks such as diabetes and complications of diabetes. Clinicians should make sure that patients make the most of these offerings.

For all of us who care for older adults with diabetes, the new AGS guidelines provide evidence-based information to guide strategies that provide high-value care and further improve the quality of life for older adults with diabetes.