Podcast Summary: Diabetes Core Update – "Diabetes in Older Adults Consensus Statement"
Episode Date: December 20, 2012
Hosts: Dr. Neil Skolnik & Dr. John J. Russell
Guest Expert: Dr. Mary T. Kortakowski, Professor, Division of Endocrinology, University of Pittsburgh
Overview
This episode focuses on the 2012 American Diabetes Association (ADA) Consensus Statement on the management of diabetes in older adults, recently published in Diabetes Care. Dr. Skolnik and Dr. Russell are joined by Dr. Mary Kortakowski, a consensus committee member, to discuss the unique challenges of treating diabetes in people over 65––a demographic comprising over one-quarter of Americans in that age bracket, with numbers expected to rise. The conversation explores new recommendations for screening, individualized treatment targets, the management of comorbidities, and practical considerations for drug therapy in older adults, including those in long-term care settings.
Key Discussion Points & Insights
1. Epidemiology & Consequences of Diabetes in Older Adults
Timestamp: 02:14 – 04:48
- Prevalence: Over 25% of Americans aged 65+ have diabetes, with many undiagnosed.
- Causes: Increased obesity, sedentary lifestyles, age-related loss of muscle mass, inefficiency in energy metabolism, and decline in β-cell function.
- Consequences: Older adults with diabetes have the highest rates of lower limb amputation, heart attacks, visual problems, and kidney failure, especially those 75+.
- Insidious onset: Many symptoms are mistakenly attributed to aging, delaying diagnosis and potentially worsening outcomes.
“About a third of those [older adults with diabetes] are not aware of the diagnosis… The consequences of not knowing that you have diabetes can be serious.” — Dr. Kortakowski (03:42)
2. Screening and Prevention
Timestamp: 05:05 – 08:29
- ADA Recommendation: Screen adults over 45 every 1–3 years with fasting glucose, A1C, or oral glucose tolerance (least used in practice for elderly). For those 65+, yearly fasting glucose is reasonable.
- Rationale: Early detection can prevent complications and improve quality and length of life.
- Prevention Data: Lifestyle interventions (diet/exercise) in older adults (60+) produced better diabetes prevention results than younger groups in a long-term study.
- Caloric restriction and exercise (30 min, 5x/week) halved the conversion to diabetes in those over 60.
- Metformin was less effective for prevention in this age group.
“Participants who were over age 60 had a greater response to lifestyle intervention than the younger participants.” — Dr. Kortakowski (06:44)
3. Individualizing Glycemic Goals
Timestamp: 09:00 – 12:24
- General ADA target: A1C <7%.
- Consensus Statement: Move away from "one-size-fits-all"; glycemic goals tailored based on functional status, comorbidities, and cognitive status:
- Healthy, few comorbidities: A1C <7.5% (down to 6.5% if easily achieved)
- Intermediate health/comorbidity: A1C <8%
- Frail, significant illness: A1C <8.5%
- Reasoning: Both very low and very high A1Cs are linked to higher mortality in elderly diabetics.
“For those who are very healthy and doing well regardless of age, aiming for an A1C less than 7.5% is reasonable… for the most frail, aiming for an A1C of less than 8.5% is reasonable.” — Dr. Kortakowski (10:40)
4. Management of Comorbidities
a. Lipid Lowering
Timestamp: 12:41 – 13:48
- Statins: Effective in reducing CVD risk by ~20% in those 70+. Recommended for healthy/intermediate patients, case-by-case for frail elderly.
b. Blood Pressure
Timestamp: 13:51 – 15:37
- ACCORD trial: No added benefit from “tight” systolic targets (<120 mmHg) versus <140 mmHg.
- Recommended targets:
- Healthy/intermediate: <140/80 mmHg
- Frail: <150/90 mmHg
- Polypharmacy: Caution against over-medication and risk of hypotension and falls.
c. Aspirin
Timestamp: 15:53 – 17:14
- Primary prevention: Low-dose aspirin reasonable for men >50 and women >60, if no contraindications.
- Bleeding risk isn’t substantially higher in the elderly; individualize use.
5. Practical Drug Therapy Considerations
Timestamp: 17:14 – 24:31
- Heightened Sensitivity: Elderly patients have altered pharmacokinetics (renal clearance, side effects).
- Avoid Glyburide: Especially high risk of hypoglycemia in elderly; should not be used.
- Metformin: Still first-line recommendation. Monitor renal function (EGFR cutoffs ~45mL/min). Also consider B12 supplementation due to risk of deficiency.
- Sulfonylureas: Risk of hypoglycemia; patient/caregiver education on low blood sugar symptoms is essential.
- Short-acting Insulin Secretagogues: Also carry hypoglycemia risk.
- Thiazolidinediones: Generally avoided due to heart failure and fracture risk.
- Incretin-based Agents (GLP-1 agonists/DPP-4 inhibitors): Little elderly-specific data, but appear safe; injectables can cause GI side effects and pancreatitis, DPP-4 inhibitors generally well tolerated but costly.
- Insulin: Not contraindicated; basal regimens preferred, adjust for cognitive/functional status.
“There are really no absolute contraindications to any particular therapy for type 2 diabetes with the exception of glyburide… Glyburide should not be used at all in older adults.” — Dr. Kortakowski (17:51)
“Metformin… does raise the issue of renal function… probably reasonable to either monitor B12 levels or to start low dose supplements [in elderly].” — Dr. Kortakowski (19:08)
6. Long-Term Care Settings
Timestamp: 24:43 – 26:42
- High Prevalence: Diabetes is more common in long-term care residents.
- Risks: Falls, cognitive and functional impairment, irregular meals, risk of both hyper- and hypoglycemia.
- Sliding Scale Insulin: Most common but least effective; avoid if possible.
- Preferred Strategies: Blood sugar monitoring, therapies that limit hypoglycemia (metformin if renal function allows, basal insulin).
- Data Gaps: Few studies guide optimal management in this setting; clinical judgment required.
Notable Quotes & Memorable Moments
-
Highlighting Underdiagnosis:
“About a third of those [older adults with diabetes] are not aware of the diagnosis… The consequences of not knowing that you have diabetes can be serious.”
— Dr. Kortakowski (03:42) -
Lifestyle Interventions Can Be Highly Effective:
“Participants who were over age 60 had a greater response to lifestyle intervention than the younger participants.”
— Dr. Kortakowski (06:44) -
Tailored Glycemic Targets:
“For those who are very healthy and doing well regardless of age, aiming for an A1C less than 7.5% is reasonable… for the most frail, aiming for an A1C of less than 8.5% is reasonable.”
— Dr. Kortakowski (10:40) -
On Sulfonylureas and Hypoglycemia:
“Glyburide should not be used at all in older adults.”
— Dr. Kortakowski (17:51) -
Emphasis on Individualization:
“We’ve moved from a one size fits all approach to more individualization of target goals…”
— Dr. Skolnik (12:24)
Timeline of Key Segments
| Segment | Timestamp | |---------------------------------------|---------------| | Episode Introduction | 00:01 | | Epidemiology & Consequences | 02:14 | | Screening Recommendations | 05:05 | | Lifestyle Interventions | 06:44 | | Individualized Glycemic Targets | 09:00 | | Lipid Management | 12:41 | | Blood Pressure Management | 13:51 | | Aspirin Therapy | 15:53 | | Drug Therapy: Medications | 17:14 | | Long-Term Care Considerations | 24:43 | | Episode Wrap-up | 26:42 |
Summary
This episode delivers a targeted review of the ADA’s consensus statement on older adults with diabetes, highlighting the need for nuanced, individualized care. The discussion underscores the diversity among older adults, the importance of early identification and tailored interventions, and the risks and benefits of various therapies particular to this age group. Clinical pearls—like the clear avoidance of glyburide, careful attention to renal function, revised A1C targets, and skepticism around sliding scale insulin—equip providers with actionable takeaways for enhancing care in their elderly diabetic patients.
For further reading, clinicians are encouraged to consult the full consensus statement at www.diabetesjournals.org.