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Assistant Professor of Medicine
Diabetes Nurse Practitioner
Division of Endocrinology, Diabetes and Metabolism
Weill Cornell Medicine
New York, New York
Jane Jeffrie Seley, DNP, MPH, MSN, GNP, BC-ADM, CDCES, has no relevant conflicts of interest to report.
In this commentary, Nurse Practitioner and Diabetes Care and Education Specialist Jane Jeffrie Seley discusses the importance of setting and safely implementing personalized treatment goals using shared decision-making for older adults with type 2 diabetes (T2D). A webinar is available where Dr. Seley and other expert faculty discuss the management of T2D in older adults including individualization of treatment goals, use of fixed-ratio combination insulin and glucagon-like peptide-1 receptor agonist (GLP-1 RA) injectables, and management considerations in long-term care facilities. Slides from the webinar are also available for self-study or to use in noncommercial presentations.
The American Diabetes Association (ADA) recommends glucose targets for nonpregnant adults as follows: preprandial blood glucose (BG) between 80-130 mg/dL and postmeal BG <180 mg/dL. Persons with diabetes (PWD) should be advised to check postprandial BG levels 1-2 hours after the first bite of the meal. The A1C target for most people is <7.0%, which is equivalent to an average BG of 154 mg/dL. In older adults, especially those with comorbidities and at higher risk for hypoglycemia, a less aggressive A1C target of 7.5% to 8.0% is safer. The ADA recommends adjusting the A1C targets for older adults based on health status and characteristics of each PWD divided into 3 main categories. For a highly functional, relatively healthy individual with a longer life expectancy, the A1C goal ranges from less than 7.0% to up to 7.5%, with a preprandial BG of 80-130 mg/dL and an 80-180 mg/dL goal at other times. The next category includes individuals who have some treatment burden and numerous chronic illnesses. Their A1C goal is <8.0%, with BG targets adjusted to 90-150 mg/dL before meals and 100-180 mg/dL at other times. The last category is for those individuals with limited life expectancy and multiple health conditions in addition to cognitive impairment. The ADA recommends avoiding the use of an A1C target and shifting the focus to preventing hypoglycemia and symptomatic hyperglycemia. Preprandial glucose levels of 100-180 mg/dL and 110-200 mg/dL at other times are acceptable. These gentler targets help the healthcare professional, in partnership with the PWD, to formulate a diabetes self-care regimen with an emphasis on safety in this vulnerable population (Figure 1).
Figure 1. Glycemic Goals in Older Adults
Practical Considerations: Glucose Data, Duration of Diabetes, Age, Medication Costs, Complexity of Regimen
Most older patients rely on BG meters to guide diabetes medication therapy and lifestyle changes. The healthcare professional should compare the available BG data with the A1C to determine whether the A1C average glucose matches the BG levels reported. If the estimated average glucose of the A1C is higher or lower than the average BG meter measurements, this may mean that the PWD is not checking their BG at enough at different times of day to get a full picture of their glycemic outcomes. For example, if the PWD is only checking before breakfast and before dinner, they have no information about what happens to the BG after meals or during the night. Personal continuous glucose monitoring (CGM), usually worn on the arm or abdomen for 10-14 days depending on the device, measures glucose levels every 1-5 minutes and emits alerts and alarms when the BG is rapidly rising or falling. This early warning system presents an opportunity for the PWD to take preventive action before the BG is high or low. Coverage for personal CGM varies and may be tied to a minimum of 3 insulin injections each day. Professional versions of CGM belong to the practice and can be easily placed on seniors periodically to obtain valuable information about glucose levels 24/7 to guide therapy adjustments. Intermittent professional CGM helps healthcare professionals make amazing discoveries along with the PWD such as the person taking basal insulin with a high fasting BG who is experiencing rebound hyperglycemia in response to hypoglycemia at night during sleep. We would now know to lower the basal insulin dose instead of raising it because of the high fasting BG. CGM can also inform medication considerations for postprandial rises after some or all meals that we would never have known if the PWD was not checking postprandial BGs. For persons with an A1C 10.0% or higher, the need for both long-acting basal and mealtime bolus insulin may be needed. This presents a huge challenge in many older adults since this regimen requires 4 injections daily, often accompanied by glucose checks prior to each meal and dose calculations.
The longer a person has T2D, the fewer the functional β cells to make enough insulin to cover both metabolic needs and meals. Since it takes up to 12 years for the person with T2D to be diagnosed, there may be considerable β cell loss at the time of diagnosis. As β cell destruction continues over time, many will require insulin to meet glycemic targets, especially if they have not made sufficient lifestyle changes such as losing weight or becoming more physically active. As PWD age and develop comorbidities, they run an increased risk of undetected or undertreated hypoglycemia. Hypoglycemia is a great concern in older adults as it can lead to adverse events such as falls and loss of cognition. To avoid causing hypoglycemia, it is best to slowly and cautiously introduce and titrate any diabetes therapies that can cause hypoglycemia such as sulfonylureas and insulin.
Medication costs are a major consideration when promoting self-care behaviors. If a medication is not covered by the patient’s insurance plan or has a high copay, many older PWD could not afford it, especially those on limited incomes. The complexity of any diabetes regimen that addresses both metabolic and mealtime needs such as basal/bolus insulin therapy is also a tremendous barrier to self-care. Basal insulin and metformin are great options to lower fasting BG levels, whereas dipeptidyl peptidase 4 inhibitors and GLP-1 RAs may work well for postprandial rises. Agents that either promote weight loss such as metformin and GLP-1 RAs should be prioritized if weight loss is needed. Adding a GLP-1 RA or metformin to basal insulin may mitigate some of the weight gain associated with insulin therapy.
Initiating Insulin Therapy
The simplest way to begin insulin therapy for persons with T2D is to start with 1 injection/day of basal insulin at the same time each day to lower the fasting BG. If mealtime coverage is also needed, the next step could be basal-plus, continuing basal insulin once daily and adding a dose of mealtime insulin at the largest meal. This stepwise approach works best with many older adults, giving them ample time to master one step before adding another. Another way to simplify the process is to introduce a fixed mealtime dose that does not require a glucose check or dose calculation. Although this requires less effort, prandial insulin has an added risk of hypoglycemia with a fixed dose if the BG is low at the time of the meal or if less of the meal is eaten.
A simple way to provide mealtime coverage and long acting-insulin for in-between meals and overnight is to prescribe basal insulin once/day at the same time each day and a GLP-1 RA once daily or once weekly to blunt postprandial glucose excursions. Although this regimen may be simple for some, older adults with changes in vision, problem-solving skills, and memory may mix up multiple medications as well as timing and amounts to take. Another option would be the fixed-ratio combination (FRC) of basal insulin and GLP-1 RA in a single injection without any dose calculations. Initial dosing is based on prior basal insulin dose then slowly titrated once or twice weekly depending on which FRC is chosen, up to a therapeutic dose. The A1C and any blood glucose meter or CGM glucose data are monitored over time and the FRC dose is adjusted periodically if needed (Figure 2).
Figure 2. Dosing Fixed-Ratio Combination Basal Insulin/GLP-1
Once you and the PWD has decided to start on an injectable medication, diabetes self-care management education (DSME) is essential for the older PWD to feel safe and comfortable self-injecting at home. Saline practice pens, pen needles, injection pillows, and pictures of injection sites should be available as teaching aids. In older adults, demonstration and return demonstration with ample time for practice is critical to determine whether the PWD can safely self-administer the medication or requires assistance (Figure 3).
Figure 3. Comfort and Safety of Injectable Medications
Recognition, treatment, and prevention of hypoglycemia should always be included in DSME if the PWD will be taking a medication that can cause hypoglycemia. Discuss the importance of eating 3 meals/day, how meals should be spaced at least 4 hours apart, and how to limit carbohydrate servings at each meal. The plate method is a simple way to teach how to limit carbohydrates; however, consultation with a dietitian allows for a more flexible and comprehensive meal plan.
Individualization of glycemic targets and choice of medication is key when caring for older adults with T2D. When choosing pharmacologic therapy for diabetes, patient-specific factors should be considered such as A1C, duration of diabetes, weight, age, comorbidities, hypoglycemia risk, cost of medication, complexity of regimen, and patient preference. A simple and easy-to-follow diabetes self-care regimen will assist in promoting self-care and successful glycemic outcomes.
In your practice, how do you teach self-care behaviors in older patients with T2D requiring insulin? Answer the polling question and share your thoughts in the comments box below.