Diabetes Care for Older People: Is It Different?

By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen Wyner, NP

The Americans Diabetes Association has addressed the care of the older person living with diabetes  in their 2014 Clinical Practice Recommendations Standards of Medical Care. These recommendations do not define “older” by any specific numerical reference but instead are based on a person’s medical conditions. Quite honestly, this makes it easier for me to interpret these recommendations when I am caring for patients because I do not know what is considered “older” anymore. I think age is just a number that I personally hope keeps getting higher and higher, especially those decade celebrations because those silly cards are my all-time favorites.

The average lifespan of Americans is approximately 76 years for men and 81 years for women. This expectation has been slightly increasing over the years and everyone has an opinion as to why this is. I believe people are living longer due to a combination of better medical care, use of technology, and (quite frankly) attitude. I have been practicing for 30 years and I see people both living longer and living younger. I’d like to discuss this recommendation and offer some suggestions to help you and your family better understand and manage diabetes across your lifespan. I also want to remind you that these practice recommendations are just that: recommendations. Each person’s care should be individualized with their health care provider.

The Standards of Medical Care from the American Diabetes Association was developed because older adults with diabetes have a greater chance of premature death, cognitive impairment, and coexisting illness such as hypertension and heart disease. However, there are not many long-term studies available about the benefits of intensive control of blood sugar and blood pressure in the older population. The ADA has determined that people with few coexisting illnesses and intact cognitive and functional abilities should have similar goals for treatment as the general population. Those with multiple coexisting illnesses and some impairment (cognitively and /or functionally), end stage chronic illnesses, and/or severe cognitive impairment should have less stringent goals for treatment per the same recommendations. Health care providers need to consider that the goals for blood sugar management need to be directed to be sure that the acute complications of hyperglycemia, such as poor wound healing, dehydration, and coma, are avoided. It’s also important for health care providers to remember to screen for complications across the lifespan and individualize this screening to be most aware of complications such as visual and lower extremity injury that can develop quickly and seriously impact functional status.

Now, how can we break this down so people living with diabetes can use this information to stay well? As we age, we may be faced with challenges such as multiple medical conditions, decreased memory ability, decreased agility and mobility, and financial challenges. People with many medical conditions have to manage multiple medications and medical appointments. It’s helpful to bring a friend or family member to appointments to be sure all important information is provided to the health care provider, and make sure that the provider’s suggestions are understood. A visiting nurse home evaluation may be in order to help with medication safety.

People who are struggling with memory issues may forget when their appointments are. They may also forget if they took their medications which could have life threatening implications, including hypo or hyper –glycemia. Family members may be able to set up simple reminders like Post- it® notes on the bathroom mirror or the kitchen counter. A simple large calendar may help with the appointment reminders.

People with mobility issues may not be able to exercise as they once did, so glucose control may be hindered. They may also be at greater risk of injury from falling. A safety assessment of the living space may be needed to avoid falls. Osteoarthritis can make checking blood sugars, administering insulin, and food preparation difficult or even unsafe. They may actually not be able to do frequent glucometer checks, meaning medication dose(s) may need to be adjusted to ensure safety.

Financial needs are very important to identify and address as costs of medications, testing supplies, and food can definitely impede people’s health. Health care providers need to inquire about these issues as people may be too embarrassed to bring it up themselves. Referral to social services for assistance is an important piece to try to work on a solution to this problem.

These are complicating factors on their own, but people with diabetes may also have severe visual impairment as the chance of developing retinopathy increases across the life span. This factor alone can be a huge negative impact on a person’s health status. Diabetes is difficult to manage at times. It takes time and dedication for the person living with diabetes, their family, and their providers. Aging is another unavoidable bump in the road of management. Adjustments in your diabetes care plan are sometimes needed because of this unavoidable fact, but the goal of these changes is to continue your good health. I think that the best approach is not to get caught up in the A1C values, but rather continuing to do all you can to stay healthy and keep collecting those silly birthday cards!


2013 ADA Clinical Practice Recommendations (Part 2)

Eileen Wyner, NP

By Eileen B. Wyner, NP
Bulfinch Medical Group

This week I want to finish reviewing the revisions to the ADA Standards of Care (click here to review Part 1). Please remember that these are guidelines.  Always review your personal health care plan with your health care providers


Many people associate immunizations with childhood, but there are several immunizations that are required throughout the lifespan. I reviewed these in the past (which you can find here), so today I will just address the ADA revisions. Annual influenza and appropriate pneumococcal vaccination is still strongly recommended for all people living with diabetes. Late in 2012 the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices decided to recommend vaccination against hepatitis B virus (HBV) for all people living with diabetes between 19 and 59 years old. People older than 60 are also considered vaccination candidates, but will first need to first be assessed by their providers as the immune response is sometimes decreased in seniors.

The CDC was prompted to make this recommendation after reviewing reports of outbreaks of HBV in long-term care facilities and hospitals where monitoring devices may have been shared by patients.  HBV is a highly contagious disease transmitted through contact with blood and infected bodily fluids. This virus can live for a long period of time on surfaces such as lancet devices, glucometers, and the reservoirs of insulin pens (even when there is no visible blood). This is the reason that these tools shouldn’t be shared with others.

Many people are vaccinated against HBV as this is a required childhood vaccine.  Many professions require this vaccine as well.  I suggest discussing this with your health care provider at your next appointment.

Blood Pressure Control

Well controlled blood pressure is imperative for people living with diabetes and this year the ADA changed their target goal for well controlled blood pressure to <140/<80 (previously <130/<80). This recommendation was developed after reviewing several randomized controlled trials published within the last 5 years demonstrating  little improvement in the reduction of cardiovascular events with the previous target.  Instances when a lower blood pressure goal is appropriate will be determined by the health care provider on an individual basis.

Retinopathy Screening and Treatment

The revised recommendations to this standard have to do with the treatment options for Diabetic Macular Edema (DME), a complication of long term and/or poorly controlled diabetes. DME occurs when damaged blood vessels in the eye leak fluid into the macula, causing swelling and blurry vision. Since 1985 the only treatment available for this condition was laser photocoagulation therapy, which could help reduce the risk of future visual loss but had no effect on damage that had already occurred. In August 2012 the FDA approved Ranibizumab (Lucentis), a medication that is given as a monthly eye injection, for DME treatment.  Studies have shown improvement in vision for people treated with this medication.

Lipid Management

Lowering LDL (“bad” cholesterol) levels with the use of statins has been well documented as a method to reduce cardiovascular events. However, many people have trouble tolerating these medications due to side effects. The ADA is advising  providers work with patients to find a dose or alternative statin  that is better tolerated as the benefits of this therapy is well proven. It is documented that very low, even less than daily, doses of statins can be beneficial.

Diabetes Care in the Hospitalized Patient

The ADA is recommending that patients admitted to the hospital may need some level of screening for diabetes. Providers should consider obtaining an A1C if there is no recent value available and/or  if the patient has any risk factors for diabetes and hyperglycemia while in the hospital.  In the latter case, follow up care needs to be set up to address these results.

There are several more updates and recommendations we did not touch on.  To view the full set of 2013 Clinical Practice Recommendations, click here.


2013 ADA Clinical Practice Recommendations (Part 1)

By Eileen B. Wyner, NP
Bulfinch Medical Group

Eileen W

Every year the multidisciplinary Professional Practice Committee of the American Diabetes Association (ADA) publishes a set of guidelines and recommendations on the diagnosis and treatment of diabetes for both adults and children. These standards guide us in how and when to screen for, diagnose and treat diabetes; how to monitor for complications; and how to educate patients in their self-management strategies.

These standards of care provide concrete data about goals of treatment, but they are not meant to be the only approach to care. Rather, they provide a guideline for the care of a person with diabetes;  providers rely on their best clinical judgment for each individual they care for and adapt the guidelines as needed.  Last year I did a review of the ADA Guidelines along with the specific updates published (you can refer to that post here). This year there were 12 revisions published which I will highlight this week and next. Please remember that these are guidelines— always review your personal health care plan with your health care provider(s).

Screening for Type 1 Diabetes

Type 1 Diabetes is generally diagnosed with an acute presentation of hyperglycemia and even ketoacidosis. There is no evidence that screening the general population for Type 1 Diabetes is helpful, but there is valid evidence that measuring islet autoantibodies in relatives of people with Type 1 Diabetes will identify at-risk individuals. Those identified can be referred to clinical studies where they can learn about their potential for developing Type 1 Diabetes and what symptoms to watch for.  Lifestyle education would also be provided and more frequent screening instituted.

Prevention/Delay of Type 2 Diabetes

There are several random controlled studies showing that people at high risk for developing Type 2 Diabetes can decrease their rate of onset with certain interventions. These interventions may include lifestyle changes and even medication in some instances. ADA supports formal education for people with impaired glucose tolerance and an A1C between 5.7 and 6.4%. People who fall into this category also need to be monitored annually for their blood sugar values and assessed for cardiovascular risk factors (obesity, hypertension, and high cholesterol).

Glucose Monitoring

I think one of the most important things we do as diabetes providers is helping people learn how to monitor their blood sugars at home and follow these patterns for better control. However, there has been some discussion in the literature about the clinical utility and expense for self-monitoring of blood glucose (SMBG) in people who aren’t on aggressive insulin or not on insulin at all. ADA has approached this issue by stating that frequency and timing of SMBG should be decided on an individual basis based on the person’s needs and goals for treatment. People using MDI or an insulin pump need frequent SMBG to assess for control and monitor for hypoglycemia. People using less frequent insulin or non-insulin therapies may check SMBG on a more variable schedule that should be determined with the health care provider. It’s also important to review testing technique at times to be sure the results are accurate.

DSME and Support Groups

ADA has always advocated for education and support for people with diabetes, and now is supporting formal education for pre-diabetic patients. ADA supports third-party payer reimbursement for both these services.


Hypoglycemia awareness and management should be frequently reviewed with patients. The self-management plan should always be re-evaluated if there have been one (1) or more episodes of severe hypoglycemia (inability to handle the episode on your own).  People with severe hypoglycemia or hypoglycemia unawareness may need the targets for glycemic control raised. People with declining cognition need to be assessed frequently for hypoglycemia by their providers and family members.  Adjustments in their glycemic management plan will also need to be made.

To view the full set of Clinical Practice Recommendations for 2013, click here.


2012 ADA Clinical Practice Recommendations

By Eileen B. Wyner, NP
Bulfinch Medical GroupEileen W

Every year the American Diabetes Association publishes a set of guidelines and recommendations on the diagnosis and treatment of Diabetes for both adults and children. These standards guide us in how and when to screen for Diabetes, how to diagnose, how to monitor for complications, how to treat Diabetes and how to educate patients in their self-management strategies. A large body of evidence-based data is reviewed by the experts annually to provide the best possible information.

These standards of care provide concrete data about goals of treatment, but they are not meant to be the only approach to care. Providers rely on their best clinical judgment for each individual they care for.  Although well controlled Diabetes may lessen the instance of complications across the lifespan, there may be associated adverse affects in the process.  Some patients simply can’t tolerate tight control for example; or medications have side affects, the most concerning of which is hypoglycemia (which can be life threatening). While we all fall back on these guidelines, we also have to adapt them as needed.

There are many aspects of these Guidelines, but I want to discuss a few points a little more closely. The ADA Standards not only addresses medical management but strongly emphasizes the importance of Diabetes self –management education, or DSME. The ADA supports all patients receiving education with diagnosis of disease and ongoing education as needed. Education and knowledge about this chronic disease has been shown to improve physical and emotional health.  People with Diabetes who have ongoing educational updates—either in a group or one-to-one—have better control of their disease, better ability to prevent/manage complications, and have better quality of life.

The Standards also identify some other medical conditions that occur in the Diabetic population more so than in the general population. This doesn’t mean that everyone will get these conditions, but it is important to be aware of them:

  • Hearing impairment is more common —this may be due to neuropathy
  • Sleep apnea, especially in obese men, is common and is a risk factor for cardiovascular disease
  • Low testosterone in men, especially if they are obese, is more prevalent in the Diabetic population and may present with symptoms of fatigue and decreased libido (routine screening isn’t done for this condition, but if you are having any concerns it’s a good idea to bring this up with your health care provider)
  • Gum disease is more serious (not necessarily more common)
  • Poor blood sugar control and noncompliance are real concerns
  • People with Diabetes have a higher risk of cognitive impairment (this is an area that needs to be studied more closely, but long-term hyperglycemia seems to be a factor)

A Note about Driving

This year the ADA added a section on Diabetes and driving.  Driving with Diabetes is a topic I try to bring up often with my patients, especially if they’re older, have known visual problems, or have had frequent hypoglycemia. While there is data to show a small increase in the risk of motor vehicle accidents due to hypoglycemia and hypoglycemia unawareness, it’s a much smaller risk than those associated with teenage male drivers. The ADA is against blanket restrictions for people with Diabetes and advises health care providers to make individual assessments as needed.  Everyone who has a license is expected to drive with caution and care; Diabetes doesn’t mean you can’t drive, but it may mean that you need to be a little more cautious.

I tell all of my patients to wear medical identification. I prefer it be a bracelet or necklace, something that hangs off the body and is easily seen— a wallet card can’t be easily accessed in an emergency. Hypoglycemia can resemble drunk driving and valuable time for your health will be lost if you are involved in a driving incident and not acting yourself.  First responders will not think “hypoglycemia”; they will think “cocktails”.

And here are some other considerations to be aware of:  You may have neuropathy, so feeling the brake and gas pedals may be difficult. That may mean you will have to stop driving. Retinopathy may diminish your nighttime or peripheral vision. You may need to curtail your driving from dusk to dawn or stop driving altogether. If you have experienced hypoglycemia frequently or to extremes, you should discuss it with your health care provider. You may need to develop a detailed plan for driving such as checking your blood sugar before you get in the car and checking frequently on the road. And, always be sure to have glucose tablets in the car.

I encourage you to think about your own circumstances.  Do you need a refresher on your self-management care?  Talk to your health care provider and see about education opportunities. Is driving a little more challenging (aside from the normal challenge of maneuvering Boston’s roads)? Set up an appointment to see the eye doctor. Use this New Year as a chance to give yourself good care. You deserve it.

To view the full standards, click here.