Updates in Managing Elderly Patients With Type 2 Diabetes

TOULOUSE, FRANCE — The management of patients over the age of 75 years with diabetes is discussed in a crucial chapter in the latest position statement from the Francophone Diabetes Society (SFD). The chapter reviews screening for geriatric complications, adjustment of glycemic targets, and new cardio- and nephroprotective treatments.

Lyse Bordier, MD, an endocrinologist and metabolic diseases specialist at Bégin Military Teaching Hospital in Saint-Mandé, France, discussed these topics at the Francophone Diabetes Society Congress.

The SFD has updated its position statement on type 2 diabetes every 2 years since 2017. A chapter is dedicated to patients over the age of 75 years, who represent a quarter of the population with type 2 diabetes. In institutions such as nursing homes, 20% of the 700,000 residents have diabetes. "The cumulative complications related to type 2 diabetes and age can weaken the patient, influencing therapeutic decisions," said Bordier. "Aging is a dynamic process, and patient categorization based on geriatric complications needs regular reassessment."

Categorizing Patients

In this growing population of elderly patients with diabetes, the initial evaluation of geriatric complications must consider various aspects such as potential depressive and cognitive disorders, as well as physical impairments or dependence. Sensory deficits and patients' nutritional status should be examined, with particular attention to potential malnutrition. For instance, the risk for malnutrition in hospitalized patients with diabetes and an average age of 78 years is 40%, according to the Mini Nutritional Assessment. The prevalence of malnutrition in this group is 53%, according to the Global Leadership Initiative on Malnutrition. In addition, elderly patients' clinical presentations can be misleading with regard to the risk for hypoglycemia. Often asymptomatic and nocturnal, hypoglycemia can affect the patient's quality of life and long-term prognosis.

On the basis of the evaluation of geriatric complications and frailty, three categories of elderly patients can be determined. First, there are healthy elderly patients who are socially well integrated and autonomous in their decisions and daily activities. Then there are more fragile patients, who present an intermediate health status and are at risk of moving to the third category. The latter includes dependent patients or those with severely impaired health, who are characterized by advanced and chronic polypathology, which generates disability and may be accompanied by social isolation.

Balancing Glycemic Targets

Based on the health categories of the elderly (healthy, fragile, dependent, or with impaired health), the SFD distinguishes three glycemic target levels. Gerontological evaluation will avoid being too strict in very frail patients and avoid excessive lenience in those who have aged well and who could develop long-term diabetic complications.

In a study conducted in Ontario, Canada, among 108,620 elderly patients diagnosed with diabetes (average age, 80.6 years, 61% with A1c < 7%), the results highlight the need to reevaluate glycemic targets in the elderly and reconsider the use of antihyperglycemic medications that can cause hypoglycemia, especially in the context of intensive glycemic control. Indeed, 21.6% of the patients had an A1c < 7% and were on high-risk hypoglycemic treatment. Their risk for events was twice as high compared with those with A1c between 7.1% and 8.5% who were treated with low-risk hypoglycemic drugs.

Which A1c Target?

Thus, the targets in terms of A1c vary according to the three categories of elderly patients. For those in good health, the target is a value less than or equal to 7%. For fragile patients, the target is less than or equal to 8%, while staying above 7% if they use hypoglycemic risk treatments such as insulin secretagogues (like sulfonylureas or glinides) or insulin.

For dependent patients and those with "very impaired health" who aim to avoid acute complications (such as dehydration and hyperosmolar coma), A1c should be between 7.5% and 9%, with preprandial capillary blood glucose between 1 and 2 g/L (or better > 1.40 g/L), when treated with sulfonylureas, glinides, or insulin.

Continuous Glucose Monitoring Devices

A novelty in the SFD position statement concerns the introduction of continuous glucose monitoring. The objectives of this monitoring differ for elderly patients than for younger patients. Patients with diabetes who are eligible for this type of monitoring have type 1 diabetes or type 2 diabetes treated with intensified insulin therapy, including at least three daily insulin injections. More recently, patients with type 2 diabetes under a single basal insulin injection also became eligible for continuous glucose monitoring if their A1c level was above 8%.

The international recommendations from Advanced Technologies and Treatments for Diabetes that the SFD has adopted have set individualized targets based on patients' clinical presentation, according to the percentage of time spent in each glycemic range. The criteria for elderly patients or those at high cardiovascular risk are a time spent in the target range greater than 50%, a time spent above the target range less than 50% between 180 and 250 mg/dL, and less than 10% beyond 250 mg/dL. The time spent below the target range should be less than 1% for a blood glucose < 70 mg/dL.

Glucagon-Like Peptide 1 Receptor Agonist (GLP-1 RA) and Malnutrition

In elderly people, therapies are like those in younger people. However, these options must be adjusted according to patients' clinical presentation, including frailty, diabetologic and geriatric complications, and the risk for hypoglycemia. Each drug class has specific advantages and disadvantages and side effects that may be more pronounced in elderly patients.

Adjusting the dosage of metformin is necessary when the estimated glomerular filtration rate (eGFR) is < 60 mL/min/1.73 m², which occurs frequently. Thus, the recommended dose is 2 g/d for an eGFR of 45-60 mL/min/1.73 m² and 1 g/d for an eGFR of 30-45 mL/min/1.73 m². Below 30 mL/min/1.73 m², metformin should be discontinued, as it should in case of intercurrent illness or before imaging requiring iodine injection, to prevent the risk for lactic acidosis.

Vigilance is particularly required regarding the risk for hypoglycemia, especially with sulfonylureas and glinides. This risk can be severe and prolonged. Therefore, this drug class should be avoided in seniors, especially when they are frail.

Moreover, some treatments induce weight loss, which can lead to malnutrition and sarcopenia, thus weakening the patient. Even in the presence of obesity, malnutrition can persist. GLP-1 RAs offer proven cardiac protection and, to a lesser extent, renal protection. Their use can lead to digestive disorders and weight loss. They are recommended even if A1c goals are met, with the aim of protecting organs. However, great caution is needed when using them in malnourished patients.

As for insulin therapy, it generally starts with low-dose basal insulin (eg, 6-10 U/d or 0.1-0.2 U/kg/d) with education on self-monitoring of blood glucose. Continuous glucose monitoring can be useful in this context. Regarding the types of insulin used, slow analogs are preferred, and U100 glargine is often favored. Other slow analogs can be adapted according to the patient's glycemic profile, such as extended-action insulins like U300 glargine, U100 and U200 degludec, or shorter-action ones like detemir. Thus, U300 glargine and degludec are appropriate when the risk for hypoglycemia, especially nocturnal, is significant (such as when the patient has a history of confirmed or symptomatic hypoglycemia, severe hypoglycemia, poor perception of hypoglycemia, chronic renal failure, frailty, or malnutrition). Detemir is appropriate when the patient's glycemic profile points to the prescription of a shorter-action insulin injection in the morning (as with patients with predominant daytime hyperglycemia or corticosteroid therapy).

Cardio and Nephroprotective Therapies

Therapeutic strategy in the elderly begins with dietary adjustments that favor a balanced diet while avoiding restrictive diets. Practicing adapted physical activity is essential, even in elderly patients. Finally, all the usual cardiovascular risk factors associated with type 2 diabetes must be controlled.

The therapeutic strategy differs according to the patient's health status. For patients in good health, treatment generally starts with metformin, staying vigilant about the risks for hypoglycemia and malnutrition in case of high-risk treatments. If metformin's efficacy is insufficient, then one can consider combining it with a sodium-glucose co-transporter 2 (SGLT-2) inhibitor, a GLP-1 receptor agonist, or possibly a dipeptidyl peptidase 4 (DPP-4) inhibitor or hypoglycemic sulfonylurea (although this last option is not favored by the SFD).

If the patient has confirmed atherosclerotic disease, heart failure, or chronic kidney disease, then new therapeutic classes are preferred because they have specifically demonstrated benefits, even in the elderly. For confirmed atherosclerotic disease, initial combination therapy is proposed to the patient, either by metformin/SGLT2 inhibitor or metformin/GLP1 RA.

In the case of heart failure or chronic kidney disease, initial combination therapy is recommended, including metformin and an SGLT2 inhibitor, regardless of the patient's A1c. If contraindicated or poorly tolerated, a GLP1 RA can be considered, but only if the patient has not reached his or her A1c goal. In all cases, combining treatments should be considered if the patient does not reach the A1c goal.

If the patient is frail, then the therapeutic strategy starts with metformin, followed by a DPP-4 inhibitor. These well-tolerated molecules do not cause hypoglycemia. Prescribing a GLP-1 RA (which can induce anorexia or precipitate malnutrition in a high-risk patient) in frail patients requires particular vigilance. In the presence of chronic kidney disease or heart failure, adding an SGLT2 inhibitor can provide rapid benefits. If glycemic control remains insufficient, basal insulin therapy can be instituted as a last resort.

For elderly and dependent patients, the therapeutic strategy starts with metformin, and then can be supplemented with a DPP-4 inhibitor if necessary. In patients with heart failure, combining with an SGLT2 inhibitor can be beneficial. If these measures do not allow for achieving glycemic targets, then progressive basal insulin therapy is necessary.

Bordier declared that she had provided various services to AstraZeneca, Boehringer Ingelheim, Eli Lilly, Merck Sharp & Dohme, Novo Nordisk, Pfizer, Sanofi, and Servier. 

This story was translated from the Medscape French edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.