2008 Clinical Practice Guidelines - Canadian Diabetes Association

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2008 CLINICAL PRACTICE GUIDELINES S182 Insulin therapy Insulin regimens in the elderly should be individualized and selected to promote patient safety. In elderly people, the use of premixed insulins as an alternative to mixing insulins (54) and prefilled insulin pens as an alternative to conventional syringes (55,56) minimizes dose errors and may improve glycemic control. Rapid-acting insulin analogue mixtures can be used and be administered after meals (57-59), although recent data suggest that the kinetics of regular and rapid-acting insulin are similar in the elderly (60). Multiple daily injections (MDI) may be associated with greater improvements in glycemic control, health status and mood than twice-daily injections of longacting insulin (61). In older people with poorly controlled type 2 diabetes requiring insulin, both continuous subcutaneous insulin infusion (CSII) and MDI can result in excellent glycemic control, with good safety and patient satisfaction (62). One study demonstrated equivalent glycemic control in older people treated with either twice-daily insulin injections or a combination of a single injection of NPH insulin with an oral antihyperglycemic agent (63). Another study demonstrated that once-daily glargine with continuation of an oral antihyperglycemic agent resulted in better glycemic control and a reduced rate of hypoglycemia when compared to twice-daily injections of 30/70 insulin (64). Prevention and treatment of complications Hypertension Treatment of isolated systolic hypertension or combined systolic and diastolic hypertension in elderly people with diabetes is associated with a significant reduction in CV morbidity and mortality (65-68). Treatment of isolated systolic hypertension may also preserve renal function in elderly people with diabetes (69). Several different classes of antihypertensive agents have been shown to be effective in reducing the risk of CV events and end-stage renal disease, including thiazide-like diuretics, long-acting calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor antagonists (65-75). Any of these agents is a reasonable first choice (70-72), although the calcium channel blocker amlodipine may be associated with an increased risk of CHF (72). Cardioselective beta blockers and alpha-adrenergic blockers are less likely to reduce CV risk than the above agents (70- 74). ACE inhibitors may be particularly valuable for people with diabetes and ≥1 other CV risk factor (76,77). Recent data suggest there has been a significant improvement in the last decade in the number of older people treated for hypertension, and therapies being used are more consistent with current clinical practice guidelines (78). Dyslipidemia The treatment of hypercholesterolemia with statins for both primary and secondary prevention of CV events has been shown in most, although not all, studies to significantly reduce CV morbidity and mortality in older people with diabetes (79-88). The data on the use of fibrates in this patient population are equivocal (89,90). Erectile dysfunction Type 5 phosphodiesterase inhibitors appear to be effective for the treatment of erectile dysfunction in carefully selected elderly people with diabetes (91-93). DIABETES IN NURSING HOMES Diabetes is often undiagnosed in nursing home patients (94- 96), and individuals frequently have established macro- and microvascular complications (97,98). In observational studies, the degree of glycemic control varies between different centres (94,98). Undernutrition is a major problem in people with diabetes living in nursing homes (98). There are very few intervention studies on diabetes in nursing homes.The short-term substitution of a regular diet RECOMMENDATIONS 1. In elderly individuals with impaired glucose tolerance, a structured program of lifestyle modification that includes moderate weight loss and regular physical activity should be considered to reduce the risk of type 2 diabetes [Grade A, Level 1A (2)]. 2. Otherwise healthy elderly people with diabetes should be treated to achieve the same glycemic, blood pressure and lipid targets as younger people with diabetes [Grade D, Consensus]. In people with multiple comorbidities, a high level of functional dependency or limited life expectancy, the goals should be less stringent [Grade D, Consensus]. 3. Elderly people with diabetes living in the community should be referred for interdisciplinary interventions involving education and support [Grade C, Level 3 (6,7,19)]. 4.Aerobic exercise and/or resistance training may benefit elderly people with type 2 diabetes and should be recommended for those individuals in whom it is not contraindicated [Grade B, Level 2 (20,23-25)]. 5. In elderly people with type 2 diabetes, sulfonylureas should be used with caution because the risk of hypoglycemia increases exponentially with age [Grade D, Level 4 (44)]. In general, initial doses of sulfonylureas in the elderly should be half those used for younger people, and doses should be increased more slowly [Grade D, Consensus]. Gliclazide and gliclazide MR [Grade B, Level 2 (48,51)] and glimepiride [Grade C, Level 3 (49)] are the preferred sulfonylureas, as they are associated with a reduced frequency of hypoglycemic events. Meglitinides (repaglinide and nateglinide) should be considered in patients with irregular eating habits [Grade D, Consensus]. 6. In elderly people, the use of premixed insulins and prefilled insulin pens as alternatives to mixing insulins should be considered to reduce dose errors, and to potentially improve glycemic control [Grade B, Level 2 (54-56)].
or a standard nutritional formula for a “diabetic diet” or a diabetic nutritional formula did not modify the level of glycemic control (99-101). For selected nursing home residents with type 2 diabetes, substitution of regular insulin by multiple injections with lispro insulin may improve glycemic control and glycated hemoglobin (A1C) levels with a reduced number of hypoglycemic episodes (102). Screening for diabetes may be warranted in selected individuals. In the absence of positive intervention studies on morbidity or mortality in this population, the decision about screening for diabetes should be made on an individual basis. OTHER RELEVANT GUIDELINES Screening for Type 1 and Type 2 Diabetes, p. S14 Prevention of Diabetes, p. S17 Organization of Diabetes Care, p. S20 Self-management Education, p. S25 Targets for Glycemic Control, p. S29 Insulin Therapy in Type 1 Diabetes, p. S46 Pharmacologic Management of Type 2 Diabetes, p. S53 Hypoglycemia, p. S62 Screening for the Presence of Coronary Artery Disease, p. S99 Dyslipidemia, p. S107 Treatment of Hypertension, p. S115 Erectile Dysfunction, p. S147 REFERENCES 1. Tessier D, Meneilly GS. Diabetes management in the elderly. In: Gerstein HC, Haynes RB, eds. Evidence-based Diabetes Care. Hamilton, ON: BC Decker Inc.; 2001:370-379. 2. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393-403. 3. Diabetes Prevention Program Research Group; Crandall J, Schade D, Ma Y, et al. The influence of age on the effects of lifestyle modification and metformin in prevention of diabetes. J Gerontol A Biol Med Sci. 2006;61:1075-1081. 4. Chiasson JL, Josse RG, Gomis R, et al; STOP-NIDDM Trial Research Group. Acarbose for prevention of type 2 diabetes mellitus: the STOP-NIDDM randomised trial. Lancet. 2002; 359:2072-2077. 5. DREAM (Diabetes REduction Assessment with ramipril and rosiglitazone Medication) Trial Investigators; Gerstein HC, Yusuf S, Bosch J, et al. Effect of rosiglitazone on the frequency of diabetes in patients with impaired glucose tolerance or impaired fasting glucose: a randomised controlled trial. Lancet. 2006;368:1096-1105. 6. Kronsbein P, Jörgens V, Mühlhauser I, et al. Evaluation of a structured treatment and teaching programme on non-insulindependent diabetes. Lancet. 1988;2:1407-1411. 7. Wilson W, Pratt C.The impact of diabetes education and peer support upon weight and glycemic control of elderly persons with noninsulin dependent diabetes mellitus (NIDDM). Am J Public Health. 1987;77:634-635. 8. Kuusisto J, Mykkänen L, Pyörälä K, et al. Non-insulin-dependent diabetes and its metabolic control are important predictors of stroke in elderly subjects. Stroke. 1994;25:1157-1164. 9. Kuusisto J, Mykkänen L, Pyörälä K, et al. NIDDM and its metabolic control predict coronary heart disease in elderly subjects. Diabetes. 1994;43:960-967. 10. Nathan DM, Singer DE, Godine JE, et al. Retinopathy in older type II diabetics. Association with glucose control. Diabetes. 1986;35:797-801. 11. Morisaki N, Watanabe S, Kobayashi J, et al. Diabetic control and progression of retinopathy in elderly patients: five-year follow-up study. J Am Geriatr Soc. 1994;42:142-145. 12. Tanaka Y,Atsumi Y, Matsuoka K, et al. Role of glycemic control and blood pressure in the development and progression of nephropathy in elderly Japanese NIDDM patients. Diabetes Care. 1998;21:116-120. 13. Stolk RP, Vingerling JR, de Jong PT, et al. Retinopathy, glucose, and insulin in an elderly population. The Rotterdam Study. Diabetes. 1995;44:11-15. 14. Beks PJ, Mackaay AJ, de Neeling JN, et al. Peripheral arterial disease in relation to glycaemic level in an elderly Caucasian population: the Hoorn study. Diabetologia. 1995;38:86-96. 15. The DECODE study group, on behalf of the European Diabetes Epidemiology Group. Glucose tolerance and mortality: comparison of WHO and American Diabetes Association diagnostic criteria. Lancet. 1999;354:617-621. 16. The DECODE study group, on behalf of the European Diabetes Epidemiology Group. Glucose tolerance and cardiovascular mortality: comparison of fasting and 2-hour diagnostic criteria. Arch Intern Med. 2001;161:397-405. 17. Kanaya AM, Grady D, Barrett-Connor E. Explaining the sex difference in coronary heart disease mortality among patients with type 2 diabetes mellitus: a meta-analysis. Arch Intern Med. 2002;162:1737-1745. 18. Barzilay JI, Spiekerman CF,Wahl PW, et al. Cardiovascular disease in older adults with glucose disorders: comparison of American Diabetes Association criteria for diabetes mellitus with WHO criteria. Lancet. 1999;354:622-625. 19. Miller CK, Edwards L, Kissling G, et al. Nutrition education improves metabolic outcomes among older adults with diabetes mellitus: results from a randomized controlled trial. Prev Med. 2002;34:252-259. 20. Tessier D, Ménard J, Fülöp T, et al. Effects of aerobic physical exercise in the elderly with type 2 diabetes mellitus. Arch Gerontol Geriatr. 2000;31:121-132. 21. Skarfors ET,Wegener TA, Lithell H, et al. Physical training as treatment for type 2 (non-insulin-dependent) diabetes in elderly men. A feasibility study over 2 years. Diabetologia. 1987; 30:930-933. 22. Ligtenberg PC, Godaert GLR, Hillenaar EF, et al. Influence of a physical training program on psychological well-being in elderly type 2 diabetes patients. Psychological well-being, physical training, and type 2 diabetes [letter]. Diabetes Care. 1998; 21:2196-2197. S183 DIABETES IN SPECIAL POPULATIONS
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2008 Clinical Practice Guidelines - Canadian Diabetes Association

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