The American Geriatrics Society (AGS) published its newly revised and updated guidelines for improving the care of older adults with diabetes. An abridged version of the full guidelines, The American Geriatrics Society Guidelines for Improving the Care of Older Adults with Diabetes Mellitus: 2013 Update, is published in the Journal of the American Geriatrics Society. The new guidelines are based on high-quality research that supports an individualized approach to managing diabetes in older adults. The update was led by an expert panel of clinicians and researchers in the fields of medicine, nursing, and pharmacy.
The individualized approach to diabetes care takes into account the patient’s goals and preferences, their functional status, and co-existing conditions common in older diabetics, such as cardiovascular disease and kidney problems. Many older adults with diabetes also have a higher incidence of cognitive impairment, urinary incontinence, injurious falls, persistent pain, depression, and polypharmacy (taking multiple medications). If untreated, these conditions can make it more difficult for the older person to manage their diabetes and can diminish their quality of life.
The 2013 guidelines include new recommendations based on the importance of individualizing and prioritizing treatment. They are an update of the 2003 Guidelines for Improving the Care of the Older Person with Diabetes Mellitus, developed by the American Geriatrics Society (AGS) and the California Health Care Foundation.
The 2013 updated guidelines:
- Recommend blood sugar control tailored to each person’s functional status, co-existing conditions, and life expectancy. If control is too aggressive it may lead to hypoglycemia (low blood sugar), and complications such as falls or loss of consciousness.
- No longer recommend the use of aspirin for primary prevention of cardiovascular disease because recent well designed studies show that the increased risk of bleeding outweighs the reduction in cardiovascular events.
- Renew the emphasis on treating elevated cholesterol with statins, but not necessarily treating to specific target levels.
- Encourage lifestyle modification for healthy older adults with diabetes, based on increased evidence supporting the importance of exercise and weight loss.
“This update was necessitated by new, high-quality research in the care of older adults with diabetes,” said Carol M. Mangione, MD, MSPH, and Gerardo Moreno, MD, MSHS, co-chairs of the interdisciplinary panel of experts who developed the recommendations. “This research provides strong evidence that ‘one size fits all’ treatment goals for blood sugar and blood pressure for older adults are not appropriate. Because of this, the AGS guidelines strongly emphasize the importance of using shared decision making to tailor treatments to the individual patients’ health status, goals and personal expectations.”
Life expectancy is a particularly important part of individualized treatment decisions for older patients, because their life expectancy may be shorter than the time needed to benefit from a given treatment designed to control blood sugar, blood pressure, or cholesterol levels. In general, the time needed to benefit from blood pressure and cholesterol control is shorter than for blood sugar control. In light of this research, the new guidelines continue to emphasize the importance of blood pressure and blood cholesterol management.
The guidelines also emphasize the importance of diabetes self-management education and support for older adults and their caregivers. For many patients, particularly those who are clinically complex, referral to a diabetes educator for one-on-one counseling or group classes may improve diabetes control. Initial and annual diabetes education is a covered benefit under Medicare Part B.