Spotlight on older diabetes patients

Several recent studies focused on the specifics of care for older patients with diabetes.

A trial published by Diabetes Care on July 26 found that a lifestyle intervention can be “highly successful” in older adults with type 2 diabetes. It randomized 100 type 2 diabetes patients who were ages 65 to 85 years to either a year-long intensive lifestyle intervention (a prescribed diet and exercise training at a facility for six months, transitioning to community-fitness centers or home exercise for another six months) or healthy lifestyle education (monthly group sessions). The intensive group had greater improvements in HbA1c level, insulin sensitivity, body weight, visceral fat, strength, gait, and physical performance than the healthy lifestyle group. The total insulin dose decreased in the intensive group patients, although they did have an increase in episodes of mild hypoglycemia. “Although lifestyle intervention is recommended as first-line treatment of diabetes at all ages, older adults were often excluded or underrepresented in studies that led to this evidence,” said the study authors, who cited their findings as evidence that “it may not be too late in life (mean age 72 years) to start lifestyle intervention, which can complement or reduce the need for medical therapy.” They noted that nutrition and exercise programs similar to the intervention may be covered by some Medicare policies.

A registry study published by JAMA Network Open on July 27 found that continuous glucose monitoring (CGM) is used less frequently in older patients. Researchers gathered data from 19,261 patients ages 10 to 85 years who were treated for type 1 diabetes at 80 U.S. clinics. Thirty percent of them reported using CGM, and the adjusted probability of CGM use decreased in adolescence, then increased until approximately age 40 years, remained relatively constant until age 60 years, and then decreased until age 75 years. The patients' mean HbA1c level was 8.57%, and CGM use was associated with lower HbA1c levels across all age groups, but this effect was smaller at older ages. The authors noted that less use of CGM among older patients may reflect barriers to Medicare coverage of the devices and that there may be “benefits to CGM use among older adults not reflected in the HbA1c outcome (eg, reduced hypoglycemia).” They called for further research on the subject.

Finally, a study in Hong Kong published by BMC Primary Care on Aug. 1 highlighted the risk of falls in older adults with hypoglycemia. It surveyed 442 patients with diabetes ages 65 years or older. Almost a quarter (23.3%) reported having at least one fall in the prior year, and 8.6% had recurrent falls. Hypoglycemic symptoms and lower visual acuity were significantly associated with fall risk (odds ratios, 2.42 and 1.75, respectively). Fall rates were higher among those ages 75 to 79 years than those 65 to 69 years. An HbA1c level of 7.0% to 7.4% was associated with lower risk of recurrent falls than an HbA1c level of 6.4% or less. Hypoglycemic symptoms were associated with a sixfold increase in risk of recurrent falls. The “alarming” fall rate in this study should motivate physicians to screen similar patients for hypoglycemic symptoms at every visit, the study authors said. “Appropriate measures should be imposed to minimize the chance of hypoglycemia by medication adjustment, less stringent HbA1c control in the frail elderly, education on home blood glucose monitoring and self-management of hypoglycemic attack,” they wrote.