Simplify Diabetes Management in Older Adults

You’ll hear about the “4S pathway” to help simplify and deprescribe diabetes meds in older adults.

Reducing med burden and improving quality of life in older patients may be more important than preventing long-term complications.

Plus intensive treatment can cause hypoglycemia in older adults and lead to falls, cognitive changes, and cardiac events.

Follow these 4 “S” steps to optimize diabetes meds in older adults.

Seek triggers. Look for red flags that may indicate a need to reevaluate treatment goals or strategies in older adults.

For example, consider whether unintended weight loss might be a side effect of a diabetes med, such as with a GLP-1 agonist (semaglutide, etc).

Or consider whether patients with cognitive changes, excessive drowsiness, or sleep problems need investigation for hypoglycemia.

Share decision-making. Work together with the patient and their caregiver to weigh treatment benefits and risks.

Be prepared to discuss the reasons that therapy changes may be needed...and address concerns from older adults and their caregivers.

Emphasize that changes in regimens are intended to meet individualized goals and to optimize patient safety.

Set or reset goals. Emphasize individualizing glycemic goals. Explain that a “one-size-fits-all” approach isn’t safe or practical.

It’s okay to stick with an A1c target below 7% for younger people with diabetes who have few comorbidities.

But a target below 7% in older patients may lead to overtreatment...and may increase the risk of adverse events and mortality.

Suggest relaxing the A1c target to between 7% and 8.5% in older patients, especially if there’s a history of recurrent severe hypoglycemia or hypoglycemia unawareness, limited life expectancy, frailty, etc.

Simplify and select safer treatment. Consider stopping or reducing the dose of the diabetes med most likely associated with a red flag.

For instance, if hypoglycemia is the problem, suggest stopping or adjusting the dose of meds associated with hypoglycemia, such as sulfonylureas or insulin. Or suggest giving basal insulin in the morning instead of at bedtime if hypoglycemia is occurring overnight.

Review kidney function and check that meds are used at lower doses or avoided as appropriate. For example, reassess metformin, sulfonylureas, and SGLT2 inhibitors (dapagliflozin, etc) in patients with severe kidney impairment.

Assess appetite and weight. If a patient has a low appetite or unintended weight loss, consider using a DPP-4 inhibitor (sitagliptin, etc) instead of other options.

See our toolbox, Chronic Meds in the Elderly: Taking a “Less is More” Approach, for tips on how to deprescribe for other conditions.

• Toolbox: Chronic Meds in the Elderly: Taking a “Less Is More” Approach