JAGS 51:S265–S280, 2003

© 2003 by the American Geriatrics Society

0002-8614/03/$15.00

Guidelines for Improving the Care of the

Older Person with Diabetes Mellitus

California Healthcare Foundation/American Geriatrics Society Panel on Improving

Care for Elders with Diabetes

BACKGROUND AND SIGNIFICANCE

iabetes mellitus (DM) is highly prevalent and increas-

ing in persons aged 65 and older, particularly among

racial and ethnic minorities. Estimates have placed the

proportion of adults aged 65 to 74 with physician-diagnosed

DM at nearly 25% in some ethnic groups.

1

Estimates from

the Centers for Disease Control and Prevention indicate

that, in 1998, 12.7% of persons aged 70 and older had a

diagnosis of DM, up from 11.6% in 1990.

2

There are also

large numbers of older adults, almost 11% of the U.S.

population aged 60 to 74, with undiagnosed DM.

1

Older persons with DM have higher rates of prema-

ture death, functional disability, and coexisting illnesses

such as hypertension, coronary heart disease (CHD), and

stroke

3,4

than do those without DM. Older adults with

DM are also at greater risk than other older persons for

several common geriatric syndromes, such as depression,

5,6

cognitive impairment,

7

urinary incontinence,

8

injurious

falls,

9–11

and persistent pain.

12,13

Although there are numer-

ous evidence-based guidelines for DM, few guidelines are

specifically targeted toward the needs of older persons

14

and help clinicians prioritize care for the heterogeneous

population of older adults they may see in their practices.

Moreover, the main emphasis of most DM guidelines is on

intensive blood glucose control and prevention of micro-

vascular complications. Although control of hyperglyce-

mia is important, in older persons with DM, greater reduc-

tion in morbidity and mortality may result from control of

cardiovascular risk factors than from tight glycemic con-

trol. Additionally, little is known about how well providers

of health care for older persons with DM adhere to

recommendations for the screening and treatment of com-

mon geriatric syndromes, such as depression, injurious

falls, urinary incontinence, cognitive impairment, chronic

pain, and polypharmacy, which are more prevalent with

DM and may significantly influence quality of life. Al-

though interventions to reduce the incidence of geriatric

syndromes and to ameliorate their symptoms have been

studied in general populations of older adults, few studies

have focused on the identification and treatment of these

common syndromes in older adults with DM. Moreover,

because conditions such as cognitive impairment, poly-

pharmacy, and injurious falls may interfere with the provi-

sion of appropriate DM care, the identification and man-

agement of these syndromes may enhance the effectiveness

of DM management for the busy primary care provider.

The purpose of this guideline is to improve the care of

older persons with DM by providing a set of evidence-

based recommendations that include DM-specific recom-

mendations individualized to persons with DM who are aged

65 and older and recommendations for the screening and de-

tection of geriatric syndromes. Table 1 summarizes the com-

ponents of care included in the guidelines and the number of

randomized controlled trials (RCTs) and systematic evidence

reviews that were evaluated for the care recommendations.

IMPORTANCE OF INDIVIDUALIZED GOAL-

SETTING IN DIABETES MELLITUS CARE

The goals of DM care in older adults, as in younger per-

sons, include control of hyperglycemia and its symptoms;

prevention, evaluation, and treatment of macrovascular and

microvascular complications of DM; DM self-management

through education; and maintenance or improvement of

general health status. Although these goals are similar in

older and younger persons, the care of older adults with

DM is complicated by their clinical and functional hetero-

geneity. Some older persons developed DM in middle age

and face years of comorbidity; others who are newly diag-

nosed may have had years of undiagnosed comorbidity or

few complications from the disease. Some older adults

with DM are frail and have other underlying chronic con-

ditions, substantial DM-related comorbidity, or limited

physical or cognitive functioning, but other older persons

with DM have little comorbidity and are active. Life expect-

ancies are also highly variable for this population. Clinicians

caring for older adults with DM must take this heteroge-

This guideline was developed and written under the auspices of the

California Healthcare Foundation/American Geriatrics Society (AGS) Panel

on Improving Care of Elders with Diabetes and approved by the AGS Board

of Directors on February 25, 2003.

This work was supported in part by the California Healthcare Foundation

Grant 01–1287.

The development of this guideline was supported by the California

Healthcare Foundation’s Program for Elders in Managed Care and an

unrestricted educational grant from Aventis Pharmaceuticals.

Address correspondence to Elvy Ickowicz, MPH, Associate Director,

Professional and Public Education,

American Geriatrics Society, 350 Fifth

Avenue, Suite 801, New York, NY 10118. E-mail:

eickowicz@americangeriatrics.org

D