Experts expect the number of older adults—people ages 65 and older—in the United States living with type 1 or type 2 diabetes to increase rapidly in the coming decades. Dennis T. Villareal, MD, a physician-scientist with specialty training in geriatrics and endocrinology, discusses the medical, psychological, functional, and social needs of older adults with diabetes, and the role of emerging technologies.

Q: What is the current prevalence of diabetes—type 1 and type 2—in older adults in the United States?

A: More than a quarter of people over age 65 have diabetes. Although type 2 diabetes is the most common type of diabetes in older adults, type 1 diabetes is becoming more common as people with the disease are living longer because of improved insulin delivery, technology, and care. We expect the number of older adults living with type 1 or type 2 diabetes to increase markedly in the coming decades.

Q: What are some issues to consider when managing diabetes in older adults? Why is it important to tailor how health care professionals manage diabetes in older adults?

A: Health care professionals and health care teams not only need to regularly assess medical care, but also psychological function and social challenges to ensure quality of life. For example, it’s imperative to accurately identify the type of diabetes patients have, how long they’ve had diabetes, their diabetes complications, and their treatment priorities.

Older adults with diabetes are more likely to have health problems related to diabetes, such as chronic kidney disease, congestive heart failure, and stroke. They also may have memory and cognitive challenges, higher rates of functional and physical issues, and other health problems such as geriatric syndromes. Unique features of known health conditions like incontinence and frailty also occur in older patients. In addition, older adults may need more caregiver support.

Q: How do physical activity, following healthy eating patterns, adequate sleep, and social support change as adults with diabetes become older?

A: Getting enough sleep and regular physical activity and consuming healthy foods and drinks are crucial for managing blood glucose levels, preserving muscle strength, and preventing diabetes health problems. Older adults with diabetes may face limits to mobility, such as joint pain and fear of falling. They may have to follow multiple dietary guidelines if they have other health problems, which could result in more restricted eating habits. Certain medicines they take could interact with foods or cause changes in appetite, which also affects diet. Older adults may also have dental issues that restrict what they are able to eat. Having social connections with available family, friends, or neighbors is also important for helping older adults manage their diabetes.

In the Lifestyle Intervention for Seniors with Diabetes (LISD) study, we found that a lifestyle intervention strategy is highly successful in improving the diabetes management and physical function of older adults with diabetes. It may never be too late in life to begin lifestyle changes that include healthy eating habits and regular physical activity. Lifestyle changes can complement or even reduce the need for medical therapy. We also found that lifestyle interventions directly counter the increase in body fat and lack of physical activity that are primarily responsible for the age-related rise in insulin resistance that leads to type 2 diabetes.

Q: What are the unique challenges in managing blood glucose levels for older adults with diabetes? How can we balance the need for meeting blood glucose level targets while avoiding hypoglycemia and its associated risks?

A: There are certainly greater risks for hypoglycemia in older adults due to polypharmacy—or managing multiple medicines that might interact with each other. The signs of hypoglycemia might also be misread as neurologic symptoms of dementia. Health care professionals should tailor diabetes treatment using medicines that are less likely to cause low blood glucose and are proven safe or protective for the heart.

Medicines such as sulfonylureas, for example, have not been proven safe for the heart. They might also increase the risk for hypoglycemia because they are insulin secretagogues, which stimulate insulin release. Medicines such as the SGLT2 inhibitors, GLP-1 agonists, and metformin are less likely to cause hypoglycemia.

Q: What are ways that health care professionals can help patients address potential medicine interactions and simplify medicine regimens?

A: Health care professionals should regularly review the number of medicines their patients are taking to identify potential interactions. They should also consider reducing the number of medicines prescribed whenever possible, which may help reduce too many medicines or ones that aren’t necessary. Enlisting the expertise of pharmacists to review medicines can be very helpful, especially during transitions of care.

Health care professionals might also consider tools, such as reminder applications that can help patients track their medicines and take them as prescribed. Using the information from electronic health records can also help health care professionals manage their patients’ medicines. Finally, simplify their medicine regimens and instructions as much as possible, and do regular follow ups.

Q: How can the growing role of technology affect outcomes for older adults with diabetes? What are the barriers?

A: Technologies such as continuous glucose monitors (CGMs), insulin pumps, and smart pens can empower older adults with diabetes and their caregivers. These technologies may reduce complications and enhance quality of life. Many older adults with diabetes, especially if they take insulin, use CGMs. That’s straightforward, but they do need to work with their diabetes care team to learn how to take full advantage of CGMs to change health behaviors and adjust insulin doses. Insulin pumps could be challenging for older adults with diabetes who have cognitive problems. For example, older adults with cognitive problems may not remember all the steps to change tubing and cannula or give repeat insulin boluses.

Q: Are there specific social determinants of health barriers for older adults with diabetes that affect access to care? How can we address these barriers?

A: Racial disparities, social barriers, housing and food insecurity, transportation challenges, and isolation can all affect access to care as well as overall wellbeing. Health care professionals, regardless of their own background, should acknowledge these disparities and provide culturally competent care—which is care that meets the social, cultural, and language needs of their older adult patients with diabetes.

Addressing these barriers needs to be a comprehensive and multidisciplinary approach. So, we need to involve social workers, diabetes educators, and others who are part of health care teams.

Q: What lessons are we learning from research on managing the care and treatment of older adults with diabetes? Have we identified areas for future research?

A: Current research shows that older adults with diabetes are a varied group with many different types of people. We need to tailor care and treatment according to their health status. Some patients could be relatively healthy, others might be less healthy, and still others might have trouble with physical tasks or thinking skills. So, the goals should be to improve the quality of life. Some of these goals could include reducing the chance of having to go to the hospital and managing problems that come with getting older, such as falling and getting weaker.

We’ve learned that relaxing the target goal for managing blood glucose might be more important in people who have many other health problems. We also know that it’s key to regularly review medicines, reduce them as much as possible, and engage help from pharmacists and social workers.

Finally, culturally competent care is a challenge and should be a topic of more investigation. This is a promising area that could empower older adults with diabetes—particularly in a context of technology—and improve the quality of care. In addressing racial disparities, we need to identify culturally and clinically diverse treatments for older adults with diabetes. We also need to pinpoint the specific subgroups and care settings where diabetes technologies can be most effectively implemented.

What have you learned about managing the care of older adults with diabetes? Share below in the comments.