Should I still screen my older patients over 70 for diabetes?

Diabetes Screening in Patients Over 70 Years Old

Yes, you should continue screening older adults over 70 for diabetes, but the approach should be individualized based on their health status, functional capacity, and life expectancy.

Rationale for Screening Older Adults

• Diabetes is highly prevalent in the aging population, with approximately 20-25% of people over age 65 having diabetes, and this number is expected to grow rapidly in coming decades 1
• Older individuals with diabetes have higher rates of premature death, functional disability, and coexisting illnesses such as hypertension, coronary heart disease, and stroke 1
• Older adults with diabetes are at greater risk for geriatric syndromes including polypharmacy, cognitive impairment, urinary incontinence, injurious falls, and persistent pain 1, 2

Screening Approach Based on Patient Categories

For Healthy Older Adults (Few Chronic Conditions, Intact Cognition)

• Screen annually for diabetes in patients over 70 who are functionally independent with few comorbidities 1
• Use standard diagnostic criteria: fasting plasma glucose ≥126 mg/dL, A1C ≥6.5%, or 2-hour plasma glucose ≥200 mg/dL during OGTT 3
• Set glycemic targets similar to younger adults (A1C <7.0-7.5%) as they can benefit from long-term intensive diabetes management 1

For Older Adults with Multiple Chronic Conditions or Mild-Moderate Cognitive/Functional Impairment

• Continue screening but consider less stringent glycemic targets (A1C <8.0%) 1
• Pay particular attention to complications that can develop over short periods and significantly impair functional status, such as visual and lower-extremity complications 1
• Consider the time frame of benefit when screening and setting treatment goals 1

For Frail Older Adults or Those with Advanced Cognitive Impairment

• Focus screening on symptoms rather than routine laboratory testing 1, 4
• Aim to avoid symptomatic hyperglycemia rather than achieve specific A1C targets 1
• Consider life expectancy when determining the utility of screening, as benefits of intensive glucose control only manifest after extended periods of treatment 4

Additional Screening Considerations

• Screen for geriatric syndromes in older adults with diabetes, including cognitive impairment, depression, urinary incontinence, and persistent pain 1, 2
• Perform cognitive screening annually in adults 65 years or older with diabetes 1
• Monitor for hypoglycemia risk, which is greater in older adults than younger adults 1
• For older adults with type 1 diabetes, consider continuous glucose monitoring to reduce hypoglycemia risk 1

Practical Implementation

• Use A1C for screening as it doesn't require fasting and reflects longer-term glycemic control 2, 3
• Consider comprehensive geriatric assessment upon initial diagnosis of diabetes to evaluate functional status, comorbidities, and life expectancy 5
• Balance the benefits of screening against the potential harms of overdiagnosis and overtreatment, particularly in those with limited life expectancy 6, 4
• Avoid excessive testing in older adults with prediabetes who may not benefit from additional diagnostic procedures like OGTT 6

Potential Pitfalls to Avoid

• Don't apply one-size-fits-all screening approaches to the heterogeneous older adult population 1, 5
• Avoid overly intensive glycemic targets in frail older adults, which may increase risk of hypoglycemia without providing benefit 1
• Don't focus exclusively on diabetes while neglecting other important health conditions in older adults 4
• Be aware that polypharmacy may increase the probability of adverse drug events and negatively impact quality of life 4