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Abstract
The proportion of the population aged 65 years and older has increased, and at least 20% of people in that age group have diabetes. This percentage is expected to increase rapidly in the future. Elderly people with diabetes have a higher incidence of heart disease and cerebrovascular disease, resulting in decreased quality of life and increased mortality and morbidity. It is important to manage diabetes in the elderly when it is concomitant with geriatric syndromes, such as depression, polypharmacy, cognitive dysfunction, urinary incontinence, and falling. Before determining target blood glucose levels and drug regimens, the comorbidities, complications, and individual circumstances of each patient should be assessed. Before determining target blood glucose levels and drug regimens, the comorbidities, complications, and individual circumstances of each patient should be assessed. In conjunction with the control of classical cardiovascular risk factors, such as blood pressure and dyslipidemia, these assessments can reduce the morbidity and mortality of diabetes further. Many clinical studies on blood glucose control are required and the results will be helpful in the management of elderly diabetic patients.
References
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Table 1.
A framework for considering treatment goals for glycemia, blood pressure, and dyslipidemia in older adults with diabetes
| Patient characteristics/ health status | Rationale | Reasonable A1C goal (A lower goal may be set for an individual if achievable without recurrent or severe hypoglycemia or undue treatment burden) | Fasting or preprandial glucose (mg/dL) | Bedtime glucose (mg/dL) | Blood pressure (mmHg) | Lipids |
|---|---|---|---|---|---|---|
| Healthy (Few coexisting chronic illnesses, intact cognitive and functional status) | Longer remaining life expectancy | < 7.5% | 90∼130 | 90∼150 | < 140/80 | Statin unless contraindicated or not tolerated |
| Complex/intermediate (Multiple coexisting chronic illnessesa or 2+ instrumental ADL impairments or mild to moderate cognitive impairment) | Intermediate remaining life expectancy, high treatment burden, hypoglycemia vulnerability, fall risk | < 8.0% | 90∼150 | 100∼180 | < 140/80 | Statin unless contraindicated or not tolerated |
| Very complex/ poor health (Long-term care or end-stage chronic illnessesb or moderate to severe cognitive impairment or 2+ ADL dependencies) | Limited remaining life expectancy makes benefit uncertain | < 8.5%c | 100∼180 | 110∼200 | < 150/90 | Consider likelihood of benefit with statin (secondary prevention moreso than primary) |
This represents a consensus framework for considering treatment goals for glycemia, blood pressure, and dyslipidemia in older adults with diabetes. The patient characteristic categories are general concepts. Not every patient will clearly fall into a particular category. Consideration of patient/caregiver preferences is an important aspect of treatment individualization. Additionally, a patient's health status and preferences may change over time. ADL, activities of daily living.
a Coexisting chronic illnesses are conditions serious enough to require medications or lifestyle management and may include arthritis, cancer, congestive heart failure, depression, emphysema, falls, hypertension, incontinence, stage III or worse chronic kidney disease, MI, and stroke. By multiple we mean at least three, but many patients may have five or more [34].
b The presence of a single end-stage chronic illness such as stage III–IV congestive heart failure or oxygen-dependent lung disease, chronic kidney disease requiring dialysis, or uncontrolled metastatic cancer may cause significant symptoms or impairment of functional status and significantly reduce life expectancy.
c A1C of 8.5% equates to an estimated average glucose of ∼200 mg/dL. Looser glycemic targets than this may expose patients to acute risks from glycosuria, dehydration, hyperglycemic hyperosmolar syndrome, and poor wound healing. Adapted from Kirkman et al. Diabetes Care 2012;35:2650–64 [10], with copyright clearance center's permission.
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