ReviewManagement of type 2 diabetes mellitus in the elderly
Introduction
Type 2 diabetes mellitus (DM) is an epidemic that continues to increase rapidly, affecting millions of people worldwide [1], [2], [3]. More than 10% of Americans ≥20 years old and 23% of Americans ≥60 years old have DM. Among adults 60–74 years of age, 11% have undiagnosed DM. Age is an important contributor to DM, as well as obesity and sedentary lifestyle. Nearly half of people with DM are ≥65 years old [4], [5]. Complications of DM in the elderly are common. Older patients have increased prevalence of cardiovascular risk factors, DM related morbidity and mortality, and comorbidities such as chronic kidney disease (CKD), congestive heart failure (CHF), cognitive impairments, depression, physical disability and frailty [6], [7], [8]. Furthermore, older patients are frequently on multiple medications, posing an increased risk of drug interactions with greater risk of adverse effects, most commonly hypoglycemia [9]. Thus, management of DM in the elderly is challenging and requires integrated care with a multi-dimensional approach focusing on preventing diabetic complications, early interventions for vascular disease, and disability assessment.
Section snippets
Clinical characteristics of elderly people with DM
Elderly diabetics have higher rates of premature death, functional disability, chronic diseases such as hypertension, cardiovascular disease and stroke than non-diabetics [10], [11]. They also have greater risk of having geriatric syndrome including depression, urinary incontinence, chronic pain and frailty causing cognitive impairment, and frequent falls [12], [13], [14], [15]. Due to these age related changes, elderly diabetics may not present with classical symptoms which makes diagnosis
Principles of DM care in the elderly
Although there are many evidence-based guidelines for DM few are specifically targeted towards the needs of the elderly; most of them are based on expert opinion and many do not offer specific recommendations for glycemic target for fasting and postprandial glucose or hemoglobin A1c (HbA1c) in the elderly [18], [19], [20], [21] (Table 1). The main emphasis of most guidelines is on intensive blood glucose control and prevention of microvascular complications [22]. Although glycemic control is
Lifestyle interventions
Obesity is a common and growing problem in the elderly and is strongly associated with metabolic syndrome, DM, hypertension, hyperlipidemia and cognitive dysfunction [36], [37], [38], [39], [40], [41], [42]. Decreased physical activity and energy expenditure with aging predispose to fat accumulation, fat redistribution, and muscle loss which cause insulin resistance. In the elderly BMI may not increase with adiposity which makes this data more difficult to interpret [43]. Meta-analyses of
Conclusion
Weighted review of expert opinion (1), published guidelines (2), the authors’ own clinical experience (3), observational studies (4), pilot studies (5), and randomized control studies (6), where (6) is accorded the most weight has led us to the following conclusions:
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HbA1c goals should be stratified for the generally well elderly HbA1c ≤ 7.0% and for the frail elderly HbA1c ≤ 8.0%.
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Every effort should be made to choose therapies which are both effective and minimize the risk of hypoglycemia, the
Contributors
Kyaw Soe, participated in writing the manuscript. Alan Sacerdote, revised the manuscript, participated in writing the abstract and conclusion. Jocelyn Karam, revised the manuscript. Gül Bahtiyar, wrote and revised the manuscript, responded to the reviewer.
Conflict of interests
Possible conflicts of interest, corporate involvement, patent holdings, etc. for each author are none.
Provenance and peer review
Commissioned and externally peer reviewed.
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