Diabetes in the older patient: heterogeneity requires individualisation of therapeutic strategies

Abstract

Owing to the worldwide increase in life expectancy, the high incidence of diabetes in older individuals and the improved survival of people with diabetes, about one-third of all individuals with diabetes are now older than 65 years. Evidence is accumulating that type 2 diabetes is associated with cognitive impairment, dementia and frailty. Older people with diabetes have significantly more comorbidities, such as myocardial infarction, stroke, peripheral arterial disease and renal impairment, compared with those without diabetes. However, as a consequence of the increased use of multifactorial risk factor intervention, a considerable number of older individuals can now survive for many years without any vascular complications. Given the heterogeneity of older individuals with type 2 diabetes, an individualised approach is warranted, which must take into account the health status, presence or absence of complications, and life expectancy. In doing so, undertreatment of otherwise healthy older individuals and overtreatment of those who are frail may be avoided. Specifically, overtreatment of hyperglycaemia in older patients is potentially harmful; in particular, insulin and sulfonylureas should be avoided or, if necessary, used with caution. Instead, glucose-dependent drugs that do not induce hypoglycaemia are preferable since older patients with diabetes and impaired kidney function are especially vulnerable to this adverse event.

Keywords: Age; Chronic kidney disease; Frailty; Glycaemic target; Hypoglycaemia; Older people; Review; Type 2 diabetes mellitus.

Fig. 1

Death from (a) any cause and (b) from a cardiovascular cause in participants with type 2 diabetes vs control participants. Data shows findings from the Swedish National Diabetes Register [9]. Mean HbA_1c levels are indicated as follows: yellow bars, <51.9 mmol/mol (≤6.9%); pink bars, 53.0–61.5 mmol/mol (7.0–7.8%); red bars, 60.7–71.6 mmol/mol (7.9–8.7%); purple bars, 72.7–81.4 mmol/mol (8.8–9.6%); blue bars, >82.5 mmol/mol (≥9.7%). Overall, 77,117 of 435,369 participants with type 2 diabetes (17.7%) died from any cause, as compared with 306,097 of 2,117,483 control participants (14.5%) (adjusted HR 1.15 [95% CI 1.14, 1.16]). p values for the interaction term between time-updated mean HbA_1c or renal disease status and time-updated age categories were <0.001 in all models. This figure is available as a downloadable slide