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.

Relationship between glycated hemoglobin level and duration of hypoglycemia in type 2 diabetes patients treated with sulfonylureas: A multicenter cross‐sectional study

“…We found that diabetes duration, but not age, was directly related to the duration of hypoglycemia in patients treated with sulfonylureas. The duration of diabetes and age have previously been shown to be associated with the incidence of hypoglycemia in patients with type 2 diabetes in other treatment settings [21][22][23] . Furthermore, we found that the dose of sulfonylureas was associated with the duration of hypoglycemia.…”

Evidence‐based diabetes care for older people with Type 2 diabetes: a critical review

“…A comprehensive discussion of this area has been published by an expert review group and the results of subgroup analyses relating to event rate by age of various cardiovascular outcome trials has also been recently examined . We summarize the results of the outcome studies for both older and newer blood glucose‐lowering agents in and in which we also report recently released data from the CARMELINA trial.…”

“…These outcome trials have involved three dipeptidyl peptidase-4 (DPP-4) inhibitor trials, four glucagon-like peptide 1 (GLP-1) receptor agonist trials and two sodium-glucose cotransporter 2 (SGLT2) inhibitor trials [36]. A comprehensive discussion of this area has been published by an expert review group [36] and the results of subgroup analyses relating to event rate by age of various cardiovascular outcome trials has also been recently examined [37]. We summarize the results of the outcome studies for both older and newer blood glucose-lowering agents in Tables S3and S4 in which we also report recently released data from the CARMELINA trial.…”

Low alanine aminotransferase levels predict low muscle strength in older patients with diabetes: A nationwide cross‐sectional study in Korea

“…One disease also associated with low muscle strength is diabetes . In older patients with diabetes, cross‐talk between insulin resistance, inflammation of adipose tissue, and inflammation of skeletal muscle can contribute to sarcopenia and frailty …”

“…4 In older patients with diabetes, cross-talk between insulin resistance, inflammation of adipose tissue, and inflammation of skeletal muscle can contribute to sarcopenia and frailty. 5 Alanine aminotransferase (ALT) is an emerging biomarker of frailty in older adults. 6 In several cohort studies, low-to-normal ALT has been shown to increase frailty, all-cause mortality and cardiovascular mortality.…”