Management of Atherosclerotic Cardiovascular Disease Risk Factors in the Older Adult Patient With Diabetes

Abstract

Older adults with diabetes are at higher risk for atherosclerotic cardiovascular disease (ASCVD) than younger adults with diabetes and older adults without diabetes. The rationale to implement ASCVD risk-lowering therapies in older adults with diabetes is compelling. Recommendations for lifestyle modification, lipidlowering therapy, blood pressure management, blood glucose control, and aspirin therapy are often based on studies that show their efficacy in younger populations. However, the risks associated with each of these interventions increase with age, and favorable risk-to-benefit ratios demonstrated in younger adults with diabetes are less certain in older populations. The variability in health status among older adults is pertinent. Those with robust health are more likely to tolerate and derive benefit from many therapies when compared with those who have more complex health including frailty. Age-and/or frailty-stratified data to help clarify these relationships are sparse. In this Perspective, current recommendations for modifying ASCVD risk are described with a review of the pertinent literature that guides their application in older adults. A pragmatic approach to the treatment of ASCVD risk factors in older adults with diabetes is presented.Diabetes is highly prevalent in the aging population, affecting .25% of individuals aged .65 years and 19% of those aged .75 years (1,2). Physiological changes associated with aging increase susceptibility to coronary heart disease and other atherosclerotic cardiovascular disease (ASCVD) processes (3). The incidence and prevalence of ASCVD-related macrovascular events essentially doubles in older adults with diabetes (4-6). The overlap of older age, diabetes, and other ASCVD risk factors enhances risk for microvascular and macrovascular complications, functional disability, and geriatric syndromes (including frailty, multimorbidity, polypharmacy, cognitive impairment, depression, urinary incontinence, and falls) (1,7-10). As the population of older adults grows, the implications of diabetes on ASCVD risk escalate, and insights regarding optimal care become increasingly important (2).Therapies directed at ASCVD risk factor reduction are important therapeutic priorities for older adults with diabetes as a way of modifying risk for vascular events and improving health-related quality of life (HRQL) (11,12). Therapeutic targets include control of lipids, blood pressure (BP), and blood glucose in combination with antiplatelet agents. The expectation is that these therapies will increase longevity, reduce ASCVD events and need for hospitalizations, and improve HRQL. However, iatrogenic risks and limited life expectancy confound these objectives

Diabetes and Aging: Unique Considerations and Goals of Care

“…Long-term mortality after hyperglycemic crises are significantly higher in older adults (23). In the Perspective by Korytkowski and Forman (24), the authors point out that although older adults are at higher risk of atherosclerotic cardiovascular disease, most of the studies examining the benefits for aggressive glucose-lowering and cardiovascular risk factor modification (i.e., lipid-lowering, hypertension, and antiplatelet therapies) are in nonelderly adults. A compelling summary of the rationale and practical recommendations for atherosclerotic cardiovascular disease risk factor reduction in older adults is presented, as is the importance of considering whether the benefits outweigh the risks in this heterogeneous population.…”

Diabetes in the elderly: is age a limiting control target?

“…Atherosclerotic disease is greater in elderly diabetics in relation to younger patients as well as in relation to elderly non-diabetic. 3,8 Reduction of cardiovascular risk with the management of blood pressure, use of antiplatelet drugs, strict glycemic control or pharmacological management of lipids are unquestionable measures in young people but controversial in elderly patients, due to the increase in adverse effects and mortality. 2,3,8 For this, it is very important to know the performance status of our elderly patients, as well as the fragility of the sample with which we work to avoid iatrogenic complications.…”

“…3,8 Reduction of cardiovascular risk with the management of blood pressure, use of antiplatelet drugs, strict glycemic control or pharmacological management of lipids are unquestionable measures in young people but controversial in elderly patients, due to the increase in adverse effects and mortality. 2,3,8 For this, it is very important to know the performance status of our elderly patients, as well as the fragility of the sample with which we work to avoid iatrogenic complications. 8 Increase in micro and macroangiopathic complications observed in diabetic elderly patients, as published in the literature, 2,3,9 we have evidenced in our study, being statistically significant erectile dysfunction, nephropathy in all stages both proteinuric and not proteinuric and diabetic neuropathy.…”

“…2,3,8 For this, it is very important to know the performance status of our elderly patients, as well as the fragility of the sample with which we work to avoid iatrogenic complications. 8 Increase in micro and macroangiopathic complications observed in diabetic elderly patients, as published in the literature, 2,3,9 we have evidenced in our study, being statistically significant erectile dysfunction, nephropathy in all stages both proteinuric and not proteinuric and diabetic neuropathy. Population older than 65, and especially the group comprised of those over 80, constitute a high-risk group, with a high fragility, in which the side effects or drugs are much more frequent.…”

Atitudes e comportamentos dos diabéticos acerca das estratégias de prevenção e controle clínico do diabetes

“…A alta morbimortalidade do DM é consequência das complicações crônicas advindas com o avançar da doença. As incidência e prevalência de eventos macrovasculares, como a doença arterial coronária, doença arterial periférica e acidentes cerebrovasculares, chegam a dobrar em se tratando de pacientes diabéticos comparado aos não diabéticos 8 . Já a retinopatia diabética apresenta prevalência entre 7 a 39% de casos em pacientes diabéticos e corresponde a uma das principais causas evitáveis de cegueira 9 , enquanto que a nefropatia diabética é uma das principais causas de base para a doença renal crônica no Brasil 10 .…”