SAN FRANCISCO — The heterogeneous nature of diabetes in the elderly makes it imperative to assess each patient individually before choosing whether to use aggressive or more conservative therapy, Dr. Hermes Florez said.
Some older diabetes patients have newly diagnosed disease and are quite functional, while others have long-standing disease and significant functional decline. Older adults are more likely to have multiple comorbidities and to be taking multiple medications.
Life expectancy also is important to consider. “In a patient who has less than 5 years of life expectancy, can we be aggressive enough with intensive glycemic control to achieve a hemoglobin A1c level of less than 6.5% when that will lead to increased risk of hypoglycemic events, frequent falls, or significant functional or cognitive decline?” he asked at a a meeting sponsored by the American Diabetes Association.
Approximately 40% of adults with type 2 diabetes mellitus are 60 years or older, comprising roughly 40 million people, noted Dr. Florez, an endocrinologist at the University of Miami and the Miami Veterans Affairs Medical Center. Looked at another way, 13% of U.S. residents aged 60 years or older have been diagnosed with diabetes, and another 12% have undiagnosed diabetes.
To help chart an individual's management plan, balance the potential benefits of aggressive glycemic control against the risks from comorbidities, medication side effects, and geriatric syndromes such as dementia, incontinence, and depression, he advised.
Published data suggest that 46% of elderly patients with type 2 diabetes have five or more comorbidities, most commonly cardiovascular problems including hypertension, lipid disorders, or coronary atherosclerosis. Older patients with diabetes and five or more comorbidities are at increased risk for hospitalizations that could have been prevented and that are two to three times longer, compared with hospitalizations of patients who have diabetes alone.
Dr. Florez described the following sample cases, which highlight treatment choices:
Low risk, high benefit. Aggressive treatment was an easy decision for a 70-year-old woman with a 20-year history of diabetes who also had hypertension, lipid abnormalities, and early appearance of retinopathy but who functioned well independently and had no other comorbidities. “She's low risk, with potential for high benefit” from aggressive glycemic control, he said.
High risk, low benefit. The opposite was true for a 68-year-old man with a 4-year history of diabetes who also had severe cardiomyopathy with ventricular tachycardia and was unable to walk. This patient already was taking 14 medications. Intensifying treatment for better blood pressure, lipid levels, or blood-sugar control could pose greater risks than benefits. “Take a conservative approach,” he said.
Low risk, low benefit. Less easy to manage was a 75-year-old woman with new-onset diabetes, none of the associated cardiovascular risk factors (no hypertension or dyslipidemia), no other comorbidities, and no functional impairment. She's at low risk, but would she benefit from intensive therapy to lower her HbA1c level below 6.5%? “We don't have evidence yet that such a patient will benefit from intensive glycemic control,” Dr. Florez said.
High risk, low benefit. Another tough call was a 72-year-old man with long-standing diabetes of 18 years' duration, a history of multiple hypoglycemic episodes, and complications related to diabetes, including recurrent foot ulcers and retinopathy. Intensive therapy for blood glucose levels, lipids, and blood pressure probably would seem indicated, except that he also had major cognitive deficits. Unless a spouse, or other caregiver can aggressively monitor therapy, intensive treatment poses too much risk for side effects, falls, or further cognitive decline. Treat conservatively, Dr. Florez advised.
Dr. Florez has received research funding from Merck & Co., which makes medications for diabetes.
Balance the potential benefits of aggressive glycemic control against the risks from side effects and comorbidities. DR. FLOREZ