The Older Patient with Type 2 Diabetes: Special Considerations and Management with Insulin

Fri, 9/5/08 - 4:54pm
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Author(s):

Charles Cefalu, MD, and William Cefalu, MD

INTRODUCTION
Diabetes mellitus (DM) is a disease that is increasingly prevalent among the aging adult population. In the United States, it is estimated that at least 18% of people age 60 years and older have the disease (diagnosed and undiagnosed), with most (90%) classified as type 2 DM (T2DM).¹ The Centers for Disease Control and Prevention have reported that from 1980 through 2002, there was an increase in the prevalence of diabetes in all age groups (Figure).² The highest prevalence, however, was found among older persons. Comparison of age groups reveals striking differences: In 2002, the prevalence of diabetes among people age 65-74 years (16.8%), was nearly 14 times that of people younger than age 45 years (1.2%).

Elderly patients often may be unaware of impaired glucose tolerance or diabetes because common symptoms of hyperglycemia may be absent. Atypical presentation of disease is common, especially with advanced age, and may include nonspecific lethargy, functional decline, weakness, and even confusion. In view of the considerably increased risk for T2DM with older age, the American Diabetes Association (ADA) recommends that screening for diabetes every 3 years should be considered for all individuals age 45 or older, particularly for those with a body mass index (BMI) 25 kg/m² or higher. The criteria for diagnosis of diabetes in adults are provided in Table I.³

This review will examine the need for glycemic control in elderly patients with T2DM, and discuss the implications for initiation of insulin in this population.

GOALS GOVERNED BY QUALITY OF LIFE: INDIVIDUALIZATION OF TREATMENT IN OLDER PATIENTS
Overall Goals
The overall goals for treatment of hyperglycemia in older patients are essentially the same as those for younger patients with T2DM. These include achieving and maintaining glycemic control, as well as decreasing the risk of complications (microvascular and macrovascular) associated with diabetes.^3,4 Not all older individuals may benefit, however, from the aggressive pursuit of glycemic control. Thus, the relative advantages of strict adherence to glycemic goals (intensive therapy) should be considered in the context of possible risks, such as hypoglycemia. This is particularly relevant in the older patient with complications of long-standing diabetes, such as nephropathy, retinopathy, or evidence of cardiovascular disease (eg, stroke and/or peripheral vascular disease). Elderly patients with diabetes who are in generally poor health, such as those in nursing home care, may be likely to have end-stage disease manifestations that could preclude an intensive approach to therapy.

Patient Level of Functioning and Individualization of Glycemic Goals
Older patients with a high level of functioning and better general health status may benefit greatly from intensive glycemic control, including prevention or delay of complications associated with diabetes. Conversely, an older patient with diabetes and poor functional status may not obtain the benefits from such a regimen.

References:

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