These pages are best viewed with Netscape version 3.0 or higher or Internet Explorer version 3.0 or higher. When viewed with other browsers, some characters or attributes may not be rendered correctly. The management of older adults with type 2 diabetes requires careful consideration of the effects that advancing age and changes in health status can have on the competing risks and benefits of therapeutic interventions. Although tight glycemic control is not always an appropriate treatment goal, many older people with diabetes are undertreated and could benefit from improved glycemic control and more aggressive management of risk factors for macrovascular disease. The prevalence of type 2 diabetes, which represents roughly 90% of all diabetes, increases with age and affects 1820% of people over age 65 in the United States (with a substantial percentage of these cases being undiagnosed). In addition to the 20% of the elderly population with frank diabetes, another 2025% fit criteria for impaired glucose tolerance, a state that is associated with a twofold increase in the incidence of macrovascular complications. Because many older diabetic patients can be expected to live a decade or more after diagnosis, clinicians must carefully weigh the potential risks and benefits of available interventions on reducing the excess morbidity and mortality associated with diabetes. Diabetes mellitus is a significant health concern for older persons in the United States. Approximately 23% of patients over the age of 60 have diabetes, with the majority suffering from type 2 diabetes. Older patients are also more likely to have comorbidities such as hypertension, dyslipidemia, and cardiovascular disease, as well as geriatric syndromes like cognitive impairment, depression, and urinary incontinence. However, the spectrum of diabetes is diverse in the elderly, and not all patients benefit from stringent glycemic control. Evidence from clinical trials demonstrates that approximately 8 years of glycemic control is required before reductions in microvascular events can be appreciated. Thus, for frail elders, patients with limited life expectancy, or those with significant complications or comorbidities, a less aggressive glycemic goal is reasonable (TABLE 1). At a minimum, glycemic control should be adequate to prevent symptoms such as polyuria and to avoid hyperglycemic crises.
Clinical judgements for a 25-year-old patient will be different than those for a 65-year-old patient because of changes in kidney function, weight distribution, metabolism, and many other age-associated factors. Still, some aspects of diabetes treatment for younger patients remain the same for the elderly. For instance, all smokers with diabetes are recommended to take smoking cessation measures regardless of age. Meanwhile, hypertension treatment has shown benefit in all patients with diabetes, including those 80 years or older. Plus, the benefits of lipid-lowering statin therapy are similar in older and younger patients with diabetes, but older patients see greater benefits overall. As recommended for younger patients, exercise and diet modifications are important for properly managing diabetes in older patients. In terms of pharmacotherapy, the first-line recommendation for type 2 diabetes in elderly patients is metformin. Jones et al (1) criticise current guidelines, which highlight possible contraindications to the use of metformin, as too vague and potentially leading to underuse in patients with type 2 diabetes. Although their desire for a “less ambiguous” approach seems sensible, their own guidelines still lack clarity. They note that any specific value of serum creatinine chosen as a cut -off for prescription of metformin will be arbitrary, because of variations in muscle mass and protein turnover. Despite this they then select – for undefined reasons- a serum creatinine value of 150 micromols/L as the cut-off point in their guideline. Hendra TJ, Sinclair AJ (1997) Improving the care of elderly diabetic patients ; the final report of the St Vincent Joint Task Force for Diabetes. They then suggest “caution should therefore be used in prescribing metformin for elderly patients”. This is a vague statement, which could be interpreted as meaning that metformin shouldn’t be prescribed at all in the elderly; that specialist opinion should be sought or creatinine clearance calculated before it is prescribed; or that renal function or serum lactate should be monitored after it is prescribed.(2) In addition, we are not informed of the authors' own definition of “elderly”. Chehade JM, Mooradian AD in Diabetes in old age eds Sinclair AJ, Finucane P. Given that the growing majority of patients with type 2 diabetes are over the age of 65 years,and that there is already evidence of undertreatment of such patients (3), it would seem particularly desirable to be as clear as is possible about this age group, if the full benefits of treatment are to be attained.
Jan 4, 2003. possible contraindications to the use of metformin, as too vague and. “caution should therefore be used in prescribing metformin for elderly Nov 26, 2018. However, in the elderly an additional unintentional weight loss could be. suggested that the use of metformin could lead to severe involuntary.