SAN FRANCISCO — The heterogeneous nature of diabetes in the elderly makes it imperative to assess each patient individually before deciding whether to use aggressive or more conservative therapy, Dr. Hermes Florez said.
Some older diabetes patients have newly diagnosed disease and are quite functional, whereas others have long-standing disease and significant functional decline. Older adults are more likely to have multiple comorbidities and to be taking multiple medications.
It is also important to consider life expectancy, noted Dr. Florez, an endocrinologist at the University of Miami and the Miami Veterans Affairs Medical Center, at a meeting sponsored by the American Diabetes Association.
To help chart an individual's management plan, one should 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, advised Dr. Florez. He described the following sample cases to 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.
▸ 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 couldn't walk. He already was taking 14 medications. Intensifying treatment for better blood pressure, lipid levels, or blood-sugar control could pose greater risks than benefits.
▸ 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 other comorbidities, and no functional impairment. She's at low risk, but evidence is lacking that she would benefit from intensive therapy to lower her HbA1c level below 6.5.
▸ High risk, low benefit. A 72-year-old man with long-standing diabetes of 18 years' duration, a history of multiple hypoglycemic episodes, and complications related to diabetes. Intensive therapy for blood glucose levels, lipids, and blood pressure probably would seem indicated, but he also had major cognitive deficits. Unless a relative or caregiver can monitor therapy, intensive treatment poses too much risk for side effects, falls, or further cognitive decline. Treatreat should be conservative.
Dr. Florez has received research funding from Merck & Co., a maker of diabetes medications.