Clinical Management of Elderly Patients with Type 2 Diabetes Mellitus
ABSTRACT With an increase in life expectancy of the general population comes an increase in the number of elderly patients with type 2 diabetes mellitus (T2DM). Although the pharmacologic treatment options for elderly patients with T2DM are the same as for younger adults, management of this growing group poses unique challenges. Changes in renal and hepatic function and an increased prevalence of multiple comorbidities mandate an individually tailored treatment strategy that balances treatment benefits with the patient's functional status and risk for hypoglycemia and polypharmacy. This approach is hampered by the relative paucity of data regarding the pharmacotherapy of T2DM in older adults, necessitating clinical guidance based on data extrapolated from a younger population. Most current guidelines are disease-focused and do not include specific instructions on how to prioritize the treatment of hyperglycemia relative to that of other comorbidities and the functional status of patients. This article reviews the epidemiology, pathophysiology, comorbidities, pharmacokinetic considerations, treatment goals, guidelines, and treatment options for the elderly population, and highlights the current knowledge gaps complicating the management of T2DM in this population.
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ABSTRACT: Frailty is considered a syndrome of decreased reserve and resistance to stressors and is clinically expressed as muscle weakness, poor exercise tolerance, factors related to body composition, sarcopenia and disability. In addition, there is a close relationship between age-related metabolic changes and the occurrence of comorbidities that may in turn lead to frailty.Even though the downward spiral of frailty is activated more quickly in older persons with type 2 diabetes, it is reversible with appropriate interventions before reaching a high level of severity. The hazard for geriatric patients with type 2 diabetes is that frailty encompasses diverse complications already associated with or caused by diabetes. Frailty is also associated with cognitive impairment, reduced ability to perform activities of daily living and increased expression of inflammatory and coagulation markers that may contribute to the adverse microvascular effects of diabetes. Although glycaemic control remains the main targeting achievement in type 2 diabetes, especially in well-functioning older persons, this is not appropriate for those with frailty. Frail elderly people with type 2 diabetes are a specific group in need of treatment parameters for both initial and maintenance therapy with oral antidiabetic agents. Therefore, the prescription of an antidiabetic agent in such individuals must take into consideration not only the standard goal of lowering hyperglycaemic levels, but also improving the quality of life and life expectancy. The clinical management of this population is currently particularly demanding, requiring special considerations with good medical decision making. Clinical aspects complicating diabetes care in older people include cognitive decline, physical functional decline and frailty. Available oral antidiabetic drugs include insulin secretagogues (meglitinides and sulfonylureas), biguanides (metformin), α-glucosidase inhibitors, thiazolidinediones and inhibitors of glucagon-like peptide 1 (GLP-1) degrading enzyme dipeptidyl peptidase 4. In addition, we will discuss injection treatment with GLP-1 analogues. This review will underline the association between diabetes and some frailty components in old patients and how specific antidiabetic agents may play a specific role in improving outcomes.Drug Safety 01/2012; 35 Suppl 1:63-71. DOI:10.1007/BF03319104 · 2.62 Impact Factor
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ABSTRACT: This paper serves to apply and compare aspects of person centered care and recent consensus guidelines to two cases of older adults with poorly controlled diabetes in the context of relatively similar multimorbidity. After review of the literature regarding the shift from guidelines promoting tight control in diabetes management to individualized person centered care, as well as newer treatment approaches emerging in diabetes care, the newer guidelines and potential treatment approaches are applied to the cases. By delving into the clinical, behavioral, social, cultural and economic aspects of the two cases in applying the new guidelines, divergent care goals are reached for the cases. Primary care practitioners must be vigilant in providing individualized diabetes treatment where multiple chronic illnesses increase the complexity of care. While two older adults with multimorbidity may appear at first to have similar care goals, their unique preferences and support systems, as well as their risks and benefits from tight control, must be carefully weighed in formulating the best approach. Newer pharmaceutical agents hold promise for improving the possibilities for better glycemic control with less self-care burden and risk of hypoglycemia.01/2013; 6:47-61. DOI:10.4137/CMED.S12231
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ABSTRACT: OBJECTIVE: To assess the extent of exclusion of older individuals from ongoing clinical trials regarding type 2 diabetes mellitus. DESIGN: Cohort study. SETTING: World Health Organization Clinical Trials Registry Platform. PARTICIPANTS: Using the Participation of the Elderly in Clinical Trials methodology, data from ongoing clinical trials on type 2 diabetes mellitus were extracted from the platform on July 31, 2011. MEASUREMENTS: Proportion of trials excluding individuals using an arbitrary upper age limit or other exclusion criteria that might indirectly cause limited recruitment of older individuals. Exclusion criteria were classified as justified or poorly justified. RESULTS: Of 440 trials investigating treatments for type 2 diabetes mellitus, 289 (65.7%) excluded individuals using an arbitrary upper age limit. Such exclusion was significantly more common in trials with calculated sample sizes of less than 100 subjects (73.6% vs 59.5%; P = .002). Exclusion for comorbidity was present in 338 trials (76.8%); this exclusion was poorly justified in 236 trials (53.6%). Exclusion for polypharmacy (29.5% of trials), cognitive impairment (18.4%), short life expectancy (8.9%), and other poorly justified exclusion criteria that could limit the inclusion of older individuals was also present. Only six trials (1.4%) were designed specifically to study older adults. CONCLUSION: Despite the recommendations of international regulatory agencies, exclusion of older individuals from ongoing trials regarding type 2 diabetes mellitus is frequent-higher than reported for other age-related diseases. This exclusion limits the value of the evidence that clinicians use when treating old, frail, complex patients with diabetes mellitus.Journal of the American Geriatrics Society 04/2013; 61(5). DOI:10.1111/jgs.12215 · 4.22 Impact Factor