Management of type 2 diabetes mellitus in the elderly

AimTo provide evidence based recommendations for optimal care diabetes care in the elderly.BackgroundDiabetes affects approximately 25% of the population ≥65 years, and that percentage is increasing rapidly, particularly in minorities who represent an important fraction of the uninsured/underinsured. Diabetes is an important cause of hospital admissions and a co-morbidity in as high as 50% of hospital inpatients. It impacts mortality and quality of life. While tools have become available to improve glycemic control, enthusiasm for their application must be tempered with the sober realization of the risks involved in intensification of glycemic control, chiefly hypoglycemia.MethodsWeighted review from PubMed and other literature search tools in descending order of randomized control trials, observational studies, pilot studies, published guidelines, the authors’ clinical experience, and expert opinion.Results/conclusions
• HbA1c targets should be stratified according to the frailty of the elderly diabetic patient: <7.0% in the generally well elderly and < 8.0% in the frail elderly.
• Therapies are available that achieve glycemic goals, while minimizing the risk of hypoglycemia, taking into consideration such factors as cognitive function, renal and hepatic function, bone density, fall risk, and hypoglycemia unawareness.
• When insulin is used determir or glargine are safer choices than NPH.
• Ultra-short acting prandial insulins are safer than regular insulin.
• Pen devices for insulin delivery significantly reduce dosing errors and the risk of hypoglycemia.
• Sudden managed care formulary changes that disrupt patients’ diabetes treatment should be prevented through national policy initiatives.
• Up to date home medication lists help prevent dangerous medication errors.
• Widespread adoption of telehealth approaches can significantly improve glycemic control and render it safer.