At least 50% of people 65 years old and over have diabetes or pre-diabetes, and the situation is expected to get worse. Not only are obesity rates rising, but the problem is compounded by the increasing insulin resistance and decrease in pancreatic islet function that develop as someone ages.
Older adults with type 2 diabetes have the highest rate of lower limb amputations, heart attacks, and kidney failures. And the number of older patients with diabetes is expected to double over the next 20 years, rising perhaps nearly five fold between 2005 and 2050.
Yet physicians and clinicians have little solid research on how to treat this growing group, in part because older people have historically been excluded from large-scale clinical trials over concerns their often-complex health issues could complicate trial results.
“In light of the paucity of data for diabetes care in older adults, treatment decisions are frequently made with considerable uncertainty,” according a consensus panel statement jointly published in the October issue of Diabetes Care, the peer-reviewed publication of the American Diabetes Association and the Journal of the American Geriatrics Society.
The ADA convened a panel of experts from across the country back in February to look at the troubling lack of clinical knowledge, plus review current treatment guidelines and make suggestions on how to treat this segment of the population.
“Globally, a lot of people are very worried about how we’re going to be able to handle all these older people with diabetes,” said Elbert Huang, MD, MPH, associate professor of medicine and director of the Center for Translational and Policy Research of Chronic Diseases. Huang was a member of the consensus panel.
One of the first steps was the creation of three categories to help recognize the heterogeneity of people over 65 who suffer from diabetes, and to serve as a foundation for differing treatment recommendations. The groups were split up according to:
- those in relatively good health;
- those with complex medical histories that might make self-care difficult;
- those with significant comorbid illness and functional impairment.
The mere delineation of these groups helped to underscore and highlight the growing recognition that one size does not fit all when treating diabetes in older adults.
“In a lot of ways, it was easier just to say there’s one goal for the whole population and we just need to push everyone towards it,” Huang said. For a long time, there had been resistance to having different goals or targets for different patients, such as for A1C levels, a standard measure of longer-term blood sugar levels. “Now, individualization of diabetes care is being fully embraced by everyone.”
A key focus of the report was a framework of goals for glycemia, blood pressure, and dyslipidemia in the three groups of older diabetics.
The direction of the consensus panel statement follows on research Huang and colleague Neda Laiteerapong, MD, instructor of medicine, published recently suggesting that perhaps half of U.S. adults with diabetes should have their A1C levels above the ADA-recommended level of seven percent. And for older diabetics, a tight control on blood sugar could actually be harmful. See a ScienceLife post on this research.
The panel made a number of treatment-related recommendations, including:
- additional screening and lifestyle intervention for those patients who would likely benefit the most from prevention of type 2 diabetes;
- examination of proper pharmacotherapy, including taking into account polypharmacy;
- regular assessment for hypoglycemia;
- assessment of the burden of treatment on older patients and caregivers plus attempts to reduce the complexity of treatment.
There were also a number of consensus recommendations for further research on diabetes in older patients. These included:
- What specific cellular and molecular mechanisms define the interactions between aging and lifestyle factors that underlie the high rates of diabetes in the older adult population? How can such mechanisms be used to develop effective intervention strategies?
- What is the optimal level of blood pressure control in older adults with diabetes? What are the best treatment strategies?
- What are the ethical and patient preference concerns about de-intensifying therapy in older adults who are deemed unlikely to reap benefits from aggressive therapy of diabetes and its comorbidities?
- Does treatment of hyperglycemia in general or via particular strategies reduce the risk of diabetes-associatedcognitive impairment? Is such impairment slowed or prevented by diabetes prevention strategies?
- Can we make it easier for clinicians to anticipate the expected lifetime beneﬁts of interventions, such as decision support tools for life expectancy embedded in electronic health records? What impact will formal use of prognostic information have on diabetes care and patient outcomes?
“The main message, certainly in diabetes and other chronic diseases, is that there is now this increasing recognition that we need to tailor and individualize goals of care and treatments in older people,” said Huang. Different targets will “definitely have implications for how you design public health programs and how you measure quality of care.”