What factors should be considered when determining the management of glycemia in older patients with type 2 diabetes?
Among U.S. residents aged ≥65 years, 12 million (25%) were known to have diabetes in 2015. When managing diabetes in the elderly, treatment decisions should be individualized and should consider medical, psychological, functional, and social conditions for each geriatric patient. Duration of diabetes and existing comorbidities, such as heart disease or renal insufficiency, as well as polypharmacy and cost, are other important considerations. The 2018 American Diabetes Association (ADA) recommendations suggest that healthy older individuals with intact cognition and normal functional status should have lower hemoglobin A 1C (HbA 1C ) goals (< 7.5% without hypoglycemia), whereas individuals with chronic illnesses, poor cognition, or functional dependence should have higher HbA 1C targets (< 8.0%–8.5%) without hypoglycemia. Elderly patients have increased susceptibility to cognitive decline related to hypoglycemia and are at risk for overtreatment of diabetes. A glycemic target of < 8% may be more prudent in managing diabetes in patients with long-term diabetes, established CVD, limited life expectancy, and increased susceptibility to severe hypoglycemia. The 2018 American College of Physicians (ACP) Guidance Statement recommends that clinicians treat octogenarians with type 2 diabetes or those with life expectancy of ≤ 10 years to minimize symptoms of hyperglycemia and not to reach a specific glycemic target. Large multicenter studies that aimed for intense glycemic control of HbA 1C < 6% to 6.5% in older individuals showed no significant reduction in their primary combined cardiovascular endpoints but reported significantly higher rates of hypoglycemia in those patients with intensive blood glucose management. Thus, risks of intensive control likely outweigh the benefits in an elderly population. Given the increasing complexity of glucose management in type 2 diabetes as new medications and drug classes are developed, a patient-centered treatment plan is necessary to reconcile glycemic management and optimize patient outcomes.