Challenges in the Management of Type 2 Diabetes in the Elderly

Edward S Horton
European Endocrinology, 2007:41-44
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It is estimated that diabetes currently affects 195 million people worldwide. This figure is expected to rise to over 330 million by 2030.1,2 The overwhelming scale of the problem will present significant challenges to healthcare systems and clinical practices. Furthermore, the population in general is aging. Both the prevalence and the incidence of type 2 diabetes rise with increasing age, leading to a large rise in the number of elderly people with diabetes: approximately 15% of people over 60 years of age in the US are affected by diabetes, and it is estimated that half of all type 2 diabetes cases occur in those above 65 years of age.3 In Europe, data from the Diabetes Epidemiology: Collaborative Analysis Of Diagnostic Criteria in Europe (DECODE) study suggest that the prevalence of diabetes is 10–20% in those 60 and 69 years of age, rising to 15–20% in the oldest age groups.4

The management of diabetes in the elderly has unique challenges. With increasing age, there is an increased prevalence of comorbid illnesses and functional disability that contributes to the complexity of managing diabetes in the elderly cohort. Thus, treatment must take into consideration not only the standard micro- and macrovascular complications associated with both aging and diabetes, but also conditions such as cognitive impairment and impaired function. Importantly, elderly patients with diabetes have an increased risk for cardiovascular disease.5

The diagnosis of diabetes in the elderly also presents challenges, and it is estimated that half of the elderly population with diabetes are not diagnosed correctly with the condition. This is due to many factors, including the observation that this cohort rarely presents with the typical symptoms of hyperglycemia,6,7 the renal threshold for glucose increases naturally with age, making it difficult to identify glucosuria, and fasting blood glucose measurements or oral glucose tests are not routinely performed in this population. Additionally, common symptoms such as fatigue, blurred vision, and polyuria are often not recognized as abnormal in this population, and polydipsia can go unnoticed because of the decreased thirst usually associated with advanced age.

The primary considerations for the treatment of elderly patients with type 2 diabetes are the evaluation of functional status, life expectancy, social and financial support, and the patient’s own desire for treatment. Individual assessment should be carried out to ascertain the best course of treatment to allow avoidance of potential problems that could impair its effectiveness. Alterations in diet and exercise are the first-line treatments for elderly patients with diabetes; however, this is not always successful at controlling the condition, and early medical therapy often becomes necessary. Ideal management regimens for geriatric patients with diabetes require a multidisciplinary approach. Comorbid-existing medical or psychiatric disorders and the potential for antidiabetic agents to contribute to the development of treatment-related complications (as well as the greater risk for hypoglycemia in older patients)8 are also important considerations.

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