Diabetes in the Elderly
A REAL PRACTICAL
CHALELENGE
MESBAH SAYED KAMEL
MD
Optimizing the Management of T2D Patients....
AGENDA Impact of diabetes in the elderly patient
Factors specific to the management of diabetes in the elderly:
Screening and diagnosis .
Specific complications of type 2 diabetes in the elderly:
Risk of hypoglycaemic episodes
Functional disability
Depression, cognitive impairment and other geriatric syndromes, such as fractures and falls.
How to adapt management and treatment goals in the elderly patient with type 2 diabetes.
Adapted from http://www.indexmundi.com/egypt/demographics_profile.html , https://www.cia.gov/library/publications/the-world-factbook/geos/eg.html , http://en.worldstat.info/World accessed 22-2-2014
2013
≥60 Years
≤60 Years
International Diabetes Federation. Managing Older People with Type 2 Diabetes Global Guidelines.
http://www.idf.org/sites/default/files/IDF%20Guideline%20for%20Older%20People.pdf accessed 15-12-2013
2050
≥60 Years
≤60 Years
These changes present significant challenges to welfare, pension, and healthcare systems in
both developing and developed nations
Diabetes-related complications are the major causes of morbidity,
disability and mortality in older patients with type 2 diabetes:
There is now overwhelming evidence that the level and duration of
glycemia influences the development of diabetes-related
complications
Sinclair 2004. Clinical guidelines for type 2 diabetes mellitus. EDWOP 2004
Microvascular: Neuropathy,Retinopathy,Nephropathy
Macrovascular: Cardiovascular disease, Stroke
• Advanced age
• Recent hospitalization
• Intercurrent illness
• Chronic liver, renal or cardiovascular disease
• Endocrine deficiency (thyroid, adrenal, pituitary)
• Loss of normal counter-regulation
• Hypoglycaemicunawareness
SU=sulfonylurea.
Adapted from Chelliah A, Burge MR. Drugs Aging. 2004; 21: 511–530.
I. Patient risk factors
• Poor nutrition or fasting
• Prolonged physical exercise
• Alcohol (ethanol)
• Use of SU and / or insulin
• Drug interactions with SUs
III. Drug risk factors
II. Lifestyle risk factors
T2DM=type 2 diabetes mellitus.
Greco D, et al. Exp Clin Endocrinol Diabetes. 2010; 118: 215–219.
Decompensated
diabetes39%
Intercurrent
illness14%
Acute
cardiovascular events
13%
Chronic
complications of diabetes
17%
Severe
hypoglycaemia17%
Prevalence of diabetes is strongly influenced by increasing age
Around 18% of people >65 years have diabetes
Diagnosed diabetes (%)
Combined age-group (years)
≥20 7.8 (7.0−8.6)
≥65 17.7 (15.6−19.7)
Age-specific groups (years)
20−39 1.9 (1.4−2.4)
40−59 8.1 (6.9−9.4)
60−74 17.6 (15.7−19.5)
≥75 15.2 (12.9−17.6)Adapted from Cowie C, et al. Diabetes Care. 2010;33:562-68.
Prevalence increases with age and peaks at age 60–74 years, falling slightly in olderages (≥75)
Crude prevalence of diagnosed diabetes by age: NHANES (National Health and Nutrition
Examination Survey) 2003-2006 (n=13094), US
Age at diagnosis The peak age at diagnosis is between 40 and 55, with a
sharp decline after age 65. Among elderly patients with diagnosed diabetes, the majority of diabetes is diagnosed in middle-age (aged 40-64 years) and a minority diagnosed at age ≥65 years.
1. Selvin E, et al. Diabetes Care. 2006;29:2415-19.2. Adapted from IDF Diabetes Atlas. 2011; Fifth Edition
Age (years)
Prevalence (%) of people with diabetes by age and sex 2011
Female
Male
0
15
10
5
605550454035302520 65 70 75
20
Screening and diagnosisin the elderly
Recommendations for screening and diagnosis in the
elderly
Clinical presentation of diabetes in old age is often asymptomatic and non-specific and clinical diagnosis may be delayed
In general, screening for and diagnosis of diabetes in older subjects should be in accordance with published international/national criteria and guidelines, and no age modified criteria are currently recognised
The prevalence and incidence rates of diabetes mellitus in elderly subjects (>65 years) may be underestimated when using only fasting plasma glucose.
Sinclair A, et al. Diabetes & Metabolism. 2011;37:S27-S38.
The presence of isolated post-challenge hyperglycaemia (IPH) is common in older subjects and should alert the clinician to screen for cardiovascular disease and institute risk intervention strategies to minimise premature death.
In high-risk older subjects with a normal fasting glucose, and where an OGTT is not feasible, determination of HbA1c may be helpful in the diagnosis of diabetes. A value of HbA1c >6.5% may indicate the likely presence of diabetes
Managing type 2 diabetes in the elderly
Special considerations
Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care
Their approach is influenced by a multitude of factors, such as the higher frequency of medical comorbidities, frailty and socioeconomic issues
Comprehensive geriatric assessment is a potentially important tool in ensuring that patients with diabetes receive a multi-professional assessment of their functional status and unmet needs.
Sinclair A. Diabetes Spectrum. 2006;19(4):229-33.
Management goals in the elderly The overall goals of diabetes management in older adults
are similar to those in younger adults and include management of both hyperglycaemia and risk factors1
However, in frail, elderly patients with diabetes, avoidance of hypoglycaemia, hypotension, and drug interactions due to poly-pharmacy are of even greater concern than in younger patients with diabetes1,2.
In addition, management of coexisting medical conditions is important because it influences their ability to perform self-management2
1.Brown AF, 2003; 51(5):S265-286. 2.Sinclair A. Diabetes Spectrum. 2006;19(4):229-33.
Major aims in managing older adults with diabetes
1. Sinclair AJ. Diabetes Spectrum. 2006;19(4):229-33; 2. Inzucchi SE, et al. Diabetes Care. 2012;55(56):1577-96.
Medical1 Patient oriented1
Freedom from hyperglycaemic symptoms
Prevention of undesirable weight loss
Avoidance of hypoglycaemia and other adverse drug reactions
Estimation of cardiovascular risk as part of screening for and preventing vascular complications
Detection of cognitive impairment and depression and functional disabilities at an early stage
Achievement of a normal life expectancy for patients where possible
Protect against heart failure, renal dysfunctions , bone fractures and drug-drug interactions2
Maintenance of general well-beingand good quality of life
Acquisition of skills and knowledge to adapt to lifestyle changes
Encouragement of diabetes self-care
Rationale for high-quality diabetes care in the
elderly
Recommendations:
Screening and early diagnosis may prevent progression of undetected vascular complications
Overall improved metabolic control will reduce cardiovascular risk
Improved screening for maculopathy and cataracts will reduce visual impairment and blind registrations
An integrated approach to management of peripheral vascular disease and foot disorders will reduce amputation rate
Sinclair A, et al. Diabetes & Metabolism. 2011;37:S27-S38.
Associated problems affecting management in the
elderly… Poor Hepatic Glycogen Reserve:
Decreased stores related to poor nutrition and decreased appetite.
Cataract: Both age and DM contribute to its causation
Neuropathy: Autonomic neuropathy (postural hypotension, constipation, etc.)
Neuropathy, atherosclerosis of peripheral vessels and poor vision makes elderly more prone to foot problems and contribute to sexual impotence in a large number of elderly diabetics.
Managing the frail, elderly patientwith type 2 diabetes
Complications of type 2 diabetes in the elderly
Hypoglycaemia
Cardiovascular
Microvascular (retinopathy/nephropathy)
Cognitive (dementia)
Depression
Falls and fractures
Peripheral neuropathy
The frail, elderly patient with diabetes
Older persons with diabetes are at higher riskthan those without diabetes of:
Vascular death and cancer mortality1
Functional disability2
Geriatric syndromes: Depression2
Cognitive impairment2
Other geriatric syndromes2
Severe hypoglycaemia2
(when treated with sulphonylureas or insulin)
Elderly patients with diabetes are at higher risk for hypoglycaemia and also lack of awareness about hypoglycaemia compared to younger patients2
Ageing andDiabetes
Cognitivedysfunction
CV disease,cancer andall cause
morbidity/mortality
Falls andfractures
Functionaldisability and
depression
1. Emerging Risk Factors Collaboration, et al. N Engl J Med. 2011;364(9):829-41.2. Sinclair A. Diabetes Spectrum. 2006;19:229-33.
Hypoglycaemia is a risk marker of frailty The relationship between
hypoglycaemia and geriatriccomorbidities
Hypoglycaemiais accompanied by many adverse consequences for which elderly patients are already at an increased risk
HypoglycaemiaFalls andfractures
Functionaldisability and
depression
Cognitivedysfunction
CV disease,cancer andall cause
morbidity/mortality
1. Sinclair A. Diabetes Spectrum. 2006;19(4):229-33.2. Emerging Risk Factors Collaboration, et al. N Med. 2011;364(9):829-41.
Ageing increases the risk of (sulphonylurea-
or insulin-induced) hypoglycaemia
Incremental increase in baseline age was associated with increased risk for severe hypoglycaemia, both for patients following intensive or standard treatment strategies
Annual incidence of hypoglycaemia requiring medical assistance (%)
Subgroup Intensive glycaemia control Standard glycaemia control
Overall 2.80 0.90
Age (years)
<65 2.38 0.80
65−69 3.04 1.00
70−74 4.25 1.39
≥75 5.27 1.39
Miller ME, et al. BMJ. 2010;340:b5444. doi: 10.1136/bmj.b5444.
Ageing increases the risk of (sulphonyl urea
or insulin-induced) hypoglycaemia
Hazard ratios from model predicting hypoglycaemia requiring medical assistance
Hazard ratio (95% CI) P value
Effects for both intensive arm participants and standard arm participants
Age (per 1 year increase) 1.03 (1.02 to 1.05) <0.0001
Each one year increment in baseline age was associated with a 3% increase in the risk for severe hypoglycaemia
Miller ME, et al. BMJ. 2010;340:b5444. doi: 10.1136/bmj.b5444.
Why is the elderly diabetic patient
at high risk of hypoglycaemia?
Defective Counter-regulation or perception of symptoms
1.The effects of ageing on the responses to hypoglycaemia1
2.The effects of type 2 diabetes on the responses to hypoglycaemia2
3.The effects of type 2 diabetes and ageing on the counter-regulatory responses to hypoglycaemia3
1. Meneilly GS, et al. J Clin Endocrinol Metab. 1994;78(6):1341-8; 2. Bolli GB. et al. J Clin Invest. 1984;73(6):1532-41; 3. Bremer JP, et al. Diabetes Care. 2009;32(8):1513-7.
Older Patients have Less Perception of Hypoglycemia
Bremer JP et al. Diabetes Care. 2009; 32 (8):1513-17
12
14
10
8
6
4
2
0
Auto
no
mic
sym
pto
ms
Baseline Hypo Recovery
**
12
10
8
6
4
2
0
Neu
rogl
yco
pen
ic
sym
pto
ms
Baseline Hypo Recovery
*
Middle-aged (39-
64 years)
Older
(≥65 years)
• 1-Attention to hypoglycemic symptoms may be reduced by depression, cognitive dysfunction or other chronic conditions.
2-Many elderly patients have limited knowledge about the symptoms of hypoglycemia: knowledge of diabetes is essential for symptom recognition.
WHY?????
1. The effects of ageing on the responses to hypoglycaemia:
There is defective perception of symptoms in the elderly 1
2. The effects of type 2 diabetes on the responses to hypoglycaemia:
Glucose counter-regulatory mechanisms may be abnormal in patients with Typ2 DM: impaired glucagon, growth hormone, cortisol, and perhaps epinephrine responses during hypoglycaemia could all contribute to a lack of compensatory increase in glucose production2
3. The effects of type 2 diabetes and ageing on the counter-regulatory responses to hypoglycaemia:
Impaired perception of hypoglycemia in older type 2 diabetes patients3
The elderly patient with diabetes is at high risk of hypoglycemia
1. Meneilly GS, et al. J Clin Endocrinol Metab. 1994;78(6):1341-8; 2. Bolli GB. J Clin Invest. 1984;73(6):1532-41; 3. Bremer JP, et al. Diabetes Care. 2009;32(8):1513-7.
Olderpatients with diabetes
have higher ratesof various comorbidities
such as hypertension, coronary heart disease, and stroke than
those without diabetes
Older adults with diabetes are at greater risk than other older adults for premature death, functional disability, and several common geriatric syndromes, such as polypharmacy, depression, cognitive impairment, or falls
The frail, elderly patient with diabetes
Ageing andDiabetes
Cognitivedysfunction
CV disease,cancer andall cause
morbidity/mortality
Falls andfractures
Functionaldisability and
depression
Sinclair A. Diabetes Spectrum. 2006;19:229-33.Emerging Risk Factors Collaboration, et al. N Engl J Med. 2011;364(9):829-41.
Older individuals with diabetes are at higher risk of cancer,
mortality and vascular death than those without diabetes
Cancer deaths (+23%,) and vascular deaths (+67%) (the most common causes of deaths in the elderly)
Emerging Risk Factors Collaboration, et al. N Engl J Med. 2011;364(9):829-41 (supplemental material).
Age at survey Cancer deathsHR
(95% CI)Interaction
p-valueVascular deaths
HR(95% CI)
p-value
40−59
60−69
70+
1.51(1.32, 1.72)
1.27(1.11, 1.45)
1.23(1.07, 1.41)
0.6208
3.03(2.59, 3.55)
2.18(1.88, 2.53)
1.67(1.41, 1.97)
0.0002
.5 1 2 4.5 1 2 4
Hazard ratios(diabetes vs. non-diabetes)
Hazard ratios(diabetes vs. non-diabetes)
The frail, elderly patient with diabetes Older persons with diabetes
are at higher risk than thosewithout diabetes of:
Cancer mortality and vascular deaths
Functional disability
Older adults with diabetes have greater difficulty walking, climbing stairs, doing housework ..., compared with their counterparts without diabetes
Ageing andDiabetes
Cognitivedysfunction
CV disease,cancer andall cause
morbidity/mortality
Falls andfractures
Functionaldisability and
depression
This excess disability in patients with diabetes was largely due to comorbidities, whereas poor glycaemic control (A1C ≥ 8%) alone only accounted for <10%
Kalyani RR, et al. Diabetes Care. 2010;33(5):1055-60.
The frail, elderly patient with diabetes
Older persons with diabetes are at higher risk than those without diabetes of:
Cancer mortality and vascular deaths
Functional disability
Geriatric syndromes, suchas depression
Ageing andDiabetes
Cognitivedysfunction
Falls andfractures
Functionaldisability and
depression
The presence of diabetes doubles the odds of comorbid depression
Anderson RJ, et al. Diabetes Care. 2001;24(6):1069-78.
CV disease,cancer andall cause
morbidity/mortality
Cognitive dysfunction should be added to the list of the complications of diabetes,along with retinopathy, neuropathy, nephropathy and cardiovascular disease.
The frail, elderly patient with diabetes
Older persons with diabetes are at higher risk than those without diabetes of:
Cancer mortality and vascular deaths
Functional disability
Geriatric syndromes:depression
Geriatric syndromes: cognitive impairment
Ageing andDiabetes
Cognitivedysfunction
Falls andfractures
Functionaldisability and
depression
Cukierman T, et al. Diabetologia. 2005;48(12):2460-9.
CV disease,cancer andall cause
morbidity/mortality
Cognitive decline in the elderly diabetes patient
When assessed by the Mini-Mental State Exam (MMSE) and the Digit Symbol Span tests (DSS), diabetes increased the odds of cognitive decline 1.2-fold and 1.7-fold respectively
Cognitive decline as assessed by the MMSE
DM (n) No DM (n) OR and 95% CI
Gregg et al 402 584 1.0 (0.8, 1.4)
Fontbonne et al 55 768 1.0 (0.5, 2.2)
Nguyen et al 347 1412 1.1 (0.9, 1.4)
Stewart et al 62 154 1.2 (0.9, 1.6)
Wu et al 585 1204 1.7 (1.2, 2.3)
Kanaya et al 118 632 0.7 (0.3, 1.7)
Total (95% CI) 1569 10014 1.2 (1.05, 1.4)
Cognitive decline as assessed by the DSS
DM (n) No DM (n) OR and 95% CI
Fontbonne et al 55 768 2.3 (1.2, 4.3)
Gregg et al 339 5098 1.6 (1.2, 2.2)
Total (95% CI) 394 5866 1.7 (1.3, 2.3)
0.01 0.1 10 1001
0.01 0.1 10 1001
Cukierman T, et al. Diabetologia. 2005;48(12):2460-9. DM= diabetes mellitus
DM (n)
No DM (n)
Risk and 95% CI
Hassing et al 38 2202.1
(0.99−4.4)
Leibson et al 1455 NA1.7
(1.3−2.0)
Macknight et al
503 50711.2 (0.9,
1.7)
Ott et al 689 45321.9
(0.9−1.7)
Peila et al 900 16741.5
(1.0−2.2)
Allparticipants
2723 100441.6
(1.4−1.8)
0.01 0.1 1 10 100
Development of dementia in patients with type 2
diabetes
Development of future dementia
The odds of future dementia is increased 1.6-fold
Cukierman T, et al. Diabetologia. 2005;48(12):2460-9.
10,025 participants in the population-based NHANES sample followed
over 8 years (83,624 person-years of follow-up)
% A
live
60 120
100
60
40
Follow-up (years)
82
20
No diabetes, no depression Diabetes present, no depression
104
80
No diabetes, depression present Diabetes and depression present
Eqede LE, et al. Diabetes Care. 2005;28(6):1339-45.NHANES = National Health and Nutrition Examination Survey
Depression among people with diabetes reduces
quality of life and is associated with morbidity and mortality
It is imperative that clinicians review patients’ depressive symptoms and that goal setting and future management may need to involve psychogeriatric input1
Management and treatment
considerations in the elderly patient
with type 2 diabetes
1. Sinclair AJ. Diabetes Spectrum. 2006;19(4):229-33;2. Inzucchi SE, et al. Diabetes Care. 2012;55(56):1577-96.
Treatment priority of the elderly: prevention of hypoglycaemia
The risks of tight glycaemic control may exceed the benefits in many elderly patients1
In elderly patients, who are frail and may have comorbidities limiting ability to self-management, tight glycaemic control is unlikely to benefit...
… and hypoglycaemia is associated with a wide variety of disabling consequences, including amputation, peripheral neuropathy, immobility, falls, stroke, and cognitive
change. The frequency of hypoglycaemia is high and is exacerbated by older people having
little knowledge about the signs and symptoms of hypoglycaemia.
The goal of minimising symptomatic hypoglycaemia, short-term geriatric syndromes and maximising quality of life should be the primary factors in individualising glycaemic targets
Glycemic targets for elderly with long-standing or more complicated disease should be less ambitious than for the younger, healthier individuals2
Apart from the UKPDS, these large studies (intensive vs standard treatment) were conducted in patients >60 years old and with a long history of diabetes (9 years)
Intensified blood glucose lowering treatment:
what are the benefits in the older patient?
Participant characteristics at baseline
ACCORD
(n=10251)
ADVANCE
(n=11140)
UKPDS(n=3867
)
VADT(n=1791
)
Demographic characteristics
Mean age (years) 62.2 65.8 53.3 60.4
Median duration of known diabetes (years)
10 7 0 10
Turnbull FM, et al. Diabetologia. 2009;52(11):2288-98.
Meta-analysis using the data from the 4 main studies explored by the Collaborators on Trials of Lowering Glucose (CONTROL) group
Intensified blood glucose lowering treatment:
what are the benefits in the older patient?
Standard Intensive
Esti
mate
d e
ffects
of
inte
nsif
ied
gly
caem
ic c
on
tro
l o
n e
ven
t rate
s(p
er
1000 in 5
years
)
20
100
60
80
40
0
CH
D
Str
oke
Blindness
one e
ye
Renal
repla
cem
ent
thera
py/
renal death
All c
auses
mort
ality
Card
iovascula
rm
ort
ality
Severe
hypogly
caem
ia
-7*
-1
-4
-2
+3
+4
+47*
CHD= cronary heart diseaseNumbers on top of the bars indicate the absolute risk reductions/increases per 1000 participants treated for 5 years.• Statistically significant treatment effects (CHD p=0.03; severe hypoglycaemia p<0.00001)
• Mean age of patients : 62 years old
Yudkin JS, et al. Diabetologia. 2010;53(10):2079-85.
The benefits of intensified glucose control require long-term adherence
Older patients or those with reduced life expectancy will therefore experience little benefit
Recent studies, which have used modelling techniques to estimate the impact of glycaemic control on life expectancy are enlightening in this respect. The UKPDS outcomes model estimated that intensified glucose control would increase quality-adjusted life years (QALY) by 0.27, or about 99 days.
Treatment priority of the elderly: prevention of hypoglycaemia
The elderly patient with diabetes is often a frail patient1
Elderly people with diabetes are also at higher risk for hypoglycaemia and hypoglycaemia unawareness1,2
Hypoglycaemia is associated with many adverse consequences1
The available data suggest that the risks of tight glycaemic control (and the greatest risk is hypoglycaemia) exceed the benefits in many elderly patients1
1. Sinclair A. Diabetes Spectrum. 2006;19(4):229-33.2. ADA Diabetes Care;2012:35(1):S11-S63
EASD/ADA recommendations for managing
hyperglycaemia in the elderly (2012)
Glycaemic targets for elderly with long-standing or more complicated disease should be less ambitious than for younger, healthier individuals
If lower targets cannot be achieved with simple interventions, an HbA1c of <7.5–8.0% may be acceptable, transitioning upward as age increases and capacity for self-care, cognitive, psychological and economic status, and support systems decline
In the aged, the choice of anti-hyperglycaemic agent should focus on drug safety, especially protecting against hypoglycaemia, heart failure, renal dysfunction, bone fractures, and drug–drug interactions. Strategies specifically minimising the risk of low blood glucose may be preferred
Inzucchi SE, et al. Diabetes Care. 2012;55(56):1577-96.
Glucose-lowering algorithm for frail patients with type 2 diabetes mellitus
Sinclair AJ, et al. Diabetes Metab. 2011;37 Suppl 3:S27-38.
3−6 months dietary
and lifestyle advice
Not achieving agreed
glucose targets
Metformin
Metformin + DPP-IV
inhibitor
Metformin + insulin
Metformin contraindicated inrenal/hepatic dysfunction,respiratory/heart failure,anorexia, gastrointestinal disease
Alternative treatments:DPP-IV inhibitors, or lower risksulphonylureas (SU)Glinides
Further weight loss with a GLP-1 agonist may have adverse consequences in a frail patient
Alternative treatments:Metformin + lower-risk SUMetformin + GLP-1 agonist
Frailty associated with increased hypoglycaemia risk: caution when using insulin or sulphonylureatherapy
Alternative treatments:Low risk SU + insulin
Failure to achieve glucose targets
Failure to achieve glucose targets
Frailty criteria:
Care home residencySignificant cognitive declineMajor lower limb mobility disorderHistory of disabling stroke
Recommended glucose targets:Fasting glucose range = 7.6−9.0 mmol/lHbA1c range = 7.6−8.5%
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
• CAUTION in the elderly
• Initial doses = HALF of usual dose
• Avoid glyburide
• Use gliclazide, gliclazide MR, glimepiride,
nateglinide or repaglinide instead
• CAUTION in the elderly
• Increased risk of fractures
• Increased risk of heart failure
• May use detemir or glargine instead of NPH or
human 30/70 for less hypos
• Premixed insulins and prefilled insulin pens
instead of mixing insulin to reduce dosing errors
• CAUTION with renal dysfunction
2015
Diabetes in the Elderly Checklist
ASSESS for level of functional dependency (frailty)INDIVIDUALIZE glycemic targets based on the above (A1C
≤8.5% for frail elderly) but if otherwise healthy, use the same targets as younger people
AVOID hypoglycemia in cognitive impairmentSELECT antihyperglycemic therapy carefullyCaution with sulfonylureas or thiazolidinediones
Basal analogues instead of NPH or human 30/70 insulin
Premixed insulins instead of mixing insulins separately
GIVE regular diets instead of “diabetic diets” or nutritional formulas in nursing homes.
Canadian D A Guidelines 2015
2015
In the frail elderly, while avoiding symptomatic
hyperglycemia, glycemic targets should be an A1C of
≤8.5% and FPG or pre-prandial PG of
5.0-12.0 mmol/L, depending on the level of frailty.
In elderly people with cognitive impairment, strategies
should be employed to strictly avoid hypoglycemia,
which include the choice of antihyperglycemic
therapy and less stringent A1C target [Grade D, Consensus].
Elderly people with type 2 diabetes should perform
aerobic exercise and/or resistance training, if not
contraindicated, to improve glycemic control [Grade B,
Summary and conclusions Advancing age is a risk factor for the development of diabetes1
Elderly onset diabetes should be diagnosed as early as possible in accordance with national guidelines to avoid the progression of vascular complications, retinopathy and renal impairment2
Hypoglycaemia is a danger in elderly diabetes patients due to a higher level of hypoglycaemic unawareness and medication combinations in this population3
The presence of comorbidities presents unique challenges for the management of elderly type 2 diabetes patients3
Cognitive dysfunction, depression, risk of falls, frailty and other morbidities need to be addressed as part of comprehensive care3
1. Cowie C et al. Diabetes Care. 2010;33:562-68; 2. Sinclair et al. Diabetes & Metabolism. 2011;37:S27-S38; 3. Sinclair A. Diabetes Spectrum. 2006;19(4):229-33
Thank you
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