Diabetes in the Elderly   (November 18, 2012)

There's an old question that asks "What's the definition of elderly?" to which the answer is: "Ten years older than I am." But I just read a report that made me feel old…

In a consensus statement issued by the American Diabetes Association and the American Geriatrics Society, titled Diabetes in Older Adults: A Consensus Report, the authors arbitrarily declare that “the elderly” includes anyone 65 years or older.  They go on to stress that differences in life expectancy and comorbidities should be considered in setting treatment goals for older diabetes patients. Some tidbits from their discussion:

1)       Older adults who are functional, are cognitively intact, and have significant life expectancy should receive diabetes care using goals developed for younger adults.

2)       Hyperglycemia leading to symptoms or risk of acute hyperglycemic complications (such as diabetic ketoacidosis and hyperglycemic nonketotic coma) should be avoided in all patients.

3)       Hypoglycemia is especially risky in the elderly: “Hypoglycemia is linked to cognitive dysfunction in a bidirectional fashion: cognitive impairment increases the subsequent risk of hypoglycemia, and a history of severe hypoglycemia is linked to the incidence of dementia.”

4)       When  diabetes is associated with coexisting medical conditions such as cardiovascular disease or cancer or dementia, these coexisting conditions can affect diabetes treatment decisions, such as whether stringent glycemic control would be appropriate.

The authors included prolonged discussions concerning glucose control, lipid lowering, blood pressure control, and use of aspirin. One recurring theme is that there are insufficient studies in the elderly population to make generalized recommendations, and hence individualized treatment plans are necessary. These individualized plans would have to take into account (among other factors):

1)       Cognitive impairment and dementia, such as Alzheimer’s and multi-infarct dementia

2)       Functional impairment such as deafness, decreased vision, and loss of balance

3)       Issues such as depression, decreased socialization, loss of support systems, and health-care costs.

4)       Unique nutrition issues: “Older adults may be at risk for undernutrition due to anorexia, altered taste and smell, swallowing difficulties, oral/dental issues, and functional impairments leading to difficulties in preparing or consuming food.”

They set up a “A Framework for Considering Treatment Goals for Glycemia, Blood Pressure, and Dyslipidemia in Older Adults with Diabetes.”  For the purposes of this framework, elderly people with diabetes were divided into three groups:

1)       Healthy (Few coexisting chronic illnesses, intact cognitive and functional status)

2)       Complex/intermediate (Multiple coexisting chronic illnesses or mild-to-moderate cognitive impairment)

3)       Very complex/poor health (Long-term care or end-stage chronic illnesses or moderate-to-severe cognitive impairment)

They then suggest that each of these three groups should have different A1C, blood glucose, and  blood pressure goals. (They also describe “Additional Consensus Recommendations for Care of Older Adults with Diabetes” and list a huge number of unanswered questions about diabetes care in the elderly.)

After reading this lengthy report, my head was spinning, and I’m left wondering what the impact of this document will be.

Will drug companies start doing studies on their drugs in the elderly? (No, not unless the government insists on including more elderly patients. Right now, the FDA has a vague motherhood-and-applepie statement that during the development of diabetes drugs, “Attention also should be paid to considerations in geriatric patients,” but unless a law similar to the Pediatric Research Equity Act is passed that forces drugmakers to evaluate elderly patients, no manufacturer will voluntarily start studies on elderly patients.)

Will Medicare allocate more financial resources to provide appropriate diabetes care for the “healthy elderly person with diabetes”? (Ha – as much as I wish they would, it’s wishful thinking)

Will physicians adjust the diabetes care provided to their patients based on a framework that subdivides elderly patients by health status? (To be sure, to some extent they already do)

Can we identify the biggest problems associated with diabetes care in the elderly? (Yes: There are two: hypoglycemia and cardiovascular disease prevention/minimization)

Should the general public be made aware of these issues? (Definitely yes: to paraphrase something that Pogo once said, "We have met the elderly and he is us." Hopefully, we’re all going to be elderly one of these days.)