Glucose control in the older patient: from intensive, to effective and safe

Older adults represent an extensive proportion of Type 2 diabetic patients. Managing diabetes in this population is challenging, because complex comorbidity and disability often mean that guidelines are not suitable on an individual basis. Recent evidence has raised animated discussion of the possibility that intensive glucose control may cause more harm than benefit, especially in older adults. The benefit of glycemic control on microvascular diabetic complications has been consistently demonstrated, but the evidence of benefit on macrovascular disease is not uniform in all studies. Glycemic control appears to prevent the development of cardiovascular events, but is less helpful in secondary prevention, when cardio- and cerebro-vascular diseases are established. In addition, treating hyperglycemia in critically ill patients (most of them over 60 years old) with a target close to normal glucose values has been shown to increase morbidity and mortality. It is possible that the attempt to reach euglycemia is not the best goal, in either older non-diabetic critically ill patients or older diabetic adults. The risks associated with hypoglycemia, which induces a counter-regulatory response with prolonged QT interval and cardiac arrhythmias in patients with established cardiovascular disease, should be carefully considered. The reported association of hypoglycemia with dementia and falls should also be examined. In the older adult, prudent, personalized therapy, with less rigid targets for patients at higher risk of hypoglycemia, is essential. The use of agents with a good safety profiles and with the least possibility of causing hypoglycemia is warranted.