Management of diabetes in the elderly: a clinical perspective

Glucose tolerance deteriorates with advancing age. According to the currently accepted National Diabetes Data Group criteria, the prevalence of diabetes increases from 2% in the 20- to 44-year-old age-group to nearly 18% in those aged 65 to 74 years. Although the principles of management of diabetes in the elderly are similar to those applied to young adults, they must be modified according to the coexisting conditions unique to the elderly. Treatment modalities include diet, exercise, oral hypoglycemic agents (sulfonylureas, metformin in the near future), and insulin. A dietary and exercise prescription should be given to all patients, but must be carefully individualized. If nonpharmacologic measures do not succeed, oral hypoglycemic agents or insulin may be used. It should not be assumed that long-term vascular complications of diabetes will not occur in elderly diabetics. An attempt should therefore be made to control hyperglycemia. The Diabetes Control and Complications Trial demonstrated that tight blood glucose control effectively delays the onset and progression of complications in young patients with insulin-dependent diabetes; however, tight control is associated with an increased risk of hypoglycemia. Hypoglycemia in older adults may have serious consequences, such as precipitating a myocardial infarction or stroke. Treatment should thus aim for a reasonable degree of blood glucose control without producing hypoglycemia or seriously interfering with the enjoyment of life. Coexisting renal or hepatic dysfunction or other factors also make the elderly more prone to developing hypoglycemia, which must be carefully avoided. If complications are present, their treatment and efforts to prevent their worsening are important objectives of the therapeutic plan.