HOME HELP SUBSCRIBE ARCHIVE SEARCH TABLE OF CONTENTS FEEDBACK EDITORIAL BOARD ABOUT DOC NEWS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Full Text (PDF) Services Email this article to a friend Similar articles in this journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Search for Related Content Social Bookmarking                What's this?

Treat to Target: ABCs for the Elderly

Question: What are appropriate targets for treatment of diabetes in older patients?

Answer: The goals of treatment of diabetes in the elderly (patients aged 65 years) are maintaining or improving general health status by control of hyperglycemia and its symptoms; prevention, evaluation, and treatment of macro- and microvascular complications; and diabetes self-management through education.

To achieve these goals, one must consider several factors that influence the clinician's ability to reach the treatment targets as defined by the clinical practice recommendations of the American Diabetes Association (ADA).¹

The ABCs of diabetes treatment identify A1C (glycated hemoglobin), blood pressure, and cholesterol targets for all patients. In the elderly, factors that mitigate these targets should be considered, including the life expectancy, comorbid conditions, polypharmacy, and functional status impairments of the individual patient.

The available data suggest that the risks of tight glycemic control exceed the benefits in many of the elderly.² The greatest risk is hypoglycemia. Itamar B. Abrass, MD, et al.³ have referenced several factors that predispose these patients to hypoglycemia. They are

• Poor or erratic nutritional intake,
  
• Changes in mental status that impair the perception or response to hypoglycemia,
  
• Increased polypharmacy and noncompliance with medications,
  
• Dependence or isolation that limits receipt of early treatment of hypoglycemia,
  
• Impaired renal or hepatic metabolism, and
  
• Presence of comorbid conditions that can mask hypoglycemia (dementia, cerebral vascular accident, depression, etc.).
  

Therefore, the American Geriatrics Society (AGS) recommends an A1C 7% in healthy adults with good functional status. An A1C 8% is acceptable for frail elders when the life expectancy is <5 years or when the risks of tight control outweigh the benefits.

BLOOD PRESSURE, LIPID CONTROL

For blood pressure control in the elderly with diabetes, the AGS recommends <140/80 mmHg, with a more aggressive target of <130/80 mmHg in more functional elderly patients.⁴ Data from the U.K. Prospective Diabetes Study of tight blood pressure control demonstrated the intensive-management group (144/82 mmHg) had a 37% reduction in microvascular end points compared with the control group (154/87 mmHg).⁵

Lipid targets for the elderly with diabetes should be the same as those for the general patient population with diabetes: LDL <100 mg/dl. Despite the evidence that suggests reductions in LDL cholesterol correlate with reduced risk of cardiovascular events and that supports the general effectiveness of statins in lowering LDL, prescribing rates and compliance with statins are suboptimal in the elderly.⁶

In conclusion, targets for treatment of diabetes in older patients need to focus on the goals of preventing hyperglycemia and macro- and microvascular complications while minimizing the risks of tight control. This is especially true of glycemic targets.

Footnotes

Eugene E. Wright, Jr., MD, is medical director of Primary Care Practices at the Cape Fear Valley Health System in Fayetteville, N.C.

References

1. American Diabetes Association: Standards of medical care in diabetes—2006 (Position Statement). Diabetes Care 29 (Suppl. 1):S4 –S42, 2006.[Free Full Text]

2. Wallace JI: Management of diabetes in the elderly. Clin Diabetes 17:19–25, 1999.

3. Schwartz RS, Abrass IB: Special presentation of endocrine disease in the elderly. In Current Practice of Medicine. Vol. 1 Korenman SG, Ed. Endocrinology. Philadelphia, Pa., Current Medicine, 1998, pp.415 –421.

4. Brown AF, Mangione CM, Saliba D, et al.: Guidelines for improving the care of older persons with diabetes mellitus. J Am Geriatr Soc 51 (5 Suppl. Guidelines):S265 –S280, 2003.[Medline]

5. U.K. Prospective Diabetes Study Group: Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ 317:703–713, 1998.[Abstract/Free Full Text]

6. Jackevicius CA, Mamdani M, Tu JV: Adherence with statin therapy in elderly patients with and without acute coronary syndromes. JAMA 288:462–467, 2002.[Abstract/Free Full Text]

CiteULike

Del.icio.us

Digg

Reddit

Technorati

This Article Full Text (PDF) Services Email this article to a friend Similar articles in this journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Search for Related Content Social Bookmarking                What's this?