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

1. Poor or erratic nutritional intake,

2. Changes in mental status that impair the perception or response to hypoglycemia,

3. Increased polypharmacy and noncompliance with medications,

4. Dependence or isolation that limits receipt of early treatment of hypoglycemia,

5. Impaired renal or hepatic metabolism, and

6. 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. ▪