The EASD PCDE (Primary Care Diabetes Europe) study group has created a consensus statement for primary care physicians on the management of elderly people with diabetes and towards the end of life. The major considerations for these patients, along with salient aspects of the new consensus statement by the PCDE and several salient issues regarding type 2 diabetes in the young are overviewed herein.
When considering the epidemiology of type 2 diabetes (T2D) in the young, one must first keep in mind that there are objective diagnostic issues and a possible spectrum of partially overlapping pathologies: type 1 diabetes (T1D), latent autoimmune diabetes in adults (LADA) and T2D. These different diseases all have different but overlying features such as age of onset, contribution of BMI and the role of immunity. However, most studies have shown that subjects with LADA have a distinct metabolic profile compared with patients with T1D or T2D; LADA is also associated with higher impairment of β-cell function and worse glycaemic control than in T2D1.
Incidence data from the UK has shown that diabetes in the young has been increasing for the past two decades, which largely parallels the global increase seen in T2D among young people (aged <40 years)2. This increase has been especially dramatic in Africa and Western Pacific. Unfortunately, T2D in the young is associated with greater mortality rates than T1D, and is even greater in females. Indeed, younger age at T2D onset confers a higher risk of mortality, and disease duration is an independent contributing factor3. To further complicate management of T2D in the young, hyperglycaemia and additional risk factors (such as hypertension and elevated lipids) are all less well controlled, and contribute to the reduced survival observed in these individuals.
As with older subjects with T2D, diabetes in the young is associated with severe, potentially life threatening complications that include non-alcoholic fatty liver disease, microalbuminuria, progression of existing nephropathy and other microvascular complications like retinopathy and peripheral neuropathy. Development of microvascular complications is accelerated in younger patients, and as such screening should be performed for these complications at diagnosis and annually thereafter. It is by now clear that early onset T2D has worse outcomes than T2D with ’usual onset’, with rates of myocardial infarction that are 14-fold higher than control subjects and rates of stroke that are 30-fold higher4. This leads to several years of life lost, which is mostly due to premature vascular deaths.
There is also evidence that rates of depression, impaired cognitive function and psychological comorbidities are high in the young with T2D. All these observations have important implications for risk management, and especially cardiovascular risk, requiring careful consideration in young patients with T2D and warranting aggressive intensive treatment.
While the benefits of intensive glycaemia control on cardiovascular disease are relatively clear in people with shorter duration of diabetes, lower HbA1c at onset and absence of previous cardiovascular disease, such benefits are less apparent in older individuals, especially those over 75 years of age.
The same considerations can be made for impaired renal function and risk of death, which is much higher in younger individuals. Older people with diabetes have significantly more comorbidities, such as myocardial infarction, stroke, peripheral arterial disease and renal impairment, compared with those without diabetes5. They may also suffer from age-related comorbidities like mild cognitive impairment and dementia, which increase the risk of poor adherence to therapy and hypoglycaemia. However, due to the increased use of multifactorial risk factor intervention, a considerable number of older individuals can now survive for many years without any vascular complications.
Overtreatment of hyperglycaemia in older patients is potentially harmful; insulin and sulphonylureas should be avoided and/or used with caution. In this regard, glucose-dependent drugs that do not induce hypoglycaemia are preferable since older patients with diabetes and impaired kidney function are especially vulnerable to this adverse event. It is thus important to avoid undertreatment of otherwise healthy older individuals and overtreatment of the frail. When indicated, safe de-intensification of therapy can be considered, taking into account the decreased impact of HbA1c and blood pressure reduction in older people through shared decision making.
Older people with diabetes indeed represent a diverse population; traditional diabetes biometrics may not be the priority in optimising overall well-being of older individuals. Given the heterogeneity of older individuals with T2D, an individualised approach is clearly needed that should take into account health status, complications and, importantly, life expectancy. Subjects with diabetes should be fully involved in making informed treatment decisions. Planned diabetes care should consider aspects such as HbA1c and target level, overall medication use and burden, quality of life and other individualised treatment goals.
Current guidelines are variable and often not person-centred and non-holistic. With these considerations in mind, the PCDE has developed a new position statement that is specific for the elderly. The position statement can offer support for primary care physicians in facilitating holistic, individualised glycaemic management for older people with T2D. The statement addresses key areas of concern in managing complex clinical situations and highlights the many challenges faced by older people with diabetes.
It further promotes best practice by drawing on recommendations from major guideline groups, informed review of the available evidence and expert opinion. For example, recommendations are provided for screening for frailty and overall management of those with cognitive impairment, and also provide recommendations for target glycaemic ranges according to functional status. It is hoped that the new position statement will help physicians treating T2D to provide older patients with high-quality, consistent care.
Present disclosure: The presenter has reported that no relationships exist relevant to the contents of this presentation.
Written by: Patrick Moore, PhD
Reviewed by: Marco Gallo, MD