Data presented by Darius Lakdawalla in the preceding session suggest that if present trends continue, 1/3 of the population over 50 years in the USA by 2050, will have diabetes. This implies that ½ of all healthcare spend will go to people with diabetes by the middle of the 21st century.
Thus in the next few decades physicians will have to face increasingly complicated therapy decisions in elderly people. There is also a relative lack of evidence about the best diabetes treatment algorithms in older people.
The ACCORD, ADVANCE and VADT studies did not show significant benefits in many diabetic complication domains for intensive therapy and this has added to the complexity of decision-making. For instance tight glycaemic control in the elderly will increase hypoglycaemia risk and hence potentiate falls. The potential to increase mortality through intensive control demonstrated in the ACCORD trial is still an open question. What this means for the clinician treating these patients is that there is an uncertain risk of doing more harm than good.
The evidence relating to which therapy is best to achieve improved glycaemia without increasing risk of adverse events is also variable. For instance, some studies suggest that adding basal insulin is better than increasing sulphonylurea dose, other do not. As cognitive impairment and dementia develop, there is evidence that the risk of hypoglycaemic events increases significantly to a peak of 27% in insulin treated over 75 year old patients.
These and other data suggest that for combined endpoints there is an argument in the over 70’s for setting an HbA1c target of less than 8.0% and that tight glycaemic control to less than 7% may increase morbidity and mortality in this age group.
Overall mortality risks are lowest between HbA1c 6-9% in the elderly and whilst this should be considered, other factors including falls risk and cognitive impairment should also be taken into account when setting individual glycaemic targets.
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