Features of management and treatment of elderly patients with type 2 diabetes mellitus

Type 2 diabetes is a serious burden on the health of the elderly, affecting approximately 25% of people over 65 years of age. It is expected that this percentage will increase sharply in the next decades due to the increase in life expectancy of the population. Diagnostic criteria for diabetes mellitus in elderly patients do not differ from the general population, there are several features of their management. The elderly population varies greatly in functional and cognitive abilities. These factors, along with an increased risk of hypoglycemia, falls and concomitant diseases, complicate the development of treatment regimens, therefore it is necessary to use a personality-oriented approach, minimizing the risk of excessive or insufficient therapy of diabetes, since the use of antidiabetic drugs in the elderly is associated with significant risk. The prevalence of diabetes mellitus significantly increases after the age of 80 with insufficient physical activity, alcohol consumption, a history of cardiovascular diseases, visceral obesity and hypertension. Cognitive impairment is 2 times more common in elderly people with diabetes. In addition to micro- and macrovascular lesions, a complication of diabetes in the elderly is also sarcopenia, which has a negative impact on the physical and psychosocial health of patients with diabetes and worsens their quality of life. Age-related metabolic changes and emerging kidney pathology predispose elderly people to an increased risk of developing diabetes mellitus and diabetic nephropathy, respectively. Despite the available therapy, a significant number of elderly patients with diabetic nephropathy have progressive renal failure and adverse cardiac outcomes, therefore, research is needed to study methods for early detection of diabetic nephropathy and new therapeutic interventions. Among the elderly with diabetes, individuals with poor glycemic control are at higher risk of cardiovascular events. Elderly patients have greater variability in glycemia and are more prone to arrhythmias, but active glucose control can reduce the risk of severe arrhythmia. Treatment of diabetes in elderly patients with heart failure can be a difficult task, taking into account numerous concomitant diseases, primarily chronic kidney disease. The complexity of treatment regimens, the clinical characteristics of patients and the ability of heart failure therapy to influence glucose metabolism and, conversely, the potential of some antidiabetic agents to modulate its outcomes are problems that need to be solved within the framework of an individual approach. Elderly men suffering from diabetes, for the prevention and treatment of osteoporosis, smoking cessation, glycemic control, regular exercise, active prevention and treatment of complications of osteoporosis, as well as testosterone replacement therapy are necessary. In elderly people, it is necessary to use individual pharmacotherapy with hypoglycemic drugs with a low risk of hypoglycemia and proven safety for the cardiovascular system, avoiding excessive treatment and simplifying therapy regimens. Glycemic targets in the elderly as part of individual treatment may be revised. Intensive treatment of elderly people with diabetes is common, creating an increased risk of adverse events such as hypoglycemia and hospitalization due to medication errors. Those receiving many drugs belong to the older age group, have numerous diseases, including kidney failure and dementia. In such patients, it is permissible to de-intensify therapy or even completely cancel hypoglycemic drugs without significantly worsening their glycemic control.

1. Алгоритмы специализированной медицинской помощи больным сахарным диабетом / Под ред. И. И. Дедова. М. В. Шестаковой, А. Ю. Майорова. 9-й выпуск. М., 2019, 212 с. [Algorithms for specialized medical care for patients with diabetes mellitus / Pod red. I. I. Dedova. M. V. Shestakovoy, A. Yu. Mayorova. 9-y vypusk. M., 2019, P. 212.]

2. Erica Wilson. Person-Centered Medication Therapy for Diabetes in Older Adults: A Practical Review // J Gerontol Nurs. 2021; 47 (10): 7-13. DOI: 10.3928/00989134-20210908-02.

3. Yuanying Sun, Wenqing Ni, Xueli Yuan, Hongshan Chi, Jian Xu. Prevalence, treatment, control of type 2 diabetes and the risk factors among elderly people in Shenzhen: results from the urban Chinese population // BMC Public Health. 2020; 20 (1): 998. DOI: 10.1186/s12889-020-09045-1.

4. Mohan Viswanathan, Anjana Ranjit Mohan, Unnikrishnan Ranjit, Gupta Prasanna Kumar, Routary Philips, Jebarani Saravanan, Venkatesan Ulagamathesan, Uma Sankari Ganesan, Gini Venisha Kumaradas, Ashok Kumar Rajendran, Rahulashankiruthiyayan Thangarajan, Pradeepa Rajendra, Shanthi Rani Coimbatore Subramanian. Clinical Profile of Elderly Patients (Over 90 Years) with Type 2 Diabetes Seen at a Diabetes Center in South India // Diabetes Technol Ther. 2020; 22 (2): 79-84. DOI: 10.1089/dia.2019.0219.

5. Muhammad Atif, Quratulain Saleem, Saima Asghar, Iram Malik, Nafees Ahmad. Extent and Predictors of Poor Glycaemic Control among Elderly Pakistani Patients with Type 2 Diabetes Mellitus: A Multi-Centre Cross-Sectional Study // Medicina (Kaunas). 2019; 55 (1): 21. DOI: 10.3390/medicina55010021.

6. Alberto J. Mimenza-Alvarado, Gilberto A. Jiménez-Castillo, Sara G. Yeverino-Castro, Abel J. Barragán-Berlanga, Mario U. Pérez-Zepeda, J. Alberto Ávila-Funes, Sara G. Aguilar-Navarro. Effect of poor glycemic control in cognitive performance in the elderly with type 2 diabetes mellitus: The Mexican Health and Aging Study // BMC Geriatr. 2020; 20 (1): 424. DOI: 10.1186/s12877-020-01827-x.

7. Anna Izzo, Elena Massimino, Gabriele Riccardi, Giuseppe Della Pepa // Nutrients. 2021; 13 (1): 183. DOI: 10.3390/nu13010183.

8. Mojtaba Azadbakht, Parisa Taheri Tanjani, Reza Fadayevatan, Mahshid Froughan, Nasibeh Zanjari. The prevalence and predictors of diabetes distress in elderly with type 2 diabetes mellitus // Diabetes Res Clin Pract. 2020; 163: 108133. DOI: 10.1016/j.diabres.2020.108133.

9. Huong Van Nguyen, Tung Thanh Tran, Cuong Tat Nguyen, Tung Hoang Tran, Bach Xuan Tran, Carl A. Latkin, Cyrus S. H. Ho, Roger C. M. Ho. Impact of Comorbid Chronic Conditions to Quality of Life among Elderly Patients with Diabetes Mellitus in Vietnam // Int J Environ Res Public Health. 2019; 16 (4): 531. DOI: 10.3390/ijerph16040531.

10. Ahmed H. Abdelhafiz. Diabetic Kidney Disease in Older People with Type 2 Diabetes Mellitus: Improving Prevention and Treatment Options // Drugs Aging. 2020; 37 (8): 567-584. DOI: 10.1007/s40266-020–00773-y.

11. Kazunaga Takamatsu. Renal status in elderly patients with type 2 diabetes // Clin Exp Nephrol. 2020; 24 (1): 53-62. DOI: 10.1007/s10157-019-01792-9.

12. Koutaro Yokote, Ryo Suzuki, Maki Gouda, Hiroaki Iijima, Akiko Yamazaki, Masaya Inagaki. Association between glycemic control and cardiovascular events in older Japanese adults with diabetes mellitus: An analysis of the Japanese medical administrative database // J Diabetes Investig. 2021; 12 (11): 2036-2045. DOI: 10.1111/jdi.13575.

13. Chrysi Koliaki, Nicholas Katsilambros. Important Considerations for the Treatment of Patients with Diabetes Mellitus and Heart Failure from a Diabetologist's Perspective: Lessons Learned from Cardiovascular Outcome Trials Int J Environ Res Public Health. 2019; 17 (1): 155. DOI: 10.3390/ijerph17010155.

14. Jianbo Zhang, Jianmin Yang, Liwei Liu, Liyan Li, Jiangyin Cui, Shuo Wu, Kuanxiao Tang. Significant abnormal glycemic variability increased the risk for arrhythmias in elderly type 2 diabetic patients // BMC Endocr Disord. 2021; 21 (1): 83. DOI: 10.1186/s12902-021-00753-2.

15. Špela Volčanšek, Mojca Lunder, Andrej Janež. Acceptability of Continuous Glucose Monitoring in Elderly Diabetes Patients Using Multiple Daily Insulin Injections // Diabetes Technol Ther. 2019; 21 (10): 566-574. DOI: 10.1089/dia.2019.0131.

16. Chunling Li, Shufang Wang, Mengru Du, Yihan Wei, Sheng Jiang. Clinical Characteristics and Controllable Risk Factors of Osteoporosis in Elderly Men with Diabetes Mellitus // Orthop Surg. 2021; 13 (3): 1001-1005. DOI: 10.1111/os.12957.

17. Cristina Monteiro, Samuel Silvestre, Ana Paula Duarte, Gilberto Alves. Assessment of suspected adverse drug reactions in elderly patients with diabetes mellitus based on a Portuguese spontaneous reporting database: analysis of reporting from 2008 to 2018 // Expert Opin Drug Saf. 2021; 20 (7): 845-853. DOI: 10.1080/14740338.2021.1928072.

18. Ju Young Kim, Young Sook Ku, Hyun Jeong Kim, Nga Thi Trinh, Woorim Kim, Bomi Jeong, Tae Young Heo, Myung Koo Lee, Kyung Eun Lee. Oral diabetes medication and risk of dementia in elderly patients with type 2 diabetes // Diabetes Res Clin Pract. 2019; 154: 116-123. DOI: 10.1016/j.diabres.2019.07.004.

19. Jeffrey Freeman. Management of hypoglycemia in older adults with type 2 diabetes // Postgrad Med. 2019; 131 (4): 241-250. DOI: 10.1080/00325481.2019.1578590.

20. Yoshiaki Tamura, Takuya Omura, Kenji Toyoshima, Atsushi Araki. Nutrients. Nutrition Management in Older Adults with Diabetes: A Review on the Importance of Shifting Prevention Strategies from Metabolic Syndrome to Frailty. 2020; 12 (11): 3367. DOI: 10.3390/nu12113367.

21. Chien-Cheng Huang, Chien-Chin Hsu, Chong-Chi Chiu, Hung-Jung Lin, JhiJoung Wang, Shih-Feng Weng. Association between exercise and health-related quality of life and medical resource use in elderly people with diabetes: a crosssectional population-based study // BMC Geriatr. 2020; 20 (1): 331. DOI: 10.1186/s12877-020-01750-1.

22. Theocharis Koufakis, Maria Grammatiki, Kalliopi Kotsa. Type 2 diabetes management in people aged over seventy-five years: targets and treatment strategies // Maturitas. 2021; 143: 118-126. DOI: 10.1016/j.maturitas.2020.10.005.

23. Labib Al-Musawe, Ana Paula Martins, Joao Filipe Raposo, Carla Torre. The association between polypharmacy and adverse health consequences in elderly type 2 diabetes mellitus patients; a systematic review and meta-analysis // Diabetes Res Clin Pract. 2019; 155: 107804. DOI: 10.1016/j.diabres.2019.107804.

24. Abdelhafiz A. H., Sinclair A. J. Deintensification of hypoglycaemic medications-use of a systematic review approach to highlight safety concerns in older people with type 2 diabetes // J Diabetes Complications. 2018; 32 (4): 444-450. DOI: 10.1016/j.jdiacomp.2017.11.011.

25. Iliana C. Lega, Michael A. Campitelli, Peter C. Austin, Yingbo Na, Afshan Zahedi, Freda Leung, Catherine Yu, Susan E. Bronskill, Paula A. Rochon, Lorraine L Lipscombe. Potential diabetes overtreatment and risk of adverse events among older adults in Ontario: a population-based study // Diabetologia. 2021; 64 (5): 1093-1102. DOI: 10.1007/s00125-020-05370-7.

26. Andrea Tumminia, Marco Graziano, Federica Vinciguerra, Andrea Lomonaco, Lucia Frittita. Efficacy, renal safety and tolerability of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in elderly patients with type 2 diabetes: A real-world experience // Prim Care Diabetes. 2021; 15 (2): 283-288. DOI: 10.1016/j.pcd.2020.10.002.

27. Molist-Brunet N., Sevilla-Sánchez D., Puigoriol-Juvanteny E., GonzálezBueno J., Solà-Bonada N., Cruz-Grullón M., Espaulella-Panicot J. Optimizing drug therapy in frail patients with type 2 diabetes mellitus // Aging Clin Exp Res. 2020; 32 (8): 1551-1559. DOI: 10.1007/s40520-019-01342-z.

28. Labib Al-Musawe, Carla Torre, Jose Pedro Guerreiro, Antonio Teixeira Rodrigues, Joao Filipe Raposo, Helder Mota-Filipe, Ana Paula Martins. Overtreatment and undertreatment in a sample of elderly people with diabetes // Int J Clin Pract. 2021; 75 (11): e14847. DOI: 10.1111/ijcp.14847.

29. Priti Pednekar, Debra A. Heller, Andrew M. Peterson. Association of Medication Adherence with Hospital Utilization and Costs Among Elderly with Diabetes Enrolled in a State Pharmaceutical Assistance Program // J Manag Care Spec Pharm. 2020; 26 (9): 1099-1108. DOI: 10.18553/jmcp.2020.26.9.1099.

30. Daniela V. Pirela, Rajesh Garg. De-intensification of diabetes treatment in elderly patients with type 2 diabetes mellitus // Endocr Pract. 2019; 25 (12): 1317-1322. DOI: 10.4158/EP-2019-0303.

31. Yujia Tao, Meng E., Jingjing Shi, Zhen Zhang. Sulfonylureas use and fractures risk in elderly patients with type 2 diabetes mellitus: a meta-analysis study // Aging Clin Exp Res. 2021; 33 (8): 2133-2139. DOI: 10.1007/s40520-020-01736-4.

32. Xiangyang Liu, Li Wang, Ying Xing, Samuel S Engel, Longyi Zeng, Bin Yao, Wen Xu, Guojuan Chen, Ye Zhang, Ruya Zhang, Shu Liu, Jianping Weng, Qiuhe Ji. Efficacy and safety of metformin and sitagliptin-based dual and triple therapy in elderly Chinese patients with type 2 diabetes: Subgroup analysis of STRATEGY study // J Diabetes Investig. 2020; 11 (6): 1532-1541. DOI: 10.1111/jdi.13277.

33. Katja S. Just, Sascha R. Tittel, Cornelius Bollheimer, Michael Naudorf, Katharina Laubner, Stefan Zimny, Andrej Zeyfang, Michael Hummel, Julia C. Stingl, Reinhard W. Holl. Hypoglycemia in Older Adults: Time Trends and Treatment Differences in Patients Aged ≥75 Years with Type 2 Diabetes // J Am Med Dir Assoc. 2021; 22 (9): 1898-1905. DOI: 10.1016/j.jamda.2021.05.006.