Heterogeneity of diabetes in older adults

Abstract

Diabetes mellitus (DM) in older adults is a highly heterogeneous clinical syndrome. Individuals of the same chronological age may differ in the duration and type of DM, physiological reserve, comorbidities, vascular complications, renal function, functional capacity, cognition, frailty, social support, and life expectancy. Therefore, age alone should not determine glycemic targets or therapeutic intensity. Current recommendations propose periodic assessment of the medical, functional, cognitive, psychological, and social domains, incorporating the patient's preferences and priorities^1,2.

From a practical perspective, older adults can be classified as healthy, with complex or intermediate health, and with very complex health. In independent individuals with intact cognition and few comorbidities, an HbA1c of 7.0–7.5% may be considered. In those with multiple illnesses, functional impairment, or mild cognitive impairment, a target of <8.0% is indicated. In patients with advanced disease, functional dependence, or moderate to severe cognitive impairment, prevention of hypoglycemia and symptomatic hyperglycemia should be prioritized, regardless of a specific HbA1c target.

Hypoglycemia is the main limitation of intensive glycemic control. Its risk increases with insulin, sulfonylureas, chronic kidney disease, irregular food intake, cognitive impairment, and polypharmacy. HbA1c can also be inaccurate in the presence of anemia, transfusions, or advanced kidney disease; in these situations, capillary or continuous glucose monitoring provides more useful information. Simplification or de-intensification is appropriate when the burden or risk outweighs the expected benefit. Advanced age should also not preclude treatments with cardiovascular and renal protection.

In older adults with type 2 diabetes, atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease, SGLT2 inhibitors and GLP-1³ receptor agonists should be considered. SGLT2 inhibitors reduce hospitalizations for heart failure and renal progression, but require monitoring of fluid volume, hypotension, genital infections, and intercurrent illnesses. GLP-1 agonists reduce cardiovascular events and albuminuria, although they should be used with caution in cases of frailty, sarcopenia, low weight, or gastroparesis. Nutrition and exercise should preserve muscle mass, mobility, and function, avoiding excessive restrictions in individuals with frailty, sarcopenia, or established malnutrition.

In short, treatment should integrate cardiorenal risk, function, nutrition, tolerability, cost, self-care capacity, and personal goals, with reassessment after hospitalizations or clinical, cognitive, or social changes.