Update on diabetes in the elderly and in nursing home residents

Diabetes is common in the elderly population and in nursing home residents. More than 20% of adults aged 65 to 75 years and 40% of adults older than 80 years suffer from diabetes. Physiological changes in elderly individuals, such as decreased physical activity, abdominal obesity, and increased inflammatory state, increase insulin resistance in peripheral tissue and reduce glucose-dependent insulin release, leading to carbohydrate intolerance and diabetes. The clinical presentation in the elderly and nursing home residents is frequently guided by the high rate of comorbidities such as hypertension, depression, and cardiovascular diseases. Treatment recommendations for glycemic control in elderly ambulatory patients are similar to those in long-term care facilities. Healthy patients with diabetes should aim for near-normal fasting plasma glucose and an HbA1C of about 7%; however, treatment goals must be individualized in patients with impaired cognitive and physical ability, reduced life expectancy, and heavy burden of comorbid disease. Elderly individuals and nursing home residents are at increased risk of hypoglycemia during pharmacological treatment. In general, a conservative and stepwise approach to the treatment of the elderly patient with diabetes is suggested. Treatment may be initiated with dietary and physical activity modification and with a single oral agent, followed by a combination of oral agents and insulin therapy if needed. Evidence from clinical trials indicates that improving glycemic control, as well as cardiovascular risk factors, reduces morbidity and mortality in older individuals with diabetes.