Diabetes management in older people: a focus on cardiovascular risk reduction

A retrospective cross-sectional study of type 2 diabetes overtreatment in patients admitted to the geriatric ward

Background

Glycemic control targets in older patients should be individualized according to functional status and comorbidities. The aim of the study was to identify high-risk patients who had evidence of tight glycemic control and thus at risk of serious hypoglycemia.

Methods

Retrospective cross-sectional study of type 2 diabetes patients admitted to the geriatric ward receiving diabetes medications. Patients’ hospital records were analyzed. The high risk of hypoglycemia group constituted patients who were aged 80+ years, diagnosed with dementia, with end- stage renal disease, or with a history of macrovascular complications. The primary outcome measure was hemoglobin A_1C (HbA_1C) ≤ 7.0% [53 mmol/mol].

Results

Two hundred thirteen patients were included (77.5% women; 49.3% 80+ year-old). 65.3% received sulfonylurea, 39,4%- metformin, 32.9%- insulin, and 4.2%- acarbose (in 61.5% as monotherapy, and in 38.5% combination therapy). We identified 130 patients (60%) as the denominator for the primary outcome measure; 73.1% had a HbA_1C value ≤7.0% [53.3 mmol/mol], but 55.4% ≤6,5% [48.8 mmol/mol], and 40.8% ≤6.0% [42 mmol/mol].

Conclusions

The results show a very high rate of tight glycemic control in older patients admitted to the geriatric ward, for whom higher HbA_1C targets are recommended. This indicates the high probability of diabetes overtreatment in this group, associated with a high risk of recurrent hypoglycemia. This is all the more likely because most of them received medications known to cause hypoglycemia. This points to the need of paying more attention to specific difficulties in diabetes treatment in older people, especially those suffering from various geriatric syndromes and diseases worsening their prognosis.

Alteration of Vascular Responsiveness to Uridine Adenosine Tetraphosphate in Aortas Isolated from Male Diabetic Otsuka Long-Evans Tokushima Fatty Rats: The Involvement of Prostanoids

We investigated whether responsiveness to dinucleotide uridine adenosine tetraphosphate (Up₄A) was altered in aortas from type 2 diabetic Otsuka Long-Evans Tokushima Fatty (OLETF) rats compared with those from age-matched control Long-Evans Tokushima Otsuka (LETO) rats at the chronic stage of disease. In OLETF aortas, we observed the following: (1) Up₄A-induced contractions were lower than those in the LETO aortas under basal conditions, (2) slight relaxation occurred due to Up₄A, but this was not observed in phenylephrine-precontracted LETO aortas, (3) acetylcholine-induced relaxation was reduced (vs. LETO), and (4) prostanoid release (prostaglandin (PG)F_2α, thromboxane (Tx)A₂ metabolite, and PGE₂) due to Up₄A was decreased (vs. LETO). Endothelial denudation suppressed Up₄A-induced contractions in the LETO group, but increased the contractions in the OLETF group. Under nitric oxide synthase (NOS) inhibition, Up₄A induced contractions in phenylephrine-precontracted aortas; this effect was greater in the LETO group (vs. the OLETF group). The relaxation response induced by Up₄A was unmasked by cyclooxygenase inhibitors, especially in the LETO group, but this effect was abolished by NOS inhibition. These results suggest that the relaxant component of the Up₄A-mediated response was masked by prostanoids in the LETO aortas and that the LETO and OLETF rats presented different contributions of the endothelium to the response.