Considerations for the Pharmacological Treatment of Diabetes in Older Adults

Abstract

More than 20 million people in America are estimated to have diabetes, with the prevalence in adults > 60 years of age now > 20%.1 The increased prevalence in older adults may be the result of several factors, including physiological changes in glucose metabolism that occur with aging, reduced physical activity, and increased prevalence of the metabolic syndrome with aging. As the proportion of the population of older adults increases with the aging of the Baby Boomer generation, so will the proportion of those who are older and have diabetes. This older population will also be faced with increasing prevalence of many other conditions, such as arthritis and high blood pressure, underscoring the need for effective management of diabetes in this population to optimize health. This article reviews the normal physiological and pharmacodynamic changes of aging and relates this information to the process of making optimal therapeutic decisions for the pharmacological treatment of diabetes in older adults. The evidence basis for treatment of older adults, or lack thereof, is discussed, and a general approach to therapy is suggested. Aging is associated with defects in glucose metabolism. In healthy older adults, glucose metabolism is characterized by reduced non–insulin-mediated glucose uptake under basal conditions, with normal response during hyperglycemia compared with younger adults.2 In older adults with diabetes, the defect in basal glucose uptake is further accentuated, and there is a weaker uptake response during hyperglycemia.3 In addition to this effect on basal conditions, glucose-stimulated insulin response is diminished in older adults with diabetes compared with nondiabetic younger adults and nondiabetic older adults or those with impaired glucose tolerance.4 β-Cell sensitivity to the incretin hormones may also be reduced with aging, and delayed gastric emptying or gastroparesis is frequently reported for older adults with diabetes.5,6 …