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MANAGEMENT
As with any older patient, a holistic approach is needed in the context of the overall health, lifestyle, environment, and wishes. For younger patients, many consider aggressive care with the goal of achieving euglycemia as the standard therapy. But in the older diabetic, there are two levels of care - basic and aggressive. Basic care is indicated for those individuals in whom the primary goal of treatment is the prevention of symptomatic hyperglycemia. The average glucose levels to achieve this goal are approximately 11.1 mmol/L of postprandial sugar or the level at which glycosuria is minimal. The elimination of glycosuria is important, as this predisposes the diabetic to volume depletion, hypotension and poor tissue perfusion. Glycosuria also causes weight loss due to loss of calories in the urine, catabolic state, loss of lean body tissue and may predispose to infections and other complications of malnutrition.
Aggressive care is appropriate when the goals of treatment include the prevention of long-term complications. Euglycemia with a fasting glucose level less than 6.1 mmol/L is optimal, with normal levels of glycosylated hemoglobin. There are several benefits of euglycemia, both immediate and long term. (Table1)
The decision regarding the treatment goals is the most important in the management of DM in the elderly. The patient and the treating physician should make this decision jointly. Current medical problems and the estimated life expectancy have to be kept in mind while deciding on the type care to be given. Until further studies are available that can help us in deciding the type of care to be given to the elderly, many elderly patients deserve the same consideration as younger adults regarding aggressive management of their disease. Age per se should not be considered as an indication for providing only basic care to any elderly diabetic.
Table 1: Benefits of euglycemia
Immediate:
1. Less nocturia, polyuria and hypovolemia.
2. Better leukocyte function and chemotaxis, hence, fewer infections
3. Better wound healing
Long term:
1. Slower progression of retinopathy, cataracts, neuropathy and nephropathy
2. Reduced lipoprotein A and glycosylated hemoglobin, with resultant reduction in cardiovascular mortality.
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