While the benefits of intensive glycaemia control on cardiovascular disease are relatively clear in people with shorter duration of diabetes, lower HbA1c at onset and absence of previous cardiovascular disease, such benefits are less apparent in older individuals, especially those over 75 years of age.
The same considerations can be made for impaired renal function and risk of death, which is much higher in younger individuals. Older people with diabetes have significantly more comorbidities, such as myocardial infarction, stroke, peripheral arterial disease and renal impairment, compared with those without diabetes5. They may also suffer from age-related comorbidities like mild cognitive impairment and dementia, which increase the risk of poor adherence to therapy and hypoglycaemia. However, due to the increased use of multifactorial risk factor intervention, a considerable number of older individuals can now survive for many years without any vascular complications.
Overtreatment of hyperglycaemia in older patients is potentially harmful; insulin and sulphonylureas should be avoided and/or used with caution. In this regard, glucose-dependent drugs that do not induce hypoglycaemia are preferable since older patients with diabetes and impaired kidney function are especially vulnerable to this adverse event. It is thus important to avoid undertreatment of otherwise healthy older individuals and overtreatment of the frail. When indicated, safe de-intensification of therapy can be considered, taking into account the decreased impact of HbA1c and blood pressure reduction in older people through shared decision making.