The concerns that have been recently raised about the appropriateness of applying care recommendations developed for the general population of diabetes patients to the care of elderly diabetes patients are significant, especially given the fact that the proportion and number of patients over 65 living with diabetes is expected to continue to rise in the coming decades. The central challenge is that clinical trial populations have not reflected the heterogeneity of the general population of elderly diabetes patients. This requires that clinicians extrapolate findings from healthier, compliant trial patients to the care of elderly patients. The clinical constraints described in this review should clearly be considered in this extrapolation process in the formulation of day-to-day management for individual elderly patients. Since 2004, the American Diabetes Association has formally acknowledged the importance of these constraints in the care of elderly diabetes patients [44
Despite these recent recommendations, the diabetes care literature and the discussions of quality of care incentives have generally ignored the heterogeneity of elderly diabetes patients [45
]. Pilot studies of diabetes disease management programs [47
] have been undertaken in elderly Medicare populations, largely without consideration for patient heterogeneity. Recent changes in diabetes care performance measures that now encourage uniform achievement of intensive glucose control levels ignore issues of patient heterogeneity [48
]. Measures that promote intensive glucose control for all elderly patients could actually cause some patients harm by either promoting intensification in patients who are not likely to benefit from such treatments or by promoting perverse incentives such as dropping patients with poor control from practices.
While there is a clear need to focus greater attention on the unique needs of elderly diabetes patients, it is less clear how to implement many of the new recommendations related to individualizing care in elderly diabetes patients. There is particular uncertainty around how to identify patients who will benefit or be harmed by intensive risk factor control related to diabetes. The clinical characteristics that have been promoted as criteria for stratifying patients have face validity and may provide clear decisions for some elderly patients. However, it is very likely that many elderly patients will have clinical characteristics that are predictive of both increased risk of complications related to diabetes as well as increased risk of adverse events related to diabetes therapies.
Another important unresolved aspect of individualizing care for elderly diabetes patients is how to respond to dynamic changes in the health status of elderly patients. Elderly patients may move into and out of states of illness and functional impairment on a regular basis. We now know that the functional impairment in elderly patients actually comes and goes and is not fixed [50
]. The problem with dynamic health states is that we may begin with goals consistent with intensive diabetes care in a given patient but be forced to modify treatment goals as illnesses develop. Lessons from clinical trials would suggest that we should continue intensive treatments for a series of years to ensure that their benefits are realized. On the other hand, data on comorbidities and functional status would tell us that the benefits of continuing intensive treatments are minimal. These issues related to altering therapies in the midst of an elderly patient’s history with diabetes are complex and should be studied in greater depth.
It is clear that significant clinical research is needed to confirm or deny the many concerns that clinicians have when caring for elderly diabetes patients. This research will also help to define the optimal approach to caring for elderly diabetes patients. The approach must somehow acknowledge the clinical constraints of caring for elderly patients while also accommodating patient preferences for treatments. The lessons learned in diabetes care may be applicable to other forms of chronic disease management in the elderly.