Management of Cardiovascular Disease Risk Factors in Older Adults with Type 2 Diabetes Mellitus: 2002–2012 Literature Review

Abstract

Diabetes Mellitus type 2 (DM) is one of the most common chronic conditions among older adults and is often present with co-morbidities and geriatric syndromes. The management of cardiovascular disease risk factors in older adults with DM is of important significance to clinicians. The literature was reviewed from 2002-2012 to provide an American Geriatrics Society (AGS) expert panel with an evidence base for updating and making new recommendations for improving the care of the older adult with DM. This review includes only the domains of the management of blood pressure, lipid control, glycemic control, and use of aspirin. Over the last ten years, new randomized clinical trial (RCT) evidence designed to study the impact of different blood pressure treatment targets did not find that intensive blood pressure control (<130 mmHg) reduced myocardial infarction and mortality. There are increased risks of side effects with achieving a blood pressure of < 120 mmHg. Statin class lipid lowering drugs are effective in reducing cardiovascular events among middle aged and older adults but data on niacin and fibrates is limited. Lipid lowering trials of statins and other lipid lowering agents do not evaluate the cardiovascular effects of treating lipids to different low density lipoprotein (LDL) cholesterol targets. There were no randomized clinical trials of lipid lowering drugs that enrolled significant numbers of adults age 80 years and above with or without DM. Three major RCTs that investigated intensive glycemic control did not find reductions in primary cardiovascular endpoints and one study reported increased mortality with a hemoglobin A1C < 6%. Two recent published RCTs were designed to study the cardiovascular benefits of aspirin use by patients with DM. Both trials failed to significantly reduce primary cardiovascular endpoints with aspirin compared to control groups. Overall, RCTs enrolled very few adults greater than 80 years of age or with significant co-morbidities. More research is needed for clinicians to effectively tailor care to older adults with DM because of heterogeneity in health status, co-morbidities, duration of disease, frailty and functional status, and differences in life expectancy.

Efficacy of Behavioral Interventions on Biological Outcomes for Cardiovascular Disease Risk Reduction among Latinos: a Review of the Literature

“…reduction of A1C levels). 20 Finally, the studies included in the review did not use the same clinical guideline criteria to categorize their patient populations as an at risk population. Because of the heterogeneity and lack of information in the papers regarding this, we accepted the author’s definition of at risk population.…”

Older type 2 diabetic patients are more likely to achieve glycaemic and cardiovascular risk factors targets than younger patients: analysis of a primary care database

“…Moreover, glycaemic goals were more often achieved by patients in the older subgroups regardless the presence of a CVD, in accordance with the results from clinical trials and observational studies suggesting that a global control of cardiovascular risk factors in older patients provides a greater benefit regarding morbidity and mortality than an intensive glycaemic control 13, 14, 15, 16, 17. Antihypertensive treatment, for instance, has benefits even in very old patients 18, 19, 20, 21, and there are also compelling evidences of the benefit of statins and antiplatelet agents in older adults in secondary prevention of CVD, while its use in primary prevention is controversial, and individual characteristics and the risk of related adverse events should be taken into account 5, 7, 22, 23, 24, 25.…”

Management of diabetes mellitus in older people with comorbidities

“…Multiple studies of care of older patients with diabetes in national datasets have shown that the intensity of treatments does not differ by health status. [64][65][66][67][68][69][70][71][72][73] One study described the intensity of diabetes treatment among older patients classified by health status in the National Health and Nutrition Examination Survey (NHANES) (2001-10). 74 The proportion of older patients achieving an HbA 1c below 7.0% was 61% overall and no different across the three tiers of health status.…”