Skip to main content

Advertisement

SpringerLink
Log in

Management of Type 2 Diabetes in Frail Older Adults

  • Current Opinion
  • Published:
Drugs & Aging Aims and scope Submit manuscript

Abstract

Aging is one of the most important factors associated with the dramatic increase in the prevalence of type 2 diabetes mellitus (T2DM) globally. In addition to traditional micro- and macrovascular complications, diabetes mellitus (DM) in older adults is of great importance due to its independent relationship with frailty, which is defined as a decline in functional reserves and vulnerability to stressors. Frailty assessment enables the determination of biological age, thus predicting potential complications in older adults and identifying tailored treatment strategies. Although the latest guidelines have acknowledged the frailty concept and provided recommendations specific to this subgroup of older adults, frail older adults are particularly considered only as anorexic, malnourished people for whom relaxed treatment targets should be set. However, this approach bypasses other metabolic phenotypes in the context of diabetes and frailty. Recently, a spectrum of metabolic phenotypes in the context of frailty in DM was suggested, and the two edges of this spectrum were defined as “anorexic malnourished (AM)” and “sarcopenic obese (SO).” These two edges were suggested to require different strategies: Opposite to the AM phenotype requiring less stringent targets and de-intensification of treatments, tight blood glucose control with agents promoting weight loss was recommended in the SO group. Our suggestion is that, regardless of their phenotype, weight loss should not be the primary goal in DM management in older adults who are overweight or obese, because of the increased malnutrition prevalence in older adults suffering from DM compared with standard older adults. Furthermore, overweight older adults have been reported to have the lowest risk of mortality compared with other groups. On the other hand, obese older individuals may benefit from intensive lifestyle interventions including caloric restriction and regular exercise with the assurance of at least 1 g/kg/day high-quality protein intake. Besides metformin (MF), sodium–glucose cotransporter-2 inhibitors (SGLT-2i) or glucagon-like peptide-1 receptor agonists (GLP-1RA) should be considered in appropriate SO cases, due to high evidence of cardiorenal benefits. MF should be avoided in the AM phenotype due to their weight loss property. Although weight loss is not desired in AM phenotype, SGLT-2i may still be preferred with close follow-up in certain individuals demonstrating high cardiovascular disease (CVD) risk. Of note, SGLT-2i should be considered earlier in the diabetes treatment in both groups due to their multiple benefits, i.e., organ protective effects, the potential to reduce polypharmacy, and improve frailty status. The concept of different metabolic phenotypes in frail older adults with diabetes once again shows “one size fits all” cannot be applied in geriatric medicine, and a tailored, individualized approach should be adopted to get the highest benefit from treatments.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
$34.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or eBook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. IDF Diabetes Atlas 2021. https://diabetesatlas.org/atlas/tenth-edition/. Accessed 5 Jan 2023.

  2. Shou J, Chen P-J, Xiao W-H. Mechanism of increased risk of insulin resistance in aging skeletal muscle. Diabetol Metab Syndr. 2020;12(1):14.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Corriere M, Rooparinesingh N, Kalyani RR. Epidemiology of diabetes and diabetes complications in the elderly: an emerging public health burden. Curr Diab Rep. 2013;13(6):805–13.

    Article  PubMed  Google Scholar 

  4. Fried LP, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146–56.

    Article  CAS  PubMed  Google Scholar 

  5. Clegg A, et al. Frailty in elderly people. Lancet. 2013;381(9868):752–62.

    Article  PubMed  Google Scholar 

  6. Visseren FLJ, et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J. 2021;42(34):3227–337.

    Article  PubMed  Google Scholar 

  7. Committee ADAPP. Older adults: standards of medical care in diabetes—2022. Diabetes Care. 2021;45(1):S195–207.

    Google Scholar 

  8. Davies MJ, et al. Management of hyperglycemia in type 2 diabetes, 2022. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2022;45(11):2753–86.

    Article  CAS  PubMed  Google Scholar 

  9. Williams B, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J. 2018;39(33):3021–104.

    Article  PubMed  Google Scholar 

  10. Wang X, Hu J, Wu D. Risk factors for frailty in older adults. Medicine (Baltimore). 2022;101(34): e30169.

    Article  PubMed  Google Scholar 

  11. Abd.Ghafar MZA, et al. Frailty and diabetes in older adults: overview of current controversies and challenges in clinical practice. Front Clin Diabetes Healthc. 2022;3:895313.

  12. Simpson FR, et al. An examination of whether diabetes control and treatments are associated with change in frailty index across 8 years: an ancillary exploratory study from the Action for Health in Diabetes (Look AHEAD) Trial. Diabetes Care. 2022;46(3):519–25.

    Article  Google Scholar 

  13. Veronese N, et al. Frailty is associated with an increased risk of incident type 2 diabetes in the elderly. J Am Med Dir Assoc. 2016;17(10):902–7.

    Article  PubMed  Google Scholar 

  14. Abdelhafiz AH, Sinclair AJ. Low HbA1c and Increased mortality risk—is frailty a confounding factor? Aging Dis. 2015;6(4):262–70.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Pansini A, et al. Hyperglycemia and physical impairment in frail hypertensive older adults. Front Endocrinol. 2022;13:831556.

  16. Mone P, et al. Cognitive impairment in frail hypertensive elderly patients: role of hyperglycemia. Cells. 2021. https://doi.org/10.3390/cells10082115.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Sinclair AJ, Pennells D, Abdelhafiz AH. Hypoglycaemic therapy in frail older people with type 2 diabetes mellitus—a choice determined by metabolic phenotype. Aging Clin Exp Res. 2022;34(9):1949–67.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Bahat G, İlhan B, Karan MA. The concept of frailty should not be limited to malnutrition. Clin Nutr. 2020;39(1):325.

    Article  PubMed  Google Scholar 

  19. Jayanama K, et al. Relationship of body mass index with frailty and all-cause mortality among middle-aged and older adults. BMC Med. 2022;20(1):404.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Ozkok S, et al. Sarcopenic obesity versus sarcopenia alone with the use of probable sarcopenia definition for sarcopenia: associations with frailty and physical performance. Clin Nutr. 2022;41(11):2509–16.

    Article  PubMed  Google Scholar 

  21. Bahat G, et al. Associations between obesity, self-reported weakness and their combinations with mortality in nursing home residents. Acta Clin Belg. 2023;78(2):112–21.

    Article  PubMed  Google Scholar 

  22. Batsis JA, Zagaria AB. Addressing obesity in aging patients. Med Clin North Am. 2018;102(1):65–85.

    Article  PubMed  Google Scholar 

  23. Bahat G, et al. Fat percentage cutoff values to define obesity and prevalence of sarcopenic obesity in community-dwelling older adults in Turkey. Aging Male. 2020;23(5):477–82.

    Article  PubMed  Google Scholar 

  24. Volkert D, et al. ESPEN practical guideline: clinical nutrition and hydration in geriatrics. Clin Nutr. 2022;41(4):958–89.

    Article  CAS  PubMed  Google Scholar 

  25. Bahat G, et al. Which body mass index (BMI) is better in the elderly for functional status? Arch Gerontol Geriat. 2012;54(1):78–81.

    Article  Google Scholar 

  26. Bowen ME. The relationship between body weight, frailty, and the disablement process. J Gerontol: Series B. 2012;67(5):618–26.

    Article  Google Scholar 

  27. Cheng FW, et al. Body mass index and all-cause mortality among older adults. Obesity (Silver Spring). 2016;24(10):2232–9.

    Article  PubMed  Google Scholar 

  28. Al Snih S, et al. The effect of obesity on disability vs mortality in older Americans. Arch Intern Med. 2007;167(8):774–80.

    Article  PubMed  Google Scholar 

  29. Shaman AM, et al. Effect of the Glucagon-like peptide-1 receptor agonists semaglutide and liraglutide on kidney outcomes in patients with type 2 diabetes: pooled analysis of SUSTAIN 6 and LEADER. Circulation. 2022;145(8):575–85.

    Article  CAS  PubMed  Google Scholar 

  30. Lee MMY, et al. Cardiovascular and mortality outcomes with GLP-1 receptor agonists in patients with type 2 diabetes: a meta-analysis with the FREEDOM cardiovascular outcomes trial. Diabetes Metab Syndr Clin Res Rev. 2022;16(1): 102382.

    Article  CAS  Google Scholar 

  31. McGuire DK, et al. Association of SGLT2 inhibitors with cardiovascular and kidney outcomes in patients with type 2 diabetes: a meta-analysis. JAMA Cardiol. 2021;6(2):148–58.

    Article  PubMed  Google Scholar 

  32. Giugliano D, et al. Sodium-glucose co-transporter-2 inhibitors for the prevention of cardiorenal outcomes in type 2 diabetes: an updated meta-analysis. Diabetes Obes Metab. 2021;23(7):1672–6.

    Article  CAS  PubMed  Google Scholar 

  33. Kittleson Michelle M, et al. 2023 ACC Expert Consensus Decision pathway on management of heart failure with preserved ejection fraction. J Am Coll Cardiol. 2023;81(18):1835–78.

    Article  CAS  PubMed  Google Scholar 

  34. Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work Group. KDIGO 2022 Clinical practice guideline for diabetes management in chronic kidney disease. Kidney Int. 2022;102(5S):S1–127.

  35. Karagiannis T, et al. GLP-1 receptor agonists and SGLT2 inhibitors for older people with type 2 diabetes: a systematic review and meta-analysis. Diabetes Res Clin Pract. 2021;174: 108737.

    Article  CAS  PubMed  Google Scholar 

  36. Heidenreich PA, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145(18):e895–1032.

    PubMed  Google Scholar 

  37. Bahat G, et al. International Validation of the Turkish Inappropriate Medication Use in the Elderly (TIME) criteria set: a Delphi Panel study. Drugs Aging. 2021;38(6):513–21.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Bahat G, et al. Turkish inappropriate medication use in the elderly (TIME) criteria to improve prescribing in older adults: TIME-to-STOP/TIME-to-START. Eur Geriatr Med. 2020;11(3):491–8.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Perkovic V, Badve SV, Bakris GL. Treatment of diabetic kidney disease. https://www.uptodate.com/contents/treatment-of-diabetic-kidney-disease/print. Accessed 11 May 2023.

  40. de Boer IH, et al. Diabetes management in chronic kidney disease: a consensus report by the American Diabetes Association (ADA) and Kidney Disease: improving global outcomes (KDIGO). Diabetes Care. 2022;45(12):3075–90.

    Article  PubMed  PubMed Central  Google Scholar 

  41. ElSayed NA, et al. 10. Cardiovascular disease and risk management: standards of care in diabetes-2023. Diabetes Care. 2023;46(Suppl 1):S158-s190.

    Article  CAS  PubMed  Google Scholar 

  42. Kumar J, et al. Antidiabetic drugs and non-alcoholic fatty liver disease: a systematic review, meta-analysis and evidence map. Dig Liver Dis. 2021;53(1):44–51.

    Article  CAS  PubMed  Google Scholar 

  43. Szekeres Z, Toth K, Szabados E. The effects of SGLT2 inhibitors on lipid metabolism. Metabolites. 2021;11(2):87.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  44. Cheng L, et al. Dapagliflozin, metformin, monotherapy or both in patients with metabolic syndrome. Sci Rep. 2021;11(1):24263.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  45. Herat LY, et al. Targeting features of the metabolic syndrome through sympatholytic effects of SGLT2 inhibition. Curr Hypertens Rep. 2022;24(3):67–74.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  46. Muskiet MHA, et al. GLP-1 and the kidney: from physiology to pharmacology and outcomes in diabetes. Nat Rev Nephrol. 2017;13(10):605–28.

    Article  CAS  PubMed  Google Scholar 

  47. Wojeck BS, et al. Ertugliflozin and incident obstructive sleep apnea: an analysis from the VERTIS CV trial. Sleep Breath. 2023;27(2):669–72.

    Article  PubMed  Google Scholar 

  48. Tanriover C, et al. Potential Use of SGLT-2 inhibitors in obstructive sleep apnea: a new treatment on the horizon. Sleep Breath. 2023;27(1):77–89.

    Article  PubMed  Google Scholar 

  49. Bahat G, Erdogan T, Karan MA. Need for increased awareness for avoiding metformin treatment in malnourished older adults with diabetes mellitus. Clin Nutr. 2020;39(1):322.

    Article  PubMed  Google Scholar 

  50. Cardiovascular Disease and Risk Management. Standards of medical care in diabetes-2022. Diabetes Care. 2022;45(Suppl 1):S144-s174.

    Google Scholar 

  51. LeRoith D, et al. Treatment of diabetes in older adults: an Endocrine Society* Clinical practice guideline. J Clin Endocrinol Metab. 2019;104(5):1520–74.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Bahat G, et al. Management of type 2 diabetes mellitus in older adults: eight case studies with focus SGLT-2 inhibitors and metformin. Acta Clin Belg. 2022;77(4):727–34.

    Article  CAS  PubMed  Google Scholar 

  53. Mone P, et al. Empagliflozin improves cognitive impairment in frail older adults with type 2 diabetes and heart failure with preserved ejection fraction. Diabetes Care. 2022;45(5):1247–51.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  54. Mone P, et al. SGLT2 inhibition via empagliflozin improves endothelial function and reduces mitochondrial oxidative stress: insights from frail hypertensive and diabetic patients. Hypertension. 2022;79(8):1633–43.

    Article  CAS  PubMed  Google Scholar 

  55. Kruger DF, LaRue S, Estepa P. Recognition of and steps to mitigate anxiety and fear of pain in injectable diabetes treatment. Diabetes Metab Syndr Obes. 2015;8:49–56.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Rea F, et al. Adherence to antidiabetic drug therapy and reduction of fatal events in elderly frail patients. Cardiovasc Diabetol. 2023;22(1):53.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Porcellati F, et al. Pharmacokinetics and pharmacodynamics of insulin glargine given in the evening as compared with in the morning in type 2 diabetes. Diabetes Care. 2014;38(3):503–12.

    Article  PubMed  Google Scholar 

  58. Sinclair AJ, et al. An international position statement on the management of frailty in diabetes mellitus: summary of recommendations 2017. J Frailty Aging. 2018;7(1):10–20.

    CAS  PubMed  Google Scholar 

  59. Cayea D, Boyd C, Durso SC. Individualising therapy for older adults with diabetes mellitus. Drugs Aging. 2007;24(10):851–63.

    Article  CAS  PubMed  Google Scholar 

  60. By the American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023. https://doi.org/10.1111/jgs.18372.

  61. Dong B, et al. The extraglycemic effect of sglt-2is on mineral and bone metabolism and bone fracture. Front Endocrinol. 2022;13:918350.

  62. Li X, et al. Effects of SGLT2 inhibitors on fractures and bone mineral density in type 2 diabetes: an updated meta-analysis. Diabetes Metab Res Rev. 2019;35(7): e3170.

    Article  PubMed  Google Scholar 

  63. Nauck MA, et al. GLP-1 receptor agonists in the treatment of type 2 diabetes—state-of-the-art. Mol Metab. 2021;46: 101102.

    Article  CAS  PubMed  Google Scholar 

  64. Marso SP, et al. Semaglutide and cardiovascular outcomes in patients with type 2 diabetes. N Eng J Med. 2016;375(19):1834–44.

    Article  CAS  Google Scholar 

  65. Celli A, et al. Lifestyle intervention strategy to treat diabetes in older adults: a randomized controlled trial. Diabetes Care. 2022;45(9):1943–52.

    Article  CAS  PubMed  Google Scholar 

  66. Donini LM, et al. Definition and diagnostic criteria for sarcopenic obesity: ESPEN and EASO consensus statement. Clin Nutr. 2022;41(4):990–1000.

    Article  CAS  PubMed  Google Scholar 

  67. Bahat G. Sarcopenic obesity: a hot yet under considered evolving concept. Eur Geriatr Med. 2022;13(5):1023–4.

    Article  PubMed  Google Scholar 

  68. Bahat G, et al. Association of different bioimpedanciometry estimations of muscle mass with functional measures. Geriatr Gerontol Int. 2019;19(7):593–7.

    PubMed  Google Scholar 

  69. Bahat G, Ilhan B. Sarcopenia and the cardiometabolic syndrome: a narrative review. Eur Geriatr Med. 2016;7:220–3.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Geriatrics, Department of Internal Medicine, Istanbul Medical School, Istanbul University, Capa, 34390, Istanbul, Türkiye

    Gulistan Bahat

  2. Division of Geriatrics, Department of Internal Medicine, Hatay Training and Research Hospital, 31040, Hatay, Türkiye

    Serdar Ozkok

  3. Section of Geriatrics, Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium

    Mirko Petrovic

Authors
  1. Gulistan Bahat
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Serdar Ozkok
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Mirko Petrovic
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Gulistan Bahat.

Ethics declarations

Funding

No external funding was used in the preparation of this manuscript.

Conflict of Interest

Gulistan Bahat, Serdar Ozkok, and Mirko Petrovic declare that they have no potential conflicts of interest that might be relevant to the contents of this manuscript.

Authors’ Contributions

GB: conceptualization, methodology, writing (reviewing and editing); SO: investigation, writing (original draft preparation as well as reviewing and editing); MP: writing (reviewing and editing).

Availability of Data and Material

Data sharing is not applicable to this article, as no datasets were generated or analyzed during the current study.

Ethics Approval

Not applicable.

Consent to Participate

Not applicable.

Consent for Publication

Not applicable.

Code Availability

Not applicable.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Bahat, G., Ozkok, S. & Petrovic, M. Management of Type 2 Diabetes in Frail Older Adults. Drugs Aging 40, 751–761 (2023). https://doi.org/10.1007/s40266-023-01049-x

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40266-023-01049-x

Search

Navigation