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Choosing Targets for Glycaemia, Blood Pressure and Low-Density Lipoprotein Cholesterol in Elderly Individuals with Diabetes Mellitus

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Abstract

Diabetes mellitus in the ‘elderly’ poses unique management challenges that contribute to conflicting priorities. Individualized management requires taking into account each patient’s medical history, functional ability, home care situation, life expectancy and his/her health beliefs; individuals value trade-offs (e.g. quantity versus quality of life, and side effects as well as risks versus long-term benefits) differently. Moreover, this decision making relies on imperfect evidence. Target goals for three intermediate outcomes — glycaemic control (glycosylated haemoglobin [HbA1c]), blood pressure control and lipid control (low-density lipoprotein cholesterol [LDL-C]) — help keep management on track. Of these, glycaemic control is usually the most complex.

Glycaemic control alleviates symptoms of hyperglycaemia and can improve micro- and macrovascular outcomes. Tight glycaemic control (HbA1c <7%) clearly improves microvascular outcomes. However, hypoglycaemia and polypharmacy are the main drawbacks of tight control. Factors that influence the benefits and drawbacks include age, longevity and co-morbidities, including the geriatric ‘syndromes’ of frailty and falls. We favour the explicit risk-stratified approach of the Department of Veterans Affairs/Department of Defense (VA/DoD) guidelines, which set HbA1c target ranges based on physiological age or the presence/severity of major co-morbidities and microvascular complications.

There are clear benefits of blood pressure and cholesterol control (primarily reduction of macrovascular events, but also microvascular events), and their overall cost effectiveness exceeds that of glycaemic control. Issues with treatment for hypertension include potential side effects of drugs, a potential increased risk of falls and risks of polypharmacy. Nevertheless, the evidence for a blood pressure target of <140/80 mmHg is reasonably strong if it can be achieved safely. In general, we recommend use of an HMG-CoA reductase inhibitor (statin) and an LDL-C target of <100mg/dL, especially if an individual cannot tolerate a moderate dose of a statin.

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References

  1. Bertoni A, Kirk J, Goff D, et al. Excess mortality related to diabetes mellitus in elderly Medicare beneficiaries. Ann Epidemiol 2004; 14: 632–367

    Article  Google Scholar 

  2. Bethel M, Sloan F, Belsky D, et al. Longitudinal incidence and prevalence of adverse outcomes of diabetes mellitus in elderly patients. Arch Intern Med 2007; 167: 921–7

    Article  PubMed  Google Scholar 

  3. King H, Aubert R, Herman W. Global burden of diabetes, 1995–2025: prevalence, numerical estimates, and projections. Diabetes Care 1998; 21: 1414–31

    Article  PubMed  CAS  Google Scholar 

  4. Selvin E, Coresh J, Brancati F. The burden and treatment of diabetes in elderly individuals in the US. Diabetes Care 2006; 29(11): 2415–9

    Article  PubMed  Google Scholar 

  5. Bourdel-Marchasson I, Helmer C, Fagot-Campagna A, et al. Disability and quality of life in elderly people with diabetes. Diabetes Metab 2007; 33Suppl. 1: S66–74

    Article  PubMed  Google Scholar 

  6. Blaum C, Cigolle C, Boyd C, et al. Clinical complexity in middle-aged and older adults with diabetes: the Health and Retirement Study. Med Care 2010; 48(4): 327–34

    Article  PubMed  Google Scholar 

  7. Aron D, Pogach L. One size does not fit all: a continuous measure for glycemic control in diabetes: the need for a new approach to assessing glycemic control. Jt Comm J Qual Improv 2007; 33: 636–43

    Google Scholar 

  8. Brown A, Mangione C, Saliba D, et al. Guidelines for improving the care of the older person with diabetes mellitus. J Am Geriatr Soc 2003; 51: S265–80

    Article  PubMed  Google Scholar 

  9. Durso S. Using clinical guidelines designed for older adults with diabetes mellitus and complex health status. JAMA 2006; 295: 1935–40

    Article  PubMed  CAS  Google Scholar 

  10. Sutin D. Diabetes mellitus in older adults: time for an overtreatment quality indicator. J Am Geriatr Soc 2010; 58(11): 2244–5

    Article  PubMed  Google Scholar 

  11. Kitabchi A, Umpierrez G, Murphy M, et al. Hyperglycemia crises in adult patients with diabetes. Diabetes Care 2006; 29(12): 2739–48

    Article  PubMed  CAS  Google Scholar 

  12. Tovi J, Engfeldt P. Well being and symptoms in elderly type 2 diabetes patients with poor metabolic control: effect of insulin treatment. Pract Diab Int 1998; 15: 73–7

    Article  Google Scholar 

  13. Brown J, Seeley D, Fong J, et al. Urinary incontinence in older women: who is at risk? Study of Osteoporotic Fractures Research Group. Obstet Gynecol 1996; 87: 715–21

    Article  PubMed  CAS  Google Scholar 

  14. DCCT Research Group. The effects of intensive diabetes treatment on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993; 329: 977–86

    Article  Google Scholar 

  15. UK Prospective Diabetes Study (UKPDS) Group. Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet 1998; 352: 854–65

    Article  Google Scholar 

  16. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998; 352: 837–53

    Article  Google Scholar 

  17. Gerstein HC, Miller ME, Genuth S, et al., ACCORD Study Group. Long-term effects of intensive glucose lowering on cardiovascular outcomes. N Eng J Med 2011; 364: 818–28

    Article  CAS  Google Scholar 

  18. Holman R, Paul S, Bethel M, et al. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 2008; 359: 1577–89

    Article  PubMed  CAS  Google Scholar 

  19. The ADVANCE Collaborative Group. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Eng J Med 2008; 358: 2560–72

    Article  Google Scholar 

  20. Duckworth W, Abraira C, Moritz T, et al. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med 2009; 360(2): 129–39

    Article  PubMed  CAS  Google Scholar 

  21. Ray K, Seshasai S, Wijesuriya S, et al. Effect of intensive control of glucose on cardiovascular outcomes and death in patients with diabetes mellitus: a meta-analysis of randomised controlled trials. Lancet 2009; 373: 1765–72

    Article  PubMed  CAS  Google Scholar 

  22. Katakura M, Naka M, Kondo T, et al. Normal mortality in the elderly with diabetes under strict glycemic and blood pressure control: outcome of 6-year prospective study. Diabetes Res Clin Pract 2007; 78: 108–14

    Article  PubMed  Google Scholar 

  23. Currie C, Peters J, Tynan A, et al. Survival as a function of HbA1c in people with type 2 diabetes a retrospective cohort study. Lancet 2010; 375: 481–9

    Article  PubMed  CAS  Google Scholar 

  24. Balkau B, Simon D. Survival in people with type 2 diabetes as a function of HbA1c. Lancet 2010; 375: 438–40

    Article  PubMed  Google Scholar 

  25. Health, United States, 2010: with special feature on death and dying. Hyattsville (MD): National Center for Health Statistics, 2011

    Google Scholar 

  26. World Health Organization. Definition of an older or elderly person: proposed working definition of an older person in Africa for the MDS Project. [online]. Available from URL: http://www.who.int/healthinfo/survey/ageingdefnolder/en/index.html [Accessed 2011 Aug 11]

  27. Motta M, Bennati E, Ferlito L, et al. Diabetes mellitus in the elderly: diagnostic features. Arch Gerontol Geriatr 2006; 42: 101–6

    Article  PubMed  CAS  Google Scholar 

  28. Meneilly G, Tessier D. Diabetes in elderly adults. Sciences 2001; 56A: M5–13

    Google Scholar 

  29. Zammitt N, Frier B. Hypoglycemia in type 2 diabetes: pathophysiology, frequency, and effects of different treatment modalities. Diabetes Care 2005; 28: 2948–61

    Article  PubMed  Google Scholar 

  30. Aizawa T, Katakura M, Naka M. Postprandial hyperglycemia is an independent risk for retinopathy in elderly patients with type 2 diabetes mellitus, especially in those with near-normal glycosylated hemoglobin. J Am Geriatr Soc 2010; 58(7): 1408–9

    Article  PubMed  Google Scholar 

  31. Florez H. Life expectancy and likely benefit of tight glucose control in elderly diabetic patients. International Diabetes Monitor 2009; 21(4): 162–4

    Google Scholar 

  32. Vijan S, Hofer T, Hayward R. Estimated benefits of glycemic control in microvascular complications in type 2 diabetes. Ann Intern Med 1997; 127(9): 788–95

    PubMed  CAS  Google Scholar 

  33. VA/DoD Diabetes Clinical Practice Guideline Working Group. VA/DoD clinical practice guideline for the management of diabetes mellitus. Version 4.0 Washington, DC: Department of Veterans Affairs (VA) and The Department of Defense (DoD), 2010 Aug [online]. Available from URL: http://www.healthquality.va.gov/diabetes/DM2010_FUL-v4e.pdf [Accessed 2011 Apr 1]

    Google Scholar 

  34. Pogach L, Tiwari A, Maney M, et al. Should mitigating comorbidities be considered in assessing healthcare plan performance in achieving optimal glycemic control? Am J Manag Care 2007; 13: 133–40

    PubMed  Google Scholar 

  35. Huang E, Zhang Q, Gandra N, et al. The effect of comorbid illness and functional status on the expected benefits of intensive glucose in older patients with type 2 diabetes: a decision analysis. Ann Intern Med 2008; 149: 11–9

    PubMed  Google Scholar 

  36. Caughey G, Roughead E, Vitry A, et al. Comorbidity in the elderly with diabetes: identification of areas of potential treatment conflicts. Diabetes Res Clin Pract 2010; 87: 385–93

    Article  PubMed  Google Scholar 

  37. Huang E. Appropriate applications of evidence to the care of elderly patients with diabetes. Curr Diabetes Rev 2007; 3: 260–3

    Article  PubMed  Google Scholar 

  38. Munshi M, Grande L, Hayes M, et al. Cognitive dysfunction is associated with poor diabetes control in older adults. Diabetes Care 2006; 29: 1794–9

    Article  PubMed  Google Scholar 

  39. Sinclair A, Girling A, Bayer A. Cognitive dysfunction in older subjects with diabetes mellitus: impact on diabetes self-management and use of care services. Diabetes Res Clin Pract 2000; 50: 203–12

    Article  PubMed  CAS  Google Scholar 

  40. Sinclair A, Conroy S, Bayer A. Impact of diabetes on physical function in older adults. Diabetes Care 2008; 31:233–5

    Article  PubMed  Google Scholar 

  41. Suh D, Kim C, Choi I, et al. Comorbid conditions and glycemic control in elderly patients with type 2 diabetes mellitus 1988 to 1994 to 1999 to 2004. J Am Geriatr Soc 2008; 56: 484–92

    Article  PubMed  Google Scholar 

  42. Trief P, Morin P, Izquierdo R, et al. Depression and glycemic control in elderly ethnically diverse patients with diabetes: the IDEATel Project. Diabetes Care 2006; 29(4): 830–5

    Article  PubMed  Google Scholar 

  43. Chen L, Chen Y, Lin M, et al. Care of elderly patients with diabetes mellitus: a focus on frailty. Aging Res Rev 2010; 95: S18–22

    Article  Google Scholar 

  44. Abbatecola A, Paolisso G, Corsonello A, et al. Anti-diabetic oral treatment in older people. Drugs Aging 2009; 1: 53–62

    Article  Google Scholar 

  45. Fontbonne A, Ducimetiere P, Berr C, et al. Changes in cognitive abilities over a 4 year period are unfavorably affected in elderly diabetic subjects. Diabetes Care 2001; 24: 366–70

    Article  PubMed  CAS  Google Scholar 

  46. McGuire L, Ford E, Ajani U. The impact of cognitive functioning on mortality and the development of functional disability in older adults with diabetes: the second longitudinal study on aging. BMC Geriatr 2006; 6: 8

    Article  PubMed  Google Scholar 

  47. Meneilly G, Cheung E, Tessier D, et al. The effect of improved glycemic control on cognitive functions in the elderly patient with diabetes. J Gerontol Med Sci 1993; 48: M117–21

    CAS  Google Scholar 

  48. Umegaki H. Pathophysiology of cognitive dysfunction in older people with type 2 diabetes: vascular changes or neurodegeneration? Age Ageing 2010; 39: 8–10

    Article  PubMed  Google Scholar 

  49. Cukierman-Yaffe T, Gerstein H, Williamson J, et al. Relationship between baseline glycemic control and cognitive function in individuals with type 2 diabetes and other cardiovascular risk factors: the Action to Control Cardiovascular Risk in Diabetes-Memory in Diabetes (ACCORD-MIND) trial. Diabetes Care 2009; 32(2): 221–6

    Article  PubMed  Google Scholar 

  50. Nguyen H, Grzywacz J, Arcury T, et al. Linking glycemic control and executive function in rural older adults with diabetes mellitus. J Am Geriatr Soc 2010; 58: 1123–7

    Article  PubMed  Google Scholar 

  51. Whitmer RA, Karter AJ, Yaffe K, et al. Hypoglycemic episodes and risk of dementia in older patients with type 2 diabetes mellitus. JAMA 2009; 301(15): 1565–72

    Article  PubMed  CAS  Google Scholar 

  52. Strachan M, Reynolds R, Marioni R, et al. Cognitive function, dementia and type 2 diabetes mellitus in the elderly. Nat Rev Endocrinol 2011; 7: 108–14

    Article  PubMed  CAS  Google Scholar 

  53. Nelson J, Dufraux K, Cook P. The relationship between glycemic control and falls in older adults. J Am Geriatr Soc 2007; 55(12): 2041–4

    Article  PubMed  Google Scholar 

  54. Tilling L, Darawil K, Britton M. Falls as a complication of diabetes mellitus in older people. J Diabetes Complications 2006; 20: 158–62

    Article  PubMed  Google Scholar 

  55. Alagiakrishnan K, Lechelt K, McCraken P, et al. Atypical presentation of silent nocturnal hypoglycemia in an older person. J Am Geriatr Soc 2001; 49: 1577

    Article  PubMed  CAS  Google Scholar 

  56. Vischer U, Perrenoud L, Genet C, et al. The high prevalence of malnutrition in elderly diabetic patients: implications for anti-diabetic drug treatments. Diabet Med 2010; 27: 918–24

    Article  PubMed  CAS  Google Scholar 

  57. Gregg E, Engelgau M, Narayan V. Complications of diabetes in elderly people. BMJ 2002; 325(7370): 916–7

    Article  PubMed  Google Scholar 

  58. Gregg E, Mangione C, Cauley J, et al. Diabetes and incidence of functional disability in older women. Diabetes Care 2002; 25: 61–7

    Article  PubMed  Google Scholar 

  59. Boyd CM, Darer J, Boult C, et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases. JAMA 2005; 294(6): 716–24

    Article  PubMed  CAS  Google Scholar 

  60. Finkelstein E, Bray J, Chen H, et al. Prevention and costs of major depression among elderly claimants with diabetes. Diabetes Care 2003; 26: 415–20

    Article  PubMed  Google Scholar 

  61. Nicholas A, Nadeau D, Johnson C. Treatment considerations for diabetes: a pharmacist’s guide to improving care in the elderly. J Pharm Pract 2009; 22(6): 575–87

    Article  Google Scholar 

  62. Ostrom JR, Haamarlund ER, Christensen DE, et al. Medication usage in an elderly population. Med Care 1985; 23: 157–64

    Article  PubMed  CAS  Google Scholar 

  63. Sinclair A, Armes DG, Randhawa G, et al. Caring for older adults with diabetes mellitus: characteristics of carers and their prime roles and responsibilities. Diabet Med 2010; 27: 1055–9

    Article  PubMed  CAS  Google Scholar 

  64. Barnett A, Cradock S, Fisher M, et al. Key considerations around the risks and consequences of hypoglycaemia in people with type 2 diabetes. Int J Clin Pract 2010; 64(8): 1121–9

    Article  PubMed  CAS  Google Scholar 

  65. Budnitz DS, Shehab N, Kegler SR, et al. Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med 2007; 147: 755–65

    PubMed  Google Scholar 

  66. Shorr R, Ray W, Daugherty J, et al. Incidence and risk factors for serious hypoglycemia in older persons using insulin or sulfonylureas. Arch Intern Med 1997; 157: 1681–5

    Article  PubMed  CAS  Google Scholar 

  67. Shorr R, Ray W, Daugherty J, et al. Individual sulfonylureas and serious hypoglycemia in older people. J Am Geriatr Soc 1996; 44(7): 751–5

    PubMed  CAS  Google Scholar 

  68. Bauduceau B, Doucet J, Bordier L, et al. Hypoglycaemia and dementia in diabetic patients. Diabetes Metab 2010; 36: S106–11

    Article  PubMed  CAS  Google Scholar 

  69. Sarkar U, Karter AJ, Moffet HH, et al. Hypoglycemia is more common among type 2 diabetes patients with limited health literacy: the Diabetes Study of Northern California (DISTANCE). J Gen Int Med 2010; 25(9): 962–8

    Article  Google Scholar 

  70. Cushman W, Evans G, Byington R, et al., ACCORD Study Group. Effects of intensive blood pressure control in type 2 diabetes mellitus. N Engl J Med 2010; 362(17): 1575–85

    Article  PubMed  CAS  Google Scholar 

  71. Calles-Escandon J, Lovato LC, Simons-Morton DG, et al. Effect of intensive compared with standard glycemia treatment strategies on mortality by baseline subgroup characteristics: the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. Diabetes Care 2010 Apr; 33: 721–7

    Article  PubMed  Google Scholar 

  72. McCall A. What’s wrong with too low? Is hypoglycemia a marker or a cause of CVD and mortality risk? Curr Diab Rep 2011; 11:71–4

    Article  PubMed  Google Scholar 

  73. Miller ME, Bonds DE, Gerstein HC, et al. The effects of baseline characteristics, glycaemia treatment approach, and glycated haemoglobin concentration on the risk of severe hypoglycaemia: post hoc epidemiological analysis of the ACCORD study. BMJ 2010 Jan 8; 340: b5444

    Article  PubMed  Google Scholar 

  74. Nandish S, Wyatt J, Oliveros R, et al. A cardiologist’s view of hypoglycemia. Curr Atheroscler Rep 2010; 12: 88–95

    Article  PubMed  CAS  Google Scholar 

  75. Zoungas S, Patel A, Chalmers J, et al. Severe hypoglycemia and risks of vascular events and death. N Engl J Med 2010 Oct 7; 363: 1410–8

    Article  PubMed  CAS  Google Scholar 

  76. Nordin C. The case for hypoglycaemia as a proarrhythmic event: basic and clinical evidence. Diabetologia 2010; 53: 1552–61

    Article  PubMed  CAS  Google Scholar 

  77. Blonde L. Current antihyperglycemic treatment guidelines and algorithms for patients with type 2 diabetes mellitus. Am J Med 2010; 123: S12–8

    Article  PubMed  CAS  Google Scholar 

  78. Bolen S, Feldman L, Vassy J, et al. Systematic review: comparative effectiveness and safety of oral medications for type 2 diabetes mellitus. Ann Intern Med 2007 Sep; 147: 386–99

    PubMed  Google Scholar 

  79. Fonseca V. Incretin-based therapies in complex patients: practical implications and opportunities for maximizing clinical outcomes: a discussion with Dr. Vivian A. Fonseca. Am J Med 2011; 124: S54–61

    Article  PubMed  Google Scholar 

  80. Defronzo R, Ratner R, Han J, et al. Effects of exenatide (exendin-4) on glycemic control and weight over 30 weeks in metformin-treated patients with type 2 diabetes. Diabetes Care 2005; 28(5): 1092–100

    Article  PubMed  CAS  Google Scholar 

  81. Mathieu C, Bollaerts K. Antihyperglycaemic therapy in elderly patients with type 2 diabetes: potential of incretin mimetics and DPP-4 inhibitors. Int J Clin Pract 2007; 61Suppl. 154: 29–37

    Article  Google Scholar 

  82. Schweizer A, Dejager S, Foley J, et al. Clinical experience with vildagliptin in the management of type 2 diabetes in a patient population ≥75 years: pooled analysis from a database of clinical trials. Diabetes Obes Metab 2011; 13: 55–64

    Article  PubMed  CAS  Google Scholar 

  83. Meneilly G. A comparison of insulin aspart and regular insulin in elderly patients with type 2 diabetes. Diabetes Obes Metab 2007; 9: 754–5

    Article  PubMed  CAS  Google Scholar 

  84. Munger MA. Polypharmacy and combination therapy in the management of hypertension in elderly patients with co-morbid diabetes mellitus. Drugs Aging 2010; 27(11): 871–83

    Article  PubMed  Google Scholar 

  85. Kaufman DW, Kelly JP, Rosenberg L, et al. Recent patterns of medication use in the ambulatory adult population of the United States: the Slone survey. JAMA 2002; 287: 337–4

    Article  PubMed  Google Scholar 

  86. Maroo BP, Lavie CJ, Milani RV. Secondary prevention of coronary heart disease in elderly patients following myocardial infarction: are all HMG-CoA reductase inhibitors alike? Drugs Aging 2008; 25(8): 649–64

    Article  PubMed  CAS  Google Scholar 

  87. Rubinow K, Hirsch I. Reexamining metrics for glucose control. JAMA 2011 Mar 16; 305(11): 1132–3

    Article  PubMed  CAS  Google Scholar 

  88. Little RR, Rohlfing CL, Sacks DB, et al. Status of hemoglobin A1c measurement of goals for improvement: from chaos to order for improving diabetes care. Clin Chem 2011; 57(2): 205–14

    Article  PubMed  CAS  Google Scholar 

  89. National Glycohemoglobin Standardization Program (NGSP). Factors that interfere with HbA1c test results. NGSP, 2010 [online]. Available from URL: http://www.ngsp.org/factors.asp [Accessed 2011 Aug 22]

    Google Scholar 

  90. Herman WH, Ma Y, Uwaifo G, et al. Differences in A1c by race and ethnicity among patients with impaired glucose tolerance in the Diabetes Prevention Program. Diabetes Care 2007; 30(10): 2453–7

    Article  PubMed  CAS  Google Scholar 

  91. Pani LN, Korenda L, Meigs JB, et al. Effect of aging on A1c levels in individuals without diabetes: evidence from the Framingham Offspring Study and the National Health and Nutrition Examination Survey 2001–2004. Diabetes Care 2008; 31: 1991–6

    Article  PubMed  Google Scholar 

  92. International Expert Committee. International Expert Committee report on the role of the A1C assay in the diagnosis of diabetes. Diabetes Care 2009; 32: 1327–34

    Article  CAS  Google Scholar 

  93. Pogach L, Aron DC. Know your A1c number or your A1c range? The need to implement glycemic numeracy into policy and practice. J Diabetes 2010; 2(2): 67–70

    Article  PubMed  Google Scholar 

  94. Dominguez L, Paolisso G, Barbagallo M. Glucose control in the older patient: from intensive, to effective and safe. Aging Clin Exp Res 2010; 22(4): 274–80

    PubMed  Google Scholar 

  95. Pogach L, Aron D. Balancing hypoglycemia and glycemic control: a public health approach for insulin safety. JAMA 2010; 303(20): 2076–7

    Article  PubMed  CAS  Google Scholar 

  96. CDC Diabetes Cost-effectiveness Group. Cost-effectiveness of intensive glycemic control, intensified hypertension control, and serum cholesterol level reduction for type 2 diabetes. JAMA 2002; 287: 2542–51

    Article  Google Scholar 

  97. Shah N, Mason J, Kurt M, et al. Comparative effectiveness of guidelines for the management of hyperlipidemia and hypertension for type 2 diabetes patients. PLoS One 2011; 6(1):e16170

    Article  PubMed  CAS  Google Scholar 

  98. American Diabetes Association. Executive summary: standards of medical care in diabetes — 2011. Diabetes Care 2011; 34Suppl. 1: S4–10

    Google Scholar 

  99. Diabetes Australia Guideline Development Consortium. National evidence based guideline for blood glucose control in type 2 diabetes. Canberra (ACT): Diabetes Australia and the NHMRC, 2009 [online]. Available from URL: http://www.diabetesaustralia.com.au [Accessed 2011 Apr 1]

    Google Scholar 

  100. European Diabetes Working Party for Older People 2004. Clinical guidelines for type 2 diabetes mellitus (older people). EUGMS, 2004 [online]. Available from URL: http://www.eugms.org/index.php?pid=30? [Accessed 2011 Apr 1]

    Google Scholar 

  101. National Institute for Health and Clinical Excellence (NICE). Type 2 diabetes: treatment of type 2 diabetes. NICE clinical guideline CG66 (updated). London: NICE, 2008 [online]. Available from URL: http://www.nice.org.uk/CG87 [Accessed 2011 Apr 1]

    Google Scholar 

  102. Canadian Diabetes Association. 2008 clinical practice guidelines. Toronto (ON): Canadian Diabetes Association, 2008 [online]. Available from URL: http://www.diabetes.ca/for-professionals/resources/2008-cpg/ [Accessed 1 Apr 2011]

    Google Scholar 

  103. Sinclair A, on behalf of the Task and Finish Group of Diabetes UK. Good clinical practice guidelines for care home residents with diabetes: an executive summary. Diabet Med 2011; 28: 772–7

    Article  PubMed  CAS  Google Scholar 

  104. Pogach L, Conlin PR, Hobbs C, et al. VA-DoD update of diabetes guidelines: what clinicians need to know about absolute risk of benefits and harms and A1c laboratory accuracy. Federal Practitioner 2011; April: 39–44

    Google Scholar 

  105. Lee SJ, Eng C. Goals of glycemic control in frail older patients with diabetes. JAMA 2011 Apr 6; 305: 1350–1

    Article  PubMed  CAS  Google Scholar 

  106. Anderson R, Bahn G, Moritz T, et al. Blood pressure and cardiovascular disease risk in the Veterans Affairs Diabetes Trial (VADT). Diabetes Care 2011 Jan; 34(1): 34–8

    Article  PubMed  Google Scholar 

  107. Beckett N, Peters R, Fletcher A, et al. Treatment of hypertension in patients 80 years of age and older. N Engl J Med 2008; 358: 1887–98

    Article  PubMed  CAS  Google Scholar 

  108. JATOS Study Group. Principal results of the Japanese trial to assess optimal systolic blood pressure in elderly hypertensive patients (JATOS). Hypertensive Research 2008; 31: 2115–27

    Article  Google Scholar 

  109. Ogihara T, Saruta T, Rakugi H, et al. Target blood pressure for treatment of isolated systolic hypertension in the elderly: Valsartan in Elderly Isolated Systolic Hypertension study. Hypertension 2010; 56: 196–202

    Article  PubMed  CAS  Google Scholar 

  110. Turnbull F, Neal B, Ninomiya T, et al. Effects of different regimens to lower blood pressure on major cardiovascular events in older and younger adults: meta-analysis of randomised trials. BMJ 2008; 336: 1121–3

    Article  PubMed  CAS  Google Scholar 

  111. UK Prospective Diabetes Study (UKPDS) Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes. UKPDS 38. BMJ 1998 Sep 12; 317(7160): 703–13

    Article  Google Scholar 

  112. Van Hatern K, Landman G, Kleefstra N, et al. Lower blood pressure associated with higher mortality in elderly diabetic patients (ZODIAC-12). Age Ageing 2010; 39: 603–9

    Article  Google Scholar 

  113. Peters R, Beckett N, Burch L, et al. The effect of treatment based on a diuretic (indapamide) +/− ACE inhibitor (perindopril) on fractures in the Hypertension in the Very Elderly Trial (HYVET). Age Ageing 2010; 39: 609–16

    Article  PubMed  Google Scholar 

  114. Hackman D, Khan N, Hemmeigarn B, et al. The 2010 Canadian Hypertension Education Program recommendations for the management of hypertension: part 2 -therapy. Can J Cardiol 2010; 26(5): 249–58

    Article  Google Scholar 

  115. Angeli F, Reboldi G, Verdecchia P. “The lower the BP the better” paradigm in the elderly vanished by VALISH. Hypertension 2010; 56: 182–4

    Article  PubMed  CAS  Google Scholar 

  116. Patel A, ADVANCE Collaborative Group, MacMahon S, et al. Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): a randomised controlled trial. Lancet 2007 Sep 8; 370(9590): 829–40

    Article  PubMed  CAS  Google Scholar 

  117. Du X, Ninomiya T, de Galan B, et al. Risks of cardiovascular events and effects of routine blood pressure lowering among patients with type 2 diabetes and atrial fibrillation: results of the ADVANCE study. Euro Heart J 2009 May; 30(9): 1128–35

    Article  Google Scholar 

  118. Zoungas S, de Galan BE, Ninomiya T, et al. Combined effects of routine blood pressure lowering and intensive glucose control on macrovascular and microvascular outcomes in patients with type 2 diabetes: new results from the ADVANCE trial. Diabetes Care 2009 Nov; 32(11): 2068–74

    Article  PubMed  CAS  Google Scholar 

  119. Gribbin J, Hubbard R, Gladman J, et al. Risk of falls associated with antihypertensive medication: population-based case-control study. Age Ageing 2010 Sep; 39(5): 592–7

    Article  PubMed  Google Scholar 

  120. Bell DSH, Al Badarin F, O’Keefe Jr JH. Therapies for diabetic dyslipidaemia. Diabetes Obes Metab 2011; 13: 313–25

    Article  PubMed  CAS  Google Scholar 

  121. Robinson JG. Lipid-lowering therapy for the primary prevention of cardiovascular disease in the elderly: opportunities and challenges. Drugs Aging 2009; 26(11): 917–31

    Article  PubMed  CAS  Google Scholar 

  122. Thomas JE, Tershakovec AM, Jones-Burton C, et al. Lipid lowering for secondary prevention of cardiovascular disease in older adults. Drugs Aging 2010; 27(12): 959–72

    Article  PubMed  CAS  Google Scholar 

  123. Pedersen TR, Wilhelmsen L, Faergeman O, et al. Follow-up study of patients randomized in the Scandinavian Simvastatin Survival Study (4S) of cholesterol lowering. Am J Cardiol 2000; 86: 257–62

    Article  PubMed  CAS  Google Scholar 

  124. Packard C, Ford I, Robertson M, et al. Plasma lipoproteins and apolipoproteins as predictors of cardiovascular risk and treatment benefit in the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER). Circulation 2009; 112: 3058–65

    Article  CAS  Google Scholar 

  125. Third report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Bethesda (MD): National Heart, Lung and Blood Institute, 2004 [online]. Available from URL: http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm [Accessed 2011 Oct 7]

  126. Rahilly-Tierney C, Lawler E, Scranton R, et al. Cardiovascular benefit of magnitude of low-density lipoprotein cholesterol reduction: a comparison of subgroups by age. Circulation 2009; 120: 1491–7

    Article  PubMed  CAS  Google Scholar 

  127. Ridker P, The JUPITER Study Group. Rosuvastatin in the primary prevention of cardiovascular disease among patients with low levels of low-density lipoprotein cholesterol and elevated high-sensitivity C-reactive protein: rationale and design of the JUPITER Trial. Circulation 2003; 108: 2292–7

    Article  PubMed  Google Scholar 

  128. Hayward R. Lack of evidence for recommended low-density lipoprotein treatment targets: a solvable problem. Ann Intern Med 2006; 145(7): 520–30

    PubMed  Google Scholar 

  129. Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5963 people with diabetes: a randomised placebo-controlled trial. Lancet 2003; 361: 2005–16

    Article  CAS  Google Scholar 

  130. Ginsberg H, Elam M, Lovato L, et al., ACCORD Study Group. Effects of combination lipid therapy in type 2 diabetes mellitus. N Engl J Med 2010; 362(17): 1563–74

    Article  PubMed  Google Scholar 

  131. Fruchart JC, Sacks FM, Hermans MP. Implications of the ACCORD Lipid study: perspective from the Residual Risk Reduction Initiative (R3i). Cur Med Res Opin 2010; 26(8): 1793–8

    Article  CAS  Google Scholar 

  132. Benner JS, Glynn RJ, Mogun H, et al. Long-term persistence in use of statin therapy in elderly patients. JAMA 2002; 288: 455–61

    Article  PubMed  Google Scholar 

  133. Sathyapalan T, Atkin S, Kilpatrick E. Variability of lipids in patients with type 2 diabetes taking statin treatment: implications for target setting. Diabet Med 2008; 25: 909–15

    Article  PubMed  CAS  Google Scholar 

  134. Dolan JG. Multi-criteria clinical decision support: a primer on the use of multiple criteria decision making methods to promote evidence-based, patient-centered healthcare. Patient 2010; 3(4): 229–48

    Article  PubMed  Google Scholar 

  135. Mcgrath C, Rofail D, Gargon E, et al. Using qualitative methods to inform the trade-off between content validity and consistency in utility assessment: the example of type 2 diabetes and Alzheimer’s disease. Health Qual Life Outcomes 2010; 8: 23

    Article  PubMed  Google Scholar 

  136. Aron DC, Pogach LM. One size does not fit all: the need for a continuous measure for glycemic control in diabetes. Jt Comm J Qual Patient Saf 2007; 33: 636–43

    PubMed  Google Scholar 

  137. Ismail-Beigi F, Moghissi ES, Tiktin M, et al. Individualizing glycemic targets in type 2 diabetes mellitus: implications of recent clinical trials. Ann Intern Med 2011 Apr 19; 154: 554–9

    PubMed  Google Scholar 

  138. Timbie JW, Hayward RA, Vijan S. Diminishing efficacy of combination therapy, response-heterogeneity, and treatment intolerance limit the attainability of tight risk factor control in patients with diabetes. Health Serv Res 2010; 45(2): 437–56

    Article  PubMed  Google Scholar 

  139. Kengne A, Patel A, Colagiuri S, et al. The Framingham and UK Prospective Diabetes Study (UKPDS) risk equations do not reliably estimate the probability of cardiovascular events in a large ethnically diverse sample of patients with diabetes: the Action in Diabetes and Vascular Disease: Preterax and Diamicron-MR Controlled Evaluation (ADVANCE) Study. Diabetologia 2010 May; 53(5): 821–31

    Article  PubMed  CAS  Google Scholar 

  140. van Dieren S, Peelen LM, Nothlings U, et al. External validation of the UK Prospective Diabetes Study (UKPDS) risk engine in patients with type 2 diabetes. Diabetologia 2011; 54: 264–70

    Article  PubMed  CAS  Google Scholar 

  141. Chamnan P, Simmons RK, Sharp SJ, et al. Cardiovascular risk assessment scores for people with diabetes: a systematic review. Diabetologia 2009; 52: 2001–14

    Article  PubMed  CAS  Google Scholar 

  142. Cooney MT, Dudina AL, Graham IM. Value and limitations of existing scores for the assessment of cardiovascular risk a review for clinicians. J Am Coll Cardiol 2009; 54: 1209–27

    Article  PubMed  Google Scholar 

  143. Corser W, Holmes-Rovner M, Lein C, et al. A shared decision-making primary care intervention for type 2 diabetes. Diabetes Educ 2011; 33: 700–8

    Article  Google Scholar 

  144. Sheridan SL, Viera AJ, Krantz MJ, et al. The effect of giving global coronary risk information to adults: a systematic review. Arch Intern Med 2010; 170(3): 230–9

    Article  PubMed  Google Scholar 

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Acknowledgements

This work was supported by the VA HSR&D Quality Enhancement Research Initiative (QUERI) Program. The authors are members of the VA/DoD Diabetes Practice Guideline Strategic Working Group. The opinions expressed are solely those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or any other organization. The authors have no conflicts of interest that are directly relevant to the content of this article.

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  1. VA HSR&D Quality Enhancement Research Initiative Diabetes Center, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH, USA

    Susan R. Kirsh &  David C. Aron

  2. Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA

    Susan R. Kirsh &  David C. Aron

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  1. Susan R. Kirsh
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  2. David C. Aron
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Correspondence to David C. Aron.

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Kirsh, S.R., Aron, D.C. Choosing Targets for Glycaemia, Blood Pressure and Low-Density Lipoprotein Cholesterol in Elderly Individuals with Diabetes Mellitus. Drugs Aging 28, 945–960 (2011). https://doi.org/10.2165/11594750-000000000-00000

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