Barry J Goldlist, MD, FRCPC, FACP
Type II diabetes mellitus is an important health problem in the elderly. Rockwood et al., in data derived from the Canadian Study of Health and Aging, reported a prevalence of diabetes of 12% in community living elderly and 17.5% in institutionalized elderly (Age and Ageing, 1998). In the Rotterdam study (American Journal of Epidemiology 1997), by the age of 85 close to 20% of the populations fulfilled diagnostic criteria for diabetes.
The real issue in dealing with the elderly who have diabetes is the nihilistic attitude that treatment will make no difference. It is important to recognize that a healthy 70-year-old woman has a life expectancy of almost 17 years (and about 13 years for her less hardy male counterpart). This is clearly a substantial length of time in which to develop diabetic complications. The report of the United Kingdom Prospective Diabetes Study Group (Lancet, 1998) gives persuasive evidence in favor of intensive control of blood sugar in patients with Type II diabetes. There is no reason to suspect that older patients do not benefit as well. The development of new drugs, and new combinations of drug therapy, will make good control of diabetes mellitus in the elderly ever more feasible.
If diabetes is common in the elderly, and treatment beneficial, should we be screening for the disease in our patients? No careful analysis has been done for this particular segment of the population, but it seems possible that screening might be beneficial in those over the age of 65. Until more data is available, most physicians will only screen those patients with other risk factors. The two most important risk factors are family history and obesity, however, there is also persuasive evidence that hypertension should also be considered an indication for diabetes screening in the elderly (KC Johnson et al, JAGS 1997).
Once the diagnosis of diabetes mellitus is made, a complete investigation for other risk factors for cardiovascular morbidity (hypertension, lipids, etc.) is mandatory. Management of the patient with diabetes mellitus means much more than just controlling the blood sugar. Readers of this editorial are advised to obtain a copy of the 1998 clinical practice guidelines for the management of diabetes in Canada. This excellent publication appeared as a supplement to the Canadian Medical Association in 1998;159(8 Suppl). It is an extremely valuable resource for those of us who treat patients with diabetes mellitus.