Type 2 diabetes mellitus in older adults: clinical considerations and management

The past 50 years have seen a growing ageing population with an increasing prevalence of type 2 diabetes mellitus (T2DM); now, nearly half of all individuals with diabetes mellitus are older adults (aged ≥65 years). Older adults with T2DM present particularly difficult challenges. For example, the accentuated heterogeneity of these patients, the potential presence of multiple comorbidities, the increased susceptibility to hypoglycaemia, the increased dependence on care and the effect of frailty all add to the complexity of managing diabetes mellitus in this age group. In this Review, we offer an update on the key pathophysiological mechanisms associated with T2DM in older people. We then evaluate new evidence relating particularly to the effects of frailty and sarcopenia, the clinical difficulties of age-associated comorbidities, and the implications for existing guidelines and therapeutic options. Our conclusions will focus on the effect of T2DM on an ageing society. The management of type 2 diabetes mellitus (T2DM) in older adults (aged ≥65 years) presents specific challenges. This Review summarizes the key age-related mechanisms contributing to T2DM and evaluates new evidence relating to frailty and sarcopenia, hypoglycaemia, comorbidities, and the implications for existing guidelines and therapeutic options. Key points Older adults (≥65 years of age) with type 2 diabetes mellitus (T2DM) account for nearly half of all individuals with diabetes mellitus. T2DM in older adults is highly heterogeneous but is generally associated with various degrees of underlying insulin resistance, excess adiposity, β-cell dysfunction and sarcopenia. The management of T2DM in older adults is complicated by the frequent occurrence of multimorbidity, necessitating highly individualized approaches. The presence of frailty, cognitive decline and functional impairments in older adults with T2DM highlights the importance of liaison with carers and social support. Targets for glycaemic control in older adults with T2DM are often less stringent than in younger adults to avoid hypoglycaemia and minimize unbeneficial interventions.