Clinical heterogeneity in elderly patients with diabetes mellitus

There is considerable heterogeneity in elderly patients with diabetes mellitus. It is of clinical importance to assess such heterogeneous features in each elderly patient, because this would lead to a better setting of target glucose level in the management of diabetes. In the present study, diabetic subjects were clinically investigated from three different aspects; past, current and future. First, the "past" aspect represents how long and how high the hyperglycemia the patient has had. Our cross-sectional investigation showed a broad range of duration of diabetes as well as of degree of hyperglycemia, and as a consequence, diabetic complications were diverse. Second, the "current" aspect implies the degree of insulin deficiency and its resistance. According to our observation, elderly patients had diverse degrees of impaired insulin secretion, together with age-related resistance to insulin. Third, "future" aspect refers to the expected length of life, which largely depends on the current age. The complication status (not limited to diabetic complications), however, also affects clinical course and death rates, indicating diversity of life expectancies due to complications besides current age. Thus, the present analysis showed that elderly individuals with diabetes mellitus exhibit a remarkable heterogeneity. The present study also indicated the clinical merit of assessment with the three aspects; past, current and future, in assessing clinical diversity of elder patients with diabetes.     

Insulin use in elderly diabetic patients

The prevalence of type 2 diabetes is increasing among older adults as is their diabetes-related mortality rate. Studies suggest that tighter glucose control reduces complications in elderly patients. However, too low a glycosylated hemoglobin (HbA_1c) value is associated with increased hypoglycemia. Moreover, the appropriateness of most clinical trial data and standards of care related to diabetes management in elderly patients is questionable given their heterogeneity. Having guidelines to safely achieve glycemic control in elderly patients is crucial. One of the biggest challenges in achieving tighter control is predicting when peak insulin action will occur. The clinician’s options have increased with new insulin analogs that physiologically match the insulin peaks of the normal glycemic state, enabling patients to achieve the tighter diabetes control in a potentially safer way. We discuss the function of insulin in managing diabetes and how the new insulin analogs modify that state. We offer some practical considerations for individualizing treatment for elderly patients with diabetes, including how to incorporate these agents into current regimens using several methods to help match carbohydrate intake with insulin requirements. Summarizing guidelines that focus on elderly patients hopefully will help reduce crises and complications in this growing segment of the population.     

Challenging aspects of treatment strategies in heart failure with preserved ejection fraction: “Why did recent clinical trials fail?”

Heart failure (HF) is the leading cause of hospitalization among older adults and the prevalence is growing with the aging populations in the Western countries. Epidemiologic reports suggest that approximately 50% of patients who have signs or symptoms of HF have preserved left ventricular ejection fraction. This HF type predominantly affects women and the elderly with other co-morbidities, such as diabetes, hypertension, and overt volume status. Most of the current treatment strategies are based on morbidity benefits such as quality of life and reduction of clinical HF symptoms. Treatment of patients with HF with preserved ejection fraction displayed disappointing results from several large randomized controlled trials. The heterogeneity of HF with preserved ejection fraction, understood as complex syndrome, seems to be one of the primary reasons. Here, we present an overview of the current management strategies with available evidence and new therapeutic approach from drugs currently in clinical trials, which target diastolic dysfunction, chronotropic incompetence, and risk factor management. We provide an outline and interpretation of recent clinical trials that failed to improve outcome and survival in patients with HF with preserved ejection fraction.     

Diversity in diabetes: the role of insulin aspart

Diabetes management is changing not only with novel treatments but also in patient demography. This presents clinical challenges and influences our view of diabetes therapies. Insulin analogues have been developed to overcome some of the limitations of traditional human insulins, with the aim of providing a more physiological pharmacokinetic/pharmacodynamic profile. The rapid-acting insulin analogue insulin aspart has been investigated in many clinical trials over the past 10 years and the aim of this review is to present the insulin aspart clinical trial data from across the spectrum of patients with diabetes. Five studies have looked at insulin aspart use (including continuous subcutaneous insulin infusion) in children and adolescents, where the analogue was as effective and well tolerated as soluble human insulin. One large-scale, randomized, controlled trial in pregnant women with type 1 diabetes observed trends towards a reduction in major hypoglycaemia, fewer preterm deliveries and lower birthweight with insulin aspart compared with soluble human insulin. Two 6-month, randomized, controlled, multicentre, multinational, parallel-group, open-label trials reported significant reductions in haemoglobin A(1c) and major nocturnal hypoglycaemia with insulin aspart compared with soluble human insulins in patients with type 1 diabetes. There are fewer data involving insulin analogue use in hospitals and in elderly patients with diabetes, but some recent studies have investigated insulin aspart in the emergency department, intensive/non-intensive care setting and in a pharmacokinetic/pharmacodynamic study in patients aged ≥ 65 years. In summary, the evidence would suggest that insulin aspart is suitable for use in a variety of patients with diabetes.     

A review on the actual trends of insulin treatment in elderly with diabetes

The diabetes of the elderly subjects has two forms: diabetes of long duration, manifesting itself in younger or medium ages, and senile diabetes, appearing above the age of 65 years. The diabetes of the elderly has usually only modest symptoms: it is not ketosic, but in spite of this, in order to avoid the chronic-degenerative complications, it is important to maintain a good, even if not an optimal compensation. The therapeutic intervention cannot neglect a correct alimentary regime and a programmed physical activity in correlation with the clinical conditions of the patient. If the compensation is not achieved only with these tools, one can add oral antidiabetic treatments. In the elderly patients we usually observe primary or secondary failure of the oral antidiabetic treatments, and in such context we have to apply insulin treatment, even in cases of moderate glycometabolic decompensations. While we are waiting for the gene-therapy or the inhalatory insulin preparations, actually there are at disposal only the insulin analogs in rapid, slow and mixed forms. We propose two treatment schemes: (i) The first one consists of three administrations of rapid insulin with the meals, and on dose of slow insulin 2h after the last meal in the evening. (ii) The second scheme consists of one administration of rapid insulin at lunch, one administration of mixed insulin at dinner, with the addition of oral antidiabetics of peripheric action, in the morning and the evening. A better compliance can be obtained, being a fundamental aspect in the elderly diabetics, and a reduction of the number and severity of the hypoglycemia, which are the most important aspects in the elderly diabetes.     

Clinical heterogeneity of type 1 diabetes (T1D) found in Asia

Diabetes mellitus among young patients in Asia is caused by a complex set of factors. Although type 1 diabetes (T1D) remains the most common form of diabetes in children, the recent unabated increase in obesity has resulted in the emergence of type 2 diabetes (T2D) as a new type of diabetes among adolescents and young adults. In addition to the typical autoimmune type 1 diabetes (T1aD) and T2D patients, there is a variable incidence of cases of non‐autoimmune types of T1D associated with insulin deficiency (T1bD). Additional forms have been described, including fulminant T1D (FT1D). Although most diagnoses of T1D are classified as T1aD, fulminant T1D exists as a hyper‐acute subtype of T1D that affects older children, without associated autoimmunity. Patient with this rare aetiology of diabetes showed a complete loss of β‐cell secretory capacity without evidence of recovery, necessitating long‐term treatment with insulin. In addition, latent autoimmune diabetes in adults is a form of autoimmune‐mediated diabetes, usually diagnosed during the insulin‐dependent stage that follows a non‐insulin requiring phase, which can be diagnosed earlier based on anti‐islet autoantibody positivity. Some reports discuss T1bD. Others are elaborating on the presence of “atypical T1b diabetes,” such as Flatbush diabetes. The prevalence of diabetes mellitus in young adults continues to rise in Asian populations as T2D increases. With improved characterization of patients with diabetes, the range of diabetic subgroups will become even more diverse in the future. Distinguishing T1D, T2D, and other forms of diabetes in young patients is challenging in Asian populations, as the correct diagnosis is clinically important and has implications for prognosis and management. Despite aetiological heterogeneity in the usual clinical setting, early diagnosis and classification of patients with diabetes relying on clinical grounds as well as measuring islet autoantibodies and fasting plasma C‐peptide could provide a possible viable method to minimize complications.     

Should There be Concern About Autoimmune Diabetes in Adults? Current Evidence and Controversies

Autoimmune diabetes has a heterogeneous phenotype. Although often considered a condition starting in childhood, a substantial proportion of type 1 diabetes presents in adult life. This holds important implications for our understanding of the factors that modify the rate of progression through the disease prodrome to clinical diabetes and for our management of the disease. When autoimmune diabetes develops in adulthood, insulin treatment is often not required at the time of diagnosis, and this autoimmune non-insulin requiring diabetes is generally termed latent autoimmune diabetes in adults (LADA). Patients with LADA are generally leaner, younger at diabetes onset; have a greater reduction in C-peptide; and have a greater likelihood of insulin treatment as compared with patients with type 2 diabetes. The LADA subset of patients with adult-onset autoimmune diabetes has highlighted many shortcomings in the classification of diabetes and invokes the case for more personalized data analysis in line with the move towards precision medicine. Perhaps most importantly, the issues highlight our persistent failure to engage with the heterogeneity within the most common form of autoimmune diabetes, that is adult-onset type 1 diabetes, both insulin-dependent and initially non-insulin requiring (LADA). This review discusses characteristics of autoimmune diabetes and specifically aims to illustrate the heterogeneity of the disease.     

Deconvolution analysis of rapid insulin pulses before and after six weeks of continuous subcutaneous administration of glucagon-like peptide-1 in elderly patients with type 2 diabetes

CONTEXT: Insulin is secreted in a pulsatile fashion with measurable orderliness (low entropy). Normal aging and diabetes in middle-aged patients is characterized by alterations in pulsatile insulin release. OBJECTIVES: We undertook the current studies to determine whether disruptions in pulsatile insulin release also accompany diabetes in the elderly. DESIGN: Two studies were performed. In the first study, insulin values were sampled every minute for 1 h under fasting conditions. In the second study, subjects underwent a 2-h hyperglycemic glucose clamp (glucose 5.4 mm above basal). From 60-120 min, insulin was sampled every 1 min. Secretory pulse analysis was conducted using a multiparameter deconvolution technique. SETTING: The study was conducted in a general clinical research center and during outpatient visits. PATIENTS: Volunteers were healthy young [n = 10; body mass index (BMI), 23 +/- 1 kg/m2; age, 23 +/- 1 yr] and elderly (n = 10; BMI, 24 +/- 1 kg/m2; age, 78 +/- 2 yr) volunteers and elderly patients with diabetes (n = 8; BMI, 28 +/- 1 kg/m2; age, 73 +/- 2 yr). Intervention: Five of the older patients with type 2 diabetes (BMI, 29 +/- 1 kg/m2; age, 72 +/- 2 yr) were treated with continuous sc glucagon-like peptide-1 (GLP-1) (7-36) amide infusion for 6 wk, and a second 2-h hyperglycemic clamp was performed. MAIN OUTCOME MEASURES: Insulin burst mass, pulsatile insulin secretion, and entropy were measured. RESULTS: Under fasting conditions, elderly patients with diabetes had a reduction in insulin burst mass (P < 0.05) that was similar to normal elderly. During hyperglycemia, elderly patients with diabetes had an even greater impairment in insulin burst mass (P < 0.05) and basal (P < 0.05) and pulsatile insulin secretion (P < 0.05) than normal elderly. Approximate entropy, a measure of irregularity of insulin release, was increased to a greater extent in older diabetes patients than normal elderly, signifying loss of orderliness of insulin secretion (P < 0.05). In response to treatment with GLP-1, insulin burst mass (P < 0.05) and pulsatile insulin secretion (P < 0.05) improved significantly in elderly patients with diabetes. CONCLUSIONS: We conclude that alterations in pulsatile insulin release can be improved in elderly patients with diabetes by the administration of sc GLP-1.     

Diabetes in Africa. Pathogenesis of type 1 and type 2 diabetes mellitus in sub-Saharan Africa: implications for transitional populations

The increasing prevalence and incidence of diabetes and its long-term complications in sub-Saharan Africa (SSA) could have devastating human and economic toll if the trends remain unabated in the future. Approximately 90% or majority of patients with diabetes belongs to the adult onset, type 2 diabetes category while 10% have type 1 diabetes in SSA. However, because of the paucity of metabolic and clinical data, a clear understanding of the natural history of both diseases and the classification of diabetes subtypes has been hampered. Nevertheless, we have attempted to provide a concise review of the pathophysiology of both type 1 and type 2 diabetes as well as phenotypic and clinical variations in patients residing in SSA. The limited metabolic data, (albeit increasing), from high-risk and diabetic individuals in the SSA, have contributed significantly to the understanding of the pathogenetic mechanisms of diabetes and the variations in the presentation of the disease. Sub-Saharan African patients with type 1 diabetes have essentially absolute insulin deficiency. In addition, patients with type 2 diabetes in SSA region also manifest severe insulin deficiency with varying degrees of insulin resistance. Although the exact genetic markers of both diseases are unknown, we believe studies in patients of SSA origin who reside in diverse geographic environments (African diaspora) could potentially contribute to our understanding of the genetic and environmental mediators of both diseases. However, many intrinsic, individual and societal obstacles such as poor education and illiteracy, low socio-economic status and lack of access to health care make uncertain the translation of diabetes research in SSA. In this regard, effective management and/or prevention of diabetes in SSA individuals should adopt multidisciplinary approaches. Finally, innovative health care delivery and educational models will be needed to manage diabetes and its long-term complications in SSA.     

老年原发性高血压与胰岛素抵抗关系的临床研究

目的　探讨老年高血压病与胰岛素抵抗之间的关系。　 方法 　对无糖尿病老年高血压病患者 6 0例、正常血压者 (对照组 ) 6 0例的空腹血糖 (FBG)、胰岛素 (FINS)和胰岛素敏感性指数 (ISI)进行对比。　 结果 　高血压组和对照组的FBG、FINS、ISI均无明显差异 (均P >0 0 5 ) ,按是否肥胖进一步分组分析 ,肥胖者中高血压组ISI明显低于对照组 (P <0 0 5 )。　 结论　无糖尿病的老年人高血压病患者总体上不存在高胰岛素血症和胰岛素抵抗 ,但在高血压病患者中的肥胖者则显示胰岛素敏感性降低的倾向。     

A comparison on insulin regimen treatment of elderly (>70 years) and younger (<70 years) type 2 diabetic patients in actual clinical practice

The incidence of type 2 diabetes mellitus increases with age. However, there are few data about the most adequate type of insulin, or the most adequate insulin regimen, for elderly patients with diabetes. The present study compared insulin regimens in patients aged more than 70 years (100 subjects) with those aged less than 70 years (73 subjects) who attended a diabetes outpatient clinic. The weight, body mass index, diabetes-associated chronic complications, other cardiovascular risk factors, type of insulin, insulin regimen, total daily dose of insulin, weight-adjusted total daily dose of insulin, concomitant treatment with oral hypoglycaemic agents (OHA) and glycosylated haemoglobin (HbA1c) were compared between the two groups. Although both groups had the same level of metabolic control (HbA1c: 7.66 ± 0.91 in the elderly group vs. 7.62 ± 0.96 in the younger group), we have found that elderly subjects were more likely to be treated with a simple regimen, as shown by a higher use of basal insulin (15% in young patients and 41% in the elderly group; P < 0.001), lower use of fast-acting insulin (32.8% vs. 15%; P = 0.005), and fewer daily injections (45% vs. 22% received at least three injections each day; P = 0.001). There were no differences in the use of OHA; however, the majority of young patients were treated with metformin, whereas repaglinide was most commonly used in the elderly group. In conclusion, in everyday clinical practice, elderly subjects were treated with the simplest regimen and achieved the same level of metabolic control as young diabetic patients.     

Cost-effectiveness of intensive insulin therapy for type 2 diabetes: a 10-year follow-up of the Kumamoto study

To evaluate the cost and effectiveness of intensive insulin therapy for type 2 diabetes on the prevention of diabetes complications in Japan, we performed economic evaluation based on a randomized controlled trial. A total of 110 patients with type 2 diabetes were randomly assigned into two groups, a multiple insulin injection therapy (MIT) group or a conventional insulin injection therapy (CIT) group, and were followed-up for 10 years. Economic evaluation (cost-consequences analysis) was applied to evaluate both health and economic outcomes. As outcome measures for effectiveness of intensive insulin therapy, the frequency of complications, such as retinopathy, nephropathy, neuropathy, macrovascular event, and diabetes-related death, was used. For estimating costs, a viewpoint of the payer (the National Health Insurance) was adopted. Direct medical costs associated with diabetes care during 10 years were calculated and evaluated. In a base case analysis, all costs were discounted to the present value at an annual rate of 3%. Sensitivity analyses were carried out to assess the robustness of the results to changes in the values of important variables. MIT reduced the relative risk in the progression of retinopathy by 67%, photocoagulation by 77%, progression of nephropathy by 66%, albuminuria by 100% and clinical neuropathy by 64%, relative to CIT. Moreover, MIT prolonged the period in which patients were free of complications, including 2.0 years for progression of retinopathy (P<0.0001), 0.3 years for photocoagulation (P<0.05), 1.5 years for progression of nephropathy (P<0.01) and 2.2 years for clinical neuropathy (P<0.0001). The total cost (discounted at 3%) per patient during the 10-year period for each group was $30310 and 31525, respectively. The reduction of total costs in MIT over CIT was mainly due to reduced costs for management of diabetic complications. Our results show that MIT is more beneficial than CIT in both cost and effectiveness. Therefore, MIT is recommended for the treatment of type 2 diabetic patients who require insulin therapy as early as possible from the perspective of both patients and health policy.     

Actual usage and clinical effectiveness of insulin preparations in patients with Type 1 diabetes mellitus in Japan: CoDiC-based analysis of clinical data obtained at multiple institutions (JDDM 3)

To clarify the actual usage of insulin preparations and their effectiveness on glycaemic control in patients with Type 1 diabetes mellitus in Japan, we analyzed clinical data collected via CoDiC, an electronic system for diabetes data collection and management, at 28 institutes. Of 18,470 diabetic patients registered with CoDiC in June, 2003, 12,279 patients were being treated with insulin preparations and/or oral hypoglycemic agents, with 861 of these patients having Type 1 diabetes mellitus and 11,418 patients having Type 2 diabetes. Three analytical surveys were carried out with the Type 1 diabetes patients. Study I: Cross-sectional survey on the treatment in 2002. Six hundred and thirteen patients received intensive conventional insulin treatment (ICT). The number of patients receiving rapid-acting insulin analogue (RA) was greater than that of patients receiving regular insulin (R). Serum CPR was lower in the patients with ICT than in the patients with conventional insulin treatment (CT). Study II: Survey on the changes in the actual usage and clinical effectiveness of insulin preparations, based on the data input in 2001 and 2002. The number of patients with ICT using RA insulin markedly increased. Study III: Analysis of the participants' clinical course over the 18-month period of the study from the time of first consultation. The dose of insulin increased during the term. The average HbA1c level fell drastically and reached to 7.5% over the first 9 months of the study and then remained between a range of 7.5% and 8% for the rest of the study period. In conclusion, ICT is actively performed and the RA insulin analogues are widely used in Type 1 diabetic patients in Japan. Basal-bolus therapy should be used to treat Type 1 diabetic patients with postprandial serum CPR of less than 0.5 ng/ml. It is difficult to obtain the ideal glycaemic control in Type 1 diabetic patients with the currently available insulin preparations.     

Diabetes in the elderly

One third of the population above 70 has a diabetic-like metabolic status. Diabetes-induced diseases as well as acute blood sugar imbalances have great impact on quality of life. Transferring the known disease management regimes from adults to the elderly is only possible to a limited extent. For patients needing short-term or long-term care, the clinical practical guidelines should, therefore, be adapted to the medical care situation. The favored live-style modification with change of nutrition or increased activity is limited by multimorbidity in the elderly. Medical therapy should be adjusted to 6.6-10.0 (11.1)?mmol/l glucose. Hypoglycemia must be avoided, whereas elderly patients with HbA(1c) values above 8% also requires insulin treatment. Simple treatment and the involvement of family members or informal caregivers are the basis of good diabetes treatment in old patients.     

Prevalence and determinants of impaired glucose metabolism in frail elderly patients: the Belgian Elderly Diabetes Survey (BEDS)

BACKGROUND: Although diabetes in elderly persons is generally type 2, the metabolic abnormalities associated with aging suggest that elderly persons may differ from younger persons with type 2 diabetes. In addition, nonobese elderly persons with type 2 diabetes show a marked impairment in insulin release accompanied by mild insulin resistance, whereas obese elderly persons have marked insulin resistance in the presence of "adequate" levels of insulin. Other factors that could adversely affect glucose tolerance in aging include drug use, associated disease, and other stressful conditions commonly encountered in geriatric inpatients units. The authors' objectives in this study were 1) to prospectively assess the prevalence of glucose homeostasis abnormalities among elderly hospitalized patients and the degree to which it reflects abnormalities in insulin secretion or insulin sensitivity using homeostasis model assessment of fasting glucose, insulin, and C-peptide; and 2) to define the social, functional, pathologic, and nutritional characteristics of persons with impaired glucose tolerance or diabetes. METHODS: Ninety-eight patients underwent a comprehensive geriatric assessment. Determinants of glucose homeostasis were assessed using the homeostasis model assessment, which provides estimates of beta-cell function (%B) and insulin sensitivity (%S). RESULTS: Twelve patients (12%) had fasting glucose concentrations greater than 110 mg/dl. Four patients had impaired fasting glucose levels greater than 110 mg/dl but less than 126 mg/dl (IFG group), and 8 patients had levels greater than 126 mg/dl (type 2 diabetes group). Except for a higher proportion of women in the IFG-diabetes group, the latter did not exhibit significant differences in functional, morbidity, or nutritional characteristics compared with the normal glucose tolerance group. The entire cohort (n=98) presented with a mean (+/-SD) %B of 71%+/-47% and a mean %S of 208%+/-198%. Compared with the normal glucose tolerance group, the IFG-diabetes group had a fasting glycemia level of 142+/-24 mg/dl (vs 92+/-9 mg/dl), a %B of 43%+/-21% (vs 74%+/-45%), and a mean %S of 126%+/-113% (vs 219%+/-205%). CONCLUSIONS: These data confirm the high prevalence of impaired glucose metabolism among elderly people, although the usual risk factors were not significantly increased. Marked beta secretory defects seem to be the rule, whereas a significant degree of insulin resistance is unusual.     

Quality of life and the treatment of hypertension in the elderly

A recent dramatic increase in the number of elderly patients with hypertension has made the proper management of the disease in this population more important. Since quality of life (QOL) is greatly affected in elderly patients with hypertension, as a life-style disease, we reviewed QOL and related issues in the treatment of hypertension in the elderly. Assessment of QOL requires multi-dimensional evaluation from many aspects. Elderly individuals, especially those with hypertension, generally have impaired QOL. It has been shown that treatment of hypertension could affect QOL, and care in treatment is required because of possible effects on QOL. Given the major role of stroke in the deterioration of QOL among elderly people, treatment of hypertension may well be targeted at prevention of stroke. A recent meta-regression analysis demonstrated that calcium channel blockers are effective in reducing risk of stroke, as their effects are not limited to blood pressure reduction. Since overall benefit of hypertension treatment is determined by multiple factors, including safety, efficacy, compliance, as well as risk reduction, it is of particular importance to pay attention to QOL in the treatment of hypertension. Further clinical evidence is needed for the establishment of proper management of hypertension in the elderly, especially from the QOL point of view.     

分析老年糖尿病患者应用甘精胰岛素联合阿卡波糖治疗的效果

目的探讨甘精胰岛素联合阿卡波糖在老年糖尿病患者中的临床疗效。方法选取该院2018年7月—2019年7月收治的113例老年糖尿病患者作为研究对象,经随机数字表法,划分A组(n=56,阿卡波糖)和B组(n=57,甘精胰岛素+阿卡波糖),比较两组临床疗效、血糖指标。结果B组患者临床治疗总有效率显著高于A组;经治疗,B组患者空腹血糖(FBG)、餐后2 h血糖(2 hPG)、糖化血红蛋白(HbAlc)水平明显低于A组。两组之间比较差异有统计学意义(P<0.05)。结论在老年糖尿病患者中应用甘精胰岛素+阿卡波糖,临床疗效显著,使患者的空腹血糖、餐后2 h血糖、糖化血红蛋白等指标得到了明显改善,安全性强。     

Effect of diabetes mellitus and insulin use on survival after acute myocardial infarction in the elderly (the Cooperative Cardiovascular Project)

Using data from a retrospective cohort study of Medicare beneficiaries hospitalized with an acute myocardial infarction (AMI), we evaluated the role of diabetes mellitus on 30-day and 1-year mortality. We classified subjects as nondiabetics, diabetics controlled with diet alone, diabetics receiving an oral hypoglycemic agent, and diabetics on insulin at time of admission. We compared baseline admission characteristics of subgroups using chi-square and Wilcoxon rank-sum tests and evaluated the effect of each diabetic state using sequential logistic models. We identified 80,832 nondiabetic patients, 9,862 diet-controlled diabetic patients, 14,664 diabetics receiving an oral hypoglycemic agent, and 12,241 diabetic patients on insulin therapy. Although mean age was similar among the groups, prevalence of hypertension, prior AMI, prior congestive heart failure, and prior revascularization were higher among diabetic patients, particularly those taking insulin. Diabetic patients, particularly those taking insulin, were less likely to receive aspirin and beta blockers and to undergo coronary revascularization. Diabetic patients had higher 30-day and 1-year mortality than nondiabetic patients. After adjustment for demographics, clinical and hospital characteristics, and treatment strategies, insulin-treated diabetics had the highest risk of mortality, followed by diabetics receiving oral hypoglycemic agents, followed by diet-controlled diabetics. Thus, diabetes is highly prevalent among elderly patients with an AMI. Mortality rates for these patients, particularly insulin-using diabetics, are higher than among their nondiabetic counterparts. Preventive and therapeutic strategies must be developed to ensure improved short- and long-term outcomes for elderly patients with diabetes and AMI.     

Diabetes im Alter

One third of the population above 70 has a diabetic-like metabolic status. Diabetes-induced diseases as well as acute blood sugar imbalances have great impact on quality of life. Transferring the known disease management regimes from adults to the elderly is only possible to a limited extent. For patients needing short-term or long-term care, the clinical practical guidelines should, therefore, be adapted to the medical care situation. The favored live-style modification with change of nutrition or increased activity is limited by multimorbidity in the elderly. Medical therapy should be adjusted to 6.6?C10.0 (11.1)?mmol/l glucose. Hypoglycemia must be avoided, whereas elderly patients with HbA_1c values above 8% also requires insulin treatment. Simple treatment and the involvement of family members or informal caregivers are the basis of good diabetes treatment in old patients.     

The genetics of the glucose intolerance disorders

Genetic heterogeneity, the concept that diabetes can have many different causes, was first suggested by the existence of rare genetic syndromes with diabetes, ethnic differences in clinical features and genetic heterogeneity of animal models. Genetic heterogeneity is now considered to be firmly established by family, twin, metabolic, immunologic and HLA disease association studies that separate idiopathic diabetes into insulin-dependent types (juvenile-onset type) and noninsulin-dependent types (maturity-onset type). Further heterogeneity is being demonstrated within each of these broad groups of disorders—within insulin-dependent diabetes using the HLA antigens and immunologic studies, and within noninsulindependent diabetes using such criteria as obesity, insulin response, age of onset and chlorpropamide-primed alcohol-induced flushing. This heterogeneity has major implications for the research and care of our diabetic patients since the precise etiology, risk of complications and genetic counseling are likely to vary among these different disorders that result in diabetes.