To the Editor: In his Grand Rounds, Dr Durso1 discussed clinical guidelines for care of older persons with diabetes mellitus. His argument is compelling: frail older individuals with a shorter life expectancy may have different therapeutic benefits compared with younger, healthier populations. This is likely to be relevant to a substantial proportion of individuals with diabetes. In the United Kingdom, half of the individuals with diabetes are older than 65 years and a quarter are aged 75 years or older.2 However, most clinical evidence is from studies of middle-aged persons. Frail older persons are generally excluded from published clinical trials, reflecting both publication bias and the unjustified exclusion of older adults from study protocols.3 Thus, we do not know how much older patients with diabetes might (or might not) benefit from treatment. When seeking patients' opinions, we are further challenged by caring for persons who may not be competent to decide due to cognitive impairment or dementia.
Much basic evidence on diagnosis and prognosis is lacking for older patients. For example, studies used to define diagnostic cut points for diabetes contain small numbers of elderly individuals.4 Moreover, with the introduction of lower diagnostic cut points for fasting glucose, a third of older participants with diabetes were undiagnosed on fasting measurement alone.5 In support of Durso's argument of heterogeneity in older age, a recent study of diabetes prevalence identified differences in performance of fasting and postprandial glucose measurements between fatter and thinner frail elderly persons living in care homes.6 However, diagnostic thresholds themselves relate to risk of microvascular disease, whereas limiting morbidity from coronary heart disease and cerebrovascular disease may be of much greater relevance to the older old.
Beyond screening, we have little evidence of the merits of treatment and educational interventions specific to older people. Currently, we may make do with extrapolation, using evidence from middle-aged patients. However, older people have the highest rates of diabetes mellitus, with high rates of cardiovascular comorbidity; this argues strongly for potential benefits of intervention until we have evidence to the contrary. Dedicated clinical trials, probably involving complex interventions, are required for this group of patients to settle the question of appropriate care.
Financial Disclosures: None reported.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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