De-intensification in older people with type 2 diabetes: why, when and for whom?

As a result of the dwindling physiological reserves in ageing, medication pharmacokinetics, pharmacodynamics, efficacy, and side-effects differ substantially among people in older age groups compared with those in younger age groups. This decline in physiological capacity worsens gradually until the end of life. Most guidelines on type 2 diabetes treatment are based on clinical trials done in carefully selected younger patients, and therefore implementation of practices based on these findings in older populations might not yield the desired effectiveness. Therefore, in choosing therapeutic options in older patients, it is paramount that clear goals of the treatment interventions are agreed upon from the outset by both doctor and patient, and actual benefits and risks of medications are discussed. Within the older age group, younger and fitter patients are usually more ambulant and functionally independent, with a reasonably longer life expectancy. Therefore, the goal of medication use in these patients is to delay death and functional deterioration and prevent or treat complications. By contrast, frail older people often have reduced life expectancy, are often less mobile, are more functionally dependent, and might have a poorer quality of life. The goal of medication use in these patients is therefore symptom control and maintaining a reasonable quality of life for as long as they live.