Case Study: Glycemic Control in the Elderly: Risks and Benefits

R.B. is a 67-year-old woman with obesity, hypertension, and coronary artery disease (CAD). Eighteen months ago, she suffered an inferior wall myocardial infarction (MI). Cardiac catheterization revealed an occluded right coronary artery and a 40% stenosis in the proximal left anterior descending artery.The patient was placed on β-blocker and aspirin therapy and was provided education regarding lifestyle modification. A lipid panel revealed mild hypertriglyceridemia and a slightly depressed HDL cholesterol level. Blood glucose was not measured. The patient initially did well, denying chest pain, shortness of breath, or any symptoms related to her cardiac condition.Over the past month, R.B. complained of increasing fatigue and episodes of polyuria and polydipsia. A fasting blood glucose level was 168 mg/dl. Physical examination revealed a mildly obese woman with blood pressure of 142/86 mmHg and a pulse of 78. A dilated eye exam revealed mild nonproliferative diabetic retinopathy. Only trace pedal edema bilaterally was found. Additional laboratory examination revealed a hemoglobin A1c (A1C) concentration of 9.4%, blood urea nitrogen 11 mg/dl, creatinine 0.9 mg/dl, and urine microalbumin 1,993 μg/dl on a spot urine sample.1. What is the relationship between diabetes and complications in the elderly?2. What are the risks of intensive therapy for elderly patients?3. What approach might be used for glycemic management?Diabetes affects nearly 20% of those over 65 years of age in the United States. The Diabetes Control and Complications Trial (DCCT) demonstrated that tight glucose control in patients 13–39 years of age with type 1 diabetes was associated with a marked decrease in microvascular complications. The United Kingdom Prospective Diabetes Study (UKPDS) confirmed the relationship between glycemic control and complications in type 2 diabetes. It is now generally agreed that all patients with diabetes should have as …