Evidence-Based Management of Diabetes in Older Adults

Sex-specific associations between total and regional Fat-to-muscle Mass ratio and cardiometabolic risk: findings from the China National Health Survey

BACKGROUND

The fat-to-muscle mass ratio (FMR), integrating the antagonistic effects of fat and muscle mass, has been suggested as a valuable indicator to assess cardiometabolic health independent of overall adiposity. However, the specific associations of total and regional FMR with cardiometabolic risk are poorly understood. We aimed to examine sex-specific associations of total and regional FMR with single and clustered cardiometabolic risk factors (CRFs).

METHODS

13,505 participants aged 20 years and above were included in the cross-sectional study. Fat mass and muscle mass were assessed using a bioelectrical impedance analysis device. FMR was estimated as fat mass divided by muscle mass in corresponding body parts (whole body, arm, leg, and trunk). Clustered CRFs was defined as the presence of two or more risk factors, including hypertension, elevated blood glucose, dyslipidemia, insulin resistance (IR), and hyperuricemia. IR was assessed by the triglyceride glucose (TyG) index. Multivariable logistic regression models were applied to explore the associations of FMR in the whole body and body parts with single and clustered CRFs.

RESULTS

The odds ratios (ORs) increased significantly for all single and clustered CRFs with the per quartile increase of total and regional FMR in both sexes (P for trend < 0.001), following adjustment for confounders. Among the regional parts, FMRs of the legs presented the strongest associations for clustered CRFs in both men and women, with adjusted OR of 8.54 (95% confidence interval (CI): 7.12-10.24) and 4.92 (95% CI: 4.24-5.71), respectively. Significant interactions (P for interaction < 0.05) were identified between age and FMRs across different body parts, as well as between BMI status and FMRs in different regions for clustered CRFs. Restricted cubic splines revealed significant non-linear relationships between FMRs of different body parts and clustered CRFs in both sexes (P for nonlinear < 0.05).

CONCLUSIONS

FMRs in the whole body and different regions were significantly associated with single and clustered CRFs in the general Chinese population. The association between FMR and clustered CRFs was more pronounced in youngers than in the elderly.

Safety and effectiveness of SGLT2 inhibitors in a UK population with type 2 diabetes and aged over 70 years: an instrumental variable approach

AIMS/HYPOTHESIS

Older adults are under-represented in trials, meaning the benefits and risks of glucose-lowering agents in this age group are unclear. The aim of this study was to assess the safety and effectiveness of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in people with type 2 diabetes aged over 70 years using causal analysis.

METHODS

Hospital-linked UK primary care data (Clinical Practice Research Datalink, 2013-2020) were used to compare adverse events and effectiveness in individuals initiating SGLT2i compared with dipeptidyl peptidase-4 inhibitors (DPP4i). Analysis was age-stratified: <70 years (SGLT2i n=66,810, DPP4i n=76,172), ≥70 years (SGLT2i n=10,419, DPP4i n=33,434). Outcomes were assessed using the instrumental variable causal inference method and prescriber preference as the instrument.

RESULTS

Risk of diabetic ketoacidosis was increased with SGLT2i in those aged ≥70 (incidence rate ratio compared with DPP4i: 3.82 [95% CI 1.12, 13.03]), but not in those aged <70 (1.12 [0.41, 3.04]). However, incidence rates with SGLT2i in those ≥70 was low (29.6 [29.5, 29.7]) per 10,000 person-years. SGLT2i were associated with similarly increased risk of genital infection in both age groups (incidence rate ratio in those <70: 2.27 [2.03, 2.53]; ≥70: 2.16 [1.77, 2.63]). There was no evidence of an increased risk of volume depletion, poor micturition control, urinary frequency, falls or amputation with SGLT2i in either age group. In those ≥70, HbA1c reduction was similar between SGLT2i and DPP4i (-0.3 mmol/mol [-1.6, 1.1], -0.02% [0.1, 0.1]), but in those <70, SGLT2i were more effective (-4 mmol/mol [4.8, -3.1], -0.4% [-0.4, -0.3]).

CONCLUSIONS/INTERPRETATION

Causal analysis suggests SGLT2i are effective in adults aged ≥70 years, but increase risk for genital infections and diabetic ketoacidosis. Our study extends RCT evidence to older adults with type 2 diabetes.

Physical performance strongly predicts all-cause mortality risk in a real-world population of older diabetic patients: machine learning approach for mortality risk stratification

Background

Prognostic risk stratification in older adults with type 2 diabetes (T2D) is important for guiding decisions concerning advance care planning.

Materials and methods

A retrospective longitudinal study was conducted in a real-world sample of older diabetic patients afferent to the outpatient facilities of the Diabetology Unit of the IRCCS INRCA Hospital of Ancona (Italy). A total of 1,001 T2D patients aged more than 70 years were consecutively evaluated by a multidimensional geriatric assessment, including physical performance evaluated using the Short Physical Performance Battery (SPPB). The mortality was assessed during a 5-year follow-up. We used the automatic machine-learning (AutoML) JADBio platform to identify parsimonious mathematical models for risk stratification.

Results

Of 977 subjects included in the T2D cohort, the mean age was 76.5 (SD: 4.5) years and 454 (46.5%) were men. The mean follow-up time was 53.3 (SD:15.8) months, and 209 (21.4%) patients died by the end of the follow-up. The JADBio AutoML final model included age, sex, SPPB, chronic kidney disease, myocardial ischemia, peripheral artery disease, neuropathy, and myocardial infarction. The bootstrap-corrected concordance index (c-index) for the final model was 0.726 (95% CI: 0.687-0.763) with SPPB ranked as the most important predictor. Based on the penalized Cox regression model, the risk of death per unit of time for a subject with an SPPB score lower than five points was 3.35 times that for a subject with a score higher than eight points (P-value <0.001).

Conclusion

Assessment of physical performance needs to be implemented in clinical practice for risk stratification of T2D older patients.

Life's Essential 8 and Risk of Stroke: A Prospective Community-Based Study

BACKGROUND

Data are lacking regarding cardiovascular health (CVH) with Life's Essential 8 approach and future stroke risk. We sought to elucidate whether the CVH score constructed by the Life's Essential 8 metrics predicted stroke risk in 2 Chinese ongoing cohorts.

METHODS

This included 41 043 participants of the Kailuan I study and 27 842 participants of the Kailuan II study who were free of cardiovascular disease or cancer in 2014. CVH score (ranged from 0 to 100) was assessed using the Life's Essential 8 metrics (body mass index, cigarette smoking, diet quality, physical activity, sleep health, lipid, blood glucose, and blood pressure). A composite of incident stroke events (ischemic stroke and hemorrhagic stroke) was identified via review of medical records. The follow-up period was calculated from the finishing date of the 2014 survey to either the date of stroke occurrence, death, loss to follow-up, or the end of follow-up (December 31, 2020). We also examined the longitudinal association between the CVH score and arterial stiffness status, as assessed by brachial-ankle pulse wave velocity, in 25 922 participants free of cardiovascular disease during the follow-up. We performed a meta-analysis to assess the association between CVH, based on the 2010 American Heart Association recommendation, and stroke integrating the results of current study and previous studies.

RESULTS

During a median follow-up of 5.65 years (interquartile range, 5.20-6.09), a total of 1750 incident stroke events were identified in the pooled Kailuan study. The pooled hazard ratios were 0.33 (95% CI, 0.20-0.54) for ideal versus poor health category of CVH (Ptrend<0.0001). Higher CVH scores were also associated with lower brachial-ankle pulse wave velocity values at baseline and slower increments of brachial-ankle pulse wave velocity during follow-up (Ptrend≤0.001 for both). Arterial stiffness mediated 9.07% (95% CI, 5.83%-15.0%) of the total association between CVH and incident stroke. The pooled hazard ratio comparing 2 extreme CVH categories for stroke was 0.45 (95% CI, 0.35-0.59) when including 10 published studies and the current study.

CONCLUSIONS

The CVH score as assessed by the Life's Essential 8 metrics significantly predicted future stroke risk and arterial stiffness status.

In-hospital risk stratification algorithm of Asian elderly patients

Limited research has been conducted in Asian elderly patients (aged 65 years and above) for in-hospital mortality prediction after an ST-segment elevation myocardial infarction (STEMI) using Deep Learning (DL) and Machine Learning (ML). We used DL and ML to predict in-hospital mortality in Asian elderly STEMI patients and compared it to a conventional risk score for myocardial infraction outcomes. Malaysia's National Cardiovascular Disease Registry comprises an ethnically diverse Asian elderly population (3991 patients). 50 variables helped in establishing the in-hospital death prediction model. The TIMI score was used to predict mortality using DL and feature selection methods from ML algorithms. The main performance metric was the area under the receiver operating characteristic curve (AUC). The DL and ML model constructed using ML feature selection outperforms the conventional risk scoring score, TIMI (AUC 0.75). DL built from ML features (AUC ranging from 0.93 to 0.95) outscored DL built from all features (AUC 0.93). The TIMI score underestimates mortality in the elderly. TIMI predicts 18.4% higher mortality than the DL algorithm (44.7%). All ML feature selection algorithms identify age, fasting blood glucose, heart rate, Killip class, oral hypoglycemic agent, systolic blood pressure, and total cholesterol as common predictors of mortality in the elderly. In a multi-ethnic population, DL outperformed the TIMI risk score in classifying elderly STEMI patients. ML improves death prediction by identifying separate characteristics in older Asian populations. Continuous testing and validation will improve future risk classification, management, and results.

Treatment of diabetic macular edema in real-world clinical practice: The effect of aging

AIMS/INTRODUCTION

In older patients, the management of diabetic macular edema (DME) can be complicated by comorbidities, geriatric syndrome, and socioeconomic status. This study aims to evaluate the effects of aging on the management of DME.

MATERIALS AND METHODS

This is a real-world clinical study including 1,552 patients with treatment-naïve center-involved DME. The patients were categorized into 4 categories by age at baseline (C1, <55; C2, 55-64; C3, 65-74; and C4, ≥75 years). The outcomes were the change in logarithm of the minimum angle of resolution best-corrected visual acuity (logMAR BCVA) and central retinal thickness (CRT), and the number of treatments from baseline to 2 years.

RESULTS

From baseline to 2 years, the mean changes in logMAR BCVA from baseline to 2 years were -0.01 in C1, -0.06 in C2, -0.07 in C3, and 0.01 in C4 (P = 0.016), and the mean changes in CRT were -136.2 μm in C1, -108.8 μm in C2, -100.6 μm in C3, and -89.5 μm in C4 (P = 0.008). Treatments applied in the 2 year period exhibited decreasing trends with increasing age category on the number of intravitreal injections of anti-VEGF agents (P = 0.06), selecting local corticosteroid injection (P = 0.031), vitrectomy (P < 0.001), and laser photocoagulation outside the great vascular arcade (P < 0.001).

CONCLUSIONS

Compared with younger patients with DME, patients with DME aged ≥75 years showed less frequent treatment, a lower BCVA gain, and a smaller CRT decrease. The management and visual outcome in older patients with DME would be unsatisfactory in real-world clinical practice.

Asian Best Practices for Care of Diabetes in Elderly (ABCDE)

The elderly population with diabetes is diverse with the majority experiencing a decline in physical and mental capabilities, impacting the entire diabetes management process. Therefore, a need for geriatric-specific guidelines, especially for the Asian population, was identified and subsequently developed by an expert panel across government and private institutions from several Asian countries. The panel considered clinical evidence (landmark trials, position papers, expert opinions), recommendations from several important societies along with their decades of clinical experience and expertise, while meticulously devising thorough geriatric-specific tailored management strategies. The creation of the ABCDE best practices document underscores and explores the gaps and challenges and determines optimal methods for diabetes management of the elderly population in the Asian region.

Efficacy / safety balance of DPP-4 inhibitors versus SGLT2 inhibitors in elderly patients with type 2 diabetes

Dipeptidyl peptidase-4 inhibitors (DPP-4is) and sodium-glucose cotransporter type 2 inhibitors (SGLT2is) offer new options for the oral management of type 2 diabetes mellitus (T2DM), with the advantage in the elderly population to be devoid of a high risk of hypoglycaemia. SGLT2is have also shown benefits regarding cardiovascular (heart failure) and renal protection, including in patients with T2DM aged ≥ 65 years while DPP-4is have only proved cardiovascular and renal safety without superiority compared with placebo. The glucose-lowering efficacy of the two pharmacological classes is almost similar including in older patients with T2DM. However, the tolerance and safety profile may be highly different and overall more favourable with DPP-4is than with SGLT2is. Some adverse events have been reported with SGLT2is which may be more prevalent or severe in older patients than in younger patients. The present comprehensive review focuses on the benefit/risk balance in the elderly population with T2DM by comparing the profile of DPP-4is and SGLT2is regarding the following potential issues: metabolic disorders (hypoglycaemia and diabetic ketoacidosis); cardiac and vascular issues (atheromatous cardiovascular disease, heart failure, volume reduction hypotension, and lower limb amputations); renal endpoints including acute renal injury; risk of infections; digestive disorders; bone and skin adverse events; and cancer risk. Both DPP-4is and SGLT2is have their own advantages and disadvantages. Personalised treatment is recommended based upon the efficacy/safety profile of each drug class and individual patient characteristics that may be markedly different among the heterogeneous population of older individuals with T2DM.

Careful use to minimize adverse events of oral antidiabetic medications in the elderly

INTRODUCTION

An increasing number of older patients has type 2 diabetes treated with different oral antidiabetic agents whose safety may raise concern considering some particularities of a heterogeneous elderly population.

AREAS COVERED

This article discusses some characteristics of older patients that could increase the risk of adverse events, with a focus on hypoglycemia. It describes the most frequent and/or severe complications reported in the elderly in both randomized controlled trials and observational studies with metformin, sulfonylureas, meglitinides, alpha-glucosidase inhibitors, thiazolidinediones, dipeptidyl peptidase-4 inhibitors (gliptins) and sodium-glucose cotransporter type 2 inhibitors (gliflozins).

EXPERT OPINION

Old patients may present comorbidities (renal impairment, vascular disease, heart failure, risk of dehydration, osteoporosis, cognitive dysfunction) that could increase the risk of severe adverse events. Sulfonylureas (and meglitinides) induce hypoglycemia, which may be associated with falls/fractures and cardiovascular events. Medications lacking hypoglycemia should be preferred. Gliptins appear to have the best tolerance/safety profile whereas gliflozins exert a cardiorenal protection. However, data are lacking in very old or frailty old patients so that caution and appropriate supervision of such patients are required. Taking advantage of a large choice of pharmacotherapies, personalized treatment is recommended based upon both drug safety profiles and old patient individual characteristics.

Dietary Intervention Impacts Immune Cell Functions and Dynamics by Inducing Metabolic Rewiring

Accumulating evidence has shown that nutrient metabolism is closely associated with the differentiation and functions of various immune cells. Cellular metabolism, including aerobic glycolysis, fatty acid oxidation, and oxidative phosphorylation, plays a key role in germinal center (GC) reaction, B-cell trafficking, and T-cell-fate decision. Furthermore, a quiescent metabolic status consolidates T-cell-dependent immunological memory. Therefore, dietary interventions such as calorie restriction, time-restricted feeding, and fasting potentially manipulate immune cell functions. For instance, intermittent fasting prevents the development of experimental autoimmune encephalomyelitis. Meanwhile, the fasting response diminishes the lymphocyte pool in gut-associated lymphoid tissue to minimize energy expenditure, leading to the attenuation of Immunoglobulin A (IgA) response. The nutritional status also influences the dynamics of several immune cell subsets. Here, we describe the current understanding of the significance of immunometabolism in the differentiation and functionality of lymphocytes and macrophages. The underlying molecular mechanisms also are discussed. These experimental observations could offer new therapeutic strategies for immunological disorders like autoimmunity.

Molecular Mechanisms of AKI in the Elderly: From Animal Models to Therapeutic Intervention

Acute kidney injury (AKI), a critical syndrome characterized by a sudden reduction of renal function, is a common disorder among elderly patients particularly in Intensive Care Unit (ICU). AKI is closely associated with both short- and long-term mortality and length of hospital stay and is considered a predictor of chronic kidney disease (CKD). Specific hemodynamic, metabolic, and molecular changes lead to increased susceptibility to injury in the aged kidney; therefore, certain causes of AKI such as the prerenal reduction in renal perfusion or vascular obstructive conditions are more common in the elderly; moreover, AKI is often multifactorial and iatrogenic. Older patients present several comorbidities (diabetes, hypertension, heart failure) and are exposed to multiple medical interventions such as the use of nephrotoxic contrasts media and medications, which can also trigger AKI. Considering the emerging relevance of this condition, prevention and treatment of AKI in the elderly should be crucial in the internist and emergency setting. This review article summarizes the incidence, the risk factors, the pathophysiology, the molecular mechanisms and the strategies of prevention and treatment of AKI in elderly patients.

Optimizing drug therapy in frail patients with type 2 diabetes mellitus

BACKGROUND

Type 2 diabetes mellitus (T2DM) is closely linked with ageing. In frail diabetic patients, the risks of intensive antidiabetic therapy outweigh the potential benefits.

AIMS

To study the prevalence of T2DM in frail elderly patients, to identify inappropriate prescription (IP) of antidiabetic drugs and to study the relationship between patients' frailty index (FI) with polypharmacy and IP.

METHODS

This was a prospective, descriptive, observational study of elderly patients. Each patient's antidiabetic treatment was analysed by applying the patient-centred prescription model (PCP), which centres therapeutic decisions on the patient's global assessment and individual therapeutic goal.

RESULTS

210 patients with T2DM were included (25.15% prevalence). They were characterised by high multimorbidity and frailty. 93.3% presented polypharmacy and 51% excessive polypharmacy. IP was identified in 66.2% of patients. A statistically significant relationship was found between the progression in FI degree and IP prevalence (p < 0.05. During the admission, drug therapy regimens were modified in 97.1% of cases with IP (n = 136).

DISCUSSION

These results suggest that in clinical practice T2DM treatment is not individualised, but rather is based on the same general recommendations for the population as a whole.

CONCLUSIONS

There is a high prevalence of T2DM in the elderly. As the frailty of patients increases, so does the prevalence of IP. The application of PCP model enables drug therapy optimization in frail patients according to their main therapeutic goal, and contributes to provide clinical evidences on the applicability of a set of knowledge areas from the theoretical framework to the daily clinical practice.

Time to modification of antidiabetic therapy in patients over the age of 65 years with newly diagnosed diabetes mellitus

AIMS

To determine the time elapsed from when a patient ≥ 65 years old is diagnosed with type 2 diabetes mellitus (T2DM) and begins antidiabetic treatment until a change in treatment is required as well as the factors associated with the change.

METHODS

A retrospective study was conducted on patients 65 years or older with a first-time diagnosis of T2DM, and these patients were followed for 60 months until an addition or change was made to their antidiabetic drug regimen. Kaplan-Meier survival analysis was performed to determine the time elapsed until such a modification occurred.

RESULTS

We identified 13,573 patients with a mean age of 76.8 ± 7.7 years; 59.3% were women. A total of 9144 (67.4%) patients began treatment with a single antidiabetic drug, 4146 (30.5%) began with two, and 282 (2.1%) began with three, especially metformin (n = 10858, 80.0%), sulfonylureas (n = 4525, 33.3%), and insulins (n = 2334, 17.2%). A total of 52.4% (n = 7106) of the patients underwent treatment modification (addition, 39.3% and change, 13.1%). Only 11.2% (n = 600) of the additions corresponded to new antidiabetic drugs (GLP-1 receptor agonists, SGLT2 inhibitors, DPP4 inhibitors). The mean time to modification was 39.1 ± 23.4 months, and the modification occurred earlier in those who started with various antidiabetic agents (33.2 vs. 42.6 months; p < 0.001), men (38.3 vs. 40.4 months; p < 0.001), and those who took glibenclamide vs. metformin (31.9 vs. 44.6 months, p < 0.001).

CONCLUSIONS

Most elderly adults who were diagnosed with T2DM after 65 years of age were treated with the appropriate medications. Therapy was modified for more than half of the patients, The addition of new antidiabetic drugs was infrequent.

Does social support effect knowledge and diabetes self-management practices in older persons with Type 2 diabetes attending primary care clinics in Cape Town, South Africa?

BACKGROUND

In South Africa with one of the most rapidly ageing populations in Africa despite the demographic impact of the HIV/AIDS epidemic, diabetes is a major cause of morbidity and mortality. Self-management is challenging for all those with the condition but is likely to create a higher demand for those who may have existing co-morbidities associated with age, and long-standing chronic diseases.

OBJECTIVE

To determine the relationship of social support, especially that of family and friends with their self-management.

METHODS

This cross-sectional study was undertaken in the Cape Town metropole primary care clinics. The sample comprised 406 people drawn from four community health centres (CHC) that are served by Groote Schuur Hospital at the tertiary level.

RESULTS

Of the 406 participants, 68.5% were females, 60.5% were living with a family member, and almost half were married. The mean duration of diabetes from diagnosis was eight years. More than half (57.4%) had no or only primary education. Half the participants (50.2%) had poor knowledge level in relation to symptoms and complications of diabetes. Multivariable linear regression showed older age was associated with poor knowledge (®: -1.893, 95% CI-3.754; -0.031) and higher income was associated with self-management practice (®: 3.434, 95% CI 0.797; 6.070). Most participants received family support to follow aspects of diabetes self-management. The ordinal logistic regression indicated that family support was positively associated with the self-management practice score for following a diabetic meal plan, taking care of feet, physical activity, testing blood sugar and handling participants' feelings about being diabetic, but not for taking medication.

CONCLUSIONS

Consideration needs to be given to developing and testing education programmes that focus on needs of older people with diabetes and emphases the role of family and friends.

Finding the Sweet Spot: An Interactive Workshop on Diabetes Management in Older Adults

INTRODUCTION

Intensive glucose lowering in older adults with diabetes leads to increased risks with minimal benefits. Surveys indicate that clinician confidence for individualizing glycemic goals and regimens remains low. We created an interactive workshop and clinical tool kit to improve clinician knowledge of safe diabetes management in older adults.

METHODS

Finding the Sweet Spot was a 1-hour workshop taught by pharmacists to medical and pharmacy learners that introduced a five-step framework for diabetes management in older adults. The interactive presentation included cases and a clinical tool kit based on current recommendations from the American Diabetes Association and American Geriatrics Society. Pilot workshops were held for 6 months, allowing for real-time revisions based on feedback; final implementation occurred for 6 months thereafter. We evaluated learner self-efficacy (via a 5-point Likert scale) and knowledge (via multiple-choice questions) of diabetes management in older adults before and after the workshop.

RESULTS

Thirty learners participated in Finding the Sweet Spot (70% medicine, 30% pharmacy). The percentage of confident learners increased from 55% to 97% (p < .05) after the workshop. All learners demonstrated improvements in knowledge, with the mean score on the knowledge assessment increasing from 61% to 80% (p < .05). Via open-ended feedback, learners expressed satisfaction and found the clinical tool kit especially helpful.

DISCUSSION

Our Finding the Sweet Spot workshop demonstrated statistically significant changes in self-efficacy and knowledge among learners, indicating that this interactive workshop improves medical and pharmacy provider confidence and skills in caring for older adults with diabetes.

Evidence-Based Cardiovascular Risk Management in Diabetes

Multipronged risk management in diabetes has contributed to the recent decline in cardiovascular mortality. Few antihyperglycemic drugs have been conclusively shown to have cardioprotective effects. These include metformin, liraglutide, semaglutide, dulaglutide, and sodium-glucose cotransporter-2 inhibitors. Statins are the cornerstone of treatment for people with established coronary artery disease (CAD) or at risk of CAD. In patients with persistent low-density lipoprotein cholesterol (LDL-C) levels > 70 mg/dL, the addition of ezetimibe or proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors is recommended. In general, angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers should be included in the treatment regimen. The goal is to have blood pressure < 140/90 mmHg, whereas a lower goal of < 130/80 mmHg is recommended in patients with CAD or proteinuria (> 1 g/day). Aspirin antiplatelet therapy should be restricted for people with established CAD or those with multiple CAD risk factors. While antiobesity medications have a modest role in managing obesity, bariatric surgery in people with body mass index (BMI) ≥ 40 or ≥ 35 with comorbidities can substantially affect quality of life and may reduce cardiovascular risks. Prescribing therapeutic agents should take into consideration a variety of factors, including the patient's preferences and the drug's affordability, side effect profile, and proven cardiovascular benefit.

Diabetes and Aging: From Treatment Goals to Pharmacologic Therapy

Diabetes is becoming one of the most widespread health burning problems in the elderly. Worldwide prevalence of diabetes among subjects over 65 years was 123 million in 2017, a number that is expected to double in 2045. Old patients with diabetes have a higher risk of common geriatric syndromes, including frailty, cognitive impairment and dementia, urinary incontinence, traumatic falls and fractures, disability, side effects of polypharmacy, which have an important impact on quality of life and may interfere with anti-diabetic treatment. Because of all these factors, clinical management of type 2 diabetes in elderly patients currently represents a real challenge for the physician. Actually, the optimal glycemic target to achieve for elderly diabetic patients is still a matter of debate. The American Diabetes Association suggests a HbA1c goal <7.5% for older adults with intact cognitive and functional status, whereas, the American Association of Clinical Endocrinologists (AACE) recommends HbA1c levels of 6.5% or lower as long as it can be achieved safely, with a less stringent target (>6.5%) for patients with concurrent serious illness and at high risk of hypoglycemia. By contrast, the American College of Physicians (ACP) suggests more conservative goals (HbA1c levels between 7 and 8%) for most older patients, and a less intense pharmacotherapy, when HbA1C levels are ≤6.5%. Management of glycemic goals and antihyperglycemic treatment has to be individualized in accordance to medical history and comorbidities, giving preference to drugs that are associated with low risk of hypoglycemia. Antihyperglycemic agents considered safe and effective for type 2 diabetic older patients include: metformin (the first-line agent), pioglitazone, dipeptidyl peptidase 4 inhibitors, glucagon-like peptide 1 receptor agonists. Insulin secretagogue agents have to be used with caution because of their significant hypoglycemic risk; if used, short-acting sulfonylureas, as gliclazide, or glinides as repaglinide, should be preferred. When using complex insulin regimen in old people with diabetes, attention should be paid for the risk of hypoglycemia. In this paper we aim to review and discuss the best glycemic targets as well as the best treatment choices for older people with type 2 diabetes based on current international guidelines.