Concerns about hypoglycaemia, plus lack of evidence of benefit, contributed to underutilisation of insulin for older people with type 2 diabetes in the past. Following the UKPDS it is clear that many elderly patients treated with diet and oral antidiabetic agents will develop beta-cell failure and will be at risk of worsening glycaemic control with reduced well-being unless insulin is considered. Following diabetes diagnosis, the mainstay of treatment will be dietary control and exercise together with management of cardiovascular risk factors. When glycaemic control deteriorates oral agents will be needed. However, whereas in the past insulin was seen as a last resort for older type 2 patients there is support for considering its early use in selected older people with preserved cognitive function and poor glycaemic control, as well as for frail older people with weight loss and poor quality of life. The regimens of choice may include a combination of basal insulin with oral agents or twice-daily combinations of premixed short and intermediate acting insulin. The development of insulin analogues with their associated reduced risk of hypoglycaemia may also herald a new era of insulin treatment for older people.
Hendra TJ, Sinclair AJImproving the care of elderly diabetic patients: the final report of the St Vincent Joint Task Force for diabetes. Age Ageing1997;26:3-6.
2.
Ford ES, Giles WH, Dietz WHPrevalence of the metabolic syndrome among US adults. Findings from the Third National Health and Nutritional Examination Study. JAMA2002;287:356-9.
3.
Sinclair AJ, Turnbull CJ, Croxson SCM.Document of care for older people with diabetes. Postgrad Med J1996;72:334-8.
4.
Sinclair AJ, Turnbull CJ, Croxson SCM.Document of diabetes care for residential and nursing homes. Postgrad Med J1997;73:611-12.
5.
UK Prospective Diabetes Study (UKPDS) Group.Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet1998;352:837-53.
6.
Ohkubo Y., Kishikawa H., Araki E. et al. Intensive insulin therapy prevents the progression of diabetic microvascular complications in Japanese patients with non-insulin-dependent diabetes mellitus: a randomized prospective 6-year study. Diabetes Res Clin Pract1995;28:103-17.
7.
Gaede P., Vedel P., Larsen N. et al. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med2003; 348:383-93.
8.
European Diabetes Working Party For Older People 2000-2003. Clinical Guidelines for Type 2Diabetes Mellitus. Available from: www.eugms.org
9.
Wright A., Burden AC, Paisey RB et al. Sulphonylurea inadequacy: efficacy of addition of insulin over 6 years in patients with type 2 diabetes in the UK Prospective Diabetes Study (UKPDS 57). Diabetes Care2002;25: 330-6.
10.
Riddle MCTimely initiation of basal insulinAm J Med2004;116(suppl 3A):3S-9S.
11.
1. Schwartz S., Sievers R., Strange P. et al. Insulin 70/30 Mix plus metformin versus triple oral therapy in the treatment of type 2 diabetes after failure of two oral drugs: efficacy, safety, and cost analysisDiabetes Care2003;26:2238-43.
12.
Qureshi KN, Hodkinson HMEvaluation of a ten-question mental test in the institutionalised elderly . Age Ageing1974;3:152-7.
13.
Folstein MF , Folstein SE, McHugh PR`Mini-mental state`: a practical method for grading the cognitive state of patients for the clinician . J Psychiatry Res1975;12:189-98.
14.
Collins C., Wade DT, Davies S., Horne V.The Barthel Index: a reliability study. Int Disabil Stud1988;10:61-3.
15.
Herrmann C.International experiences with the Hospital Anxiety and Depression Scale - a review of validation data and clinical results . J Psychosomatic Research1987;42:17-42.
16.
Pop Bogatean M., Hancu N.People with type 2 diabetes facing the reality of starting insulin therapy: factors involved in psychological insulin resistance . Pract Diab Int2004;21:247-52.
17.
Riddle MC, Rosenstock J., Gerich MJThe Treat To Target Trial. Randomized addition of glargine or human NPH insulin to oral therapy of type 2 diabetic patients. Diabetes Care2003;26:3080-6.
18.
Taylor R., Davies R., Fox C. et al. Appropriate insulin regimens for type 2 diabetes. Diabetes Care2000;23:1612-18.
19.
Yki-Jarvinen H., Ryysy L., Nikkila K. et al. Comparison of bedtime insulin regimens in patients with type 2 diabetes mellitus. Ann Int Med1999; 130:389-96.
20.
Reza M., Taylor C., Towse K. et al. Insulin improves well-being for selected elderly type 2 diabetic subjects. Diabetes Res Clin Pract2002;55:201-07.
21.
Hendra TJ, Taylor CDA randomized trial of insulin on well being and carer strain, in elderly type 2 diabetic subjects. J Diabetes Compl2004 ; 18:148-54.
22.
Watson GS, Craft S.Modulation of memory by insulin and glucose: neurophysiological observations in Alzheimer's disease. Eur J Pharmacol2004 :490:97-113.
23.
Barnett AHA review of basal insulins. Diabetic Med2003 ;20:873-85.
24.
Update on insulin analogues. Drug Ther Bull2004;42:77-80.
25.
National Institute for Clinical Excellence.Guidance on the use of long-acting insulin analogues for the treatment of diabetes- insulin glargine. December 2002(online). http://nice.org.uk/pdf/53_Insulin_analogues_full_guidance.pdf .
Hermansen K. , Ronnemaa T., Petersen AH, Bellaire S., Adamson U.Intensive therapy with inhaled insulin via the AERx Insulin Diabetes Management System. Diabetes Care2004;27:162-7.
28.
Taylor C., Towse K., Reza M. et al. Transferring elderly patients to insulin: a prospective study of diabetes nurses' physicians' and patients' perceptions. Pract Diab Int2002;19:37-9.
29.
Schwartz AV , Hillier TA, Sellmeyer DE et al. Older women with diabetes have a higher risk of falls: a prospective study. Diabetes Care2002;25: 1749-54.
30.
DeWitt DE, Hirsch IBOutpatient insulin therapy in type 1 and type 2 diabetes mellitus. JAMA2004;289:2254-64.
