Diabetes and Cardiovascular Disease in Older Adults: Current Status and Future Directions

Jeffrey B. Halter; Nicolas Musi; Frances McFarland Horne; Jill P. Crandall; Andrew Goldberg; Lawrence Harkless; William R. Hazzard; Elbert S. Huang; M. Sue Kirkman; Jorge Plutzky; Kenneth E. Schmader; Susan Zieman; Kevin P. High

Disclosures

Diabetes. 2014;63(8):2578-2589. 

In This Article

Abstract and Introduction

Abstract

The prevalence of diabetes increases with age, driven in part by an absolute increase in incidence among adults aged 65 years and older. Individuals with diabetes are at higher risk for cardiovascular disease, and age strongly predicts cardiovascular complications. Inflammation and oxidative stress appear to play some role in the mechanisms underlying aging, diabetes, cardiovascular disease, and other complications of diabetes. However, the mechanisms underlying the age-associated increase in risk for diabetes and diabetes-related cardiovascular disease remain poorly understood. Moreover, because of the heterogeneity of the older population, a lack of understanding of the biology of aging, and inadequate study of the effects of treatments on traditional complications and geriatric conditions associated with diabetes, no consensus exists on the optimal interventions for older diabetic adults. The Association of Specialty Professors, along with the National Institute on Aging, the National Institute of Diabetes and Digestive and Kidney Diseases, the National Heart, Lung, and Blood Institute, and the American Diabetes Association, held a workshop, summarized in this Perspective, to discuss current knowledge regarding diabetes and cardiovascular disease in older adults, identify gaps, and propose questions to guide future research.

Introduction

In the U.S., approximately one in four adults aged 65 years or older has diabetes.[1] Patients with diabetes are at very high risk for developing cardiovascular disease (CVD) and associated morbidity and mortality, and this risk increases dramatically with age.[2,3] Contributors to CVD risk in diabetes include hyperglycemia, dyslipidemia, obesity, insulin resistance, inflammation, hypertension, autonomic dysfunction, and diminished vascular responsiveness. The Cardiovascular Health Study and others have documented the CVD risk in diabetic patients, as well as relevant associations in elderly populations, in some detail.[3,4] Although many interventions targeting hypertension and dyslipidemia have been demonstrated to reduce risk of CVD in individuals with diabetes, only limited data are available from studies directly testing the effectiveness of these interventions in older populations with diabetes.[2,3] Thus far, interventions targeting hyperglycemia have had limited or no benefit on cardiovascular risk reduction (reviewed in 3). Interventions to prevent or delay progression from prediabetes to diabetes in high-risk individuals have been effective, especially lifestyle interventions in older individuals,[5] but long-term outcomes for cardiovascular events are not known.

This workshop brought together experts in diabetes, diabetes-related CVD, and geriatric conditions.[3] The primary goals of the workshop were to review current knowledge and to identify key research areas to be addressed. Discussions focused on clinical epidemiology of diabetes and concomitant CVD in aging populations, including racial and ethnic disparities in diabetes prevalence, metabolic changes with age and their impact on diabetes, vulnerabilities of the heart and blood vessels to aging with diabetes, and end-organ sequelae that lead to disability. The workshop concluded with a thorough discussion of prevention and treatments for CVD in older patients with diabetes or prediabetes and unanswered research questions in this area.

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