Diagnosis and treatment of type 2 diabetes in older adults General principles

Nationwide estimates of the prevalence of diabetes in Germany from Robert Koch Institute (RKI) surveys were 7.2% (18- to 79-year-olds), from RKI telephone surveys 8.9% (18-year-olds and older), and based on data from statutory health insurance companies 9.9% (all age groups). According to analyses of DaTraV data (data processing center at DIMDI [German Institute for Medical Documentation and Information] of the approximately 70 million people insured by statutory health insurance in Germany) for the reporting years 2011, 2012, and 2013, the diabetes prevalence in 2011 was 9.7% (women: 9.4%, men: 10.1%). It was clearly age-dependent: 15.5% in 60- to 64-year-old women and 21.9% in men, with a linear increase up to 31.9 and 34.7% in women and men, respectively, in the 80-84 year age range. In contrast, incidence decreased by 2.4% in both women and men. Diagnosis is made by venous plasma glucose and HbA(1c) (glycated hemoglobin) levels using quality-assured laboratory analyses, independent of age. The diagnosis should be based on two independent laboratory measurements. For all laboratory parameters, there are preanalytical and/or analytical problems and influencing factors that must be taken into account when interpreting the results in order to avoid over- or underdiagnosis. Information from the laboratory on the accuracy and precision of measurements is also important. Measurement uncertainty is best assessed using the minimum difference (MD) from the laboratory. It indicates the specific concentration of glucose or HbA(1c) at which the corresponding measured value differs from a diagnostic cut-off with a 95% confidence interval. In addition, laboratory diagnostics must be conducted following the German Medical Association ("Bundesarztekammer") guidelines. If the diagnosis remains unclear, a differential diagnosis should be considered. The multimorbidity frequently found in older patients must be taken into consideration in the decision-making regarding therapy of diabetes. Depending on the individual risk profile, which must be considered on an individual and medical basis, joint clinical targets should be agreed upon with the affected person. This and innovations in medical technology increase the still insufficient patient adherence to treatment and improve treatment satisfaction of the patients. Prioritization of the usually complex treatment and potential de-escalation of polypharmacy must be considered.