Targets and Expectations of Older Patients with Type 2 Diabetes Included in CVOTs

The global prevalence of old people with type 2 diabetes is ~20%. A national register reveals that “21% of all deaths in Germany were attributable to diabetes” (Jacobs, E. et al., Diab. care, 2017). Old individuals are in >75% affected by diseases of the metabolic syndrome leading to multimorbidity and frailty. 
Frail patients are underrepresented in CVOTs with MACE as primary objectives. In CVOTs with SGLT2 Inhibitors and GLP1 analogues were effective to reduce MACE in selected high risk populations together with weight loss and low risk of hypoglycaemia. They however present no evidence of benefit for old patients with frailty or sarcopenia. 
“The clinical complexity and functional and psychosocial heterogeneity of the older population in LTC facilities require innovative thinking and individualized strategies to care for them (7,21–24).” (ADA, 2016)
On the other hand, we must avoid harmful consequences of undertreatment leading to increased mortality in older patients. In these patients, quality of life, physical and mental fitness are primary objectives.  Here we have only evidence for benefit of life-style intervention, LDL-Cholesterol lowering with statins and symptom-centred glucose control. 
In conclusion, management of older patients should be individualized taking into account these variables.