Universidade Federal Fluminense, Brazil
Title: The complexities and priorities for the treament of older diabetics
Jose Mario is the Deputy Editor for Diabetes at the Community Forum of healthcare professionals in British Medical Journal. He is an Associate Professor in the Department of Medicine at Universidade Federal Fluminense, and a Senior Staff Physician in the Intensive Care Unit-Adults at Hospital Federal da Lagoa, all in Rio de Janeiro, Brazil. He has a special interest in type 2 Diabetes, Preventive Cardiology, Hypertension, the renin-angiotensin-aldosterone system and Cardiovascular Diseases associated with Chronic Kidney Diseases. He also has been a principal investigator, and has published clinical studies & Letters to Editors about the mechanisms of cardiovascular diseases associated with type 2 diabetes mellitus in peer reviewed journals like British Medical Journal, Hypertension, New England Journal of Medcine, and American Journal of Hypertension. He was also a post-doctoral Clinical & Research Fellow in the Endocrinology-Diabetes and Hypertension Division of the Brigham & Women´s Hospital at Harvard Medical School where he did many angiotensin II infusions in humans, normotensive, hypertensive, and diabetic individuals. When at Harvard Medical School, he also became certified in the Principles of Epidemiology by the Harvard School of Public Health. He expect for the newer future better prevention and treatment strategies for macrovascular and microvascular diabetic complications, based on more rational and effective strategies. In the University, he is proud of running a busy Hypertension and type 2 diabetes clinic. At British Medical Journal, he enjoy the freedom and internationality of opinions. And also expect a brighter debate about all the clinical future research pathways and controversies surrounding diabetes mellitus.
With the ageing of the population, the heterogenous affluent phenotypes of obesity, hypertension, dyslipidaemia, hyperglycaemia, Alzheimer dementia, and cancer are increasingly becoming health problems of older people. As the epidemiology of diabetes and its complications shifts towards older people, the pathogenesis and pathologic findings in older diabetics are also changing. In elderly diabetics, the pathologic findings also suggest ischaemia, endothelial dysfunction, and hypertension. This demographic shift and the associated changes in pathology due to ageing and atherosclerosis have significant impact on various aspects of clinical management related to this disease in old age, such as the trend for more severe hypoglycaemic episodes with increased CVD deaths and hospitalizations, the higher association of microalbuminuria with systemic vascular inflammation and brain dysfunction, instead of kidney diseases, the important ischaemic and hypertensive multi-organ vascular damage, the paradoxical and U shaped relationship between traditional cardiovascular risk factors and outcomes, beyond the common cognitive dysfunction, frailty, associated co-morbities, and the increased susceptibity for harms associated with overtreatment and polypharmacy. All these pathogenic features, are not responsive to reductionistic interventions with polypharmacy; and point in the direction of holistic, individualised, and patient-centred therapies, taking in the core of it survival with less dysutilities and more quality of life rather than numerical, blanket, or unrealistic targets.