Guy Rutten was Professor of Diabetology in Primary Care (1998-2018) and Director of the training-course for executives in Diabetology in Primary Care at University Medical Center Utrecht.

His research activities focus on person-centred diabetes care, screening for diabetes, T2DM and cardiovascular disease and diabetes primary care. He is (co-)author of more than 400 original articles in (inter) national peer reviewed journals and supervised 14 RCTs on type 2 diabetes. Besides he wrote several books on type 2 diabetes and general practice topics as well. He is a principal investigator of the ADDITION study and was member of the writing committee of the NAVIGATOR study and member of the global expert panel of the LEADER trial.

He chaired the Dutch General Practice Advisory Group for more than 20 years and was founder of the EASD Primary Care Study Group from 2006 to 2011. From 2004-2010 he was member of the scientific Advisory Board of the Dutch Diabetes Research Foundation. He was the first editor-in-chief of the journal Primary Care Diabetes, until it was indexed in Medline in 2008. In 1989-1990 he was Head of the Department of Guidelines development of the Dutch College of General Practitioners.

From 1982-2014 he worked as a general practitioner in his group practice. In 2005 he received the biennial prize for the highest impact article in Medisch Contact, a weekly journal for Dutch health care professionals. In 2017 he was appointed Member of Merits by the Dutch College of General Practitioners and in 2018 he received the royal award ‘Knight in the Order of the Dutch Lion’.

For several reasons many more “old and very old” people with T2DM will be treated in primary care in the forthcoming years. However, it is difficult to generalise the gap between calendar age and biological age. That’s why diabetes management in older adults requires a regular assessment of medical, psychological, functional and social domains. Based on such an assessment, the ADA framework for considering treatment goals could be applied. Suggested  treatment goals should be discussed with the patient and/or his relatives, resulting in person-centred diabetes care and shared decision making. Physicians should realise that the pathophysiology of T2DM in the elderly involves age-related loss of beta-cell function and that trial data to underpin treatment for older people with T2DM are lacking to a l arge extent. Besides, many trials that did include older adults excluded those with comorbidities, people with polypharmacy or those with cognitive impairment. So, the ones who are left in the trials are not the ones we see in our practice.

Having set goals together, the possible side effects of medications and the complexity and costs of the regimen are issues to be resolved. Unintended consequences of strict glycaemic control in older adults include hypoglycaemia, difficulty of coping with the treatment, increased caregiver burden, loss of independence, and increased financial burden. Diabetes overtreatment is a frequent and major issue in older people with type 2 diabetes that should be avoided.

In older adults medication classes with low risk of hypoglycaemia are preferred; however, in developing treatment plans costs of care should be considered in order to reduce risk of cost-related nonadherence.

Learning outcomes:

Comorbidities and polypharmacy are highly prevalent in older people with T2DM.

Many large-scale RCTs do not include older people with T2DM and comorbidities

A framework that primary care physicians could use for setting targets is at hand.

Learning objectives:

Helping primary care physicians to treat older patients with T2DM in the best possible way.