Strain Corresponding Author E-mail address: d. Tools Request permission Export citation Add to favorites Track citation. Share Give access Share full text access. Share full text access. Please review our Terms and Conditions of Use and check box below to share full-text version of article. Abstract Rates of population ageing are unprecedented and this, combined with the progressive urbanization of lifestyles, has led to a dramatic shift in the epidemiology of diabetes towards old age, particularly to those aged 60—79 years.
Impact of diabetes in an ageing population Rates of population ageing are unprecedented and this, combined with the progressive urbanization of lifestyles, has led to a dramatic shift in the epidemiology of diabetes towards old age, particularly to those aged 60—79 years 1. Current availability of clinical guidance and recognition of complexity of illness issues Effective management of diabetes in older adults requires the appreciation by both clinicians and policy makers that care has to take into account the increasing complexity of the illness and that such care may need to operate over four decades 60—90 years and older and respond to the changing circumstances of an individual's health status 7.
Need for closer working between primary care teams and specialist care: problem of communication, overprescribing and avoidable hospital admissions In younger people with diabetes, it is likely that any quality of life impairments will be driven by either the consequences of metabolic syndrome or the complications of diabetes itself. Figure 1 Open in figure viewer PowerPoint. An implementable frailty assessment scheme. Figure 2 Open in figure viewer PowerPoint. Avoid TZDs because of risk of heart failure. Cautious use of insulin and metformin mindful of renal function.
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TZDs may increase risk of heart failure. Review timings and suitability of NPH insulin with regard to risk of hypoglycaemia. Therapies that promote weight loss may exacerbate sarcopenia.
Educate carers and relatives regarding risk of hypoglycaemia. Treatment of the mild to moderately frail The mild to moderately frail population represents the majority of older adults who have additional comorbidities Management of the very frail Frailty itself is the most important prognostic indicator. Funding sources None. Competing interests W. Diabetes Res Clin Pract ; 94 : — Crossref PubMed Google Scholar. PubMed Google Scholar.
Google Scholar. Citing Literature. Volume 35 , Issue 7 July Pages Figures References Related Information. Close Figure Viewer. Browse All Figures Return to Figure. Previous Figure Next Figure. Email or Customer ID. Forgot password? Old Password. New Password. Password Changed Successfully Your password has been changed. Returning user. Request Username Can't sign in? Patients on enteral or parenteral nutrition and insulin develop hypoglycemia when feeding is stopped abruptly for various reasons Thus, safety measures must be in place at every institution.
Aiming at glycemia targets below this range is dangerous. Point-of-care glucose monitoring is helpful only when it is performed frequently and when a knowledgeable person reviews the data and makes appropriate adjustments , — Most hospitalized patients with diabetes are treated with insulin Most missteps in diabetes management occur not at the selection of the initial doses of insulin but because of poor follow-up and lack of appropriate and timely adjustments.
Whereas glycemia of critically ill patients is usually managed in the intensive care unit with IV insulin administration, most noncritically ill patients are treated with basal-bolus regimens. Hypoglycemia increases length of hospital stay and mortality — The presence of renal failure, poor nutrition, and sepsis is highly predictive of a high risk of hypoglycemia in older individuals.
Although a causal relationship between hypoglycemia and mortality has not been established, a strong association between hypoglycemia and more severe illness is likely , , An RCT comparing treatment with oral agents and basal insulin in older patients with T2D in LTCFs demonstrated that treatment within both arms resulted in a similar frequency of hypoglycemia , suggesting that a low daily dose of basal insulin is sufficient to achieve reasonable and safe glycemia in older patients. Clearly, patients with T1D in institutional settings should never be left without insulin.
Patients with late-stage cancer, organ failure, or pre—solid organ or post—solid organ or bone marrow transplant, patients on dialysis, and those in the intensive care unit present unique challenges. Higher glycemic targets may be acceptable in patients with severe comorbidities and in terminally ill individuals. A simplified management approach is fully justified in these patients. Although measurements of HbA1c have earned their recognition in the diagnosis of diabetes mellitus and in the process of monitoring glycemic control in patients with diabetes , they can also help to assess the chronicity of hyperglycemia in patients admitted to the hospital who do not have a previous diagnosis of diabetes Admission HbA1c levels have been shown to correlate with greater morbidity and mortality in patients with acute myocardial infarction , , heart failure , and poor functional outcome after acute ischemic stroke The exact mechanism of these associations is not well understood, but one may surmise that chronic hyperglycemia has an adverse influence on the cardiovascular system in patients with undiagnosed diabetes or prediabetes.
Transition of care from hospital to home or to an LTCF rightfully represents a critical element in the treatment of older patients with diabetes. The most important aspect of successful transition is effective, detailed, and thorough bidirectional communication between the discharging and receiving teams of health care providers.
Older patients newly diagnosed with diabetes during their hospital stay may present additional obstacles during transitions of care. These patients deal with the shock of a new chronic disease and may not have a clear ability to understand and integrate complicated medical regimens, changes in lifestyle, home glucose monitoring, and other challenges of diabetes.
The Writing Committee consisted of 10 content experts representing the following specialties: endocrinology, neurology, and geriatrics. Two of the committee members brought an international perspective to this guideline topic. The Writing Committee also included a clinical practice guideline methodologist who led the team of comparative effectiveness researchers that conducted the systematic reviews and meta-analyses.
The Society applies the steps in the GRADE framework to research questions for which there is an ample body of knowledge of low-to-moderate quality or higher Table 8 for descriptions of low- and moderate-quality evidence. In these situations, GRADE provides the methodological and statistical rigor that results in robust recommendations that are classified using quality of evidence and strength of recommendation as described in by Guyatt et al. This unclassified clinical guidance can include expert opinion statements on good practice, references to recommendations made in other guidelines, and observations on preventive care and shared decision-making.
Guideline recommendations include the relevant population, intervention, comparator, and outcome. When further clarification on implementation is needed, we include technical remarks. These provide supplemental information such as timing, setting, dosing regimens, and necessary expertise. All recommendations are followed by a synopsis of the evidence on which they are based. To be considered for membership of a Writing Committee, nominees are required to disclose all relationships with industry for the month period prior to guideline writing committee initiation.
The Chair of the Clinical Guidelines Subcommittee reviews these disclosed relationships and determines whether they are relevant to the topic of the guideline and present a relevant conflict of interest COI. The Endocrine Society Council then reviews and endorses the nominees or makes appropriate changes. The chair of the Writing Committee must be free of any COI or other biases that could undermine the integrity or credibility of the work.
Following initiation of the committee, members are asked to disclose any new relationships with industry at every in-person meeting and on most conference calls. Staff, Writing Committee Chairs, and members must be alert for situations that might present a potential or perceived conflict of interest. Consideration that the patient categories are general concepts and that individual patients may not fall clearly in one category is important. However, considering most patients in group 2 as prefrail and most in group 3 as frail with one or more disabilities may be helpful.
Nevertheless, we recognize that neither the category nor patient values are necessarily static and may change over time with disease progression or may shift in either direction, for example, because of temporary disability. The framework prioritizes blood glucose targets over HbA1c, recognizing that both are important in clinical practice. Shared decision-making SDM is a collaborative, patient-directed decision-making process that helps the patient set goals and priorities with input from their health care team, family, and other caregivers.
In the conceptual framework, the SDM arrow indicates that after consideration of these factors, some patients may have lower or higher targets. Jones is a year-old woman with T1D and rheumatoid arthritis who presents for the first time for ongoing management of her diabetes, which she has had for 40 years. She has retinopathy without impaired vision, peripheral polyneuropathy that has just become painful this past year, and stage 3 CKD with a GFR of She has hypertension on two agents with SBP between and on recent checks.
Owing to her rheumatoid arthritis, she uses a walker in the home and a wheelchair or scooter outdoors but is able to manage insulin and glucose monitoring independently, although some days her dexterity is so poor that she manages to only check twice. Her son pays her bills for her because she can no longer manage her online accounts due to MCI; otherwise, she is very involved in the local church and has evening activities three times a week. Her HbA1c has been between 6. She uses long-acting basal insulin and rapid-acting insulin up to five times daily according to a carbohydrate ratio and correction factor, which, with further inquiry, you find that she applies very accurately; she declined an insulin pump and CGM in the past.
You discuss the concerns around hypoglycemia, and she agrees that it is concerning. Together, you agree for her to wear a continuous glucose monitor for up to 10 days to evaluate her glucose patterns, and you place this device in the office. You both agree to focus on the glucose ranges rather than HbA1c.
Diabetes Management: Team-Based Care for Patients with Type 2 Diabetes
You suggest that her son come with her to the next visit to discuss options for safe glucose monitoring going forward, as her rheumatoid arthritis is affecting her ability to self-monitor blood glucose. An anonymous, unvalidated survey was developed by members of the writing committee and administered electronically via E-mail and in person to 80 adults.
The survey was designed to address specific aspects of the guideline, namely, the perception of how diabetes and treatment of diabetes impact overall health. Based on the preponderance of responses, the committee identified four common themes: i many older adults do not anticipate changing their various treatment targets with advancing age; ii diabetes is often not listed as the top health condition by older patients with diabetes, as other conditions are often considered more serious or important to them; iii most older patients with diabetes express significant fear of complications microvascular and macrovascular and primarily consider glucose control to be the most important factor for prevention; and iv lipid-lowering medications may be underused among older adults, which may be due to a lack of perceived benefit by themselves or their clinicians.
The Writing Committee developed a question anonymous survey that included demographics, diabetes-specific characteristics, and perspectives on the health problems addressed in the guideline. The survey was tested internally but was not formally validated. Individual patients were identified through a clinical database and were asked to submit the survey online. The survey was also administered in person to a focus group of older adults participating in a community program.
All data collected directly from individuals did not include personal health information or identifiers. Overall, 80 respondents completed the survey, and 77 of them reported having diabetes three reported taking the survey on behalf of a family member. One-third of respondents either agreed or strongly agreed that they fear having low blood glucose on most days. Other conditions common among older adults that are potentially related to diabetes were also ranked high hypertension, heart disease, bladder control, depression, and overweight. There are several limitations to employing a limited survey approach to illustrate the patient experience.
First, the population was largely ambulatory and did not represent nonambulatory older adults or those living in LTCFs. This finding may also suggest that some older adults may not be willing or able to invest the time and expense required to fulfill recommendations made in the guideline. Responses to the survey also highlight the potentially inconsistent messages heard by older patients regarding tailoring clinical targets BP and glucose and prevention of complications. Perhaps consistent with these results, most participants reported not being willing to relax glucose goals over time as they become older.
Taken as a whole, the results highlight the importance of clear communication between clinicians and patients on the actual risks and benefits of different therapeutic strategies. The guideline writing committee thanks the participating organizations and individuals with diabetes for their invaluable contribution to the patient voice in this guideline. The writing committee thanks the cosponsors of this guideline for their contribution to the development effort.
Affirmation of value means that AGS supports the general principles in this document and believes it is of general benefit to its membership. No other entity provided financial support. The guidelines should not be considered inclusive of all proper approaches or methods, or exclusive of others. The guidelines cannot guarantee any specific outcome, nor do they establish a standard of care.
The guidelines are not intended to dictate the treatment of a particular patient. The Endocrine Society makes no warranty, express or implied, regarding the guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose. The Society shall not be liable for direct, indirect, special, incidental, or consequential damages related to the use of the information contained herein. Sign In. Advanced Search.
Article Navigation. Close mobile search navigation Article Navigation. Volume Article Contents. List of Recommendations. Systematic Review and Meta-Analyses. Role of the Endocrinologist and Diabetes Care Specialist. Screening for Diabetes and Prediabetes, and Diabetes Prevention. Assessment of Older Patients With Diabetes. Treatment of Hyperglycemia. Treating Complications of Diabetes. Special Settings and Populations. E-mail: derek.
Oxford Academic. Google Scholar. Geert Jan Biessels. Susan S Braithwaite. Felipe F Casanueva. Boris Draznin. Jeffrey B Halter. University of Michigan, Ann Arbor, Michigan. Irl B Hirsch. Marie E McDonnell. Mark E Molitch. M Hassan Murad. Alan J Sinclair. Cite Citation. Permissions Icon Permissions. Abstract Objective. Open in new tab Download slide. Table 1. Open in new tab. Table 2. Table 3. Table 4. Based on data from the Canadian Study of Health and Aging; seven-point scale; predictive of future events including mortality; easy to employ in routine clinical practice Comprises only five questions no procedures covering fatigue, climbing stairs, walking, number of illnesses, and weight loss Table 5.
Good correlation with gait speed, Barthel Index, and measures of balance 47 , Easy to perform. Can be used to measure functional status in older adults and to predict future health and well-being. Population norms available 49 , Predictive of increased future functional limitations and disability, increased fracture risk, and increased all-cause mortality Table 6. Increased risk of hypoglycemia. Dosages may need adjusting. Consider giving rapid-acting insulin postprandially because of gastroparesis.
May worsen fluid retention when used with thiazolidinediones. Can cause fluid retention. Can increase fractures. Pioglitazone has been shown to reduce CVD mortality. Not studied in CKD. Table 8. Appendix Table 1. Appendix C. Search ADS. Prevalence of and trends in diabetes among adults in the United States, Diabetes in older adults. Diabetes in America. Impact of recent increase in incidence on future diabetes burden: U.
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Diabetes Management: Team-Based Care for Patients with Type 2 Diabetes
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Sign up now. Diabetes care: 10 ways to avoid complications Diabetes care is a lifelong responsibility. By Mayo Clinic Staff. References American Diabetes Association. Standards of medical care in diabetes — Diabetes Care. Accessed Nov. Smoking and diabetes. Centers for Disease Control and Prevention. Accessed Dec. McCulloch DK. Overview of medical care in adults with diabetes mellitus. Diabetes, gum disease and other dental problems.
American Diabetes Association. How to care for your diabetic feet. Rochester, Minn. Boden MT, et al. Exploring correlates of diabetes-related stress among adults with type 1 diabetes in the T1D exchange clinic registry.
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Diabetes Research and Clinical Practice. In press. Castro MR expert opinion.