NEW ORLEANS – New guidelines from the endocrine community address the many complex problems involved in managing the growing population of older adults with diabetes.
Document, Treatment of Diabetes in Older Adults: A Clinical Practice for Endocrine Society Guideline was presented on March 23 here at ENDO 2019: Endocrine Society Annual Meeting and was published simultaneously in the Journal of Clinical Endocrinology and Metabolism along with other online resources.
The guidelines are cosponsored by the European Society of Endocrinology, the Gerontological Society of America and the Obesity Society.
"For many decades and many years, we have not really put much emphasis on the elderly person with diabetes because they were considered to have a limited life span. But we now know that 65-70 year olds live to 85- 90 years, and so long-term complications prevent much, much like the short-term problems they suffer, "said then-president Derek LeRoith, MD, PhD, at the Icahn School of Medicine in Mount Sinai, New York City, during a press release.
The document relates especially to adults with diabetes over the age of 65 and older. It covers the screening, prevention and management of glycemia, blood pressure and lipids, as well as comorbidities, complications and special situations such as diabetes care in the hospital and long-term care facilities and management of type 1
"We believe that regular screening should be done. If you screen for prediabetes and diabetes in the elderly, it may allow you to intervene," LeRoith said.
And more importantly because of the heterogeneity of health status In older people with diabetes, the document emphasizes shared decision making and provides a framework to help healthcare providers individualize treatment goals. "We believe all decisions in terms of managing these patients should be a team approach," he stressed.
Avoidance of hypoglycemia is a key issue, co-author Mark E. Molitch, MD, of Northwestern University's Feinberg School of Medicine, Chicago, Illinois, told reporters during the briefing.
"A 70-year-old who has hypoglycaemia and falls on the floor can break a hip, so we need to be very careful about avoiding hypoglycaemia. Do not want to be too aggressive because it can lead to falls. All these things play a role in how to adjust medication for these patients. "
Other specific aging-related co-morbidities and problems addressed in the guidelines include sarcoplasia, weakness, cognitive dysfunction, decreased drug inhibition, and loss of independence in daily life activities.
In addition, "both kidney disease and heart disease are very important and we are discussing in these guidelines" LeRoit h.
Comparison with other guidelines
The new guidelines largely cover the same reason as the guidelines of the American Diabetes Association / American Geriatrics Society 2012 (ADA / AGS), Medha Munshi, MD, director of Joslin Geriatric Diabetes Program at Beth Israel Deaconess Medical Center, Boston, noted in an interview with Medscape Medical News .
Munshi co-authored the ADA / AGS Guidelines, which has since been revised in 2019 ADA Standards of Medical Care in Diabetes.
"I think the guidelines add to each other. Most older adults with diabetes will be better taken care of if these basic concepts are understood."
Munshi specifically praised the new endocrine society's document emphasis on hypertension and lipid management in Addition to Glycemia and its inclusion of patients as consultants.
She also noted that the two sets of guidelines also classify older adult patients into categories of good health (ie, no or few comorbidities and no or few disabilities), intermediate health (three or more comorbidities, mild cognitive impairment, and / or or two or more disabilities) and poor health (medical condition of the final stage [s] moderate-severe dementia, two or more functional limitations and / or long-term nursing facility stay).
But Munshi praised the endocrine community for adding an additional category to the framework: use of substances that can cause hypoglycaemia such as insulin, sulfonylureas or glinides.
However, in the framework of the evidence for some of the recommended target groups for HbA 1c she asked between ≥ 7.0% and <7.5% for patients with good health using hypoglycaemia – exposed medicine.
Some patients within this category may need a higher goal, she noted.
"There is no real data for this recommendation. It's just expert opinion. Instead of liberalizing the higher level, they put it in the tighter area."
She also failed the document for not providing specific instructions for simplifying regimens, as recommended for patients with limited life expectancy, cognitive impairment and / or multiple comorbidities.
Such guidance, which was first included in the 2016 ADA's guidelines for diabetes care in fatal care and long-term care facilities, was added to ADA's recommendations in current standards of care.
"Simplification is a good philosophy, but difficult for practitioners to practice," Munshi said.
She was the lead author of the 2016 Long-term Care Guidelines, stressing that it was important to provide different guidelines for the different settings.
"Hospitals and long-term care facilities are very different environments with very different management goals," she says. told Medscape Medical News . "In the ADA Declaration, I explained why they do not belong to each other, but the endocrine society has again lumped them together."
Is Type 1 diabetes in older adults deserved separate guidelines?
And although the Endocrine Society document contains a section on the treatment of type 1 diabetes in older adults, Munshi said that the growing population really deserves separate guidelines.
"With type 1 diabetes is very expert opinion, as there is not much data," she said, adding that long-term care is a major concern in this population.
"The lack of understanding of how different insulins work and how to deal with diabetes generally in the type 2 population is difficult enough, and then you put a type 1 patient … We need to write something about type 1 diabetes for a long time Care. "
But in general, Munshi said that the new guidelines of the endocrine society will increase care for older adults and that the differences between documents are generally less.
"The main concepts are the same … As long as the guidelines reach the wider audience, they will give people a better understanding of the complexity of managing older adults with diabetes."  LeRoith is a consultant for AstraZeneca and MannKind, and serves on MSD advisory boards. Molitch is a consultant for and / or serves on data security monitoring boards for Merck, Pfizer, Janssen, Chiasma and Novartis. Munshi is a consultant for Sanofi and Lilly.
ENDO 2019. Presented March 23, 2019.
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