Guidelines abstracted from the American Geriatrics Society Guidelines for Improving the Care of Older Adults with Diabetes Mellitus: 2013 update

Factors influencing safe glucose-lowering in older adults with type 2 diabetes: A PeRsOn-centred ApproaCh To IndiVidualisEd (PROACTIVE) Glycemic Goals for older people: A position statement of Primary Care Diabetes Europe

Diabetes in later life is associated with a range of factors increasing the complexity of glycaemic management. This position statement, developed from an extensive literature review of the subject area, represents a consensus opinion of primary care clinicians and diabetes specialists. It highlights many challenges facing older people living with type 2 diabetes and aims to support primary care clinicians in advocating a comprehensive, holistic approach. It emphasises the importance of the wishes of the individual and their carers when determining glycaemic goals, as well as the need to balance intended benefits of treatment against the risk of adverse treatment effects. Its ultimate aim is to promote consistent high-quality care for older people with diabetes.

A scoping review of best practice guidelines for the dietary management of diabetes in older adults in residential aged care

Over the last two decades guidelines have been published on the subject of the care and liberalised nutrition management of older adults with diabetes in residential aged care, recognising that they may have different needs to those older adults in their own home. This study aimed to scope and appraise these guidelines using the AGREE II tool. Overall physician developed guidelines were more robust, but there was discordance in their recommendations compared to guidelines developed by dietitians; particularly regarding the use of therapeutic diets. A lack of standardised approach has implications for optimal dietary management of diabetes in aged care.

Approaches to Risk Assessment Among Older Patients With Diabetes

PURPOSE OF REVIEW

A patient's prognosis and risk of adverse drug effects are important considerations for individualizing care of older patients with diabetes. This review summarizes the evidence for risk assessment and proposes approaches for clinicians in the context of current clinical guidelines.

RECENT FINDINGS

Diabetes guidelines vary in their recommendations for how life expectancy should be estimated and used to inform the selection of glycemic targets. Readily available prognostic tools may improve estimation of life expectancy but require validation among patients with diabetes. Treatment decisions based on prognosis are difficult for clinicians to communicate and for patients to understand. Determining hypoglycemia risk involves assessing major risk factors; models to synthesize these factors have been developed. Applying risk assessment to individualize diabetes care is complex and currently relies heavily on clinician judgment. More research is need to validate structured approaches to risk assessment and determine how to incorporate them into patient-centered diabetes care.

Assessing an Interprofessional Polypharmacy and Deprescribing Educational Intervention for Primary Care Post-graduate Trainees: a Quantitative and Qualitative Evaluation

BACKGROUND

Polypharmacy and potentially inappropriate medications (PIMs) are increasingly common and associated with adverse health effects. However, post-graduate education in polypharmacy and complex medication management for older adults remain limited.

OBJECTIVE

The Initiative to Minimize Pharmaceutical Risk in Older Veterans (IMPROVE) polypharmacy clinic was created to provide a platform for teaching internal medicine (IM) and nurse practitioner (NP) residents about outpatient medication management and deprescribing for older adults. We aimed to assess residents' knowledge of polypharmacy and perceptions of this interprofessional education intervention.

DESIGN

A prospective cohort study with an internal comparison group.

PARTICIPANTS

IM residents and NP residents; Veterans ≥ 65 years and taking ≥ 10 medications.

INTERVENTION

IMPROVE consists of a pre-clinic conference, shared medical appointment, individual appointment, and interprofessional precepting model.

MAIN MEASURES

We assessed residents' performance on a pre-post knowledge test, residents' qualitative assessment of the educational impact of IMPROVE, and the number and type of medications discontinued or decreased.

KEY RESULTS

The IMPROVE intervention group (n = 18) had a significantly greater improvement in test scores than the control group (n = 18) (14% ± 15% versus - 1.3% ± 16%) over a period of 6 months (Wilcoxon rank sum, p = 0.019). In focus groups, residents (n = 17) reported perceived improvements in knowledge and skills, noting that the experience changed their practice in other clinical settings. In addition, residents valued the unique interprofessional experience. Veterans (n = 71) had a median of 15 medications (IQR 12-19), and a median of 2 medications (IQR 1-3) was discontinued. Vitamins, supplements, and cardiovascular medications were the most commonly discontinued medications, and cardiovascular medications were the most commonly decreased in dose or frequency.

CONCLUSIONS

Overall, IMPROVE is an effective model of post-graduate primary care training in complex medication management and deprescribing that improves residents' knowledge and skills, and is perceived by residents to influence their practice outside the program.

Cardiovascular safety and lower severe hypoglycaemia of insulin degludec versus insulin glargine U100 in patients with type 2 diabetes aged 65 years or older: Results from DEVOTE (DEVOTE 7)

AIMS

The aim of this study was to describe the risks of cardiovascular (CV) events and severe hypoglycaemia with insulin degludec (degludec) vs insulin glargine 100 units/mL (glargine U100) in patients with type 2 diabetes (T2D) aged 65 years or older.

MATERIALS AND METHODS

A total of 7637 patients in the DEVOTE trial, a treat-to-target, randomized, double-blind trial evaluating the CV safety of degludec vs glargine U100, were divided into three age groups (50-64 years, n = 3682; 65-74 years, n = 3136; ≥75 years, n = 819). Outcomes by overall age group and randomized treatment differences were analysed for major adverse cardiovascular events (MACE), all-cause mortality, severe hypoglycaemia and serious adverse events (SAEs).

RESULTS

Patients with increasing age had higher risks of CV death, all-cause mortality and SAEs, and there were non-significant trends towards higher risks of MACE and severe hypoglycaemia. Treatment effects on the risk of MACE, all-cause mortality, severe hypoglycaemia and SAEs were consistent across age groups, based on the non-significant interactions between treatment and age with regard to these outcomes.

CONCLUSIONS

There were higher risks of CV death, all-cause mortality and SAEs, and trends towards higher risks of MACE and severe hypoglycaemia with increasing age after adjusting for baseline differences. The effects across age groups of degludec vs glargine U100 on MACE, all-cause mortality and severe hypoglycaemia were comparable, suggesting that the risk of MACE, as well as all-cause mortality, is similar and the risk of severe hypoglycaemia is lower with degludec regardless of age. Evidence is conclusive only until 74 years of age.

OVERTREATMENT AND HYPOGLYCEMIA PREVALENCE IN GERIATRIC PATIENTS WITH TYPE-2 DIABETES IN THE TURKISH POPULATION

OBJECTIVE

To determine the prevalence of over-treatment and hypoglycemia in Turkish type-2 diabetes patients and to identify the risk factors.

METHODS

Patients ≥ 65 years, having a minimum 5 years of type-2 diabetes, were included in the study. Patients' body mass index, mean HbA1c level, disease onset and medications related with their co-morbidities were recorded. Over-treatment is defined as the use of non-metformin therapies despite having HbA1c levels < 7%. A history of hypoglycemia episodes in the last three months and patients' home blood glucose measurements were recorded. Factors relating to hypoglycemia and over-treatment were analyzed.

RESULTS

After applying criteria, 755 patients were included in the study: 728 patients (96.4%) had at least one comorbidity. 257 patients (34%) were found to have HbA1c levels < 7%. 217 of them (84.4%) were using non-metformin therapies. 497 patients (65.8%) were using insulin. The over-treatment prevalence in the ≥ 65 years group was 28.7%. The over-treatment ratio in ≥ 80 years group was 28.2%. Hypoglycemia prevalence in the last three months was 23.3%. It was 22.7% for patients ≥ 80 years. Mean age, disease duration, body mass index, insulin usage and doses were found to be significantly different in over-treated patients compared to the others.

CONCLUSIONS

This study showed that despite recent guidelines, there is still a considerable amount of over-treated geriatric patients who are at risk of hypoglycemia and related morbidity and mortality. Insulinization rate was high. Physicians should not avoid de-intensifying the treatment of geriatric patients who have multiple co-morbidities.

Type 2 diabetes and cognitive dysfunction in minorities: a review of the literature

OBJECTIVES

The purpose of this review was to summarize the current status of knowledge regarding cognitive dysfunction and diabetes in minorities. Literature on the interaction of cognitive dysfunction and diabetes was analyzed to (a) examine the number and characteristics of studies in minority populations; (b) identify tests used to assess cognitive function in diabetes; (c) consider the impact of diabetes on cognitive function; and (d) assess the moderators of the association between diabetes and cognitive function.

DESIGN

A literature review and thematic analysis was conducted. Studies were mapped to describe their design, target population, instruments used, and the physiologic, psychosocial, and socioeconomic findings related to cognitive function and diabetes. Twelve studies met the inclusion criteria.

RESULTS

Hispanics were studied more than any other ethnic group. Rates and degree of cognitive dysfunction were more prevalent in minorities than non-Hispanic whites. Overall, 28 different tests were administered to evaluate cognitive function. There was some variation among findings regarding the relationship of cognitive function and diabetes. Risk for cognitive decline was associated with the diagnosis of diabetes alone, regardless of whether the diabetes was treated or untreated. Higher rates of discrimination were associated with greater cognitive decline Conclusion: Given the context of minority health, there is a potential for higher negative health impact due to the increased prevalence of diabetes and cognitive dysfunction and other related health disparities. Reduction of physiological risk factors for diabetes, consistency in assessment, as well as elimination of structural barriers such as access to care should be helpful in decreasing the incidence of both diabetes and cognitive decline. More research is needed to determine whether the observed differences are modifiable and to identify factors involved in the interaction of diabetes and cognitive decline-not only physiological factors, but factors related to socioeconomic status and quality of life.

Multiple Antihyperglycemic Drug Use is Associated with Undernutrition Among Older Adults with Type 2 Diabetes Mellitus: A Cross-Sectional Study

INTRODUCTION

Undernutrition is prevalent in older age. Current management of type 2 diabetes mellitus (T2DM) requires modified diet patterns; however, older adults with diabetes may also be at the risk of undernutrition due to age, disease, and medication-related factors. Our objectives in this study were to examine the proportion and associations of undernutrition among community-dwelling older adults with T2DM.

METHODS

This prospective, cross-sectional study involved older outpatient adults (≥ 65 years) with and without T2DM. We assessed the nutritional status using the Mini Nutritional Assessment-Short Form. Undernutrition referred to being either at risk of malnutrition or malnourished. Variables independently associated with undernutrition were evaluated by logistic regression analysis.

RESULTS

Five hundred forty-six older adults [n = 215 with T2DM and n = 331 control; mean (SD) age, 74.9 (6.3) years; 388 (71.1%) female] were included in the study. The frequency of undernutrition was 31.1%, which was higher in patients with T2DM than in those without (36.7% vs. 27.5%, p < 0.05). However, the difference was no longer significant after adjustment for covariates (gender, lower education, lower body mass index, cardiovascular disease, multimorbidity, cognitive performance, functional performance, depressive symptoms, and polypharmacy). In the T2DM group, the ratio of multiple antihyperglycemic drug use (≥ 2) was higher in those with undernutrition compared with normal nutritional status (78.5% vs. 59.6%, p = 0.005). On multivariable analysis, decreased functional performance, depressive symptoms, and use of multiple antihyperglycemic drugs were associated with undernutrition in patients with T2DM.

CONCLUSIONS

Undernutrition was more common among older adults with T2DM compared with the control group. Undernutrition was further dependent on chronic conditions and diabetes management.

Differences in National Diabetes Treatment Patterns and Trends between Older and Younger Adults

BACKGROUND/OBJECTIVES

The treatment of type 2 diabetes in older adults requires special considerations including avoidance of hypoglycemia, yet variation in diabetes treatment with aging is not well understood. In this study, we compared nationally representative diabetes treatment patterns and trends between older adults (≥65 y) and younger adults (30-64 y).

DESIGN

Repeated cross-sectional physician surveys from 2006 to 2015.

SETTING

The National Ambulatory Medical Care Survey, an annual probability sample of visits to office-based US physicians.

PARTICIPANTS

Adults with type 2 diabetes using one or more diabetes medications.

MEASUREMENTS

Proportions of visits in which patients treated with each diabetes medication class were compared between older and younger adults in 2-year intervals.

RESULTS

From 2006 to 2015, the average number of yearly visits for older and younger adults was 25.4 million and 24.2 million, respectively. In 2014-2015, visits for older compared with younger adults involved less use of metformin (56.0% vs 70.0%; p < .001) and glucagon-like peptide 1 receptor agonists (2.9% vs 6.2%; p = .004), and more use of long-acting insulin (30.2% vs 22.4%; p = .017); other classes were used similarly. During the study period, long-acting insulin use increased markedly in older adults, particularly between 2010 and 2015 where it rose from 12.5% to 30.2% of visits (P-trend <.001). In younger adult visits, long-acting insulin use increased modestly (17.2% to 22.4%) and at a slower rate compared with older adult visits (p < .001).

CONCLUSION

The ambulatory treatment of type 2 diabetes differs between older and younger adults, with the treatment of older adults characterized by low use of newer diabetes medications and a greater and rapidly increasing use of long-acting insulin. These findings call for further research clarifying the comparative effectiveness and safety of newer diabetes medications and long-acting insulin to optimize diabetes care for older patients. J Am Geriatr Soc 67:1066-1073, 2019.

Efficacy and safety of insulin glargine/lixisenatide (iGlarLixi) fixed-ratio combination in older adults with type 2 diabetes

AIMS

This study assessed the efficacy and safety of iGlarLixi (a titratable, fixed-ratio combination of insulin glargine [iGlar] plus lixisenatide) in older patients with type 2 diabetes.

METHODS

This post hoc analysis used patient-level data from patients aged ≥65 years from the phase III LixiLan-O and LixiLan-L studies, which compared iGlarLixi with iGlar and lixisenatide (LixiLan-O only). Efficacy endpoints were changes in glycated hemoglobin A1C, fasting plasma glucose, postprandial glucose, weight, and achievement of A1C <7.0% (53 mmol/mol). Safety measures included incidence of documented symptomatic hypoglycemia (defined as typical symptoms of hypoglycemia plus self-measured plasma glucose ≤70 mg/dL [3.9 mmol/L]), severe hypoglycemia (requiring assistance of another person), and incidence of gastrointestinal adverse events. Results were compared with those from patients aged <65 years.

RESULTS

In both trials, older patients treated with iGlarLixi achieved significantly greater reductions in A1C at Week 30 than comparators. Treatment with iGlarLixi mitigated insulin-associated weight gain and lixisenatide-associated gastrointestinal events. Results were largely comparable between patients aged ≥65 versus <65 years.

CONCLUSIONS

iGlarLixi provides significant improvements in glycemic control in patients aged ≥65 years without increasing hypoglycemia risk. As a once-daily injection, it simplifies treatment regimens and may contribute to improved adherence in this patient population.

Management of hypoglycemia in older adults with type 2 diabetes

Treatment of older adults with type 2 diabetes (T2D) is complex because they represent a heterogeneous group with a broad range of comorbidities, functional abilities, socioeconomic status, and life expectancy. Older adults with T2D are at high risk of recurring hypoglycemia, a condition associated with marked morbidity and mortality, because their counter-regulatory mechanism to hypoglycemia is attenuated, and recurring hypoglycemic episodes can lead to hypoglycemia unawareness. In addition, polypharmacy, a result of multiple chronic comorbidities (including heart disease, stroke, and chronic kidney disease), can increase the risk of severe hypoglycemia, especially when patients are taking sulfonylureas or insulin. Often the signs of hypoglycemia are nonspecific (sweating, dizziness, confusion, visual disturbances) and are mistaken for neurological symptoms or dementia. Consequences of hypoglycemia include acute and long-term cognitive changes, cardiac arrhythmia and myocardial infarction, serious falls, frailty, and death, often resulting in hospitalization, which come at a high economic cost. The American Diabetes Association has recently added three new recommendations regarding hypoglycemia in the elderly, highlighting individualized pharmacotherapy with glucose-lowering agents with a low risk of hypoglycemia and proven cardiovascular safety, avoidance of overtreatment, and simplifying treatment regimens while maintaining HbA1c targets. Thus, glycemic goals can be relaxed in the older population as part of individualized care, and physicians must make treatment decisions that best serve their patients' circumstances. This article highlights the issues faced by older people with T2D, the risk factors for hypoglycemia in this population, and the challenges faced by health care providers regarding glycemic management in this patient group.

Designing for implementation: user-centered development and pilot testing of a behavioral economic-inspired electronic health record clinical decision support module

Background

Current guidelines recommend less aggressive target hemoglobin A1c (HbA1c) levels based on older age and lower life expectancy for older adults with diabetes. The effectiveness of electronic health record (EHR) clinical decision support (CDS) in promoting guideline adherence is undermined by alert fatigue and poor workflow integration. Integrating behavioral economics (BE) and CDS tools is a novel approach to improving adherence to guidelines while minimizing clinician burden.

Methods

We will apply a systematic, user-centered design approach to incorporate BE “nudges” into a CDS module and will perform user testing in two “vanguard” sites. To accomplish this, we will conduct (1) semi-structured interviews with key informants (n = 8), (2) a 2-h, design-thinking workshop to derive and refine initial module ideas, and (3) semi-structured group interviews at each site with clinic leaders and clinicians to elicit feedback on three proposed nudge module components (navigator section, inbasket refill protocol, medication preference list). Detailed field notes will be summarized by module idea and usability theme for rapid iteration. Frequency of firing and user action taken will be assessed in the first month of implementation via EHR reporting to confirm that module components and related reporting are working as expected as well as assess utilization. To assess the utilization and feasibility of the new tools and generate estimates of clinician compliance with the Choosing Wisely guideline for diabetes management in older adults, a 6-month, single-arm pilot study of the BE-EHR module will be conducted in six outpatient primary care clinics.

Discussion

We hypothesize that a low burden, user-centered approach to design will yield a BE-driven, CDS module with relatively high utilization by clinicians. The resulting module will establish a platform for exploring the ability of BE concepts embedded within the EHR to affect guideline adherence for other use cases.

Electronic supplementary material

The online version of this article (10.1186/s40814-019-0403-z) contains supplementary material, which is available to authorized users.

Diabetes and Aging: From Treatment Goals to Pharmacologic Therapy

Diabetes is becoming one of the most widespread health burning problems in the elderly. Worldwide prevalence of diabetes among subjects over 65 years was 123 million in 2017, a number that is expected to double in 2045. Old patients with diabetes have a higher risk of common geriatric syndromes, including frailty, cognitive impairment and dementia, urinary incontinence, traumatic falls and fractures, disability, side effects of polypharmacy, which have an important impact on quality of life and may interfere with anti-diabetic treatment. Because of all these factors, clinical management of type 2 diabetes in elderly patients currently represents a real challenge for the physician. Actually, the optimal glycemic target to achieve for elderly diabetic patients is still a matter of debate. The American Diabetes Association suggests a HbA1c goal <7.5% for older adults with intact cognitive and functional status, whereas, the American Association of Clinical Endocrinologists (AACE) recommends HbA1c levels of 6.5% or lower as long as it can be achieved safely, with a less stringent target (>6.5%) for patients with concurrent serious illness and at high risk of hypoglycemia. By contrast, the American College of Physicians (ACP) suggests more conservative goals (HbA1c levels between 7 and 8%) for most older patients, and a less intense pharmacotherapy, when HbA1C levels are ≤6.5%. Management of glycemic goals and antihyperglycemic treatment has to be individualized in accordance to medical history and comorbidities, giving preference to drugs that are associated with low risk of hypoglycemia. Antihyperglycemic agents considered safe and effective for type 2 diabetic older patients include: metformin (the first-line agent), pioglitazone, dipeptidyl peptidase 4 inhibitors, glucagon-like peptide 1 receptor agonists. Insulin secretagogue agents have to be used with caution because of their significant hypoglycemic risk; if used, short-acting sulfonylureas, as gliclazide, or glinides as repaglinide, should be preferred. When using complex insulin regimen in old people with diabetes, attention should be paid for the risk of hypoglycemia. In this paper we aim to review and discuss the best glycemic targets as well as the best treatment choices for older people with type 2 diabetes based on current international guidelines.

The Role of Deprescribing in Older Adults with Chronic Kidney Disease

Older adults with chronic kidney disease (CKD) often experience polypharmacy, a recognized predictor of prescribing problems including inappropriately dosed medications, drug-drug and drug-disease interactions, morbidity and mortality. Polypharmacy is also associated with nonadherence, which leads to recurrent hospitalizations and poorer hemodialysis outcomes in CKD patients. Further complicating medication management in this vulnerable population are the physiologic changes that occur with both age and CKD. This guide for pharmacists and prescribers offers considerations in medication evaluation and management among older adults with CKD. Careful prescribing with the aid of tools such as the American Geriatrics Society Beers Criteria can support safe medication use and appropriate prescribing. Polypharmacy may be systematically addressed through 'deprescribing,' an evidence-based process that enables identification and elimination of unnecessary or inappropriate medications. Detailed guidance for deprescribing in older adults with CKD has not been published previously. We highlight three specific targets for medication optimization and deprescribing in older adults with CKD: (1) proton pump inhibitors, (2) oral hypoglycemic agents, including newer classes of agents, and (3) statins. These medication classes have been chosen as they represent three of the most commonly prescribed classes of medications in the United States. For each area, we review considerations for medication use in older adults with CKD and provide strategies to avoid, modify, or discontinue these medications when clinically indicated. By utilizing deprescribing techniques, pharmacists are well positioned to help decrease the medication burden in older adults with CKD, thereby potentially reducing the risk of morbidity and mortality associated with polypharmacy.

Impact of Diabetes Mellitus on the Presentation and Response to Treatment of Adults With Pulmonary Tuberculosis in Qatar

BACKGROUND

Persons with diabetes mellitus (DM) have a 3-fold increased risk of tuberculosis (TB). Atypical radiographic findings and differences in bacteriologic response during anti-TB treatment have been reported in earlier studies; however, the findings have varied. We evaluated the effect of DM on manifestations and response to treatment in adults with pulmonary TB in Qatar.

METHODS

The impact of DM on the clinical and radiographic presentations of pulmonary TB and bacteriologic response during anti-TB treatment was evaluated between January 2007 and December 2011, comparing patients with and without DM. This is a retrospective unmatched case-control study conducted at a large national hospital. Cases and controls were randomly selected from patients diagnosed with pulmonary TB over a 5-year period. Sputum culture conversion was assessed after 2 months of anti-TB treatment.

RESULTS

Clinical symptoms were similar between patients with and without DM. Patients with DM had a higher initial sputum acid-fast bacillus (AFB) smear grade and were less likely to have cavitary lesions on initial chest radiographs than patients without DM. Of 134 adults with DM and TB, 71 (53%) remained sputum culture positive after 2 months of anti-TB treatment, compared with 36 (27%) patients without DM.

CONCLUSIONS

DM was associated with atypical radiographic findings and delayed sputum culture conversion at 2 months in adults with pulmonary TB in Qatar. Increased health education of patients with DM about symptoms of TB, low thresholds for evaluation for active TB, and close monitoring of bacteriologic response to treatment among patients with TB and DM are warranted.

12. Older Adults: Standards of Medical Care in Diabetes-2019

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Neighborhood Environment and Disparities in Health Care Access Among Urban Medicare Beneficiaries With Diabetes: A Retrospective Cohort Study

Older adults' health is sensitive to variations in neighborhood environment, yet few studies have examined how neighborhood factors influence their health care access. This study examined whether neighborhood environmental factors help to explain racial and socioeconomic disparities in health care access and outcomes among urban older adults with diabetes. Data from 123 233 diabetic Medicare beneficiaries aged 65 years and older in New York City were geocoded to measures of neighborhood walkability, public transit access, and primary care supply. In 2008, 6.4% had no office-based "evaluation and management" (E&M) visits. Multilevel logistic regression indicated that this group had greater odds of preventable hospitalization in 2009 (odds ratio = 1.31; 95% confidence interval: 1.22-1.40). Nonwhites and low-income individuals had greater odds of a lapse in E&M visits and of preventable hospitalization. Neighborhood factors did not help to explain these disparities. Further research is needed on the mechanisms underlying these disparities and older adults' ability to navigate health care. Even in an insured population living in a provider-dense city, targeted interventions may be needed to overcome barriers to chronic illness care for older adults in the community.

Glycaemic control and mortality in older people with type 2 diabetes: The Fremantle Diabetes Study Phase II

AIM

To investigate whether tight glycaemic control achieved with metformin, insulin or sulphonylurea-based pharmacotherapy increases all-cause mortality in older people with type 2 diabetes.

MATERIALS AND METHODS

We conducted a prospective cohort study of individuals with known diabetes recruited between 2008 and 2011 and followed until 2016. The impact of baseline glycated haemoglobin (HbA1c) on mortality hazards was investigated in participants aged ≥75 years. Proportional hazards models for time to death were constructed from the baseline clinical assessment, then the variables of interest (HbA1c, treatment category and their interactions) were entered.

RESULTS

There were 367 participants (mean age 80.1 ± 3.9 years, median [interquartile range] HbA1c 50 [45-56] mmol/mol or 6.7 [6.3-7.3]%) who were followed for a median (interquartile range) 6.7 (4.5-7.7) years, during which 40.9% of the participants died. At baseline, 60.4% were on metformin-based treatment, 35.3% on sulphonylurea-based treatment and 23.2% on treatment including insulin. Baseline HbA1c was significantly associated with mortality in a model that included interactions between HbA1c and the three treatment-based groups compared with non-pharmacological treatment. The metformin treatment group had higher mortality when HbA1c levels were <48 mmol/mol (<6.5%) and the sulphonylurea and insulin treatment groups had higher mortality when HbA1c levels were <52 mmol/mol (<7.0%), with hazard ratios of 2.63 (95% confidence interval [CI] 1.39-4.97), 2.49 (95% CI 1.14-5.44) and 2.22 (95% CI 1.12-4.43), respectively.

CONCLUSIONS

Tight glycaemic control may be hazardous in older people with type 2 diabetes when achieved with pharmacotherapy with metformin, and especially with insulin or sulphonylureas. These data confirm that overtreatment is likely to be an important clinical problem in this vulnerable population.

Reduced Glucose Variability With Glucose-Dependent Versus Glucose-Independent Therapies Despite Similar Glucose Control and Hypoglycemia Rates in a Randomized, Controlled Study of Older Patients With Type 2 Diabetes Mellitus

BACKGROUND

Few studies have evaluated continuous glucose monitoring (CGM) in older patients with type 2 diabetes mellitus (T2DM) not using injectable therapy. CGM is useful for investigating hypoglycemia and glycemic variability, which is associated with complications in T2DM.

METHODS

A CGM substudy of Individualized treatMent aPproach for oldER patIents in a randomized trial in type 2 diabetes Mellitus (IMPERIUM)) was conducted. Patients were vulnerable (moderately ill and/or frail) older (≥65 years) individuals with suboptimally controlled T2DM. Strategy A comprised glucose-dependent therapies (n = 26) with a nonsulfonylurea oral antihyperglycemic medication (OAM) and a glucagon-like peptide-1 receptor agonist as the first injectable. Strategy B comprised non-glucose-dependent therapies (n = 21) with sulfonylurea as the preferred OAM and insulin glargine as the first injectable. Primary endpoints were duration and percentage of time spent with blood glucose (BG) ≤70 mg/dL over 24 hours at week 24.

RESULTS

Duration and percentage of time spent with hypoglycemia at ≤70 mg/dL were similar for Strategy A and Strategy B; glycemic control improved similarly in both arms (LSM change in HbA1c at week 24; A = -1.2%, B = -1.4%). Duration and percentage time spent with euglycemia and hyperglycemia were also similar in both arms. However, Strategy A was associated with lower within-day (21.1 ± 1.2 vs 25.1 ± 1.4, P = .046) and between-day (5.4 ± 1.0 vs 9.1 ± 1.3, P = .038) BG variability (coefficient of variance [LSM ± SE]) at week 24.

CONCLUSIONS

This CGM substudy in older patients with T2DM showed lower within- and between-day BG variability with glucose-dependent therapies but similar HbA1c reductions and hypoglycemia duration with glucose-independent strategies.

Older Adults' Preferences for Discussing Long-Term Life Expectancy: Results From a National Survey

PURPOSE

Clinical practice guidelines recommend incorporating long-term life expectancy to inform a number of decisions in primary care. We aimed to examine older adults' preferences for discussing life expectancy in a national sample.

METHODS

We invited 1,272 older adults (aged 65 or older) from a national, probability-based online panel to participate in 2016. We presented a hypothetical patient with limited life expectancy who was not imminently dying. We asked participants if they were that patient, whether they would like to talk with the doctor about how long they may live, whether it was acceptable for the doctor to offer this discussion, whether they want the doctor to discuss life expectancy with family or friends, and when it should be discussed.

RESULTS

The 878 participants (69.0% participation rate) had a mean age of 73.4 years. The majority, 59.4%, did not want to discuss how long they might live in the presented scenario. Within this group, 59.9% also did not think that the doctor should offer the discussion, and 87.7% also did not want the doctor to discuss life expectancy with family or friends. Fully 55.8% wanted to discuss life expectancy only if it were less than 2 years. Factors positively associated with wanting to have the discussion included higher educational level, believing that doctors can accurately predict life expectancy, and past experience with either a life-threatening illness or having discussed life expectancy of a loved one. Reporting that religion is important was negatively associated.

CONCLUSIONS

The majority of older adults did not wish to discuss life expectancy when we depicted a hypothetical patient with limited life expectancy. Many also did not want to be offered discussion, raising a dilemma for how clinicians may identify patients' preferences regarding this sensitive topic.

Risk of hypoglycaemia in people aged ≥65 years receiving linagliptin: pooled data from 1489 individuals with type 2 diabetes mellitus

AIMS

To investigate the risk of hypoglycaemia in people aged ≥65 years with type 2 diabetes mellitus (T2DM) treated with linagliptin, in the largest pooled analysis performed to date.

MATERIALS AND METHODS

One thousand four hundred and eighty-nine patients aged ≥65 years with T2DM were pooled from 11 randomised, double-blind, parallel group, placebo-controlled trials evaluating linagliptin 5 mg alone, or in addition to various background therapies. The primary safety endpoint was the incidence of investigator-defined hypoglycaemia.

RESULTS

There was no significant difference in the risk of hypoglycaemia between linagliptin and placebo in the all-patient population at 24 weeks (hazard ratio [HR] 1.07; 95% confidence interval [CI]: 0.84, 1.36; P = 0.5943)-despite significant (P < 0.0001) improvements in glycaemic control-and 1 year (HR 1.02; 95% CI: 0.81, 1.27; P = 0.8803). Similar findings were observed for linagliptin vs placebo in subgroup analyses by background medication (eg, sulphonylureas (SUs) and/or insulin vs no such drugs), age, baseline glycated haemoglobin (HbA1c), ethnicity, and baseline estimated glomerular filtration rate. Patients with a baseline HbA1c ≥7.5% had significantly higher odds of achieving HbA1c <7.5% without hypoglycaemia in the linagliptin group compared with placebo at 24 weeks (34.1% vs 13.7%; 95% CI: 2.04, 4.12; P < 0.0001).

CONCLUSIONS

This pooled analysis indicates that linagliptin was effective in treating older people with T2DM towards their HbA1c targets with a favourable safety and tolerability profile and low risk of hypoglycaemia. The safety profile was maintained even on background therapies with known risk of hypoglycaemia, such as insulin and SU.

The impact of cognitive impairment in dementia on self-care domains in diabetes: A systematic search and narrative review

Self-management is integral to effective chronic disease management. Cognitive impairments (CogImp) associated with dementia have not previously been reviewed in diabetes mellitus (DM) self-care. The aims of this study are to know (1) whether CogImp associated with dementia impact self-care and (2) whether specific CogImp affects key DM self-care processes. A systematic literature search with a narrative review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. This review examined studies published from January, 2000 to February, 2016 describing the relationship between cognition and DM self-care domains in community dwelling older adults with dementia/CogImp. Eight studies met inclusion criteria. Decrements in all self-care domains were associated with CogImp. Problem solving was related to reduced disease knowledge (OR 0.87, 95% CI = 0.49-1.55), resulting in poorer glycemic control. Decision-making impairments manifested as difficulties in adjusting insulin doses, leading to more hospital admissions. People without CogImp were better able to find/utilize resources by adhering to recommended management (OR 1.03, 95% CI = 1.02-1.05). A lack of interaction with health care providers was demonstrated through reduced receipt of important routine investigation including eye examinations (ARR = 0.85, 95% CI = 0.85-0.86), HbA1c testing (ARR = 0.96, 95% CI = 0.96-0.97), and LDL-C testing (ARR = 0.91, 95% CI = 0.901-0.914). People without CogImp had better clinic attendance (OR 2.17, 95% CI = 1.30-3.70). Action taking deficits were apparent through less self-testing of blood sugar levels (20.2% vs 24.4%, P = 0.1) resulting in poorer glycemic control, self-care, and more frequent micro/macrovascular complications. Persons with diabetes and CogImp, particularly in domains of learning, memory and executive function, were significantly impaired in all self-care tasks.

Burden of Illness in Type 2 Diabetes Mellitus

An estimated 30.2 million Americans have diabetes, and this number is expected to increase based on trends over recent decades and compounded by an aging U.S.

POPULATION

As reviewed in this article, type 2 diabetes mellitus (T2DM) is associated with impaired health-related quality of life (HRQoL) and with a substantial socioeconomic burden. Compared with individuals without T2DM, those with T2DM have worse HRQoL, greater decrements in HRQoL over time, and possibly greater depressive symptomology. Diabetes-related complications and comorbidities (e.g., obesity and cardiovascular disease) are associated with worse HRQoL. Hypoglycemic episodes are associated with reduced HRQoL and greater levels of depression; they can also interfere with social and occupational activities. In turn, low HRQoL can be a driver for poor glycemic control. In 2012, the total estimated cost associated with diagnosed diabetes in the United States was $245 billion. Factors contributing to increased health care resource utilization and costs in patients with T2DM include medical comorbidities, diabetes-related complications, inadequate glycemic control, and hypoglycemic episodes. Readmission is a key driver of hospital-related costs and is more common among elderly patients with T2DM. Elderly patients with T2DM represent a particularly vulnerable population given that these patients may have varying degrees of physical and mental comorbidities that can increase their risk of hypoglycemia, falls, and depression. This review demonstrates that T2DM imposes a considerable burden on both the individual and society. Treatment strategies should consider the effects of treatment on HRQoL and on outcomes (e.g., complications and hypoglycemia) that affect both HRQoL and costs. Management strategies that maximize HRQoL while minimizing the risk of hypoglycemia and other treatment-related complications are particularly critical in the elderly.

DISCLOSURES

This supplement was funded by Novo Nordisk. Cannon reports speaker fees and owns stock in Novo Nordisk. Handelsman reports research grants from Amgen, AstraZeneca, Bristol-Myers Squibb, Boehringer Ingelheim, Grifols, Janssen, Lexicon, Merck, Novo Nordisk, Regeneron, and Sanofi; speaker fees from Amarin, Amgen, AstraZeneca, Boehringer Ingelheim-Lilly, Janssen, Merck, Novo Nordisk, Regeneron, and Sanofi; and has served in advisory capacity to Amarin, Amgen, AstraZeneca, Boehringer Ingelheim, Eisai, Intarcia, Janssen, Lilly, Merck, Merck-Pfizer, Novo Nordisk, Regeneron, and Sanofi. Heile reports speaker fees from and has served as advisor to Novo Nordisk. Shannon reports consultant and speaker fees from Novo Nordisk and Boehringer Ingelheim-Lilly Alliance.

Effect of collaborative depression treatment on risk for diabetes: A 9-year follow-up of the IMPACT randomized controlled trial

Considerable epidemiologic evidence and plausible biobehavioral mechanisms suggest that depression is an independent risk factor for diabetes. Moreover, reducing the elevated diabetes risk of depressed individuals is imperative given that both conditions are leading causes of death and disability. However, because no prior study has examined clinical diabetes outcomes among depressed patients at risk for diabetes, the question of whether depression treatment prevents or delays diabetes onset remains unanswered. Accordingly, we examined the effect of a 12-month collaborative care program for late-life depression on 9-year diabetes incidence among depressed, older adults initially free of diabetes. Participants were 119 primary care patients [M (SD) age: 67.2 (6.9) years, 41% African American] with a depressive disorder but without diabetes enrolled at the Indiana sites of the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) trial. Incident diabetes cases were defined as diabetes diagnoses, positive laboratory values, or diabetes medication prescription, and were identified using electronic medical record and Medicare/Medicaid data. Surprisingly, the rate of incident diabetes in the collaborative care group was 37% (22/59) versus 28% (17/60) in the usual care group. Even though the collaborative care group exhibited greater reductions in depressive symptom severity (p = .024), unadjusted (HR = 1.29, 95% CI: 0.69-2.43, p = .428) and adjusted (HR = 1.18, 95% CI: 0.61-2.29, p = .616) Cox proportional hazards models indicated that the risk of incident diabetes did not differ between the treatment groups. Our novel preliminary findings raise the possibility that depression treatment alone may be insufficient to reduce the excess diabetes risk of depressed, older adults.

HbA1c and hypoglycaemia in intensively treated type 2 diabetes: a retrospective cohort study in primary care

Objective

To establish whether low HbA1c is associated with clinical hypoglycaemia among people with type 2 diabetes prescribed insulins or sulphonylureas.

Design

Retrospective cohort study using routine electronic GP health records collected between January 2013 and December 2015.

Setting

Three east London Clinical Commissioning Groups.

Participants

Two cohorts of adults with type 2 diabetes prescribed either (i) insulins with or without other oral antidiabetic medication (n = 6788, 36.4%) or (ii) sulphonylureas with or without other oral antidiabetic medications excluding insulins (n = 11,840, 63.6%).

Main outcome measures

First clinically recorded hypoglycaemia and all-cause mortality. Hazard ratios (HR) adjusting for age, ethnicity, renal function and comorbidities were calculated using Cox regression models.

Results

Compared with an HbA1c of 53–63 mmol/mol, the adjusted HR of hypoglycaemia in those with a low HbA1c, below 53 mmol/mol, in the insulin and sulphonylurea cohorts were 1.26 (95% CI, 0.97 to 1.62) and 1.54 (95% CI, 1.27 to 1.87), respectively. Adjusted HRs of all-cause mortality from low HbA1c in the insulin and sulphonylurea cohorts were 1.54 (95% CI, 1.15 to 2.07) and 1.42 (95% CI, 1.11 to 1.81), respectively. Increasing age and renal impairment were also associated with increased hypoglycaemic risk in both cohorts.

Conclusions

HbA1c below 53 mmol/mol was associated with episodes of clinical hypoglycaemia among people with type 2 diabetes prescribed sulphonylureas, and all-cause mortality in those prescribed insulins and sulphonylureas. These findings support the need for reviewing glycaemic targets and the intensities of treatment in those with low HbA1c prescribed insulins or sulphonylureas to reduce the risk of hypoglycaemia.

Incidence rate and patient characteristics of severe hypoglycemia in treated type 2 diabetes mellitus patients in Japan: Retrospective Diagnosis Procedure Combination database analysis

AIMS/INTRODUCTION

To evaluate the incidence rate of and identify factors associated with severe hypoglycemic episodes in patients with treated type 2 diabetes mellitus.

MATERIALS AND METHODS

Using Diagnosis Procedure Combination hospital-based medical database, we carried out a retrospective cohort study to assess the incidence rate of severe hypoglycemia in treated type 2 diabetes mellitus patients. We evaluated the associations between severe hypoglycemia and age, sex, complications, and current use of insulin or sulfonylurea (SU) in a nested case-control study.

RESULTS

Of 166,806 eligible patients, 1,242 had episodes of severe hypoglycemia during the observational period. The incidence rate of the first hypoglycemic events was 3.70/1,000 patient years. Based on the nested case-control analysis, age was associated with hypoglycemic events with adjusted odds ratios (ORs) of 1.64 or 65-74-year-old patients and 3.79 for ≥75-year-old patients in comparison with 20-64-year-old patients. Comorbidities, such as cognitive impairment, cancer, macrovascular disease and diabetic complications (retinopathy, nephropathy and neuropathy), were associated with severe hypoglycemia, with adjusted ORs ranging from 1.25 to 3.80. Severe hypoglycemic events also increased in patients with current use of both SU and insulin, either SU or insulin, with adjusted ORs of 18.36, 6.31 or 14.07, respectively, compared with patients with other antihyperglycemic agents. In patients with an SU glimepiride, adjusted ORs increased dose-dependently from 3.65 (≤1 mg) to 13.34 (>2 mg).

CONCLUSIONS

The incidence rate of severe hypoglycemia in this cohort was 3.70/1,000 patient years. Age, cognitive impairment, cancer, diabetic complications, current use of insulin + SU and SU dosage were identified as risk factors for severe hypoglycemia.

An Analysis of Diabetes Mobile Applications Features Compared to AADE7™: Addressing Self-Management Behaviors in People With Diabetes

BACKGROUND

Diabetes self-management (DSM) applications (apps) have been designed to improve knowledge of diabetes and self-management behaviors. However, few studies have systematically examined if diabetes apps followed the American Association of Diabetes Educators (AADE) Self-Care Behaviors^™ guidelines. The purpose of this study was to compare the features of current DSM apps to the AADE7™ guidelines.

METHODS

In two major app stores (iTunes and Google Play), we used three search terms "diabetes," "blood sugar," and "glucose" to capture a wide range of diabetes apps. Apps were excluded based on five exclusion criteria. A multidisciplinary team analyzed and classified the features of each app based on the AADE7^™. We conducted interviews with six diabetes physicians and educators for their opinions on the distribution of the features of DSM apps.

RESULTS

Out of 1050 apps retrieved, 173 apps were identified as eligible during November 2015 and 137 apps during December 2017. We found an unbalanced DSM app development trend based on AADE7^™ guidelines. Many apps were designed to support the behaviors of Healthy Eating (77%), Monitoring (76%), Taking Medication (58%), and Being Active (45%). On the other hand, few apps explored the behaviors of Problem Solving (31%), Healthy Coping (10%), and Reducing Risks (5%). From interviews, we identified the main reasons why only a few apps support the features related to Problem Solving, Healthy Coping, and Reducing Risks.

CONCLUSIONS

Future diabetes apps should attempt to incorporate features under evidence-based guidelines such as AADE7^™ to better support the self-management behavior changes of people with diabetes.

Factors associated with the use of potentially inappropriate medications by older adults in primary health care: An analysis comparing AGS Beers, EU(7)-PIM List , and Brazilian Consensus PIM criteria

BACKGROUND

Potentially inappropriate medications (PIM) for the older adults are those with an unfavorable risk-benefit ratio when more effective and safe therapeutic alternatives are available and is an important public health problem.

PURPOSE

To analyze the factors associated with the use of PIM by the older adults and to investigate the agreement of PIM use frequency using the 2015 American Geriatric Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults - 2015 AGS Beers Criteria, the Brazilian consensus on potentially inappropriate medication for older adults (BCPIM) and the European union list of potentially inappropriate medications - EU (7)-PIM List.

METHODS

This is a cross-sectional study conducted in two primary health care centers in southeastern Brazil. The 2015 AGS Beers Criteria, BCPIM, and EU (7)-PIM List were used for the classification of PIM. The association between PIM use and independent variables was assessed by multiple logistic regression. The level of agreement of PIM use among the three criteria was measured with the Cohen's kappa coefficient.

RESULTS

A total of 227 patients ≥60 years of age were included in the study. The frequency of PIM use was 53.7% for 2015 AGS Beers, 55.9% for BCPIM and 63.4% for the EU (7)-PIM List. The agreement between 2015 AGS Beers and BCPIM and between this and the EU (7)-PIM List was high, and moderate between the 2015 AGS Beers and the EU (7)-PIM List. Logistic regression showed association of PIM use with polypharmacy, self-reported neuropsychiatric and musculoskeletal diseases, age ≤70 years, preserved cognition and positive self-perception of health.

CONCLUSION

The frequency of PIM use by the older adults of health centers investigated is high. Strategies for improving the pharmacotherapy of the older adults in primary health care should be implemented.

Blood pressure targets for hypertension in patients with type 2 diabetes

BACKGROUND

Clinical guidelines vary in determining optimal blood pressure targets in adults with diabetes mellitus.

METHODS

We systematically searched PubMed, EMBASE, Cochrane Library, and clinicaltrials.gov in March 2018; conducted random effects frequentist meta-analyses of direct aggregate data; and appraised the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

RESULTS

From eligible 14 meta-analyses and 95 publications of randomized controlled trials (RCT), only 6 RCTs directly compared lower versus higher blood pressure targets; remaining RCTs aimed at comparative effectiveness of hypotensive drugs. In adults with diabetes mellitus and elevated systolic blood pressure (SBP), direct evidence (2 RCTs) suggests that intensive target SBP <120-140 mmHg decreases the risk of diabetes-related mortality [relative risk (RR) =0.68; 95% confidence interval (CI), 0.50-0.92], fatal (RR =0.41; 95% CI, 0.20-0.84) or nonfatal stroke (RR =0.60; 95% CI, 0.43-0.83), prevalence of left ventricular hypertrophy and electrocardiogram (ECG) abnormalities, macroalbuminuria, and non-spine bone fractures, with no differences in all-cause or cardiovascular mortality or falls. In adults with diabetes mellitus and elevated diastolic blood pressure (DBP) ≥90 mmHg, direct evidence (2 RCTs) suggests that intensive DBP target ≤80 versus 80-90 mmHg decreases the risk of major cardiovascular events. Published meta-analyses of aggregate data suggested a significant association between lower baseline and attained blood pressure and increased cardiovascular mortality.

CONCLUSIONS

We concluded that in adults with diabetes mellitus and arterial hypertension, in order to reduce the risk of stroke, clinicians should target blood pressure at 120-130/80 mmHg, with close monitoring for all drug-related harms.

Defining and measuring population health quality of outpatient diabetes care in Israel: lessons from the quality indicators in community health program

In Israel, as in other Organization for Economic Co-operation and Development countries, performance measurement is a key public health strategy in monitoring and improving population health outcomes. The Israeli Quality Indicators in Community Healthcare (QICH) program has utilized electronic health records to monitor ambulatory care for the entire Israeli population since 2002. In 2006 the measures were updated to include laboratory values. They have been subsequently revised by stratifying by age, duration, adding medications, and changing frequency of testing for certain process measures. However, the QICH glycemic control measures do not address co-morbid conditions either thru exclusion criteria or higher target ranges. They also do not address potential over treatment in patients with complex medication conditions.

In the United States there have also been changes in nationally endorsed diabetes specific performance measures since 2007. However, there have also been public disagreements among United States professional societies, government agencies, and performance measurement organizations as to whether the current glycemic dichotomous (“all or none”) threshold measures, without exclusion criteria, are consistent with the most recent evidence. Specifically, most guidelines now recommend individualized target goals based upon co-morbid conditions, risk of harms from medications, and patient preferences.

Concerns have been raised that the current glycemic performance measures have resulted in inappropriate care, such as medication over-treatment, and serious harms, such as hypoglycemia, especially in older adults. There currently are no national surveillance systems or measures that monitor these untoward outcomes.

We recommend several actions that QICH could consider to advance diabetes specific performance measurement science and population health: Convene an international conference; implement technical modifications of current measures and surveillance systems; and, most importantly, acknowledge patient autonomy by developing measures that document individualization of target values using shared decision making.

A Randomized Controlled Study Comparing a DPP4 Inhibitor (Linagliptin) and Basal Insulin (Glargine) in Patients With Type 2 Diabetes in Long-term Care and Skilled Nursing Facilities: Linagliptin-LTC Trial

OBJECTIVES

Safe and easily implemented treatment regimens are needed for the management of patients with type 2 diabetes mellitus (T2DM) in long-term care (LTC) and skilled nursing facilities.

DESIGN

This 6-month open-label randomized controlled trial compared the efficacy and safety of a DPP4 inhibitor (linagliptin) and basal insulin (glargine) in LTC residents with T2DM.

SETTINGS

Three LTC institutions affiliated with a community safety-net hospital, US Department of Veterans Affairs and Emory Healthcare System in Atlanta, Georgia.

PARTICIPANTS

A total of 140 residents with T2DM treated with oral antidiabetic agents or low-dose insulin (≤0.1 U/kg/d), with fasting or premeal blood glucose (BG) > 180 mg/dL and/or HbA1c >7.5%.

INTERVENTION

Baseline antidiabetic therapy, except metformin, was discontinued on trial entry. Residents were treated with linagliptin 5 mg/d (n = 67) or glargine at a starting dose of 0.1 U/kg/d (n = 73). Both groups received supplemental rapid-acting insulin before meals for BG > 200 mg/dL.

MEASUREMENTS

Primary outcome was mean difference in daily BG between groups. Main secondary endpoints included differences in frequency of hypoglycemia, glycosylated hemoglobin (HbA1c), complications, emergency department visits, and hospital transfers.

RESULTS

Treatment with linagliptin resulted in no significant differences in mean daily BG (146 ± 34 mg/dL vs. 157 ± 36 mg/dL, P = .07) compared to glargine. Linagliptin treatment resulted in fewer mild hypoglycemic events <70 mg/dL (3% vs. 37%, P < .001), but there were no differences in BG < 54 mg/dL (P = .06) or <40 mg/dL (P = .05) compared to glargine. There were no significant between-group differences in HbA1c, length of stay, complications, emergency department visits, or hospitalizations.

CONCLUSION

Treatment with linagliptin resulted in noninferior glycemic control and in significantly lower risk of hypoglycemia compared to insulin glargine in long-term care and skilled nursing facility residents with type 2 diabetes.

Diabetes in the Elderly

The elderly are an important and distinct yet heterogeneous group of persons living with diabetes. The elderly have a unique biomedical, psychological, and social constitution. Their needs are different from those of younger adults. This implies that special care must be taken while evaluating and planning their nursing and management. Diabetes management in the elderly should focus on prevention and limitation of geriatric syndromes (medical conditions encountered in elderly persons), hypoglycemia (low blood glucose), and neurocognitive dysfunction (impairment in the functioning of the nervous system and brain). This review takes a practical approach to the assessment, nursing care, and medical treatment of diabetes in the elderly. It highlights major challenges and suggests solutions to these commonly encountered clinical problems.

Mismatch between ADA and AGS recommendations for glycated hemoglobin targets for older adults

In recent years, modified glycemic targets have been defined for older adults with diabetes mellitus. In a sample of elderly patients, we have identified several inconsistencies between the real life applicability of glycated hemoglobin goals recommended by the American Diabetes Association and the American Geriatrics Society.

Trends in Diabetes Treatment and Monitoring among Medicare Beneficiaries

BACKGROUND

Diabetes is a costly and common condition, but little is known about recent trends in diabetes management among Medicare beneficiaries.

OBJECTIVE

To evaluate the use of diabetes medications and testing supplies among Medicare beneficiaries.

DESIGN/SETTING

Retrospective cohort analysis of Medicare claims from 2007 to 2014.

PARTICIPANTS

Traditional Medicare beneficiaries with a diagnosis of diabetes in the current or any prior year.

MAIN MEASURES

We analyzed choices of first diabetes medication for those new to medication and patterns of adding medications. We also examined the use of testing supplies, use of statins and ACE inhibitors/angiotensin receptor blockers, and spending.

KEY RESULTS

Diagnosed diabetes increased from 28.7% to 30.2% of beneficiaries from 2007 to 2014. The use of metformin as the most commonly prescribed first medication increased from 50.2% in 2007 to 70.2% in 2014, whereas long-acting sulfonylureas decreased from 16.6% to 8.2%. The use of thiazolidinediones fell considerably, while the use of new diabetes medication classes increased. Among patients prescribed insulin, long-acting insulin as the first choice increased substantially, from 38.9% to 56.8%, but short-acting or combination regimens remained common, particularly among older or sicker beneficiaries. Prescriptions of testing supplies for more than once-daily testing were also common. The mean total cost of diabetes medications per patient increased over the period due to the increasing use of high-cost drugs, particularly by those patients with costs above the 90th percentile of spending, although the median costs decreased for both medications and testing supplies.

CONCLUSIONS

The use of metformin and long-acting insulin have increased substantially among elderly Medicare patients with diabetes, but a substantial subgroup continues to receive costly and complex treatment regimens.

Using Shared Decision-Making to Address Possible Overtreatment in Patients at High Risk for Hypoglycemia: The Veterans Health Administration's Choosing Wisely Hypoglycemia Safety Initiative

IN BRIEF Successful management of patients with diabetes requires individualizing A1C and treatment goals in conjunction with identifying and managing hypoglycemia risk. This article describes the Veterans Health Administration's Choosing Wisely Hypoglycemia Safety Initiative (CW-HSI), a voluntary program that aims to reduce the occurrence of hypoglycemia through shared decision-making about deintensifying diabetes treatment in a dynamic cohort of patients identified as being at high risk for hypoglycemia and potentially overtreated. The CW-HSI incorporates education for patients and clinicians, as well as clinical decision support tools, and has shown decreases in the proportions of high-risk patients potentially overtreated and impacts on the frequency of reported hypoglycemia.

Patient-Centered Guidelines for Geriatric Diabetes Care: Potential Missed Opportunities to Avoid Harm

BACKGROUND

Clinicians strive to deliver individualized, patient-centered care. However, these intentions are understudied. This research explores how patient characteristics associated with an high risk-to-benefit ratio with hypoglycemia medications affect decision making by primary care clinicians.

METHODS

Using a vignette-based survey, we queried primary care clinicians on their intended management of geriatric patients with diabetes. The patients' ages, disease durations, and comorbidities were systematically varied. Clinicians indicated whether they would intensify glycemic control by adding a second-line hypoglycemia medication.

RESULTS

A convenience sample of 336 primary care clinicians completed the survey. Despite the recommendations for HbA_1c targets <8% for more complex patients, an 80-year-old woman with an HbA_1c of 7.5%, longstanding diabetes, coronary disease, and cognitive impairment and with instrumental activity of daily living dependencies, had a predicted probability of treatment intensification of 35%. Internists were 11% and nurse practitioners were 14% more likely to intensify treatment than family physicians (P < .01). These provider differences remained significant after controlling for geographic differences in treatment intensification. Providers in Florida were more likely to intensify treatment (P < .01).

CONCLUSIONS

Primary care clinicians often chose to intensify glycemic control despite individual patient factors that warrant higher glycemic targets based on existing guidelines. This research identifies possible missed opportunities for patient-centered goal setting and raises questions about the influence of training and practice environment on clinical decision making.

Glycaemic control and treatment of type 2 diabetes in adults aged 75 years or older

AIM

The aim of this study was to assess glycaemic control and prescribing practices of antihyperglycaemic treatment in patients with diabetes mellitus type 2 aged 75 years or older.

METHODS

We analysed data from health electronic records from 4,581 persons attended at primary healthcare centres of the Institut Català de la Salut (ICS), in the Girona Sud area of Catalonia, Spain, during 2013 and 2016. Variables such as age, gender, body mass index (BMI), diabetes duration, age at diabetes diagnosis, glycated haemoglobin (HbA1c), creatinine, glomerular filtrate rate and the albumin/creatinine ratio in urine were collected. A descriptive analysis of the study variables was done to determinate the percentage of persons on antidiabetic treatment.

RESULTS

We identified 4,421 persons aged 75 years or older who provided data on HbA1c and antidiabetic treatment. Mean age was 82.3 (5.1) years. In 58.1% of patients, the level of HbA1c was below 7.0%, while in 36.8% it was below 6.5%. Between patients with HbA1c below 7.0%, antidiabetic drugs were taken by 70.2%, where 15.2% were either on insulin, sulphonylureas or repaglinide therapy.

CONCLUSION

Intensive treatment among older adults with diabetes mellitus type 2 is common in primary care clinical practice in our area. Intensive glycaemic control confers an increased risk of hypoglycaemia and little benefit among older individuals with diabetes. Physicians should take care more not to harm those populations and treatment should be de-intensified to reduce the risk of hypoglycaemia.

Overtreatment and Deintensification of Diabetic Therapy among Medicare Beneficiaries

BACKGROUND

Deintensification of diabetic therapy is often clinically appropriate for older adults, because the benefit of aggressive diabetes treatment declines with age, while the risks increase.

OBJECTIVE

We examined rates of overtreatment and deintensification of therapy for older adults with diabetes, and whether these rates differed by medical, demographic, and socioeconomic characteristics.

DESIGN, SUBJECTS, AND MAIN MEASURES

We analyzed Medicare claims data from 10 states, linked to outpatient laboratory values to identify patients potentially overtreated for diabetes (HbA1c < 6.5% with fills for any diabetes medications beyond metformin, 1/1/2011-6/30/2011). We examined characteristics associated with deintensification for potentially overtreated diabetic patients. We used multinomial logistic regression to examine whether patient characteristics associated with overtreatment of diabetes differed from those associated with undertreatment (i.e. HbA1c > 9.0%).

KEY RESULTS

Of 78,792 Medicare recipients with diabetes, 8560 (10.9%) were potentially overtreated. Overtreatment of diabetes was more common among those who were over 75 years of age and enrolled in Medicaid (p < 0.001), and was less common among Hispanics (p = 0.009). Therapy was deintensified for 14% of overtreated diabetics. Appropriate deintensification of diabetic therapy was more common for patients with six or more chronic conditions, more outpatient visits, or living in urban areas; deintensification was less common for those over age 75. Only 6.9% of Medicare recipients with diabetes were potentially undertreated. Variables associated with overtreatment of diabetes differed from those associated with undertreatment.

CONCLUSIONS

Medicare recipients are more frequently overtreated than undertreated for diabetes. Medicare recipients who are overtreated for diabetes rarely have their regimens deintensified.

Individualizing Prevention for Older Adults

Prevention can help older adults avoid illness by identifying and addressing conditions before they cause symptoms, but prevention can also harm older adults if conditions that are unlikely to cause symptoms in the individual's lifetime are identified and treated. To identify older adults who preventive interventions are most likely to benefit (and most likely to harm), we propose a framework that compares an individual's life expectancy (LE) with the time to benefit (TTB) for an intervention. If LE is less than the TTB, the individual is unlikely to benefit but is exposed to the risks of the intervention, and the intervention should generally NOT be recommended. If LE is longer than the TTB, the individual could benefit, and the intervention should generally be recommended. If LE is similar to the TTB, the individual's values and preferences should be the major determinant of the decision. To facilitate the use of this framework in routine clinical care, we explored ways to estimate LE, identified the TTB for common preventive interventions, and developed strategies for communicating with individuals. We have synthesized these strategies and demonstrate how they can be used to individualize prevention for a hypothetical beneficiary in the setting of a Medicare annual wellness visit. Finally, we place prevention in the context of curative and symptom-oriented care and outline how prevention should be focused on healthier older adults, whereas symptom-oriented care should predominate in sicker older adults.

Deprescribing antihyperglycemic agents in older persons: Evidence-based clinical practice guideline

OBJECTIVE

To develop an evidence-based guideline to help clinicians make decisions about when and how to safely taper, stop, or switch antihyperglycemic agents in older adults.

METHODS

We focused on the highest level of evidence available and sought input from primary care professionals in guideline development, review, and endorsement processes. Seven clinicians (2 family physicians, 3 pharmacists, 1 nurse practitioner, and 1 endocrinologist) and a methodologist comprised the overall team; members disclosed conflicts of interest. We used a rigorous process, including the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach, for guideline development. We conducted a systematic review to assess evidence for the benefits and harms of deprescribing antihyperglycemic agents. We performed a review of reviews of the harms of continued antihyperglycemic medication use, and narrative syntheses of patient preferences and resource implications. We used these syntheses and GRADE quality-of-evidence ratings to generate recommendations. The team refined guideline content and recommendation wording through consensus and synthesized clinical considerations to address common front-line clinician questions. The draft guideline was distributed to clinicians and stakeholders for review and revisions were made at each stage. A decision-support algorithm was developed to accompany the guideline.

RECOMMENDATIONS

We recommend deprescribing antihyperglycemic medications known to contribute to hypoglycemia in older adults at risk or in situations where antihyperglycemic medications might be causing other adverse effects, and individualizing targets and deprescribing accordingly for those who are frail, have dementia, or have a limited life expectancy.

CONCLUSION

This guideline provides practical recommendations for making decisions about deprescribing antihyperglycemic agents. Recommendations are meant to assist with, not dictate, decision making in conjunction with patients.

[Not Available]

Objectif

Formuler des lignes directrices fondées sur les données probantes afin d’aider les cliniciens à décider du moment et de la façon sécuritaire de réduire la dose des antihyperglycémiants, de mettre fin au traitement ou de passer à un autre agent chez les personnes âgées.

Méthodes

Nous nous sommes concentrés sur les données les plus probantes disponibles et avons cherché à obtenir les commentaires des professionnels de première ligne durant le processus de rédaction, de révision et d’adoption des lignes directrices. L’équipe était formée de 7 professionnels de la santé (2 médecins de famille, 3 pharmaciens, 1 infirmière praticienne et 1 endocrinologue) et d’une spécialiste de la méthodologie; les membres ont divulgué tout conflit d’intérêts. Nous avons eu recours à un processus rigoureux, y compris l’approche GRADE (Grading of Recommendations Assessment, Development and Evaluation) pour formuler les lignes directrices. Nous avons effectué une revue systématique dans le but d’évaluer les données probantes indiquant les bienfaits et les torts liés à la déprescription des antihyperglycémiants. Nous avons révisé les revues des torts liés à la poursuite du traitement antihyperglycémiant, et effectué des synthèses narratives des préférences des patients et des répercussions sur les ressources. Ces synthèses et évaluations de la qualité des données selon l’approche GRADE ont servi à formuler les recommandations. L’équipe a peaufiné le texte sur le contenu et les recommandations des lignes directrices par consensus et a synthétisé les considérations cliniques afin de répondre aux questions courantes des cliniciens de première ligne. Une version préliminaire des lignes directrices a été distribuée aux cliniciens et aux intervenants aux fins d’examen, et des révisions ont été apportées au texte à chaque étape. Un algorithme d’appui décisionnel a été conçu pour accompagner les lignes directrices.

Recommandations

Nous recommandons de déprescrire les antihyperglycémiants reconnus pour contribuer à l’hypoglycémie chez les personnes âgées à risque ou dans les situations où les antihyperglycémiants pourraient causer d’autres effets indésirables, et d’individualiser les cibles et de déprescrire en conséquence chez les personnes frêles, atteintes de démence ou dont l’espérance de vie est limitée.

Conclusion

Les présentes lignes directrices émettent des recommandations pratiques pour décider du moment et de la façon de déprescrire les antihyperglycémiants. Elles visent à contribuer au processus de décision conjointement avec le patient et non à le dicter.

Efficacy and safety of metformin in the management of type 2 diabetes mellitus in older adults: a systematic review for the development of recommendations to reduce potentially inappropriate prescribing

Background

Metformin is usually prescribed as first line therapy for type 2 diabetes mellitus (DM2). However, the benefits and risks of metformin may be different for older people. This systematic review examined the available evidence on the safety and efficacy of metformin in the management of DM2 in older adults. The findings were used to develop recommendations for the electronic decision support tool of the European project PRIMA-eDS.

Methods

The systematic review followed a staged approach, initially searching for systematic reviews and meta-analyses first, and then individual studies when prior searches were inconclusive. The target population was older people (≥65 years old) with DM2. Studies were included if they reported safety or efficacy outcomes with metformin (alone or in combination) for the management of DM2 compared to placebo, usual or no treatment, or other antidiabetics. Using the evidence identified, recommendations were developed using GRADE methodology.

Results

Fifteen studies were included (4 intervention and 11 observational studies). In ten studies at least 80% of participants were 65 years or older and 5 studies reported subgroup analyses by age. Comorbidities were reported by 9 studies, cognitive status was reported by 4 studies and functional status by 1 study. In general, metformin showed similar or better safety and efficacy than other specific or non-specific active treatments. However, these findings were mainly based on retrospective observational studies. Four recommendations were developed suggesting to discontinue the use of metformin for the management of DM2 in older adults with risk factors such as age > 80, gastrointestinal complaints during the last year and/or GFR ≤60 ml/min.

Conclusions

On the evidence available, the safety and efficacy profiles of metformin appear to be better, and certainly no worse, than other treatments for the management of DM2 in older adults. However, the quality and quantity of the evidence is low, with scarce data on adverse events such as gastrointestinal complaints or renal failure. Further studies are needed to more reliably assess the benefits and risks of metformin in very old (>80), cognitively and functionally impaired older people.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-017-0574-5) contains supplementary material, which is available to authorized users.

Effectiveness and safety of dipeptidyl peptidase 4 inhibitors in the management of type 2 diabetes in older adults: a systematic review and development of recommendations to reduce inappropriate prescribing

Background

Preventable drug-related hospital admissions can be associated with drugs used in diabetes and the benefits of strict diabetes control may not outweigh the risks, especially in older populations. The aim of this study was to look for evidence on risks and benefits of DPP-4 inhibitors in older adults and to use this evidence to develop recommendations for the electronic decision support tool of the PRIMA-eDS project.

Methods

Systematic review using a staged approach which searches for systematic reviews and meta-analyses first, then individual studies only if prior searches were inconclusive. The target population were older people (≥65 years old) with type 2 diabetes. We included studies reporting on the efficacy and/or safety of DPP-4 inhibitors for the management of type 2 diabetes. Studies were included irrespective of DPP-4 inhibitors prescribed as monotherapy or in combination with any other drug for the treatment of type 2 diabetes. The target intervention was DPP-4 inhibitors compared to placebo, no treatment, other drugs to treat type 2 diabetes or a non-pharmacological intervention.

Results

Thirty studies (reported in 33 publications) were included: 1 meta-analysis, 17 intervention studies and 12 observational studies. Sixteen studies were focused on older adults and 14 studies reported subgroup analyses in participants ≥65, ≥70, or ≥75 years. Comorbidities were reported by 26 studies and frailty or functional status by one study. There were conflicting findings regarding the effectiveness of DPP-4 inhibitors in older adults. In general, DPP-4 inhibitors showed similar or better safety than placebo and other antidiabetic drugs. However, these safety data are mainly based on short-term outcomes like hypoglycaemia in studies with HbA1c control levels recommended for younger people. One recommendation was developed advising clinicians to reconsider the use of DPP-4 inhibitors for the management of type 2 diabetes in older adults with HbA1c <8.5% because of scarce data on clinically relevant benefits of their use. Twenty-two of the included studies were funded by pharmaceutical companies and authored or co-authored by employees of the sponsor.

Conclusions

Other than the surrogate endpoint of improved glycaemic control, data on clinically relevant benefits of DPP-4 inhibitors in the treatment of type 2 diabetes mellitus in older adults is scarce. DPP-4 inhibitors might have a lower risk of hypoglycaemia compared to other antidiabetic drugs but data show conflicting findings for long-term benefits. Further studies are needed that evaluate the risks and benefits of DPP-4 inhibitors for the management of type 2 diabetes mellitus in older adults, using clinically relevant outcomes and including representative samples of older adults with information on their frailty status and comorbidities. Studies are also needed that are independent of pharmaceutical company involvement.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-017-0571-8) contains supplementary material, which is available to authorized users.