Essential steps in primary care management of older people with Type 2 diabetes: an executive summary on behalf of the European geriatric medicine society (EuGMS) and the European diabetes working party for older people (EDWPOP) collaboration

We present an executive summary of a guideline for management of type 2 diabetes mellitus in primary care written by the European Geriatric Medicine Society, the European Diabetes Working Party for Older People with contributions from primary care practitioners and participation of a patient's advocate. This consensus document relies where possible on evidence-based recommendations and expert opinions in the fields where evidences are lacking. The full text includes 4 parts: a general strategy based on comprehensive assessment to enhance quality and individualised care plan, treatments decision guidance, management of complications, and care in case of special conditions. Screening for frailty and cognitive impairment is recommended as well as a comprehensive assessment all health conditions are concerned, including end of life situations. The full text is available online at the following address: essential_steps_inprimary_care_in_older_people_with_diabetes_-_EuGMS-EDWPOP___3_.pdf.

Hypoglycemia in Older Adults: Time Trends and Treatment Differences in Patients Aged ≥75 Years With Type 2 Diabetes

OBJECTIVES

Hypoglycemia is a potentially life-threatening drug event under antidiabetic treatment. The aim of the study was to examine time trends in severe hypoglycemia in older adults with type 2 diabetes mellitus (T2DM) and antidiabetic treatment.

DESIGN

Multicenter prospective diabetes patient follow-up registry (DPV).

SETTING AND PARTICIPANTS

Patients aged ≥75 years with T2DM and documented treatment between 2005 and 2019.

METHODS

Outcomes of interest were rates of severe hypoglycemia, diabetes therapy, body mass index, HbA1c, and estimated glomerular filtration rate. Time trends of outcomes were analyzed in the whole cohort and compared between age groups (75-<80, 80-<85, ≥85 years).

RESULTS

A total of 136,931 patients from 188 diabetes centers were included. The adjusted HbA1c decreased from 7.3% (95% confidence interval 7.3-7.4) in 2005 to 7.2% (7.2-7.2) in 2019 (P < .001), with no significant difference between age groups (P = .47). Rates of severe hypoglycemia decreased from 6.7 (6.0-7.4) to 4.1 of 100 person-years (3.7-4.5) (P < .001) in the entire population. Patients aged ≥85 years had constantly lower HbA1c levels compared with younger groups (P < .001). Although severe hypoglycemia decreased the most in the ≥85 age group (P < .001), severe hypoglycemia remained consistently higher in this group compared with the 75 to <80 years group (P < .001).

CONCLUSIONS AND IMPLICATIONS

During the analyzed time, the risk for severe hypoglycemia decreased. Although drugs with intrinsic risk for hypoglycemia were used less frequently, antidiabetic treatment in older adults should be further improved to continue reducing severe hypoglycemia in this age group, potentially accepting less strict metabolic control and age-specific target ranges.

[Diabetes mellitus in old age]

In the treatment of diabetes in old age cognitive, functional and constitutional resources of the individual must be taken into account. Purely glycated hemoglobin (HbA1c)-oriented treatment goals are less relevant. The primary focus should be freedom from symptoms while avoiding hypoglycemia and maintaining the quality of life. The geriatric assessment helps to clarify the current functional, psychological and cognitive status as well as the need for support in multimorbid older people and to define appropriate treatment strategies. With drug treatment of diabetes in old age, particular attention must be paid to renal insufficiency and dehydration as well as slow dose adjustments. According to the Robert Koch Institute (RKI), diabetes patients belong to the risk group for a severe course of the coronavirus disease 2019 (COVID-19); further risk factors are high blood pressure, underlying oncological diseases, cerebrovascular and coronary heart diseases.

Continuous Glucose Monitoring in Adults with Type 1 Diabetes: Real-World Data from the German/Austrian Prospective Diabetes Follow-Up Registry

Background: To analyze key indicators of metabolic control in adults with type 1 diabetes (T1D) using real-time or intermittent scanning continuous glucose monitoring (rtCGM/iscCGM) during real-life care, based on the German/Austrian/Swiss Prospective Diabetes Follow-up (DPV) registry. Methods: Cross-sectional analysis including 233 adults with T1D using CGM. We assessed CGM metrics by gender, age group (18 to <30 years vs. ≥30 years), insulin delivery method (multiple daily injections vs. continuous subcutaneous insulin infusion [CSII]) and sensor type (iscCGM vs. rtCGM), working days versus weekends, and daytime versus night-time using multivariable linear regression models (adjusted for demographic variables) or Wilcoxon signed-rank test. Results: Overall, 79/21% of T1D patients used iscCGM/rtCGM. Those aged ≥30 years spent more time in range (TIR [70-180 mg/dL] 54% vs. 49%) and hypoglycemic range <70 mg/dL (7% vs. 5%), less time in hyperglycemic range >180 mg/dL (38% vs. 46%) and had a lower glucose variability (coefficient of variation [CV] 36% vs. 37%) compared with adults aged <30 years. We found no significant differences between genders. Multivariable regression models revealed the highest Time In Range (TIR) and lowest time with sensor glucose >250 mg/dL, CV and daytime-night-time differences in those treated with CSII and rtCGM. Glucose profiles were slightly more favorable on working days. Conclusions: In our real-world data, rtCGM versus iscCGM was associated with a higher percentage of TIR and improved metabolic stability. Differences in ambulatory glucose profiles on working and weekend days may indicate lifestyle habits affecting glycemic stability. Real-life CGM results should be included in benchmarking reports in addition to hemoglobin A1c (HbA1c) and history of hypoglycemia.

Evidence gap on antihyperglycemic pharmacotherapy in frail older adults : A systematic review

Background

Although antihyperglycemic pharmacotherapy in frail older adults with type 2 diabetes mellitus (T2DM) is challenging, recommendations from international guidelines are mainly based on indirect evidence from trials not including frail participants.

Objective

This systematic review investigated the effectiveness and safety of pharmacotherapy in frail older adults with T2DM.

Material and methods

Randomized (RCT) and non-randomized prospective clinical trials (non-RCT) were searched in three electronic databases (Medline, Embase, Central) up to October 2018. Trials in older adults with T2DM who were assessed as significantly or severely impaired by defined cut-off scores of assessment instruments on frailty, activities of daily living or physical functional impairment were included.

Results

Two reviewers independently screened 17,391 references for inclusion and assessed risk of bias with ROBINS‑I. Five non-RCTs and no RCT were identified. Treatment of T2DM without insulin compared to insulin could be associated with increased improvement in cardiac functions in patients with cardiac resynchronization therapy and with decreased falls in frail older women. While better glycemic control with low variability and low HbA1c (hemoglobin A1c) values (<7%) was associated with better maintenance of physical function in community-dwelling older persons, higher HbA1c values (8–8.9%) were associated with a reduction in the composite outcome of death or functional decline in community-dwelling diabetic older adults with need for skilled assistance. Due to serious risk of bias in all studies, results should be considered with caution.

Conclusion

Well-designed, large-scale RCTs including this important group of patients are required to assess the effectiveness and safety of pharmacotherapy and HbA1c targets.

Electronic supplementary material

The online version of this article (10.1007/s00391-020-01724-3) contains supplementary material, which is available to authorized users.

Effectiveness of a multimodal intervention in functionally impaired older people with type 2 diabetes mellitus

BACKGROUND

Type 2 diabetes, a highly prevalent chronic disease, is associated with increasing frailty and functional decline in older people. We aimed to evaluate the effectiveness of a multimodal intervention on functional performance in frail and pre-frail participants aged ≥70 years with type 2 diabetes mellitus.

METHODS

The MID-Frail study was a cluster-randomized multicenter clinical trial conducted in 74 trial sites across seven European countries. The trial recruited 964 participants who were aged >70 years [mean age in intervention group, 78.4 (SD 5.6) years, 49.2% male and 77.6 (SD 5.29) years, 52.4% male in usual care group], with type diabetes mellitus and determined to be frail or pre-frail using Fried's frailty phenotype. Participants were allocated by trial site to follow either usual care (UCG) or intervention procedures (IG). Intervention group participants received a multimodal intervention composed of (i) an individualized and progressive resistance exercise programme for 16 weeks; (ii) a structured diabetes and nutritional educational programme over seven sessions; and (iii) Investigator-linked training to ensure optimal diabetes care. Short Physical Performance Battery (SPPB) scores were used to assess change in functional performance at 12 months between the groups. An analysis of the cost-effectiveness of the intervention was undertaken using the incremental cost-effectiveness ratio (ICER). Secondary outcomes included mortality, hospitalization, institutionalization, quality of life, burden on caregivers, the frequency and severity of hypoglycaemia episodes, and the cost-effectiveness of the intervention.

RESULTS

After 12 months, IG participants had mean SPPB scores 0.85 points higher than those in the UCG (95% CI, 0.44 to 1.26, P < 0.0001). Dropouts were higher in frail participants and in the intervention group, but significant differences in SPPB between treatment groups remained consistent after sensitivity analysis. Estimates suggest a mean saving following intervention of 428.02 EUR (2016) per patient per year, with ICER analysis indicating a consistent benefit of the described health care intervention over usual care. No statistically significant differences between groups were detected in any of the other secondary outcomes.

CONCLUSIONS

We have demonstrated that a 12 month structured multimodal intervention programme across several clinical settings in different European countries leads to a clinically relevant and cost-effective improvement in the functional status of older frail and pre-frail participants with type 2 diabetes mellitus.

S2k-Leitlinie Diagnostik, Therapie und Verlaufskontrolle des Diabetes mellitus im Alter

Die Diabetesprävalenz liegt in der Altersgruppe ab 80 Jahren bei über 30 %. Bei der Diagnostik und Therapie älterer Menschen mit Typ-1- und Typ-2 Diabetes müssen altersspezifische Besonderheiten wie funktionelle und kognitive Einschränkungen sowie Komorbiditäten und Aspekte der Polypharmazie in besonderem Maße berücksichtigt werden. Die S2k-Leitlinie der Deutschen Diabetes Gesellschaft wurde mit 6 weiteren Fachgesellschaften (Deutsche Gesellschaft für Kardiologie, Deutsche Gesellschaft für Allgemeinmedizin und Familienmedizin, Deutsche Gesellschaft für Geriatrie, Deutsche Gesellschaft für Ernährungsmedizin, Deutsche Gesellschaft für Pflegewissenschaft, Deutsche Gesellschaft für Palliativmedizin) und der Patientenvertretung (DBW) erarbeitet. Therapieziele wie Erhalt der Lebensqualität und strikte Vermeidung von Akutkomplikationen wie schwere Hypoglykämien treten in den Vordergrund. HbA1c-Ziele sollten gemeinsam mit den Patienten in Abhängigkeit der individuellen Wünsche und Fähigkeiten festgelegt werden. Altersspezifische Besonderheiten einzelner Medikamente müssen insbesondere im Kontext der Multimorbidität beachtet werden. In der Leitlinie werden pflegerische Aspekte, Schnittstellenmanagement, Schmerztherapie sowie häufige Komorbiditäten bei Diabetes wie Hypertonie, Frailty, Sarkopenie, Demenz, Depression, End-of-Life Situationen ausführlich dargestellt.

Comparison of MDRD, CKD-EPI, and Cockcroft-Gault equation in relation to measured glomerular filtration rate among a large cohort with diabetes

AIMS

To analyze the performance of Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), Cockcroft-Gault (CG), and CG calculated with ideal bodyweight (CG-IBW) equations to estimate glomerular filtration rate (eGFR) based on serum creatinine in a large diabetic population.

METHODS

24,516 adults with type-1-diabetes or type-2-diabetes from the multicenter diabetes prospective follow-up registry DPV were analyzed. We compared eGFR and measured GFR (mGFR) based on 24-h urine collection by calculating mean bias (difference), precision (SD of this difference), accuracy (proportion of eGFR within ±10% of mGFR), Bland-Altman-plots.

RESULTS

CG overestimates, whereas MDRD, CKD-EPI, and CG-IBW underestimate. Smallest mean bias and highest accuracy (75.3%) were observed for MDRD compared to the other equations (p<0.0001). MDRD and CKD-EPI estimated most accurately in stages 1 (MDRD:57.7%, CKD-EPI:57.3%) and 2 (MDRD:80.2%, CKD-EPI:80.7%). In stages 3 to 5, highest accuracy was observed for the MDRD (stage 3:82.3%, stage 4:77.8%, stage 5:71.0%). Among younger subjects, accuracy was higher using the CKD-EPI (18-<40years:63.7%, 40-<60years:72.8%). Above age 60years, MDRD estimated most accurately (60-<70years:77.3%, ≥70years:78.8%). In males and females, MDRD estimated most accurately (males:75.3%, females:75.3%).

CONCLUSION

In this large diabetic cohort, smallest bias and highest accuracy were observed for the MDRD.

[Individualized diabetes therapy in older persons]

BACKGROUND

A majority of older people with type 2 diabetes are multimorbid, frail or have limitations in functions. Polypharmacotherapy is unfortunately a frequent occurrence and dangerous. In particular the administration of antihyperglycemic therapy must be carefully weighed up against the risks associated with hypoglycemia.

AIM

The conditions and characteristics of older persons with diabetes are highlighted with respect to the use of individualized therapy of diabetes.

RESULTS AND CONCLUSION

The advantages and disadvantages of oral antidiabetic agents, insulins and substances with novel active principles, such as gliflozin drugs are discussed. Established oral therapeutic drugs, such as metformin as well as the new substance groups, such as gliptins are advantageous in this patient group. Injection-based therapies with glucagon-like peptide 1 (GLP-1) mimetics and the new insulins can also expand the spectrum of therapy if they are prudently used.

Prevalence and comorbidities of double diabetes

BACKGROUND

A growing number of people with type 1 diabetes (T1DM) are identified with features of metabolic syndrome (MS) known as "double diabetes", but epidemiologic data on the prevalence of MS in T1DM and its comorbidities are still lacking. Aim of this cross sectional study is to better estimate the prevalence of MS in T1DM, and to assess its association with comorbidities.

METHODS

Data of 31,119 persons with autoimmune diabetes mellitus were analysed for signs of MS and presence of late complications. Double diabetes was defined as T1DM coexisting with MS (obesity, hypertension, dyslipidemia). Multiple linear or logistic regression analyses were performed to identify associations between double diabetes and late complications.

RESULTS

25.5% (n=7926) of persons with T1DM presented additionally the MS. Persons with double diabetes showed significantly more macrovascular comorbidities (coronary heart disease 8.0% versus 3.0% w/o MS, stroke 3.6% versus 1.6%, diabetic foot syndrome 5.5% versus 2.1%). Also microvascular diseases were increased in people with double diabetes (retinopathy 32.4% versus 21.7%, nephropathy 28.3% versus 17.8%). Both macrovascular and microvascular comorbidities were increased independent of glucose control, even if patients with good metabolic control (HbA1c <7.0%, 53mmol/mol) showed significantly less macrovascular (coronary heart disease 2.3% versus 1.8%, p<0.0001) and microvascular problems (retinopathy 8.7% versus 6.6%, p<0.0001).

CONCLUSIONS

Double diabetes seems to be an independent and important risk factor for persons with T1DM in developing macrovascular and microvascular comorbidities. Therefore, patients should be identified and development of MS should be avoided. Longterm studies are needed to observe the effect of insulin resistance on patients with autoimmune diabetes.

High rate of hypoglycemia in 6770 type 2 diabetes patients with comorbid dementia: A multicenter cohort study on 215,932 patients from the German/Austrian diabetes registry

AIMS

Dementia and type 2 diabetes (T2D) are two major phenomena in older people. To compare anti-hyperglycemic therapy and diabetes-related comorbidities between elderly T2D patients with or without comorbid dementia.

METHODS

215,932 type 2 diabetes patients aged ≥ 40 years (median [Q1;Q3]: 70.4 [61.2;77.7] years) from the standardized, multicenter German/Austrian diabetes patient registry, DPV, were studied. To identify patients with comorbid dementia, the registry was searched by ICD-10 codes, DSM-IV/-5 codes, respective search terms and/or disease-specific medication. For group comparisons, multiple hierarchic regression modeling with adjustments for age, sex, and duration of diabetes was applied.

RESULTS

3.1% (n=6770; 57% females) of the eligible T2D patients had clinically recognized comorbid dementia. After adjustment for demographics, severe hypoglycemia (insulin group: 14.8 ± 0.6 vs. 10.4 ± 0.2 events per 100 patient-years, p<0.001), hypoglycemia with coma (insulin group: 7.6 ± 0.4 vs. 3.9 ± 0.1 events per 100 patient-years, p<0.001), depression (9.9 vs. 4.7%, p<0.001), hypertension (74.7 vs. 72.2%, p<0.001), stroke (25.3 vs. 6.5%, p<0.001), diabetic foot syndrome (6.0 vs. 5.2%, p=0.004), and microalbuminuria (34.7 vs. 32.2%, p<0.001) were more common in dementia patients compared to T2D without dementia. Moreover, patients with dementia received insulin therapy more frequently (59.3 vs. 54.7%, p<0.001), but metabolic control (7.7 ± 0.1 vs. 7.7 ± 0.1%) was comparable to T2D without dementia.

CONCLUSIONS

In T2D with dementia, higher rates of hypoglycemia and other diabetes-related comorbidities were observed. Hence, the risks of a glucocentric and intense diabetes management with insulin and a focus on tight glycemic control without considering other factors may outweigh the benefits in elderly T2D patients with comorbid dementia.

Importance of Geriatric Syndromes in Older Patients with Diabetes with de novo Insulin Treatment: The VEGAS Study

Aims

The VEGAS study was conducted to evaluate representative data of de novo insulin-treated older patients with type 2 diabetes in the outpatient setting in Germany.

Methods

In this prospective, multicenter, non-interventional observational study, a nationwide written survey was carried out among practitioners (02/2011–06/2011). Older patients, aged ≥70 years, starting de novo insulin therapy, were documented.

Results

Data from 4,858 patients from about 500 centers (mean age: 78.2 ± 5.4 years; mean glycosylated hemoglobin [HbA_1c]: 70 ± 14.2 mmol/mol [8.6 ± 1.3 %]) were collected. The mean target HbA_1c value was 55 ± 6.6 mmol/mol (7.2 ± 0.6 %). 91.1 % of geriatric patients were multi-morbid. 96.2 % showed at least one physical or psychological geriatric syndrome. Most of the patients were notably impaired according to their age. Conventional insulin therapy and basal-supported oral therapy were the most frequently planned treatment regimens (39.1 and 31.1 %). Important factors in the selection of the insulin treatment regimen were an efficient HbA_1c decrease (65.6 %), easy administration (55.7 %), and also a patient’s ability to self-administer insulin (38.5 %). De novo insulin treatment increased care requirements (22.7 %). 22.3 % of the relatives were scheduled to receive special training. Specific training programs for older patients with diabetes were planned in only 7.3 % of cases.

Conclusions

The data demonstrate the high prevalence of geriatric syndromes during de novo insulin treatment. Individual therapeutic goals and regimes are based on practicability, in particular, the receipt of autonomy and the care requirement. Diabetes education with adapted programs is currently under-represented. Important factors for the choice of an insulin treatment regimen were an efficient HbA_1c decrease, easy administration, and a patient’s ability for self-administration.

Electronic supplementary material

The online version of this article (doi:10.1007/s40801-015-0014-9) contains supplementary material, which is available to authorized users.

Psychological insulin resistance in geriatric patients with diabetes mellitus

OBJECTIVE

To determine the extent to which geriatric patients with diabetes mellitus experience psychological insulin resistance (PIR).

METHODS

A total of 67 unselected geriatric patients with diabetes (mean age 82.8±6.7 years, diabetes duration 12.2 [0.04-47.2] years, 70.1% female) were recruited in a geriatric care center of a university hospital. A comprehensive geriatric assessment (CGA) was performed including WHO-5, Hospital Anxiety and Depression Scale (HADS), Mini Mental State Examination (MMSE) and Barthel-Index. We assessed PIR using the Barriers of Insulin Treatment Questionnaire (BIT) and the Insulin Treatment Appraisal Scale in a face-to-face interview.

RESULTS

Insulin-naïve patients (INP) showed higher PIR scores than patients already on insulin therapy (BIT-sum score: 4.3±1.4 vs. 3.2±1.0; p<0.001). INP reported in the BIT increased fear of injection and self-testing (2.4±2.4 vs. 1.3±0.8; p=0.016), expect disadvantages from insulin treatment (2.7±1.6 vs. 1.9±1.4; p=0.04), and fear of stigmatization by insulin injection (5.2±2.3 vs. 3.6±2.6; p=0.008). Fear of hypoglycemia, however, did not differ significantly (6.3±2.8 vs. 5.1±3.1; p=0.11). Depression was not shown to be a barrier to insulin therapy.

CONCLUSION

INP with diabetes have a significantly more negative attitude toward insulin therapy in comparison to patients already on insulin.

PRACTICE IMPLICATIONS

Systematic assessment of barriers of insulin therapy, individualized diabetes treatment plans and information of patients may help to overcome such negative attitudes, leading to quicker initiation of therapy, improved adherence to treatment and a better quality of life.

An evaluation of the effectiveness of a multi-modal intervention in frail and pre-frail older people with type 2 diabetes--the MID-Frail study: study protocol for a randomised controlled trial

BACKGROUND

Diabetes, a highly prevalent, chronic disease, is associated with increasing frailty and functional decline in older people, with concomitant personal, social, and public health implications. We describe the rationale and methods of the multi-modal intervention in diabetes in frailty (MID-Frail) study.

METHODS/DESIGN

The MID-Frail study is an open, randomised, multicentre study, with random allocation by clusters (each trial site) to a usual care group or an intervention group. A total of 1,718 subjects will be randomised with each site enrolling on average 14 or 15 subjects. The primary objective of the study is to evaluate, in comparison with usual clinical practice, the effectiveness of a multi-modal intervention (specific clinical targets, education, diet, and resistance training exercise) in frail and pre-frail subjects aged ≥70 years with type 2 diabetes in terms of the difference in function 2 years post-randomisation. Difference in function will be measured by changes in a summary ordinal score on the short physical performance battery (SPPB) of at least one point. Secondary outcomes include daily activities, economic evaluation, and quality of life.

DISCUSSION

The MID-Frail study will provide evidence on the clinical, functional, social, and economic impact of a multi-modal approach in frail and pre-frail older people with type 2 diabetes.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01654341.

Is there a benefit to use calculated percent body fat or age- and gender-adjusted BMI-SDS(LMS) to predict risk factors for cardiovascular disease? A German/Austrian multicenter DPV-Wiss analysis on 42 048 type 2 diabetic patients

OBJECTIVE

In clinical practice Body Mass Index is generally used to evaluate overweight status in adults. The present multicenter study examines whether Body Mass Index (BMI), age- and gender-adjusted Body Mass Index Standard Deviation Score, or calculated %body fat is a better predictor for cardiovascular disease risk factors, specifically hypertension and dyslipidemia, in a high-risk population.

METHODS

Data of 42 048 adult type 2 diabetic patients (median age: 67.1 years) from 161 centers in Germany (n=158) and Austria (n=3) registered in a standardized, prospective, computer-based documentation program, were included in the study. For each patient body weight, height, blood pressure and blood lipids were documented. Spearman correlation analyses as well as multivariable logistic regression models were used to examine the relationship between anthropometric measurements and cardiovascular disease risk factors.

RESULTS

Correlation and regression analyses revealed minor, non significant differences between the 3 anthropometric measurements (all p>0.05). In both genders, relationships between anthropometric measurements and hypertension or reduced HDL-cholesterol were nearly identical. Only for increased triglycerides, the relations with the 3 anthropometric measurements were significantly stronger in males than in females (p<0.0001, respectively). With increasing age, associations between anthropometric measurements and hypertension, reduced HDL-cholesterol or increased triglycerides became weaker. Spearman correlation coefficients for total cholesterol and LDL-cholesterol revealed weak associations with the 3 anthropometric measurements.

CONCLUSION

Compared to Body Mass Index, age- and gender-adjusted Body Mass Index Standard Deviation Score, or calculation of %body fat, has no further benefit to predict cardiovascular disease risk factors in adult type 2 diabetic patients.

Type 2 diabetes from pediatric to geriatric age: analysis of gender and obesity among 120,183 patients from the German/Austrian DPV database

AIM

To characterize the clinical phenotype of type 2 diabetes mellitus (T2DM) with respect to age, gender, and BMI.

METHOD

Anonymized data of 120,183 people with T2DM from the German/Austrian multicenter Diabetes Patienten Verlaufsdokumentation database were analyzed based on chronological age or age at diagnosis (0-19, 20-39, 40-59, 60-79, and ≥80 years). Age, gender, and BMI comparisons with clinical phenotype were made using χ(2) and Kruskal-Wallis tests (SAS V9.2).

RESULTS

Of all the patients, 51.3% were male, average age was 67.112.7 years, and average disease duration was 9.99.1 years. More girls than boys were diagnosed during adolescence and more men than women during adulthood (2060 years). No gender differences existed when age at diagnosis was 60 years. Patients were obese on average (BMI: 30.5±6.1 kg/m(2)) and had significantly higher BMI values than German population peers. The BMI gap was widest in the younger age categories and closed with increasing age. Adult women were significantly more obese than men. Obese patients more often had elevated HbA1c (≥7.5%), hypertension or dyslipidemia (irrespective of age), microalbuminuria (adults), or retinopathy (elderly) than nonobese patients. More men than women (20-60 years) had hypertension, dyslipidemia, or microalbuminuria while more women than men (≥60 years) had hypertension or dyslipidemia.

CONCLUSION

During puberty, more girls than boys were diagnosed with T2DM while during adulthood males predominated. T2DM manifested at comparatively lower BMI in males, and younger patients were more obese at diagnosis. Age, gender, and BMI were also associated with poor metabolic control and cardiovascular disease comorbidities/complications.

Multiple complications and frequent severe hypoglycaemia in 'elderly' and 'old' patients with Type 1 diabetes

AIM

Elderly and old patients with Type 1 diabetes represent a growing population that requires thorough diabetes care. The increasing relevance of this subgroup, however, plays only a minor role in the literature. Here, we describe elderly patients with Type 1 diabetes on the basis of a large multi-centre database in order to point out special features of this population.

METHOD

Data of 64609 patients with Type 1 diabetes treated by 350 qualified diabetes treatment centres were assessed and analysed by age group.

RESULTS

Compared with the age group ≤ 60 years, patients aged >60 years (n=3610 61-80 years and n=377 >80 years old) were characterized by a longer diabetes duration (27.7 vs. 7.7 years), an almost double risk for severe hypoglycaemia (40.1 vs. 24.3/100 patient-years), a lower level of HbA(1c) [60 vs. 67 mmol/mol (7.6 vs. 8.3%)] and higher percentages of microalbuminuria (34.5 vs. 15.6%), diabetic retinopathy (45.2 vs. 8.3%), myocardial infarction (9.0 vs. 0.4%) or stroke (6.8 vs. 0.3%). Elderly patients used insulin pumps less frequently (12.2 vs. 23.8%), but more often used conventional premixed insulin treatment (10.8 vs. 3.8%). Differences between elderly and younger patient groups were significant, respectively.

CONCLUSION

Diabetes care of elderly patients with Type 1 diabetes involves individualized treatment concepts. Increased hypoglycaemia risk and functional impairment attributable to diabetes-associated and/or age-related disorders must be taken into account.