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.

[Diabetes mellitus in old age]. / Diabetes mellitus im Alter.

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.

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 ROBINS­I. 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.

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.

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.

SGS: a structured treatment and teaching programme for older patients with diabetes mellitus--a prospective randomised controlled multi-centre trial.

OBJECTIVES: evaluation of the effectiveness of a new structured diabetes teaching and treatment programme (DTTP) with specific didactical approaches and topics for geriatric patients with diabetes mellitus. DESIGN: a prospective randomised controlled multi-centre trial. SETTING AND PARTICIPANTS: a total of 155 geriatric patients were randomly admitted to either the new DTTP SGS (n = 83) or the standard DTTP (n = 72) for insulin-treated patients with type 2 diabetes mellitus (HbA1c 8.0 +/- 1.4%, age 76.2 +/- 6.3 years). MEASUREMENTS: biometrical data, metabolic control, acute complications, diabetes knowledge, self-management. RESULTS: SGS participants showed improved levels of HbA1c 6 months after the DTTP, and less acute complications than the standard group (P<0.009). Both groups demonstrated a good capacity for diabetes self-management and improvement in diabetes knowledge after the DTTP (P<0.01). CONCLUSION: the new SGS diabetes education programme, focusing on the learning capabilities and the particular needs of older persons, is effective in improving metabolic control and in maintaining auto-sufficiency in geriatric patients with diabetes mellitus.

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.

[Diabetes mellitus]. / Diabetes mellitus.

Diabetes mellitus has a prevalence of up to 25% in the age group above 75 years and is thus a major disease of the elderly. Geriatric syndromes (e.g. immobility or falls, incontinence or intellectual decline) occur more often in the diabetic elderly. Moreover there is a mutual interaction between the syndromes and the control and therapy of diabetes. This fact can be explained by the molecular mechanisms of frailty. Advanced glycation end products, inflammatorial cytokines like IL-6 or TNF-alpha are elevated in subjects with metabolic syndrome as well as in frail elderly. Insulin has anabolic effects inhibiting protein catabolism. The situation of frail elderly with diabetes sometimes can be improved by starting an insulin therapy because of its anabolic effects beyond the action of normalizing blood glucose.

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.

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.

[Specific aspects of diabetes management in the elderly]. / Neue Diabetes-Leitlinie für geriatrische Patienten. Die Besonderheiten bei Senioren auf einen Blick.

More than two-thirds of all diabetics in Germany are older than 60, and a considerable number with multimorbidity and functional disorders must be considered "geriatric patients". Geriatric syndromes (e.g. intellectual decline, immobility, incontinence and instability) appear to be closely interrelated to diabetes in the old patient. By achieving close-to-normal control of blood sugar, geriatric syndromes can also be improved. In the case of geriatric diabetics, certain peculiarities in terms of diet, instruction, pharmacotherapy and compliance must receive consideration. In addition to the reduction of sequelae and concomitant diseases, an improvement in quality of life achieved by prolonging the impairment-free intervals is the main therapeutic aim in the elderly patient.

[Diabetes in old age: HbA1c - and then what?]. / Diabetes im Alter: HbA1c und wie weiter?

HbA1c is a surrogate parameter used to determine metabolic control. In old age different conditions influence erythrocyte half-life falsifying the validity of HbA1c. In older people with diabetes the ranges of HbA1c are frequently chosen higher. However hypoglycemia cannot be ruled out even with high HbA1c levels. Functional aspects, especially regarding cognitive function, are important to choose treatment goals, mainly regarding the risk of hypoglycemia.