[Diabetes in elderly: a tailored management]. / Diabète de la personne âgée: une prise en charge sur mesure.

In developed countries, 12-25 % of the aged population (>65 years old) have diabetes. Treatment of the old diabetic patients is less well studied compared to younger patients although diabetic and geriatric medical associations have issued specific treatment and priority guidelines for these patients. Treatment and targets of glycemic control must be adapted to the functional condition of the patients, prevent symptoms and complications of the geriatric syndrome. Prevention and screening of chronic complication of diabetes have to be integrated in the overall care of aged diabetic patients to optimize their quality of life and health state.

[Trauma in the elderly]. / Traumatisme chez le patient âgé.

Older patients can suffer severe trauma, especially in home environment. In Switzerland, falls are the main cause of trauma mortality in patients older than 65. Low kinetics mecanisms can cause severe trauma. Undertriage is frequent in emergency rooms and could result in delayed mortality. Except for hip fractures and simple fractures of extremities, age more then 65 should be a criteria for admitting the patient in a trauma center and activating the trauma team.

The high prevalence of malnutrition in elderly diabetic patients: implications for anti-diabetic drug treatments.

BACKGROUND: Type 2 diabetes usually occurs in the context of obesity and associated insulin resistance. Current treatment recommendations are based on lifestyle modifications and incremental drug therapy. However, this approach could lead to inappropriate priorities upon ageing, when diabetes may be compounded by malnutrition and reduced insulin resistance. METHODS: We prospectively evaluated glycaemic and nutritional parameters in 146 consecutive diabetic patients (age 82.5 +/- 7.3 years, mean +/- sd) admitted to our geriatric service. We also implemented nutritional support therapy and a drug therapy adjustment protocol. Oral hypoglycaemic agent withdrawal was attempted in cases of good glycaemic control (HbA(1c) < 7.5% (<47 mmol/mol) or fasting blood glucose < 7.5 mmol/l). RESULTS: Mean BMI and HbA(1c) were 29.6 +/- 7.1 kg/m(2) and 6.9 +/- 1.2% (52 +/- 9 mmol/mol), respectively. Of the patients, 51.4% were taking 1-3 oral hypoglycaemic agents, 30.8% were on insulin and 9.6% on were on insulin and oral hypoglycaemic therapy. Low Mini Nutritional Assessment scores and serum marker levels indicated a high prevalence of malnutrition and/or chronic disease, even in obese patients. Mini Nutritional Assessment scores were positively associated with HbA(1c) values. Among patients treated by oral hypoglycaemic agents, complete drug withdrawal was achieved in 65.8%, much more often than new treatments were added (P = 0.002). Glycaemic control did not worsen after approximately 30 days, despite in-hospital nutritional therapy. Successful oral hypoglycaemic therapy withdrawal was associated with lower Mini Nutritional Assessment scores. CONCLUSIONS: Malnutrition is highly prevalent in elderly diabetic inpatients and, paradoxically, contributes to 'good' glycaemic control. Malnutrition should be screened for in these patients and, when present, should prompt a revision in diet and drug therapy. In particular, the possibility of reducing unnecessary drug therapy should be considered.

[Hypoglycemia and diabetes]. / Hypoglycémie et diabète.

Hypoglycaemia represents the limiting factor to obtain good glycemic control. Dysregulation of counteracting mechanisms and autonomic nervous system neuropathy contribute a strong increase in the incidence of hypoglycaemia in type 1 diabetic patients, but also in long lasting type 2 diabetic patients. Hypoglycaemia in elderly poses a diagnostic and clinical challenge of the unsual clinical presentation causing a delay in treatment. Treatment however, is simple and follows early detection of symptoms by the patient and his family. Prevention has a major role and involves identification of individual risk factors for hypoglycaemia and patient's education with the objective of adapting treatment to the usual habits of the patient.

[When and how to withdraw glucocorticoid therapy in elderly?]. / Quand et comment arrêter une corticothérapie au long cours chez la personne gée?

Glucocorticoid therapy (GCT) is commonly used for the treatment of many chronic diseases. It is prescribed in almost 3% of the population > or = 70-years-old. Numerous short- and long-term side effects can occur even at low doses. GCT should be preceded by screening for and stabilization of disorders that can be aggravated by treatment. During GCT regular monitoring for side effects, adjusting of the treatment to the lowest effective dose and regular re-evaluation of the indication are required. The GC withdrawal protocols are not evidence-based and are chosen essentially according to the risk of reactivation of the treated disorder. The risk of secondary adrenal insufficiency is real but quite low, and does not in itself justify the continuation of a GCT.

[How urgent is it to decrease high blood pressure?]. / Abaisser la pression artérielle: urgent ou pas urgent?

Severe hypertension represents a frequent problem for the general practitioner. One has to decide if the blood pressure needs to be decreased immediately (hypertensive emergency), or if the blood pressure maybe progressively decreased in a few hours and normalized in a few days (hypertensive crisis). Thus it is crucial to identify on the basis of the clinical history and a careful physical examination, the patients for whom the arterial blood pressure elevation represents an acute danger for organ damage or a vital threat in the absence of immediate blood pressure control. In the case of hypertensive crisis, oral medication is usually sufficient (slow release or GITS nifedipine, nitroglycerin, labetalol, captopril). The hypertensive emergency sometimes requires an oral medication before the admission to the emergency room, then followed by intravenous drug administration (sodium nitroprussiate, nitroglycerin, labetalol).