An International Geriatric Diabetes workshop was held in Boston, USA, on Sept 23–24, 2019, to address the need for evidence-based recommendations in the management of older adults with diabetes. The workshop organisers selected topics that were deemed the most important in clinical practice, and had notable knowledge gaps. The participants included authors of this paper, clinicians, leading researchers, policy leaders, patient representatives, and industry partners focusing on the care of older
ReviewDiabetes in ageing: pathways for developing the evidence base for clinical guidance
Introduction
Over the past decade, several diabetes organisations and societies have published position statements, guidelines, and consensus reports to guide the management of older adults with diabetes with consideration of the unique challenges that are involved.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 In addition, there have been published articles with a main focus on diabetes and older adults where the emerging science, the complexity of management, and the goals of care have been discussed12 in varying situations, such as the presence of cognitive dysfunction13 or the management of inpatient hyperglycaemia.14 This literature supports the view that many factors necessitate different approaches to diabetes care in older adults compared with younger adults.
Older adults are a heterogeneous population and are frequently defined on the basis of chronological age, functional status, or the presence of comorbid conditions. This variability in definitions is seen in the studies in current literature focusing on older adults. Because of this variability, defining older adults in the context of the purpose of the study or review might be necessary. In the past decade, various guidelines and consensus reports have provided clinical recommendations based on the presence of severe comorbidities, cognitive status, and functionality, avoiding chronological age as the defining factor. The three groups of older adults with diabetes that are usually defined for the purposes of allocating recommendations are: (1) individuals in good health with little or no cognitive or functional impairment and a long life expectancy (eg, >10–15 years); (2) those who have some comorbidities and mild disabilities; and (3) those who have a high number of comorbidities or disabilities, or both, and a shorter life expectancy (eg, <5 years).
The recommendations from these guidelines offer important information for clinicians providing care for older adults with diabetes. However, older adults, particularly those who have evidence of functional loss, frailty, and cognitive impairment, are under-represented in clinical trials leading to management guidelines that rely on expert opinions only. In addition, there is little research and clinical guidance on the care of older adults with type 1 diabetes. Thus, there is an increasing and urgent need to develop evidence-based treatment recommendations for this growing population that has unique and often unmet needs. In this Review, we describe the current evidence in seven important areas in geriatric diabetes (figure), and outline key research gaps and research questions in each of these areas.
Section snippets
Current evidence
Several international organisations have developed criteria for screening for diabetes. Although large data sets have found that mean glycaemia increases with age,16, 17, 18, 19 most of the guidelines do not have age-specific criteria or recommendations for screening frequency based on age.11, 20, 21, 22 In addition, data suggest that if only fasting plasma glucose or HbA1c concentrations are measured, a substantial number of patients with impaired glucose tolerance or diabetes will be missed.23
Current evidence
One of the great clinical challenges of managing diabetes in older adults is that the disease is frequently accompanied by multiple comorbidities.30, 31 On the basis of concepts such as mortality caused by competing illnesses and lag time to benefit,32 classifying older patients by comorbidities has been viewed as an important way to individualise the intensity and approach to diabetes management. There have been few studies to classify older patients by comorbid conditions, but these few
Current evidence
In older adults with diabetes, a multidimensional and individual treatment and management approach is needed.37 Microvascular complications develop over time, and for many older patients with a lower life expectancy, intensive glycaemic treatment will offer no net benefits. Factors such as functional status, comorbidities, life expectancy, social factors, and patient preferences, need to be considered. These aspects will also establish the appropriate target ranges for glycaemia. Indeed, many
Current evidence
Most clinical guidelines for the treatment of diabetes now recommend personalising therapy through a shared decision-making approach. In the majority of cases, these guidelines have relied on data extrapolated from trials in younger, generally healthier individuals or are based on expert consensus opinion. Minimising hypoglycaemia is often a key goal when guidelines are tailored for older people, and guidance often precludes the use of glyburide (glibenclamide) because of its long half-life and
Current evidence
People with type 1 diabetes are living longer in high-income societies.73 Although there is a survival gap between people with and without diabetes,74 the life expectancy for people with type 1 diabetes is getting closer to the population average.75 Studies of people with type 1 diabetes who survive into older age have identified many protective factors, including: a family history of longevity; elevated HDL; good glycaemic control (HbA1c <7·8%, 62 mmol/mol); a non-smoking status; and low
Current evidence
Despite good evidence in younger individuals with type 1 diabetes, with respect to the efficiency and safety of insulin pump use, few data exist for those older than 65 years, as many of the randomised controlled trials excluded older people.87, 88 Studies making use of sensor-augmented pump therapy and automated insulin delivery, specifically the hybrid closed loop G670 system, have included individuals older than 60 years and reported a similar improvement in glucose indices for the entire
Current evidence
It has been recognised for some time that for the patients in long-term care facilities, there is little evidence of structured diabetes care or clear oversight on the safety and efficiency of different treatment regimens.101 Together, a position statement of diabetes in long-term care and skilled nursing facilities4 and a comprehensive review of this area97 have provided priority lists of actions that if undertaken are likely to lead to an improvement in the quality of care provided in these
Current evidence
In the absence of an adequate evidence base, guidelines are almost exclusively based on expert opinion and extrapolated from trials in younger or healthier populations.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 Thus, additional studies are urgently needed to: (1) identify which older adults with diabetes would benefit from which diabetes interventions and (2) establish which outcomes are most important for subpopulations of older adults with diabetes.
Research gaps
Since relatively little is known about diabetes in
Conclusion
With the increasing number of older adults with diabetes around the world,117 and the emerging recognition that goals of care might vary according to the health profiles of these individuals, we feel it is timely to emphasise the importance of further research (figure). This knowledge will provide a more robust platform to develop evidence-based recommendations to improve the outcomes of interest in this population. We hope that this paper will be of interest and use for future investigators in
Search strategy and selection criteria
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