Diabetes mellitus is a highly prevalent metabolic condition in ageing societies associated with high levels of morbidity, multiple therapies, and functional deterioration that challenges even the best of health care systems to deliver high-quality, individualized care. Most international clinical guidelines have ignored the often-unique issues of frailty, functional limitation, changes in mental health, and increasing dependency that characterize many aged patients with diabetes. A collaborative Expert Group of the IAGG and EDWPOP and an International Task Force have explored the key issues that affect diabetes in older people using a robust method comprising a Delphi process and an evidence-based review of the literature. Eight domains of interest were initially agreed and discussed: hypoglycemia, therapy, care home diabetes, influence of comorbidities, glucose targets, family/carer perspectives, diabetes education, and patient safety. A set of "consensus" statements was produced in each domain of interest. These form a foundation for future policy development in this area and should influence the clinical behavior and approach of all health professionals engaged in delivering diabetes care to older people.

Aims/hypothesis We wanted to identify a five-item short form of the Problem Areas in Diabetes Scale and a single-item measure for rapid screening of diabetes-related emotional distress. Methods Using an existing database of 1,153 patients with diabetes, we conducted a principal-components analysis to identify a set of five items and then conducted a reliability analysis and validity checks. From those five items, we identified the item with the strongest psychometric properties as a one-item screening tool. Results We identified a reliable and valid short version of the Problem Areas in Diabetes Scale (PAID) comprising five of the emotional-distress questions of the full PAID items (PAID-5, with items 3, 6, 12, 16, 19). The PAID-5 has satisfactory sensitivity (94%) and specificity (89%) for recognition of diabetes-related emotional distress. We also identified a one-item screening tool, the PAID-1 (Question 12: Worrying about the future and the possibility of serious complications), which has concurrent sensitivity and specificity of about 80% for the recognition of diabetes-related emotional distress. Conclusions/interpretation The PAID-5 and PAID-1 appear to be psychometrically robust short-form measures of diabetes-related emotional distress.Electronic supplementary material The online version of this article

Objective: Hypertension and other noncommunicable diseases represent a growing threat to low/middle-income countries (LMICs). Mobile health technologies may improve noncommunicable disease outcomes, but LMICs lack resources to provide these services. We evaluated the efficacy of a cloud computing model using automated self-management calls plus home blood pressure (BP) monitoring as a strategy for improving systolic BPs (SBPs) and other outcomes of hypertensive patients in two LMICs. Subjects and Methods: This was a randomized trial with a 6-week follow-up. Participants with high SBPs ( ‡140 mm Hg if nondiabetic and ‡130 mm Hg if diabetic) were enrolled from clinics in Honduras and Mexico. Intervention patients received weekly automated monitoring and behavior change telephone calls sent from a server in the United States, plus a home BP monitor. At baseline, control patients received BP results, hypertension information, and usual healthcare. The primary outcome, SBP, was examined for all patients in addition to a preplanned subgroup with low literacy or high hypertension information needs. Secondary outcomes included perceived health status and medicationrelated problems. Results: Of the 200 patients recruited, 181 (90%) completed follow-up, and 117 of 181 had low literacy or high hypertension information needs. The median annual income was $2,900 USD, and average educational attainment was 6.5 years. At follow-up intervention patients' SBPs decreased 4.2 mm Hg relative to controls (95% confidence interval -9.1, 0.7; p = 0.09). In the subgroup with high information needs, intervention patients' average SBPs decreased 8.8 mm Hg ( -14.2, -3.4, p = 0.002). Compared with controls, intervention patients at follow-up reported fewer depressive symptoms (p = 0.004), fewer medication problems (p < 0.0001), better general health (p < 0.0001), and greater satisfaction with care (p £ 0.004). Conclusions: Automated telephone care management plus home BP monitors can improve outcomes for hypertensive patients in LMICs. A cloud computing model within regional telecommunication centers could make these services available in areas with limited infrastructure for patient-focused informatics support.

We used data from Interactive Voice Response (IVR) self-management support studies in Honduras, Mexico, and the United States (US) to determine whether IVR calls to Spanish-speaking patients with chronic illnesses is a feasible strategy for improving monitoring and education between face-to-face visits. 268 patients with diabetes or hypertension participated in 6–12 weeks of weekly IVR follow-up. IVR calls emanated from US servers with connections via Voice over IP. More than half (54%) of patients enrolled with an informal caregiver who received automated feedback based on the patient’s assessments, and clinical staff received urgent alerts. Participants had on average 6.1 years of education, and 73% were women. After 2,443 person weeks of follow-up, patients completed 1,494 IVR assessments. Call completion rates were higher in the US (75%) than in Honduras (59%) or Mexico (61%; p<0.001). Patients participating with an informal caregiver were more likely to complete calls (adjusted odds ratio [AOR]: 1.53; 95% confidence interval [CI]: 1.04, 2.25) while patients reporting fair or poor health at enrollment were less likely (AOR:0.59; 95% CI: 0.38, 0.92). Satisfaction rates were high, with 98% of patients reporting that the system was easy to use, and 86% reporting that the calls helped them a great deal in managing their health problems. In summary, IVR self-management support is feasible among Spanish-speaking patients with chronic disease, including those living in less-developed countries. Voice over IP can be used to deliver IVR disease management services internationally; involving informal caregivers may increase patient engagement.

These studies highlight some important similarities and differences in comparing a middle class subgroup of older diabetics in Mexico City with diabetics of Mexican origin living in the United States.

Premixed insulins are an important tool for glycemic control in persons with diabetes. Equally important in diabetes care is the selection of the most appropriate insulin regimen for a particular individual at a specific time. Currently, the choice of insulin regimens for initiation or intensification of therapy is a subjective decision. In this article, we share insights, which will help in rational and objective selection of premixed formulations for initiation and intensification of insulin therapy. The glycemic status and its variations in a person help to identify the most appropriate insulin regimen and formulation for him or her. The evolution of objective glucometric indices has enabled better glycemic monitoring of individuals with diabetes. Management of diabetes has evolved from a ‘glucocentric’ approach to a ‘patient-centered’ approach; patient characteristics, needs, and preferences should be evaluated when considering premixed insulin for treatment of diabetes.Funding: Novo Nordisk, India.

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