Type 2 diabetes mellitus in older people: a brief statement of key principles of modern day management including the assessment of frailty. A national collaborative stakeholder initiative

Abstract

Rates of population ageing are unprecedented and this, combined with the progressive urbanization of lifestyles, has led to a dramatic shift in the epidemiology of diabetes towards old age, particularly to those aged 60-79 years. Both ageing and diabetes are recognized as important risk factors for the development of functional decline and disability. In addition, diabetes is associated with a high economic, social and health burden. Traditional macrovascular and microvascular complications of diabetes appear to account for less than half of the diabetes-related disability observed in older people. Despite this, older adults are under-represented in clinical trials. Guidelines from organizations such as the National Institute for Health and Care Excellence (NICE), the European Association for the Study of Diabetes, and the American Diabetes Association acknowledge the need for individualized care, but the glycaemic targets that are suggested to constitute good control [HbA 53-59 mmol/mol (7-7.5%)] are too tight for frail older individuals. We present a framework for the assessment of older adults and guidelines for the management of this population according to their frailty status, with the intention of reducing complications and improving quality of life for these people.

The challenge of ageing populations and patient frailty: can primary care adapt?

“…Using frailty information more directly in management decisions might also bring efficiencies 19. Adequate discussion of this is beyond the current article, but one example would be having specific guidelines for subgroups of frail older people, such as people with type 2 diabetes 36. Such initiatives may already be happening locally, but frailty could offer opportunities on a national scale.…”

Changes in Cognitive Function and in the Levels of Glycosylated Haemoglobin (HbA1c) in Older Women with Type 2 Diabetes Mellitus Subjected to a Cardiorespiratory Exercise Programme

“…More evident states of prefragility-fragility are shown in patients with DM2 than in non-diabetic people of the same age and sex [4], with both states increasing the risk of mortality and cardiovascular events [5]. Therefore, aging and diabetes are recognised as important risk factors for the development of functional deterioration and disability [6]. However, changes in lifestyle, nutrition, physical activity and cognitive training decrease the fragility index [7], since it has been reported that cognitive deterioration and/or physical fragility are powerful factors that identify diabetic people with high mortality risk [8].…”

Evidence gap on antihyperglycemic pharmacotherapy in frail older adults

“…Well designed, large-scale RCTs, including not the same team replications [15], are required to establish the effectiveness of implementing internationally established guidelines, based on the most recentpositionpapersmanagingfrailtyin DM [38,41]. To address the well-known challenges in research with frail older persons [34], we suggest a prospective network meta-analysis [42] as methodological framework as well as coordinated practice-based research networks [11,27] and patient representatives as stakeholder partners to ensure rigorous scientific methods, sufficient recruitment and a patient-centered and practice-oriented study plan [9].…”