GuidelinesAbstractedfromtheAmericanGeriatricsSocietyGuidelinesforImprovingtheCareofOlderAdultswithDiabetesMellitus:2013Update
AmericanGeriatricsSocietyExpertPanelontheCareofOlderAdultswithDiabetesMellitus
OBJECTIVES
●Incorporatehigh-qualitynewevidencewithsignificanteffectondiabetesmellitus(DM)carethathasbecomeavailablesincethe2003“GuidelinesforImprovingthe CareoftheOlderPersonwithDiabetesMellitus”intoanew2013Guidelineupdate.
●ImprovethecareofolderpeoplewithDMbyprovidinganupdatedsetofevidence-basedrecommendationsindividualizedtoadultswithDMaged65andolder.
enyearsago,theCaliforniaHealthCareFoundation(CHCF)/AmericanGeriatricsSociety(AGS)Panelpub-lishedsomeofthefirstpatient-centeredclinicalguidelines to assist clinicians with the complex and individualizedcareofolderadultswithDM.1 Theabstractedsetofrec-ommendations presented here provides essential guidanceinthecareofolderadultswithDMandisbasedonthe2013AGSGuidelines,whichhaveincorporatednewevi-denceavailablesince2003.Thefullversionoftheupdatedguidelines, AmericanGeriatricsSociety(AGS)GuidelinesforImprovingtheCareoftheOlderAdultwithDiabetesMellitus: 2013 Update, is available at
CareOnline.org.
COMPONENTSOFCARE
Thecomponentsofthe2003guidelineswereaspirin,tobaccocessation,glucosecontrol,bloodpressuremanage-ment,lipidsmanagement,eyecare,footcare,andDMself-managementeducationandsupport(DSME/S).Specificgeriatricsyndromesthathavebeenincludedand empha-sizedintheupdated2013guidelinesaredepression,poly-pharmacy,cognitiveimpairment,urinaryincontinence,injuriousfalls,andpersistentpain.
ClinicalandfunctionalheterogeneitiesinolderadultswithDMthatwerealsoaddressedinthe2013guidelines aredifferencesingeneralhealthstatus,ageanddurationof disease at diagnosis, number of years of treatment,
AddresscorrespondencetoAimeeCegelka,SeniorCoordinator,ProfessionalEducationandSpecialProjects,AmericanGeriatricsSociety,40FultonStreet,18thFloor,NewYork,NY10038.
E-mail:
DOI:10.1111/jgs.12514
comorbiditiesandunderlyingchronicconditions,rangeofcomplications,degreeoffrailty,limitsinphysicalorcogni-tivefunction,anddifferencesinlifeexpectancy(timehori-zonforbenefit).
PATIENT-CENTEREDCAREANDINDIVIDUALIZEDGOALS
The2013guidelinesupdaterecommendsDMcarethatiscustomizedandprioritizedtotheindividualpersonwithDM,withattentiontoqualityoflifeandpersonalandcaregiverchoicesrelatedtohealthcare.The2013guide-linesupdate:
●Nolongerrecommendsaspirinfortheprimarypreven-tionofcardiovasculardisease(CVD).
●Renewstheemphasisontreatingdyslipidemiaswithstatinsbutnottotargetlevels.
●Continuestosupportglycemiccontrolrecommenda-tionscustomizedtoburdenofcomorbidity,functionalstatus,andlifeexpectancy.
●Presentsstronger,more-prescriptive,patient-centeredrecommendationsforlifestylemodificationbecauseofincreasedevidenceofitsimportanceforhealthyolderadultswithDM.
EVIDENCE
Theguidelineswereupdatedbyreviewingtheexistingpeer-reviewedliterature(2002–2012)andguidelinesoneachDMtopic.PubMedwassearchedforrelevantstudiespublishedinthepeer-reviewed literaturefrom2002to2012.Randomizedclinicaltrials andsystematicreviewsormeta-analyseswerereviewed.When reasonable,theexpert panelextrapolatedfindingstoolderadultswithDM.Evi-dencetables(availableat line.org)wereconstructedsummarizingnewevidence.
Anexpertpanelconsistingofgeneralinternists,familypractitioners,geriatricians,clinicalpharmacists,health servicesresearchers,andcertifiedDMeducatorswascon-vened.Potentialconflictsofinterestweredisclosedappro-priately.ExpertpanelmembersfollowedtheU.S.PreventiveServicesTaskForcescaleforratingtheevidence.Someoftherecommendationsarebasedonclinicalexperi-enceandtheconsensusoftheexpertpanel(Table1).
JAGS 61:2020–2026,2013
©2013,Copyrightthe Authors
Journalcompilation©2013,TheAmericanGeriatricsSociety0002-8614/13/$15.00
VALIDATION
AdraftoftheguidelinewaspostedontheAGSwebsiteforpubliccommentandsenttothefollowingorganiza-tionswithspecialinterestandexpertiseinthetreatmentofDMinolderadultsforpeerreview:AmericanDiabetesAssociation, AmericanAssociation of Clinical Endocrinol-ogists,AmericanAcademyofFamilyPhysicians,AmericanCollegeofPhysicians,SocietyforGeneralInternal Medicine,AmericanCollegeofClinicalPharmacy,Ameri-canSocietyofConsultantPharmacists,AmericanAssocia-tionofNursePractitioners,AmericanAcademyofNutritionandDietetics,AmericanAssociationofDiabetesEducators,andtheAmericanMedicalDirectorsAssocia-tion.
THEGUIDELINES
GuidingPrinciplesforCareofOlderAdultswithDM
CliniciansshouldestablishspecificgoalsofcareortargetoutcomesforpersonswithDMincollaborationwithpatients,families,orcaregivers.Suchtargetsshouldbeiden-tifiedanddocumentedinthemedicalrecordforallaspectsofcare,suchasmanagementofhypertension,hyperlipid-emia,hyperglycemia,mooddisorderifpresent,andscreen-ingandtreatmentofgeriatricsyndromeswhenrequired.
Ifthedocumentedgoalsarenotbeingmet,thepatientshould beevaluatedforcontributingcauses.Effortsshouldalsobemadetoassesspatientandcaregiverpreferencestokeepcaresimpleandinexpensive.Iftargetoutcomesarestillnotbeingmet,specialistsmayprovidevaluableassistance.
RECOMMENDATIONS
Aspirin
1.IfanolderadulthasDMandknowncardiovasculardisease,dailyaspirintherapy81to325mg/disrecom-mended,unlesscontraindicatedorthepatientistaking otheranticoagulanttherapy.(IA)
Thereisnoevidencethatahigherdoseismoreeffec-
tivethana75-mg/ddose,2andthereisinsufficientevi-dencetorecommendtheuseofaspirinforprimaryCVDpreventionforolderadultswithtype2DM.Foradults aged80andolder,aspirinshouldbeusedwithcaution.
Smoking
1.OlderadultswithDMwhosmokeshouldbeassessedforreadinesstoquitandshouldbeofferedcoun-selingandpharmacologicinterventionstoassistwithsmokingcessation.(IIA)
Hypertension
General Recommendations
1.IfanolderadulthasDMandrequiresmedicalther- apyforhypertension,thenthetargetbloodpressureshouldbelessthan140/90mmHgifitistolerated.(IA)
Thereispotentialharminloweringsystolicbloodpressuretolessthan120mmHginolderadultswithtype 2DM.(1B)
Systolicbloodpressureoflessthan130mmHgisnot
associatedwithbetterCVDoutcomesthanbloodpressurecontrolbetween130and140mmHg.3,4
RecentevidencecomparingclassesofantihypertensivemedicationsforpersonswithDMindicatesthat many,suchasdiuretics,angiotensin-convertingenzyme(ACE)inhibitors,beta-blockers,andcalciumchannelblockers,havecomparableeffectivenessinreducingcardiovascularmorbidityandmortality.Angiotensin-receptorblockers(ARBs)mayalsohavecardiovascularandrenalbenefitforpersonswithDM.
2.OlderadultswithDMandhypertensionshouldbeofferedatherapeuticinterventiontolowerbloodpressurewithin3monthsifsystolicbloodpressure is 140 to160mmHgordiastolicbloodpressureis90to100mmHg orwithin1monthifbloodpressureisgreaterthan160/100mmHg.(IIIB)
Medication
3.OlderadultswithDMwhoaretakinganACEinhibitororARBshouldhaverenalfunctionandserumpotassiumlevels monitored after approximately 1 to2weeksofinitiationoftherapy,witheach dosageincrease,andatleastyearly.(IIIA)
4.OlderadultswithDMwhoareprescribedathia-zideorloopdiureticshouldhaveelectrolytescheckedafterapproximately1to2weeksofinitiationoftherapy,witheachdosageincrease,andatleastyearly.(IIIA)
GlycemicControl
General Recommendations
1.Targetgoalfor glycosylatedhemoglobin (HbA1c) inolderadultsgenerallyshouldbe7.5%to8%.HbA1cbetween7%and7.5%maybeappropriateifitcanbesafelyachievedinhealthyolderadultswithfewcomorbidi- tiesandgoodfunctionalstatus.HigherHbA1ctargets(8–9%)areappropriateforolderadultswithmultiplecomorbidities, poor health,and limitedlifeexpectancy.(1AevidenceforHbA1c 7–8%, andIIAfor 8–9%)
ThereispotentialharminloweringHbA1c to lessthan6.5%inolderadultswithtype2DM.(11A)
There is no evidence that using medications to
achievetightglycemiccontrolinolderadultswithtype2DMisbeneficial.Foradultsyoungerthan65,usingmedicationstoachieveHbA1clevelsoflessthan6.5%isassociatedwithharms,includinghypoglycemiaandmortality,exceptforreductionsinMI and mortality withmetformin.5Giventhelongtimeframeneededtoachieveareductioninmicrovascularcomplications(retinopathy,neuropathy,andnephropathy),glycemicgoalsshouldreflectpatientgoals,healthstatus,andlifeexpectancy.
AccordingtotheAmericanDiabetesAssociation(ADA)2013recommendationsforfrailolderadults,per-sonswithlimitedlifeexpectancyorextensivecomorbidconditions, and others in whom the risks of intensive
glycemiccontrolappeartooutweighthepotentialbenefits, aless-stringenttargetsuchas8.0%isappropriate.6
Monitoring
2.OlderadultswithDMwhoseindividualtargetsarenotbeingmetshouldhavetheirHbA1clevelsmeasuredatleastevery6monthsandmorefrequentlyasneededorindicated.ForolderadultswithstableHbA1coverseveral years,measurementevery12monthsmaybeappropriate.(IIIB)
More-frequentmonitoringmaybeappropriateforper-
sonsinwhomthereisaclinicalindicationtoachievetight glycemiccontrol(e.g.,symptomaticindividualswithhighHbA1clevels).6
3.ForolderadultswithDM,ascheduleforself-monitoringofbloodglucoseshouldbeconsidered,depend-ingonfunctionalandcognitiveabilities.Thescheduleshouldbebasedonthegoalsofcare,targetHbA1clevels, potentialformodifyingtherapy,andriskofhypoglycemia.(IIIB)
Theoptimalfrequencyandtimingofself-monitoring
isnotknown.Somepeopledonotneedtoself-monitor
Despiteconcernaboutlacticacidosiswithmetformin,recentdatasuggestthattheriskis low.
Lipids
General Recommendations
1.ForolderadultswithDManddyslipidemia,effortsshouldbemadetocorrectthelipidabnormalitiesiffeasi-bleafteroverallhealthstatusisconsidered.(IA)
Evidencesupportstheuseoflipid-loweringagents,particularlystatins,inolderadultswithDMwhoare youngerthan75,buttherearenoclinicaltrialdatacol-lectedoverthelast10yearsinpeopleaged80andolderwithDM.Thebeneficialeffectsoflipidloweringhavebeenseenprimarilywith5-hydroxy-3-methylglutaryl-coenzymeAreductaseinhibitors(statins).
2.Pharmacologicaltherapywithastatinisrecom-mendedinadditiontomedicalnutritiontherapyandincreasedphysicalactivityunlesscontraindicatedornottolerated.(1B)
TheevidenceforreductionofCVDendpointswith
9
andmayneedto balanceself-monitoringwiththe intensity
drugsotherthanstatinsislimitedinallagegroups,
and
oftherapy,qualityoflife,andriskofhypoglycemia.Self-monitoringmayreducetheriskofserioushypoglycemiainolderadultswithDMwhouseinsulinororalantidiabeticagents.TheADArecommendsthatself-monitoring“shouldbedictatedbytheparticularneedsandgoalsofthepatient,”andfrequencyshouldbeincreasedwhenadd-ingtoormodifyingtherapy.6
4.Themanagementplanforolderadultswith DMwithsevereorfrequenthypoglycemiashouldbeevaluated;theindividualshouldbeofferedreferraltoaDMeduca-tor,endocrinologist,ordiabetologist,andthe individualandanycaregiversshouldhavemore-frequentcontactswiththehealthcareteam(e.g.,physicians,certifiedDMeducators,pharmacists,nursecasemanager)whiletherapyisbeingreadjusted.(IIIB)
Medications
5.Ifan older adult isprescribed anoral antidiabeticagent,metformin,unlesscontraindicated,isthepreferredfirst-lineagentincombinationwithlifestyletherapy.(IA)
Aftertheuseofmetformin,glucose-loweringmedica-tiontherapyshouldbeindividualized.7Sulfonylureashavebeenassociatedwithgreaterriskofhypoglycemia,andthe riskincreaseswithage.Glyburideshouldgenerallynotbeprescribedtoolderadultswithtype2DMbecauseofthe highriskofhypoglycemia.Chlorpropamidehasapro- longedhalf-life,particularlyinolderadultsandshouldbeavoided.ExpertopinionsupportsthesafetyofinsulinuseinhealthyolderadultswithDMeducation,carefulmoni-toring,andongoingcognitiveassessmentandsuggeststhe eliminationofinsulinslidingscaleinnursinghomes.8
6.Useestimatedglomerularfiltrationrate(eGFR)ratherthanserumcreatininelevelstoguidemetforminuse.Specifically,donotusemetformininpatientswithaneGFRoflessthan30mL/minper1.73m2.ForindividualswithaneGFRbetween30and60mL/minper 1.73m2,checkrenalfunctionmorefrequentlyand use lowerdosages.(IIB)
theevidencedoesnotsupportcombinationtherapywitha
statinandniacinorfenofibrate,whichisgenerallynotrecommended.
Medical nutrition therapy,supplemented Mediterra- neandiet,enhancedphysicalactivity,andweightlosshavealsobeenshowntoplayaroleinimprovingcardiovascularriskprofilesinolder adults with DM.
Optimallow-densitylipoproteincholesterol(LDL-C)targetshavenotbeenestablished.ExpertopinionsupportstheselectionofspecificLDL-Clevelsaspromptsforspecificactions.
Itisrecommendedthatgoalsforhigh-densitylipopro-
teincholesterol(HDL-C)andtriglyceridesbeconsistentwithADArecommendationsof HDL-C greater than40mg/dLinmen,HDL-Cgreaterthan50mg/dLinwomen,andtriglycerideslessthan150mg/dL.Expertconsensussuggeststhatpersonswithlow-risklipidvalues(LDL-C 100mg/dL; HDL-C 50mg/dL, triglycerides
150mg/dL)onaninitialassessmentmayhavelipidscheckedevery2years;inmostpersonswithDM,measure-mentofafastinglipidprofileisrecommendedatleastannu- allyandmorefrequentlyiftargetsarenotbeingmet.6
Monitoring
3.OlderadultswithDMwhoarenewlyprescribedastatinshouldhavealanineaminotransferaselevelmeasuredbeforetreatmentwiththenewmedicationbeginsandas clinicallyindicatedthereafter.(IIIB)
Thereisnoclinicaltrialevidencesupportingthemoni-
toringofliverenzymes.
EyeCare
1.Olderadultswithnew-onsetDMshouldhaveanini-tialscreeningdilated-eyeexaminationwithfunduscopy performedbyaneyecarespecialist.(IB)
2.OlderadultswithDMandwhoareathighriskofeyedisease(symptomsofeyediseasepresent;evidenceof
retinopathy, glaucoma,or cataracts onan initial dilated-
eyeexaminationorsubsequentexaminationsduringtheprior2years;HbA1c≥8.0%;type1DM;orbloodpres-sure ≥140/90mmHg) on the prior examination should
haveascreeningdilated-eyeexaminationperformedbyaneyecarespecialistwithfunduscopytrainingatleastannu-ally.Personsatlowerriskorafteroneormorenormaleyeexaminationsmayhaveadilated-eyeexaminationatleast every2years.(IIB)
Decisionanalyticalmodelssuggestthatscreeningfor
diabeticretinopathyiscost-effective,althoughannualscreeninginpersonsatlowriskofretinopathyisnotmorecost-effectivethanless-frequentscreeningintervals.10Less-frequentexaminations,every2to3years,maybecost-effectiveafteroneormorenormaleyeexaminationsinlow-riskindividuals.11
FootCare
1.OlderadultswithDMshouldhaveacarefulfootexaminationatleastannuallytocheckskinintegrityandtodeterminewhetherthereislossof sensation ordecreasedperfusionandmorefrequentlyifthereisevi-denceofanyofthesefindings.(IIIA)
Quality of evidence is Level II for more-frequent
examinationsforpersonsathighriskoffootproblemsandLevelIIIforroutineannualscreening,basedonrecommen-dations fromthe ADA.6
NephropathyScreening
1.A testforthe presenceofalbuminuriashouldbeper-formedinindividualsatdiagnosisoftype2DM.Aftertheinitialscreeningandintheabsenceofpreviouslydemon-stratedmacro-ormicroalbuminuria,atestforthepresenceofmicroalbuminuriashouldbeperformedannually.(IIIA)There islittleevidencesupportingannualmicroalbu-minuriascreening.Thisisespeciallysoinolderadultswithlimitedlifeexpectancy.IfanindividualistakinganACE
inhibitororARB,thereisnoneedforscreening.
DMSelf-ManagementEducationandSupport
1.PersonswithDMand,ifappropriate,familymem-bersandcaregiversshouldreceiveDSME/Swithreassess-mentandreinforcementperiodicallyasneeded.(IA)
RecommendedDSME/SisdescribedintheNationalStandardsforDiabetesSelf-ManagementandSupport.12
2.ThemonitoringtechniqueofolderadultswithDMwhoself-monitorbloodglucoselevelsshouldberoutinelyreviewed.(IIIB)
3.OlderadultswithDMandnormalcognitionandfunctionalstatusshouldperformatleast150minutesperweekofmoderate-intensityaerobicphysicalactivity.(1A)Unlesstherearecontraindications,olderadultswithDMshouldbeadvisedtoperformaerobicandresistanceexer-cisestothebestoftheirabilityunderthedirectionoftheir healthcareprovider.(IA)
OlderadultswithDMshouldalsoreceivestructured
lifestylecounselingbasedontheDiabetesPreventionProgramstrategiesandshouldbeurgedtoengageinphysi- calactivityatleast3daysperweek.13
4.OlderadultswithDMshouldbeevaluatedregu-larlyfordietandnutritionalstatusand,ifappropriate,shouldbeofferedreferralforculturallyappropriatemedi-calnutritiontherapyandcounseledonthecontentoftheir diet(e.g.,intakeofhigh-cholesterolfoodsandappropriateintakeofcarbohydrates)andonthepotentialbenefitsofweightreduction.(IA)
Meal planning should be based on a personalized
plandevelopedcollaborativelybetweentheindividualandaregistereddietitianaspartofmedicalnutritiontherapy counseling.Themealplanshouldincorporatepersonalpreferencesandculturalandreligiouspracticesandaccommodateotherchronicandacuteconditions,livingsituation,andanyactivityofdailylivingorotherimpair-ments.Weightreductionshouldbedoneundermedicalsupervisionbutmaynotbean appropriategoalinallcases.
5.OlderadultswithDMwhoareprescribedanewmedicationandanycaregivershouldreceiveeducationaboutthepurposeofthedrug,howtotakeit,andthecommonsideeffectsandimportantadversereactions,with reassessmentandreinforcementasneeded.(IA)
6.OlderadultswithDMandanycaregivershouldreceiveeducationaboutriskfactorsforfootulcersandamputation.Physicalabilitytoprovideproperfootcareshouldbeevaluated,withreassessmentandreinforcementperiodicallyasneeded.(IB)
Depression
1.OlderadultswithDMareatgreaterriskofmajordepressionandshouldbescreened for depression duringtheinitialevaluationperiod(first3months)andifthereisanyunexplaineddeclineinclinicalstatus.(IIB)
OninitialpresentationofanolderadultwithDM,a
healthcareprofessionalshouldassesstheindividualfor symptomsofdepressionusingastandardizedshortscreener,14suchastheGeriatricDepressionScale,PatientHeathQuestionnaire(PHQ-9),orotheravailableinstru-ments.15 Expertopinionsuggestsscreeningfordepressionwhenthereisnew-onsetcognitivedecline.
Psychosocialproblemsotherthandepression,suchasattitudesaboutDM,qualityoflife,DM-relateddistress,andlack of financial resources,are alsoimportant for olderadultswithtype2DM.
2.OlderadultswithDMwhopresentwithnew-onsetorarecurrenceofdepressionshouldbetreatedorreferredwithin2weeksofpresentation,orsooneriftheyareadangertothemselves,unlessthere isdocumentationthatthepatienthasimproved.(IIIB)
There is evidence from carefully conducted meta-
analysesofRCTsthatpharmacologicalandpsychologicaltreatmentofolderadults(aged≥55)iseffectiveinreducing
depressivesymptoms.16–18Thequalityandstrengthofevi-denceisIAforundertakingclinicalinterventionbutIIIBforthetimingofreferralortreatment.Forindividualswhoshowevidenceofsubstanceabuseordependence,initiation oftherapyfordepressionmaywaituntiltheindividualisinadrug- oralcohol-free state.
3.Olderadultswhohavereceivedtherapyfordepres-sionshouldbeevaluatedforimprovementintargetsymp-toms within 6weeksoftheinitiationoftherapy. (IIIB)
Table1.Designations / of / Quality and / Strength / ofEvidence
Evidence / Description
Quality
LevelIEvidencefrom atleastone properlyrandomizedcontrolledtrial
LevelIIIEvidencefromrespectedauthoritiesbasedonclinicalexperience, descriptivestudies,orreportsofexpertcommittees
AGoodevidencetosupporttheuseofarecommendation;clinicians“shoulddothisallthetime”
CPoorevidencetosupportortorejecttheuseofarecommendation;clinicians“mayormaynotfollowtherecommendation”
EGoodevidence againsttheuseofa recommendation;clinicians“shouldnotdothis”
Thereisnewevidencethatcollaborativeprograms,inwhichprimarycarecliniciansworkcloselywithmentalhealthspecialists,aresignificantlymoreeffectivethantypi-calprimarycaretreatment.19,20
Polypharmacy
1.OlderadultswithDMshouldbeadvisedtomaintainanupdatedmedicationlistforreviewbytheclinician.(IIA)
Intheoutpatientsetting,itisrecommendedthatacom-prehensivemedicationreviewbeperformedannually.Theavailabilityofanupdatedmedicationlistthatincludesover-the-counterdrugs,vitamins,andherbalsupplementsallowshealthcareproviderstoevaluatetheneedforcurrentmedi-cations,thepotentialfordrug–druganddrug–diseaseinter-actions,andwaystoenhancemedicationadherence.Itisalso recommendedthat individualsreceivemedicationrec-onciliationupondischargefromthehospital.
2.ThemedicationlistofanolderadultwithDMwhopresentswithdepression,falls,cognitiveimpairment,orurinaryincontinenceshouldbereviewed.(IIA)
Epidemiologicalevidenceshowsthatmedicationsmay
contributetoorexacerbategeriatricsyndromesaloneorthroughdrug–drugordrug–diseaseinteractions.Medica-tionuse,particularlythosewithasedatingeffect,isoftencitedasariskfactorforfalls.21–23TheAGSBeersCriteriaprovideclinicians withinformation onpotentiallyinappro- priatemedicationsinolderadults.8
CognitiveImpairment
1.CliniciansshouldassessolderadultswithDMforcognitive impairment using a standardized screening
instrumentduringtheinitialevaluationperiodandwith anysignificantdeclineinclinicalstatus.Increaseddifficultywithself-careshouldbeconsideredachangeinclinicalsta-tus.(IIIA)
Systematic review andmeta-analyses of upto 15 stud-
iesfoundthatdementiawasmorelikelyinpersonswithDMandsuggestedthatDMwasassociatedwithfastercognitivedeclineinolderadults.24–26
Simpletoolsareavailabletoclinicians(
2.IfthereisevidenceofcognitiveimpairmentinanolderadultwithDManddeliriumhasbeenexcludedasacause,thenaninitialevaluationdesignedtoidentifyreversibleconditionsthatmaycauseorexacerbatecogni- tiveimpairment should be performed within the first3monthsafterdiagnosisandwithanysignificantchangeinclinicalstatus.(IIIA)
TheAmericanAcademyofNeurologyguidelinesrec-
ommendscreeningolderadultswithevidenceofcognitiveimpairmentfordepression,B12deficiency,andhypothy-roidism;structuralneuroimagingtoidentifylesionsisalsorecommendedforthoserecentlydiagnosed.27Ifthecogni-tiveimpairmentisduetodelirium,urgentassessmentfor etiologyandmanagementisindicated.
UrinaryIncontinence
1.OlderadultswithDMshouldbeevaluatedforsymptomsofurinaryincontinenceduringannualscreening.(IIIA)
Individualscommonlydonotreporturinaryinconti-nence,andhealthcareprovidersoftendonotdetectit,butitseffectsmaybeprofound,anditmaybeassociatedwithsocialisolation,depression,falls,andfractures.28,29AlthoughtheevidencesupportingthisrecommendationisLevelIII(expertopinion),becauseoftheprofoundnega-tiveeffectofunderdiagnosisandundertreatmentofthisconditiononqualityoflife,itisgivenanimportancerat-ingofA.
2.IfthereisevidenceofurinaryincontinenceintheevaluationofanolderadultwithDM,thenanevaluationdesignedtoidentifytreatablecausesofurinaryinconti-nenceshouldbepursued.(IIIB)
InjuriousFalls
1.OlderadultswithDMshouldbeaskedaboutfallsevery12monthsormorefrequentlyifneeded.(IIIB)
2.Ifanolderadultpresentswithevidenceoffalls,theclinicianshoulddocumentabasicfallsevaluation,includ-inganassessmentofinjuriesandexaminationofpoten-tiallyreversiblecausesof thefalls(e.g.,medications,environmentalfactors).(IIIB)
Fallsarefrequentlyunreportedandundetectedand
maybeassociatedwithreversiblefactors.Commonriskfactorsforfallsincludebalancedisorders,functionalimpairment,visualdeficits,cognitiveimpairment,andcertaintypesofmedications.30,31Componentscommoninmultifactorialinterventionsincludemedicationreviewand
management,exercise,assessmentsofinstrumentalactivi-tiesofdailyliving,orthostaticbloodpressuremeasure-ment,visionassessment,gaitandbalanceevaluation,cognitiveevaluation,andassessmentofenvironmentalhazards.Qualityindicatorsforfallsandmobilityproblemsinvulnerableolderadultsareavailable,32andtheAGSGuidelineforthePreventionofFallsinOlderPersons(2010)alsoprovidesdetailedrecommendationsoneffec-tiveinterventionstoreducefalls(
Pain
1.OlderadultswithDMshouldbeassessedduringtheinitialevaluationperiodforevidenceofpersistentpain.(IIIA)
Neuropathicpainmayoccurinasmanyas50%of
individualswithDM,butitisoftenunderreportedandun-dertreatedinthispopulation.Pharmacologicalandnon- pharmacologicaltreatmentsareavailableandshouldbeindividualizedbasedoncost,patientpreferences,goalsoftreatment,potentialdrug–druginteractions,comorbidities,andcommonsideeffects.32,33
WRITINGGROUP
GerardoMoreno,MD,MSHS,andCarolM.Mangione,MD,MSPH,wereco-chairpersonsofthewritingcommit-teeforthisguideline.GroupmembersalsoincludedLindsayKimbro,MPA,andEkaterinaVaisberg.
PANELMEMBERSANDAFFILIATIONS
TheAGSPanelonImprovingtheCareforOlderPersonswithDiabetesincludesCarolM.Mangione,MD,MSPH(Co-Chair)andGerardoMoreno,MD,MSHS(Co-Chair):DavidGeffenSchoolofMedicineatUCLA,LosAngeles,CA;CarolineS.Blaum,MD,MS:NewYorkUniversityLangoneMedicalCenterBellevueHospitalCenter,New York,NY;AudreyChun,MD:DepartmentofGeriatricsandPalliativeMedicine,MountSinaiSchoolofMedicine,NewYork,NY;SamuelC.Durso,MD:JohnsHopkins UniversitySchoolMedicine,Baltimore,MD;MarthaM.Funnell,MD,RN,CDE:MichiganDiabetesResearchandTrainingCenter,AnnArbor,MI;EdwardGregg,PhD:CentersforDiseaseControlandPrevention,Atlanta,GA;SeiLeeMD,MAS:UniversityofCalifornia,SanFran-cisco,SanFrancisco,CA;SunnyLinnebur,PharmD,FCCP,BCPS,CGP:SkaggsSchoolofPharmacyandPhar-maceuticalSciences,UniversityofColorado,Aurora,CO;DebraSaliba,MD,MPH:VAGreaterLosAngelesandUCLA/JHBorunCenterforGerontologicalResearch,LosAngeles,CA.
ACKNOWLEDGMENTS
Thedecisionsandcontentofthe2013AGSDiabetesGuidelinesarethoseoftheAGSandthepanelistsandare notnecessarilythoseoftheU.S.DepartmentofVeteransAffairs,theNationalInstituteofAging(NIA),ortheCen-tersforDiseaseControlandPrevention.Dr.Morenoreceivedsupport froman NIA (K23AG042961–01) andthe
AmericanFederationforAgingResearchPaulB.BeesonCareerDevelopmentAward.Dr.Mangionereceivedsup-portfromthe UniversityofCaliforniaatLosAngeles(UCLA),ResourceCentersforMinorityAgingResearchCenterforHealthImprovementofMinorityElderlyunder NationalInstitutesofHealth(NIH)/NIAGrantP30-AG021684,andfromNIH/NationalCenterforAdvancingTranslationalSciencesUCLAClinicalandTranslational ScienceInstituteGrantUL1TR000124.Dr.MangioneholdstheBarbara A. LeveyandGeraldS. Levey EndowedChairinMedicine,whichpartiallysupportedherwork.AimeeCegelkaandElvyIckowicz,MPH,providedaddi-tionalresearchandadministrativesupport.
ConflictofInterest:Dr.ChunisonanadvisoryboardrelatedtoPatientCenteredMedicalHomeandAlzheimer’scareforJanssenAlzheimerImmunotherapyResearchDevelopment,LLC.Dr.FunnellhasservedasamemberofanAdvisory BoardforEliLilly;HalozyneTherapeutics;Briston-MeyersSquibb;HygeiaInc;Boehringer-Ingelheim; JohnsonJohnson,Animas/Lifescan;IntuityMedical;OmadaHealth;NovoNordisk;Hygia,Inc.; Bayer Diabe-tes;AmalynPharmaceuticals.SheissupportedinpartbytheNIHwithanR34grantforpeer-basedDMself-man- agementeducation.Dr.LeeholdssharesinMylanInc.Dr.LinneburservesasaconsultantfortheAmericanGeriat-ricsSocietyBeersCriteriaExpertPanel.ShehasreceivedagrantfromEliLillyandCompanyforaPhase2studyinvestigatingfallsandmuscleweakness.
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