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Si PEH, Parker S, Abdelhafiz D, Summerbell A, Muzulu S, Abdelhafiz AH. Cardiovascular risk reduction in older people with type 2 diabetes mellitus-a comprehensive narrative review. Diabetes Res Clin Pract 2024; 211:111662. [PMID: 38599285 DOI: 10.1016/j.diabres.2024.111662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 04/01/2024] [Accepted: 04/07/2024] [Indexed: 04/12/2024]
Abstract
Metabolic targets are controversial in older people with type 2 diabetes due to functional heterogeneity and morbidity burden. Tight blood pressure and metabolic control appears beneficial in fit individuals who are newly diagnosed with type 2 diabetes and have fewer comorbidities. The benefits of low blood pressure and tight metabolic control is attenuated with the development of comorbidities, especially frailty. Guidelines consider frail older people as one category and recommend relaxed targets. However, sarcopenic obese frail individuals may benefit from tight targets and intensification of therapy due to their unfavourable metabolic profile, accelerated diabetes trajectory and high cardiovascular risk. In addition, the early use of sodium glucose transporter-2 inhibitors and glucagon like peptide-1 receptor agonists may be beneficial in this frailty phenotype due to their cardio-renal protection, which is independent of glycaemic control, provided they are able to engage in resistance exercise training to avoid loss of muscle mass. In the anorexic malnourished frail individual, early use of insulin, due to its weight gain and anabolic properties, is appropriate. In this phenotype, targets should be relaxed with deintensification of therapy due to significant weight loss, decelerated diabetes trajectory and increased risk of medication side effects.
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Affiliation(s)
- Pann Ei Hnynn Si
- Sheffield Kidney Institute, Sheffield Teaching Hospitals, Herries Road, Sheffield S5 7AU, UK
| | - S Parker
- Translational Health Sciences, Bristol Medical School, Bristol, BS8 1QU
| | - D Abdelhafiz
- Lancaster Medical School, Lancaster, LA1 4YG, UK
| | - A Summerbell
- Department of Geriatric Medicine, Rotherham General Hospital, Moorgate Road, Rotherham S60 2 UD, UK
| | - S Muzulu
- Department of Diabetes and Endocrinology Rotherham General Hospital, UK
| | - Ahmed H Abdelhafiz
- Department of Geriatric Medicine, Rotherham General Hospital, Moorgate Road, Rotherham S60 2 UD, UK.
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Bourdel-Marchasson I, Maggi S, Abdelhafiz A, Bellary S, Demurtas J, Forbes A, Ivory P, Rodríguez-Mañas L, Sieber C, Strandberg T, Tessier D, Vergara I, Veronese N, Zeyfang A, Christiaens A, Sinclair A. Essential steps in primary care management of older people with Type 2 diabetes: an executive summary on behalf of the European geriatric medicine society (EuGMS) and the European diabetes working party for older people (EDWPOP) collaboration. Aging Clin Exp Res 2023; 35:2279-2291. [PMID: 37665557 PMCID: PMC10628003 DOI: 10.1007/s40520-023-02519-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 07/26/2023] [Indexed: 09/05/2023]
Abstract
We present an executive summary of a guideline for management of type 2 diabetes mellitus in primary care written by the European Geriatric Medicine Society, the European Diabetes Working Party for Older People with contributions from primary care practitioners and participation of a patient's advocate. This consensus document relies where possible on evidence-based recommendations and expert opinions in the fields where evidences are lacking. The full text includes 4 parts: a general strategy based on comprehensive assessment to enhance quality and individualised care plan, treatments decision guidance, management of complications, and care in case of special conditions. Screening for frailty and cognitive impairment is recommended as well as a comprehensive assessment all health conditions are concerned, including end of life situations. The full text is available online at the following address: essential_steps_inprimary_care_in_older_people_with_diabetes_-_EuGMS-EDWPOP___3_.pdf.
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Affiliation(s)
| | - Stefania Maggi
- National Research Council, Neuroscience Institute, Via Giustiniani 2, 35128, Padua, Italy
| | - Ahmed Abdelhafiz
- Department of Geriatric Medicine, Rotherham General Hospital, Rotherham, S60 2UD, UK
| | | | - Jacopo Demurtas
- Primary Care Department, Azienda USL Toscana Sud Est, Grosseto, Italy
| | - Angus Forbes
- Division of Care in Long Term Conditions, King's College London, London, UK
| | | | | | - Cornel Sieber
- Institute for Biomedicine of Aging, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nuremberg, Germany
- Department of Medicine, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Timo Strandberg
- University of Helsinki, Clinicum, and Helsinki University Hospital, Helsinki, Finland
- University of Oulu, Center for Life Course Health Research, Oulu, Finland
| | - Daniel Tessier
- Research Centre on Aging, Affiliated with CIUSSS de L'Estrie-CHUS, 1036, Rue Belvédère Sud, Sherbrooke, QC, J1H 4C4, Canada
- Faculty of Medicine and Health Sciences, University of Sherbrooke, 2500, Boul. de L'Université, Sherbrooke, QC, J1K 2R1, Canada
| | - Itziar Vergara
- Biodonostia Health Research Institute, Paseo Dr. Begiristain S/N, 20014, Donostia, Basque Country, Spain
| | - Nicola Veronese
- Geriatric Unit, Department of Internal Medicine and Geriatrics, University of Palermo, Palermo, Italy
| | - Andrej Zeyfang
- Department of Internal Medicine, Geriatric Medicine, Palliative Medicine and Diabetology, Medius Klinik Ostfildern-Ruit and Nürtingen, Nürtingen, Germany
| | - Antoine Christiaens
- Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium
- Fund for Scientific Research, Brussels, Belgium
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Keegan GL, Bhardwaj N, Abdelhafiz AH. The outcome of frailty in older people with diabetes as a function of glycaemic control and hypoglycaemic therapy: a review. Expert Rev Endocrinol Metab 2023; 18:361-375. [PMID: 37489773 DOI: 10.1080/17446651.2023.2239907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/08/2023] [Accepted: 07/19/2023] [Indexed: 07/26/2023]
Abstract
INTRODUCTION Frailty is an emerging and newly recognized complication of diabetes in older people. However, frailty is not thoroughly investigated in diabetes outcome studies. AREAS COVERED This manuscript reviews the effect of glycemic control and hypoglycemic therapy on the incidence of frailty in older people with diabetes. EXPERT OPINION Current studies show that both low glycemia and high glycemia are associated with frailty. However, most of the studies, especially low glycemia studies, are cross-sectional or retrospective, suggesting association, rather than causation, of frailty. In addition, frail patients in the low glycemia studies are characterized by lower body weight or lower body mass index (BMI), contrary to those in the high glycemia studies, who are either overweight or obese. This may suggest that frailty has a heterogeneous metabolic spectrum, starting with an anorexic malnourished (AM) phenotype at one end, which is associated with low glycemia and a sarcopenic obese (SO) phenotype on the other end, which is associated with high glycemia. The current little evidence suggests that poor glycemic control increases the risk of frailty, but there is a paucity of evidence to suggest that tight glycemic control would reduce the risk of incident frailty. Metformin is the only well-studied hypoglycemic agent, so far, to have a protective effect against frailty independent of glycemic control in the non-frail older people with diabetes. However, once frailty is developed, the choice of the best hypoglycemic agent for these patients will be affected by the metabolic phenotype of frailty. For example, sodium glucose transporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1RA) are appropriate in the SO phenotype due to their weight losing properties, while insulin therapy may be considered early in the AM phenotype due to its anabolic and weight gaining benefits. Future studies are still required to further investigate the metabolic effects of frailty on older people with diabetes, determine the most appropriate HbA1c target, and explore the most suitable hypoglycemic agent in each metabolic phenotype of frailty.
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Affiliation(s)
- Grace L Keegan
- Department of Geriatric Medicine, Rotherham General Hospital, Rotherham, UK
| | - Namita Bhardwaj
- Department of Geriatric Medicine, Rotherham General Hospital, Rotherham, UK
| | - Ahmed H Abdelhafiz
- Department of Geriatric Medicine, Rotherham General Hospital, Rotherham, UK
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Abdelhafiz AH, Keegan GL, Sinclair AJ. Metabolic Characteristics of Frail Older People with Diabetes Mellitus-A Systematic Search for Phenotypes. Metabolites 2023; 13:705. [PMID: 37367862 DOI: 10.3390/metabo13060705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 05/17/2023] [Accepted: 05/24/2023] [Indexed: 06/28/2023] Open
Abstract
Frailty in older people with diabetes is viewed as one homogeneous category. We previously suggested that frailty is not homogeneous and spans across a metabolic spectrum that starts with an anorexic malnourished (AM) frail phenotype and ends with a sarcopenic obese (SO) phenotype. We aimed to investigate the metabolic characteristics of frail older people with diabetes reported in the current literature to explore whether they fit into two distinctive metabolic phenotypes. We performed systematic review of studies published over the last 10 years and reported characteristics of frail older people with diabetes mellitus. A total of 25 studies were included in this systematic review. Fifteen studies reported frail patients' characteristics that could fit into an AM phenotype. This phenotype is characterised by low body weight, increased prevalence of malnutrition markers such as low serum albumin, low serum cholesterol, low Hb, low HbA1c, and increased risk of hypoglycaemia. Ten studies reported frail patients' characteristics that describe a SO phenotype. This phenotype is characterised by increased body weight, increased serum cholesterol, high HbA1c, and increased blood glucose levels. Due to significant weight loss in the AM phenotype, insulin resistance decreases, leading to a decelerated diabetes trajectory and reduced hypoglycaemic agent use or deintensification of therapy. On the other hand, in the SO phenotype, insulin resistance increases leading to accelerated diabetes trajectory and increased hypoglycaemic agent use or intensification of therapy. Current literature suggests that frailty is a metabolically heterogeneous condition that includes AM and SO phenotypes. Both phenotypes have metabolically distinctive features, which will have a different effect on diabetes trajectory. Therefore, clinical decision-making and future clinical studies should consider the metabolic heterogeneity of frailty.
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Affiliation(s)
- Ahmed H Abdelhafiz
- Department of Geriatric Medicine, Rotherham General Hospital, Moorgate Road, Rotherham S60 2UD, UK
| | - Grace L Keegan
- Department of Geriatric Medicine, Rotherham General Hospital, Moorgate Road, Rotherham S60 2UD, UK
| | - Alan J Sinclair
- Foundation for Diabetes Research in Older People, Diabetes Frail Ltd., Droitwich Spa WR9 0QH, UK
- King's College, London WC2R 2LS, UK
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Sinclair AJ, Abdelhafiz AH. Metabolic Impact of Frailty Changes Diabetes Trajectory. Metabolites 2023; 13:metabo13020295. [PMID: 36837914 PMCID: PMC9960364 DOI: 10.3390/metabo13020295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/25/2023] [Accepted: 02/13/2023] [Indexed: 02/19/2023] Open
Abstract
Diabetes mellitus prevalence increases with increasing age. In older people with diabetes, frailty is a newly emerging and significant complication. Frailty induces body composition changes that influence the metabolic state and affect diabetes trajectory. Frailty appears to have a wide metabolic spectrum, which can present with an anorexic malnourished phenotype and a sarcopenic obese phenotype. The sarcopenic obese phenotype individuals have significant loss of muscle mass and increased visceral fat. This phenotype is characterised by increased insulin resistance and a synergistic increase in the cardiovascular risk more than that induced by obesity or sarcopenia alone. Therefore, in this phenotype, the trajectory of diabetes is accelerated, which needs further intensification of hypoglycaemic therapy and a focus on cardiovascular risk reduction. Anorexic malnourished individuals have significant weight loss and reduced insulin resistance. In this phenotype, the trajectory of diabetes is decelerated, which needs deintensification of hypoglycaemic therapy and a focus on symptom control and quality of life. In the sarcopenic obese phenotype, the early use of sodium-glucose transporter-2 inhibitors and glucagon-like peptide-1 receptor agonists is reasonable due to their weight loss and cardio-renal protection properties. In the malnourished anorexic phenotype, the early use of long-acting insulin analogues is reasonable due to their weight gain and anabolic properties, regimen simplicity and the convenience of once-daily administration.
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Affiliation(s)
- Alan J. Sinclair
- Foundation for Diabetes Research in Older People (fDROP), King’s College, London WC2R 2LS, UK
| | - Ahmed H. Abdelhafiz
- Foundation for Diabetes Research in Older People (fDROP), King’s College, London WC2R 2LS, UK
- Department of Geriatric Medicine Rotherham General Hospital, Rotherham S60 2UD, UK
- Correspondence:
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Hypoglycaemic therapy in frail older people with type 2 diabetes mellitus-a choice determined by metabolic phenotype. Aging Clin Exp Res 2022; 34:1949-1967. [PMID: 35723859 PMCID: PMC9208348 DOI: 10.1007/s40520-022-02142-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 04/21/2022] [Indexed: 11/01/2022]
Abstract
Frailty is a newly emerging complication of diabetes in older people and increasingly recognised in national and international clinical guidelines. However, frailty remains less clearly defined and frail older people with diabetes are rarely characterised. The general recommendation of clinical guidelines is to aim for a relaxed glycaemic control, mainly to avoid hypoglycaemia, in this often-vulnerable group of patients. With increasing age and development of frailty, body composition changes are characterised by an increase in visceral adipose tissue and a decrease in body muscle mass. Depending on the overall body weight, differential loss of muscle fibre types and body adipose/muscle tissue ratio, the presence of any associated frailty can be seen as a spectrum of metabolic phenotypes that vary in insulin resistance of which we have defined two specific phenotypes. The sarcopenic obese (SO) frail phenotype with increased visceral fat and increased insulin resistance on one side of spectrum and the anorexic malnourished (AM) frail phenotype with significant muscle loss and reduced insulin resistance on the other. In view of these varying metabolic phenotypes, the choice of hypoglycaemic therapy, glycaemic targets and overall goals of therapy are likely to be different. In the SO phenotype, weight-limiting hypoglycaemic agents, especially the new agents of GLP-1RA and SGLT-2 inhibitors, should be considered early on in therapy due to their benefits on weight reduction and ability to achieve tight glycaemic control where the focus will be on the reduction of cardiovascular risk. In the AM phenotype, weight-neutral agents or insulin therapy should be considered early on due to their benefits of limiting further weight loss and the possible anabolic effects of insulin. Here, the goals of therapy will be a combination of relaxed glycaemic control and avoidance of hypoglycaemia; and the focus will be on maintenance of a good quality of life. Future research is still required to develop novel hypoglycaemic agents with a positive effect on body composition in frailty and improvements in clinical outcomes.
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Abdelhafiz AH, Sinclair AJ. Metabolic phenotypes explain the relationship between dysglycaemia and frailty in older people with type 2 diabetes. J Diabetes Complications 2022; 36:108144. [PMID: 35151546 DOI: 10.1016/j.jdiacomp.2022.108144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/17/2022] [Accepted: 01/29/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND Dysglycaemia (hyperglycaemia and hypoglycaemia) increase the risk of frailty in older people with diabetes, which appears contradictory. However, the characteristics of patients included in these studies are different and may reflect different metabolic phenotypes of frailty that may explain this apparent contradiction. AIMS To review the characteristics of frail patients included in clinical studies that reported an association between dysglycaemia and frailty in order to explore whether there is any metabolic differences in the profile of these patients. METHODS A systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. Key words around older people, type 2 diabetes mellitus, frailty, hyperglycaemia and low glycaemia were used in the literature search. RESULTS Only 8 studies met the inclusion criteria. Four studies investigated the risk of frailty associated with low glycaemia. Two studies showed that hypoglycaemia increased the risk of frailty by 44% (HR 1.60, 95% CI 1.14 to 2.42) and predicted greater level of dependency (p < 0.001), respectively. The other two studies reported that HbA1c inversely correlated with clinical frailty scale (r = -0.31, p < 0.01) and HbA1c < 6.0% was associated with increased risk of disability (3.45, 1.02 to 11.6), respectively. Compared with non-frail patients, those with frailty tended to have lower body weight or body mass index (BMI), have features of malnutrition such as low serum albumin or low total cholesterol and suffer from more comorbidities including dementia. Four studies explored the association of high glycaemia with frailty. Higher HbA1c predicted frailty (OR 1.43, 95% CI 1.045 to 1.97) and positively correlated with Edmonton frail score (r = 0.44, p < 0.001), respectively in two studies. The other two studies found that subjects with HbA1c ≥ 6.5% had the greatest prevalence of frailty (70.3%) and subjects with higher HbA1c at baseline to have a higher frailty level throughout later life, respectively. Compared with non-frail patients, those with frailty tended to have higher body weight, waist circumference and BMI. They also have less physical activity, higher cholesterol level and have more comorbidities. CONCLUSIONS Dysglycaemia increases the risk of frailty but the characteristics of patients in these studies suggest different metabolic phenotypes of frailty. Therefore, these metabolic differences in frailty should be taken into consideration in the management of older people with diabetes.
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Affiliation(s)
- A H Abdelhafiz
- Department of Geriatric Medicine, Rotherham General Hospital, Moorgate Road, Rotherham S60 2UD, UK
| | - A J Sinclair
- King's College, London, UK; Foundation for Diabetes Research in Older People (fDROP), Droitwich Spa WR9 0QH, UK.
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8
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López-Rubio C, Koponen M, Lampela P, Taipale H, Tanskanen A, Bell JS, Tolppanen AM, Hartikainen S. Changes in the use of diabetes drugs among community-dwelling people with Alzheimer's disease. BMC Geriatr 2021; 21:701. [PMID: 34911481 PMCID: PMC8672592 DOI: 10.1186/s12877-021-02694-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 11/29/2021] [Indexed: 11/10/2022] Open
Abstract
Background Type 2 diabetes is common in persons with Alzheimer’s disease (AD). Management of diabetes in persons with AD is challenging due to changing goals of care and susceptibility to adverse drug events including hypoglycemia. The aim of this study was to investigate the prevalence of diabetes drug use from 5 years before to 5 years after the time of AD diagnosis among persons with and without AD. Methods This was a nationwide register-based study of persons with and without AD and diabetes in Finland. We analyzed data from the Medication Use and Alzheimer’s disease (MEDALZ) study that included 70,718 community-dwelling people diagnosed with AD from 2005 to 2011. The study population included 8418 persons with AD and 6666 matched persons without AD who were diagnosed with diabetes 5 years before AD diagnosis (index date). We defined the prevalence of diabetes drug use in three-month evaluation periods from 5 years before until 5 years after the index date. Results Nearly all people with diabetes (94% in both cohorts) used one or more diabetes drugs on the index date. The most prevalent drug metformin was used by 60.9% of people with AD and 59.1% of people without AD. The next most prevalent drugs were sulfonylureas and insulin. The prevalence of diabetes drug use was similar in people with and without AD but began to decline 1 year after AD diagnosis in the AD cohort compared to non-AD cohort. Conclusions The decline in diabetes drug use after AD diagnosis may be attributed to clinicians and patients seeking to avoid serious adverse drug events including hypoglycemia. In addition, the findings may reflect personalized glycemic control and unintentional weight loss in persons with AD reducing the need for diabetes drugs. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02694-w.
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Affiliation(s)
| | - Marjaana Koponen
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, PO Box 1627, 70210, Kuopio, Finland.,Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Pasi Lampela
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, PO Box 1627, 70210, Kuopio, Finland
| | - Heidi Taipale
- School of Pharmacy, University of Eastern Finland, PO Box 1627, 70210, Kuopio, Finland.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland
| | - Antti Tanskanen
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland
| | - J Simon Bell
- School of Pharmacy, University of Eastern Finland, PO Box 1627, 70210, Kuopio, Finland.,Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Anna-Maija Tolppanen
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland.,School of Pharmacy, University of Eastern Finland, PO Box 1627, 70210, Kuopio, Finland
| | - Sirpa Hartikainen
- Kuopio Research Centre of Geriatric Care, University of Eastern Finland, Kuopio, Finland. .,School of Pharmacy, University of Eastern Finland, PO Box 1627, 70210, Kuopio, Finland.
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Mannucci E. Prescribing, monitoring, and deprescribing drugs in geriatric DM patients. JOURNAL OF GERONTOLOGY AND GERIATRICS 2021. [DOI: 10.36150/2499-6564-n459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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10
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Abdelhafiz AH, Peters S, Sinclair AJ. Low glycaemic state increases risk of frailty and functional decline in older people with type 2 diabetes mellitus - Evidence from a systematic review. Diabetes Res Clin Pract 2021; 181:109085. [PMID: 34634389 DOI: 10.1016/j.diabres.2021.109085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 09/18/2021] [Accepted: 09/29/2021] [Indexed: 10/20/2022]
Abstract
AIMS To explore risk of frailty and functional decline associated with low glycaemia in older people with type 2 diabetes. METHODS Systematic review. RESULTS 11 studies included. Six studies investigated risk of frailty or physical decline with hypoglycaemia. Hypoglycaemia increased risk of incident frailty (HR 1.60, 95% CI 1.14 to 2.42) in one study and risk of fractures in four studies (2.24, 1.56 to 3.21, 1.24, 1.13 to 1.37, 1.94, 1.67 to 2.24 and 1.71, 1.35 to 2.16 respectively). In sixth study, hypoglycaemia associated with dependency (P < 0.001). Five studies explored association of low blood glucose/HbA1c with frailty. One study showed that mean blood glucose decreased with increasing frailty (p = 0.003). Two studies reported that HbA1c inversely correlated with clinical frailty scale (r = -0.31, p < 0.01) and HbA1c < 6.9% increased risk of frailty (HR, 1.41 95% CI 1.12 to 1.78) respectively. Last two studies showed that HbA1c < 6.5% associated with risk of any fracture (HR 1.08, 95% CI 1.06 to 1.11) and HbA1c < 6.0% associated with increased risk of care need (3.45, 1.02 to 11.6) respectively. CONCLUSIONS Low glycaemia increases risk of frailty and functional decline in older people with type 2 diabetes. Management should minimise incidence of low glycaemia in these patients.
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Affiliation(s)
- A H Abdelhafiz
- Department of Geriatric Medicine, Rotherham General Hospital, Moorgate Road, Rotherham S60 2UD, United Kingdom
| | - S Peters
- Department of Geriatric Medicine, Rotherham General Hospital, Moorgate Road, Rotherham S60 2UD, United Kingdom
| | - A J Sinclair
- King's College, London, United Kingdom; Foundation for Diabetes Research in Older People (fDROP), Droitwich Spa WR9 0QH, UK.
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11
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Abdelhafiz AH, Emmerton D, Sinclair AJ. Impact of frailty metabolic phenotypes on the management of older people with type 2 diabetes mellitus. Geriatr Gerontol Int 2021; 21:614-622. [PMID: 34151494 DOI: 10.1111/ggi.14214] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 05/08/2021] [Accepted: 05/27/2021] [Indexed: 12/25/2022]
Abstract
AIMS To provide a pathophysiological basis for distinguishing metabolic variants of the frailty phenotype in older adults with type 2 diabetes. METHODS We have made an in-depth review of the possible mechanisms in diabetes, ageing and frailty that will alter allow us to describe phenotypic changes which might assist in predicting responses to particular glucose-lowering therapy. RESULTS Our review has enable us to describe with some confidence a sarcopenic obese phenotype and an anorexic malnourished phenotype. CONCLUSIONS By identifying these two phenotypes we can predict which would be most responsive to certain classes of therapy and where therapies may be ill-advised. This represents the first novel approach in this area. Further work is being planned to develop this hypothesis. Geriatr Gerontol Int 2021; 21: 614-622.
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Affiliation(s)
- Ahmed H Abdelhafiz
- Department of Geriatric Medicine, Rotherham General Hospital, Rotherham, UK
| | - Demelza Emmerton
- Department of Geriatric Medicine, Rotherham General Hospital, Rotherham, UK
| | - Alan J Sinclair
- Foundation for Diabetes Research in Older People, Diabetes Frail Ltd, Droitwich Spa, UK
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12
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Oktora MP, Kerr KP, Hak E, Denig P. Rates, determinants and success of implementing deprescribing in people with type 2 diabetes: A scoping review. Diabet Med 2021; 38:e14408. [PMID: 32969063 PMCID: PMC7891362 DOI: 10.1111/dme.14408] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/20/2020] [Accepted: 09/15/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Individualizing goals for people with type 2 diabetes may result in deintensification of medication, but a comprehensive picture of deprescribing practices is lacking. AIMS To conduct a scoping review in order to assess the rates, determinants and success of implementing deprescribing of glucose-, blood pressure- or lipid-lowering medications in people with diabetes. METHODS A systematic search on MEDLINE and Embase between January 2007 and January 2019 was carried out for deprescribing studies among people with diabetes. Outcomes were rates of deprescribing related to participant characteristics, the determinants and success of deprescribing, and its implementation. Critical appraisal was conducted using predefined tools. RESULTS Fourteen studies were included; eight reported on rates, nine on determinants and six on success and implementation. Bias was high for studies on success of deprescribing. Deprescribing rates ranged from 14% to 27% in older people with low HbA1c levels, and from 16% to 19% in older people with low systolic blood pressure. Rates were not much affected by age, gender, frailty or life expectancy. Rates were higher when a reminder system was used to identify people with hypoglycaemia, which led to less overtreatment and fewer hypoglycaemic events. Most healthcare professionals accepted the concept of deprescribing but differed on when to conduct it. Deprescribing glucose-lowering medications could be successfully conducted in 62% to 75% of participants with small rises in HbA1c . CONCLUSIONS Deprescribing of glucose-lowering medications seems feasible and acceptable, but was not widely implemented in the covered period. Support systems may enhance deprescribing. More studies on deprescribing blood pressure- and lipid-lowering medications in people with diabetes are needed.
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Affiliation(s)
- M. P. Oktora
- Department of Clinical Pharmacy and PharmacologyUniversity of GroningenUniversity Medical Centre GroningenGroningenThe Netherlands
| | - K. P. Kerr
- School of Biomedical Sciences and PharmacyFaculty of Health and MedicineUniversity of NewcastleNewcastleNSWAustralia
| | - E. Hak
- Unit of PharmacoTherapy, Epidemiology and EconomicsGroningen Research Institute of PharmacyUniversity of GroningenGroningenThe Netherlands
| | - P. Denig
- Department of Clinical Pharmacy and PharmacologyUniversity of GroningenUniversity Medical Centre GroningenGroningenThe Netherlands
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Silverii GA, Caldini E, Dicembrini I, Pieri M, Monami M, Mannucci E. Deprescription in elderly patients with type 2 diabetes mellitus. Diabetes Res Clin Pract 2020; 170:108498. [PMID: 33068664 DOI: 10.1016/j.diabres.2020.108498] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 08/29/2020] [Accepted: 10/05/2020] [Indexed: 11/30/2022]
Abstract
AIMS The Primary aim is to verify physicians' adherence to the 2016 Italian diabetes guidelines therapeutic targets, and their habits on deprescription in elderly persons with Type 2 Diabetes Mellitus (T2DM). Secondary aims are the assessment of the potential impact of the targets' changes in 2018 Italian guidelines, and the outcomes of deprescription in the management of T2DM. METHODS Observational retrospective cohort study, enrolling persons with T2DM, aged > 75 years, who attended a visit throughout 2017, and a second visit 6 months later in our outpatient clinic. RESULTS Of the 387 patients included, 336 (87, 8%) were on target, according to 2016 guidelines. Deprescription was advisable in 62% of patients on target. Among those, 22% were deprescribed. In patients undergoing deprescription, during the following 6 months, no severe hypoglycemia occurred (versus 5 cases in the prior 6 months). Glycated Hemoglobin (HbA1c) increased (p < 0.05) from 47.0 [41.7-51.0] to 53.0 [45.4-59.5] mmol/mol). Applying to the sample the 2018 Italian Guidelines targets, 57.2% would have been on target, 18.5% above, and 24.3% below (needing deprescription). CONCLUSION In our study, a minority of suitable patients received deprescription. Deprescription led to a significant reduction in severe hypoglycemia rate, whereas HbA1c remained on target in the majority of cases.
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Affiliation(s)
| | - Eleonora Caldini
- University of Florence, Viale Morgagni, 50 - 50134 Firenze, Italy
| | | | - Maria Pieri
- Careggi Hospital, Diabetology Unit, Largo Brambilla, 3 - 50134 Firenze, Italy
| | - Matteo Monami
- Careggi Hospital, Diabetology Unit, Largo Brambilla, 3 - 50134 Firenze, Italy
| | - Edoardo Mannucci
- University of Florence, Viale Morgagni, 50 - 50134 Firenze, Italy
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14
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Abdelhafiz AH, Emmerton D, Sinclair AJ. New hypoglycaemic therapy in frail older people with diabetes mellitus-phenotypic status likely to be more important than functional status. Diabetes Res Clin Pract 2020; 169:108438. [PMID: 32920102 DOI: 10.1016/j.diabres.2020.108438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 08/20/2020] [Accepted: 09/08/2020] [Indexed: 12/21/2022]
Abstract
Frail older people are largely excluded from clinical trials and therefore glycaemic targets and optimum hypoglycaemic therapy in this group has not been fully investigated. Guidelines generally recommend tight glycaemic control in functionally fit individuals and relaxed targets in frail ones mainly due to the fear of hypoglycaemia. The newly introduced sodium glucose cotransporter-2 inhibitors and the glucagon like peptide-1 receptor agonists have shown benefit that is independent of glycaemic control and a minimal risk of hypoglycaemia. However, guidelines still express caution about its use in frail older people due to fear of other side effects such as weight loss, hypotension and falls. Some frail older people will miss out on the benefits of this new therapy if frailty is considered as a one entity with a blanket application of guidelines. We propose that frailty should be viewed as two distinct metabolically different phenotypes, the sarcopenic-obese, in which new therapy will improve their metabolic profile and should be liberally used if no contraindications, and the anorexic-malnourished phenotype in which the new therapy should be cautiously considered. In other words, glycaemic targets should be driven by individual's overall function but the use of new therapy should be driven by frailty phenotype.
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Affiliation(s)
- A H Abdelhafiz
- Department of Geriatric Medicine, Rotherham General Hospital, Moorgate Road, Rotherham S60 2UD, UK.
| | - D Emmerton
- Department of Geriatric Medicine, Rotherham General Hospital, Moorgate Road, Rotherham S60 2UD, UK
| | - A J Sinclair
- Foundation for Diabetes Research in Older People, Diabetes Frail Ltd, Droitwich Spa WR9 0QH, UK
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15
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Sinclair AJ, Abdelhafiz AH. Challenges and Strategies for Diabetes Management in Community-Living Older Adults. Diabetes Spectr 2020; 33:217-227. [PMID: 32848343 PMCID: PMC7428661 DOI: 10.2337/ds20-0013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The prevalence of diabetes is increasing, especially in older people, mainly because of an increase in life expectancy. The number of comorbidities also increases with increasing age, leading to a unique diabetes phenotype in old age that includes vascular disease, physical and neuropathic complications, and mental dysfunction. These three categories of complications appear to have a synergistic effect that can lead to a vicious cycle of deterioration into disability. Early assessment and appropriate, timely interventions may delay adverse outcomes. However, this complex phenotype constitutes a great challenge for health care professionals. This article reviews the complex diabetes phenotype in old age and explores management strategies that are predominantly based on the overall functional status of patients within this heterogeneous age-group.
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Affiliation(s)
- Alan J. Sinclair
- Foundation for Diabetes Research in Older People, Diabetes Frail Ltd., Droitwich Spa, UK
- Kings College, London, UK
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16
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Hussain S, Chowdhury TA. The Impact of Comorbidities on the Pharmacological Management of Type 2 Diabetes Mellitus. Drugs 2019; 79:231-242. [PMID: 30742277 DOI: 10.1007/s40265-019-1061-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Diabetes mellitus affects over 20% of people aged > 65 years. With the population of older people living with diabetes growing, the condition may be only one of a number of significant comorbidities that increases the complexity of their care, reduces functional status and inhibits their ability to self-care. Coexisting comorbidities may compete for the attention of the patient and their healthcare team, and therapies to manage comorbidities may adversely affect a person's diabetes. The presence of renal or liver disease reduces the types of antihyperglycemic therapies available for use. As a result, insulin and sulfonylurea-based therapies may have to be used, but with caution. There may be a growing role for sodium-glucose co-transporter 2 (SGLT-2) inhibitors in diabetic renal disease and for glucagon-like peptide (GLP)-1 therapy in renal and liver disease (nonalcoholic steatohepatitis). Cancer treatments pose considerable challenges in glucose therapy, especially the use of cyclical chemotherapy or glucocorticoids, and cyclical antihyperglycemic regimens may be required. Clinical trials of glucose lowering show reductions in microvascular and, to a lesser extent, cardiovascular complications of diabetes, but these benefits take many years to accrue, and evidence specifically in older people is lacking. Guidelines recognize that clinicians managing patients with type 2 diabetes mellitus need to be mindful of comorbidity, particularly the risks of hypoglycemia, and ensure that patient-centered therapeutic management of diabetes is offered. Targets for glucose control need to be carefully considered in the context of comorbidity, life expectancy, quality of life, and patient wishes and expectations. This review discusses the role of chronic kidney disease, chronic liver disease, cancer, severe mental illness, ischemic heart disease, and frailty as comorbidities in the therapeutic management of hyperglycemia in patients with type 2 diabetes mellitus.
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Affiliation(s)
- Shazia Hussain
- Department of Diabetes and Metabolism, Barts and the London School of Medicine and Dentistry, The Royal London Hospital, 7th Floor, John Harrison House, Whitechapel, London, E1 1BB, UK
| | - Tahseen A Chowdhury
- Department of Diabetes and Metabolism, Barts and the London School of Medicine and Dentistry, The Royal London Hospital, 7th Floor, John Harrison House, Whitechapel, London, E1 1BB, UK.
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17
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Seidu S, Kunutsor SK, Topsever P, Hambling CE, Cos FX, Khunti K. Deintensification in older patients with type 2 diabetes: A systematic review of approaches, rates and outcomes. Diabetes Obes Metab 2019; 21:1668-1679. [PMID: 30938038 DOI: 10.1111/dom.13724] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 03/19/2019] [Accepted: 03/27/2019] [Indexed: 02/06/2023]
Abstract
AIM To assess deintensification approaches and rates and evaluate the harm and benefits of deintensification with antidiabetic medication and other therapies among older people (≥ 65 years) with type 2 diabetes with or without cardiometabolic conditions. METHODS We identified relevant studies in a literature search of MEDLINE, Embase, Web of Science and Cochrane databases to 30 October 2018. Data were extracted on baseline characteristics, details on deintensification and outcomes, and was synthesized using a narrative approach. RESULTS Ten studies (observational cohorts and interventional studies) with data on 26 558 patients with comorbidities were eligible. Deintensification approaches included complete withdrawal, discontinuation, reducing dosage, conversion, or substitution of at least one medication, but the majority of studies were based on complete withdrawal or discontinuation of antihyperglycaemic medication. Rates of deintensification approaches ranged from 13.4%-75%. The majority of studies reported no deterioration in HbA1c levels, hypoglycaemic episodes, falls or hospitalizations on deintensification. On adverse events and mortality, no significant differences were observed among the comparison groups in the majority of studies. CONCLUSION Available but limited evidence suggests that the benefits of deintensification outweigh the harm in older people with type 2 diabetes with or without comorbidities. Given the heterogeneity of patients with diabetes, further research is warranted on which deintensification approaches are appropriate and beneficial for each specific patient population.
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Affiliation(s)
- Samuel Seidu
- Diabetes Research Centre, Diabetes & Metabolic Medicine, University of Leicester, Leicester, UK
| | - Setor K Kunutsor
- Translational Health Sciences, Bristol Medical School, Musculoskeletal Research Unit, NHS Foundation, National Institute for Health Research Bristol, Biomedical Research Centre, University Hospitals Bristol Trust and University of Bristol, Bristol, UK
| | - Pinar Topsever
- Department of Family Medicine, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| | - Clare E Hambling
- Department of Public Health and Primary Care, School of Clinical Medicine, Cambridge, UK
| | - Francesc X Cos
- Diabetes & Metabolic Medicine, Jordi Gol Institute for Research in Primary Care, The Foundation University Institute for Primary Health, Barcelona, Spain
| | - Kamlesh Khunti
- Diabetes Research Centre, Diabetes & Metabolic Medicine, University of Leicester, Leicester, UK
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18
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Abdelhafiz AH, Sinclair AJ. Deintensification of hypoglycaemic medications-use of a systematic review approach to highlight safety concerns in older people with type 2 diabetes. J Diabetes Complications 2018; 32:444-450. [PMID: 29274807 DOI: 10.1016/j.jdiacomp.2017.11.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 11/22/2017] [Accepted: 11/23/2017] [Indexed: 02/07/2023]
Abstract
IMPORTANCE Intensive treatment of older people with diabetes is common placing them at increased risk of adverse events such as hypoglycaemia and hospitalisation for drug errors. Little is known about when, how or for whom to deintensify hypoglycaemic medications. OBJECTIVE To explore the characteristics of patients for whom deintensification is appropriate and to determine the outcome of deintensification. EVIDENCE REVIEW Medline, Google scholar and EmBase search from 1997 to present was performed using keywords relating to diabetes mellitus, polypharmacy, hypoglycaemia, hospitalisation, deintensification, deprescribing and reduction, simplification or withdrawal of hypoglycaemic medications. Only English language articles were selected. Articles were reviewed for relevance by abstract. A manual review of citations in retrieved articles was performed in addition to the electronic literature search. FINDINGS Those who are over treated appear to be of older age group, frail with weight loss and have multiple medical morbidities especially renal impairment and dementia. Simplification, reduction or even complete withdrawal of hypoglycaemic medications in these patients appears to be feasible without deterioration of glycaemic control. CONCLUSIONS Over treatment is common in frail older people with multiple comorbidities and deintensification appears safe in this group of patients. Current recommendations emphasise preventing underuse rather than overuse of medications, and therefore, a change in guidelines advice may be warranted.
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Affiliation(s)
- A H Abdelhafiz
- Department of Geriatric Medicine, Rotherham General Hospital, Moorgate Road, Rotherham S60 2UD, UK
| | - A J Sinclair
- University of Aston, UK; Foundation for Diabetes Research in Older People, Diabetes Frail Ltd., Droitwich Spa WR9 0QH, UK.
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19
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Mair ML, Athavale R, Abdelhafiz AH. Practical considerations for managing patients with diabetes and dementia. Expert Rev Endocrinol Metab 2017; 12:429-440. [PMID: 30063433 DOI: 10.1080/17446651.2017.1395692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Diabetes and dementia appear to be linked epidemiologically and share a common pathogenetic mechanism. The development of dementia in older people with diabetes will have a significant impact on diabetes self-care and will increase the risk of hypoglycaemia and frailty which ultimately lead to disability and poor outcome. Areas covered: We performed a Medline and Embase search from 1997 to present on relevant dementia and diabetes studies published in English language. Expert commentary: Older people with comorbid diabetes and dementia are functionally heterogeneous and interventions should be proportionate to patients 'functional capacity. Metabolic targets can be tightened in fit persons and relaxed when cognitive abilities continue to decline and overall function deteriorates. A holistic multidisciplinary team approach that involves patients, their carers and integrated primary and secondary care services at one point of care that focuses on improving function and maintaining quality of life is needed.
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Affiliation(s)
- Michelle L Mair
- a Department of Geriatric Medicine , Rotherham General Hospital , Rotherham , UK
| | - Rohin Athavale
- a Department of Geriatric Medicine , Rotherham General Hospital , Rotherham , UK
| | - Ahmed H Abdelhafiz
- a Department of Geriatric Medicine , Rotherham General Hospital , Rotherham , UK
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20
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Abdelhafiz AH, McNicholas E, Sinclair AJ. Hypoglycemia, frailty and dementia in older people with diabetes: Reciprocal relations and clinical implications. J Diabetes Complications 2016; 30:1548-1554. [PMID: 27524280 DOI: 10.1016/j.jdiacomp.2016.07.027] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 07/22/2016] [Accepted: 07/23/2016] [Indexed: 01/21/2023]
Abstract
The relationships between hypoglycemia, frailty and dementia appear to be reciprocal and can lead to a vicious circle. Frailty appears to be a crucial factor increasing the risk for both hypoglycemia and dementia, initiating the reciprocal relationships. Weight loss is likely to be the underlying risk factor for frailty. Many frail older people with diabetes seem to have unnecessarily tight glycemic control, being treated with hypoglycemic medications that likely increase the risk of hypoglycemia. As patients get older with significant weight loss their glycemic targets should be reviewed, and reduction or even withdrawal of their hypoglycemic medications should be considered.
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Affiliation(s)
- Ahmed H Abdelhafiz
- Department of Geriatric Medicine, Rotherham General Hospital, Moorgate Road, Rotherham, S60 2UD, UK.
| | - Emily McNicholas
- Department of Geriatric Medicine, Rotherham General Hospital, Moorgate Road, Rotherham, S60 2UD, UK
| | - Alan J Sinclair
- Foundation for Diabetes Research in Older People, Diabetes Frail Ltd, Droitwich Spa, WR9 0QH, UK
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21
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McNicholas E, Abdelhafiz AH. Diabetes management in older people: a focus on cardiovascular risk reduction. Postgrad Med 2016; 129:169-177. [PMID: 27726478 DOI: 10.1080/00325481.2017.1246346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Cardiovascular disease remains the most common cause of death in persons with diabetes regardless of age. Increasing age combined with diabetes exert a synergistic effect on the vascular system increasing the atherosclerosis burden in older people with diabetes. Due to their high baseline risk, they stand to benefit most from interventions to reduce cardiovascular risk. Older people with diabetes are functionally heterogeneous and their management is challenging. Fit and independent individuals are likely to benefit from tight targets while a relaxed approach putting quality of life at the heart of management plans is more appropriate in the frail and dependent individuals with limited life expectancy.
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Affiliation(s)
- Emily McNicholas
- a Department of Geriatric Medicine , Rotherham General Hospital , Rotherham , UK
| | - Ahmed H Abdelhafiz
- a Department of Geriatric Medicine , Rotherham General Hospital , Rotherham , UK
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22
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The effect of frailty should be considered in the management plan of older people with Type 2 diabetes. Future Sci OA 2016; 2:FSO102. [PMID: 28031949 PMCID: PMC5137864 DOI: 10.4155/fsoa-2015-0016] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 01/18/2016] [Indexed: 12/25/2022] Open
Abstract
The prevalence of diabetes is increasing especially in older age due to increased life expectancy. In old age, diabetes is associated with high comorbidity burden and increased prevalence of geriatric syndromes including frailty in addition to micro- and macro-vascular complications. The emergence of frailty may change the natural history of Type 2 diabetes from a progressive to a regressive course with increased risk of hypoglycemia. This may result in normalization of blood glucose levels and lead to a state of burnt-out diabetes in frail older people with significant weight loss. Although guidelines suggest relaxed glycemic control in frail elderly with diabetes, complete withdrawal of hypoglycemic medications may be necessary in these frail populations to reduce the risk of hypoglycemia. Lay abstract: Diabetes is a common disease especially in older people. Aging is associated with reduced appetite and reduced food intake due to lack of exercise and diminished energy consumption. In certain individuals this may be significant leading to weight loss, malnutrition and the development of frailty. As a result the doses of diabetes medications may be too strong for this frail population especially if they have organ dysfunction reducing medication clearance and increasing the risk of low blood glucose level events. Therefore, reduction or complete withdrawal of diabetes medications may be considered in this frail group.
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