Care of Older People with Diabetes E-Book
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- Sprache: Englisch
A concise and accessible overview to the treatment of diabetes in older patients
Care of older people is rapidly becoming one of the most important components of the healthcare profession. An ageing population provides new challenges for the healthcare industry and drives new demand for healthcare professionals with dedicated elder care experience and training. Few aspects of care for older patients are more important than diabetes, a condition characterized by its unique challenges and clinical heterogeneity.
Care of Older People with Diabetes offers a concise and readable introduction to the essentials of this vital clinical practice. Building on the knowledge contained within the successful Diabetes in Old Age textbook series, this book brings to bear the work of global experts in the field to provide a working reference for students and early career healthcare professionals alike. Anyone with an interest in caring for older patients with diabetes should find this a lucid and invaluable resource.
Care of Older People with Diabetes readers will also find:
- One to two clinical case questions per chapter with model answers
- Clear and easy-to-follow division into Background, Key Facts, and Key Management aspects
- A minimum of 10 key references per chapter
Care of Older People with Diabetes is ideal for medical and nursing students, early career doctors, senior nurses, and all other members of the healthcare team.
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Veröffentlichungsjahr: 2025
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Table of Contents
Cover
Table of Contents
Title Page
Copyright Page
Contributors
Foreword
Preface
About the Companion Website
Characteristics and Care Needs
1 Epidemiology and Pathophysiology
Introduction
Epidemiology
Pathophysiology of Diabetes in Older Adults
What Are the Key Issues?
Management
Summary
Clinical Practice Question
References
2 Screening and Diagnosis
Introduction
Background
Key Issues
Clinical Practice Questions
References
3 Lifestyle Interventions
Introduction
Impact of Lifestyle Changes
Lifestyle Intervention
Care Homes
Summary
Clinical Practice Question
References
4 Oral Hypoglycaemic Therapy
Introduction
Hypoglycaemic Agents
Low Hypoglycaemia‐Risk Agents
High Hypoglycaemia Risk Agents
Therapeutic Approach
Summary
Future Perspectives
Clinical Practice Question
References
5 Insulin Therapy
Introduction
Basal Insulin Analogues
Rapid‐acting Analogues
Treatment Regimens
Summary
Clinical Practice Question
References
6 Use of Continuous Glucose Monitoring in Older People with Diabetes
Introduction
Continuous Glucose Monitoring
Patient Assessment
Challenges
Clinical Practice Question
References
7 Education: Key Features for Achieving Success
Introduction
Key Issues
Management
Clinical Practice Question
References
8 Carers and Care Needs
Introduction
Care Needs
Carer Groups
Role of Carers
Benefit of Care on Outcomes
Caring for Carers
Summary
Clinical Practice Question
References
9a Macrovascular Complications: Peripheral Arterial Disease
Epidemiology
Pathogenesis
Consequences of Peripheral Arterial Disease
Investigations
Management
Clinical Practice Question
References
9b Macrovascular Complications: Coronary Arterial Disease
Epidemiology
Pathogenesis
Medical Treatment
Indications for Revascularisation
Management of Cardiovascular Risk Factors According to Baseline Functional and Cognitive Status
Physical Exercise and Diet
Frailty Management
Management
Summary
Clinical Practice Question
References
9c Macrovascular Complications: Cerebrovascular Disease
Introduction
Epidemiology
Risk Factors
Aetiology and Pathophysiology
Management of Cerebrovascular Disease
Prognosis
Summary
Clinical Practice Question
References
10a Microvascular Complications: Diabetic Eye Disease
Introduction
Epidemiology
Presentation
Pathophysiology
Management
Summary
Clinical Practice Questions
References
10b Microvascular Complications: Diabetic Kidney Disease
Introduction
Diabetic Kidney Disease
Definitions and Diagnoses
Management
Summary
Clinical Practice Question
References
10c Microvascular Complications: Peripheral Neuropathy
Introduction
Prevalence and Risk Factors
Clinical Manifestations and Complications
Diagnosis and Assessment
Management of Diabetic Neuropathy
Diabetes Foot Care in Care Homes
Summary
Clinical Practice Question
References
11a Vascular Risk Factors: Hypertension
Introduction
Age‐related Blood Pressure Changes
Definition
Diagnosis
Types
Management
Summary
Clinical Practice Question
References
11b Vascular Risk Factors: Dyslipidaemia
Introduction
Ageing and Lipid Profile
Diabetes and Lipid Profile
Diabetes and Risk of Atherosclerotic Cardiovascular Disease
Atherosclerotic Cardiovascular Disease Risk Reduction
Lipid‐lowering Agents
Goals of Therapy in Old Age
Recommendations from Guidelines
Goals in Frailty
Summary
Clinical Practice Question
References
12a Metabolic Decompensation: Hyperglycaemic Crisis
Introduction
Epidemiology
Precipitating Factors
Pathogenesis
Clinical Presentation
Diagnosis
Management
Complications
Prevention
Clinical Practice Question
References
12b Metabolic Decompensation: Hypoglycaemia
Introduction
Definition
Recognition
Epidemiology
Pathophysiology
Clinical Consequences
Impact on Cognition
Impact on Frailty
Management
Summary
Clinical Practice Question
References
13a Management of Diabetes in Hospital
Introduction
Fundamentals of Care
Key Considerations for Effective Inpatient Care for Older People with Diabetes
Key Considerations to Reduce Unscheduled Admission to Hospital
Summary
Clinical Practice Questions
References
13b Management of Diabetes in Care Homes
Introduction
Important Considerations for Diabetes Care
Importance of Monitoring Glucose Levels
Other Management Issues
Hypoglycaemia
Diabetes Foot Disease
Nutritional Deficiency and Weight Loss
Frailty
Education
Communication and Collaboration
Use of Audit
Measuring Outcomes
Summary
Clinical Practice Question
References
14 Nutrition
Introduction
Nutritional Deficiencies
Causes of Malnutrition in the Elderly
Recommendations
Practical Steps for Nutritional Care in the Elderly
Enteral Nutrition
Parenteral Nutrition
General Considerations for Patients on Nutritional Support
Summary
Clinical Practice Questions
References
15 Sexual Health
Introduction
Ageing and Sexual Function
Diabetes and Sexual Dysfunction
Sexual Dysfunction in Men
Sexual Dysfunction in Women
Summary
Clinical Practice Questions
References
16a Special Issues in Old Age: Frailty
Introduction
Frailty–diabetes Inter‐relationship
Effect of Diabetes on Frailty
Effects of Frailty on Diabetes
Prevention and Management
Special Considerations
Summary
Future Perspectives
Clinical Practice Question
References
16b Special Issues in Old Age: Multimorbidity
Introduction
Multimorbidity
Multimorbidity–Frailty Interaction
Multimorbidity Effects on Diabetes
Clusters of Multimorbidity
Clinical Implications
Summary
Future Perspectives
Clinical Practice Question
References
16c Special Issues in Old Age: Type 1 Diabetes Mellitus
Introduction
Epidemiology and Diagnosis
Management
Summary
Clinical Practice Question
References
16d Special Issues in Old Age: Cognitive Health Agility, Cognitive Dysfunction, Dementia and Diabetes
Introduction
Population Studies Demonstrating the Relationship Between Cognitive Dysfunction, Dementia and Diabetes
Implications of the Relationship Between Diabetes and Cognitive Dysfunction
The Effect of Cognitive Dysfunction on Self‐care Capacity in Older People with Diabetes
Assessment of Cognitive Health Agility in Older People with Diabetes
Prevention and Treatment of Cognitive Dysfunction in Older People with Diabetes
Summary, Knowledge Gaps and Future Research
Clinical Practice Question
References
16e Special Issues in Old Age: Depression
Introduction
Depression and Diabetes
Evaluation
Management
Summary
Clinical Practice Question
References
16f Special Issues in Old Age: Foot Care
Introduction
Epidemiology
Pathogenesis
Ageing and Diabetic Foot Ulcer Disease
Assessment of a Diabetic Foot
Management
Prevention
Summary
Clinical Practice Question
References
16g Special Issues in Old Age: Skin Care
Introduction
Age‐related Skin Changes
Diabetes Mellitus‐related Skin Conditions
Summary
Clinical Practice Question
References
16h Special Issues in Old Age: Falls and Bone Health
Introduction
Epidemiology
Pathophysiology of Fracture Risk in Diabetes
Pathophysiology and Risk Factors for Falls in Diabetes
Assessment of the Risk of Falls in the Community
Assessment of Bone Health in Community
Management and Prevention
Summary
Clinical Practice Question
References
16i Special Issues in Old Age: Avoiding Hospitalisation
Introduction
Risk Factors for Hospitalisation
Avoiding Hospitalisation
Patient‐Related Interventions
Healthcare System‐related Interventions
Summary
Clinical Practice Question
References
16j Special Issues in Old Age: Use of Technology
Introduction
Management
Integration of Diabetes Technologies with Remote Patient Monitoring
What Are the Key Issues?
Clinical Practice Questions
References
16k Special Issues in Old Age: Annual Reviews
Introduction
Diabetes Phenotype in Older People
Functional Implications
Annual Review Contents
Summary
Clinical Practice Question
References
16l Special Issues in Old Age: Mouth Care
Introduction
Age‐related Oral Changes
Diabetes‐related Oral Changes
Common Oral Conditions in Older People with Diabetes
Mouth Care
Summary
Clinical Practice Question
References
16m Special Issues in Old Age: Pain Management
Introduction
Aetiology
Assessment
Pain in Care‐home Residents
Management
Prevention
Clinical Practice Question
References
17 Deintensification of Therapy
Introduction
Key Issues
Management
Clinical Practice Questions
References
18 Diabetes in End‐of‐Life Care
Introduction
Background
What is End of Life and How is the Need for End‐of‐life Care Identified?
Management of Diabetes in End‐of‐Life Care
Medicines Management and De‐escalation of Therapies
Advanced Care Planning
Treatment Withdrawal
Workforce Training and Competencies
Summary
Clinical Practice Questions
References
Answers to Clinical Practice Questions
Index
End User License Agreement
List of Tables
Characteristics and Care Needs
Table 1: Frailty metabolic phenotypes in older people with diabetes.
Chapter 1
Table 1.1: Clinical considerations given the physiological changes associat...
Chapter 2
Table 2.1: Spectrum of symptoms and conditions suggesting possible high blo...
Table 2.2: Main Differences in Presentation of New‐onset Diabetes Mellitus....
Chapter 3
Table 3.1: Differences between resistance and aerobic exercise.
Chapter 4
Table 4.1: Advantages and disadvantages of oral hypoglycaemic therapy in ol...
Chapter 5
Table 5.1: Type of rapid acting and long‐acting insulin for use in older pe...
Chapter 6
Table 6.1: Continuous glucose monitoring in older people with diabetes.
Table 6.2: International consensus on time in range.
Chapter 9c
Table 9c.1: Summary of acute stroke management considerations in diabetes....
Table 9c.2: General targets for cerebrovascular disease risk reduction in d...
Chapter 10a
Table 10a.1: United Kingdom national screening guidelines for diabetic reti...
Chapter 10c
Table 10c.1: Some available diagnostic tests for assessing diabetic neuropa...
Chapter 11a
Table 11a.1: Main guidelines for blood pressure targets in diabetes.
Table 11a.2: Common types of hypertension in older people.
Chapter 11b
Table 11b.1: Lipid‐lowering agents.
Table 11b.2: Statins strengths.
Table 11b.3: Guidelines for dyslipidaemia treatment in older people with di...
Chapter 12a
Table 12a.1: Diagnostic criteria of hyperglycaemic crisis in older people w...
Table 12a.2: Criteria for intensive care admission of older people with hyp...
Table 12a.3: Comparison of diabetic ketoacidosis and hyperglycaemic hyperos...
Chapter 13a
Table 13a.1: Fundamentals of care.
Chapter 13b
Table 13b.1: Key metrics for use in care home diabetes management.
Table 13b.2: Key Metrics and Areas of Management in Care Homes.
Chapter 14
Table 14.1: Causes of malnutrition and suggested interventions.
Table 14.2: Glucose monitoring and insulin administration during enteral an...
Chapter 15
Table 15.1: Advantages and cautions of testosterone therapy.
Chapter 16a
Table 16a.1: Studies investigating glycaemic effects on frailty.
Table 16a.2: Studies investigating frailty effects on diabetes adverse outc...
Chapter 16b
Table 16b.1: Commonly used multimorbidity scales.
Chapter 16d
Table 16d.1: Diabetes‐specific interventions in cognitive decline.
Chapter 16e
Table 16e.1: Predominant depression presenting symptoms in younger compared...
Table 16e.2: Depression screening tools.
Chapter 16f
Table 16f.1: Interventions based on foot risk stratification in diabetes.
Chapter 16g
Table 16g.1: Clinical effects of ageing on the skin.
Chapter 16h
Table 16h.1: Clinical risk factors for fractures.
Chapter 16j
Table 16j.1: Key diabetes technologies.
Table 16j.2: Challenges for continuous glucose monitoring and automated ins...
Chapter 16m
Table 16m.1: Types of pain.
Table 16m.2: Pharmacological agents for pain control in older people with d...
Chapter 18
Table 18.1: Medicines Management: Non‐insulin therapies
List of Illustrations
Characteristics and Care Needs
Figure 1: The impact of old age and diabetes on the characteristics of older...
Chapter 1
Figure 1.1: Development of type 2 diabetes in older adults.
Chapter 3
Figure 3.1: Impact of lifestyle changes on high‐risk patients with no diabet...
Chapter 4
Figure 4.1: Suggested therapeutic approach of oral hypoglycaemic agents in o...
Chapter 8
Figure 8.1: Increasing age and diabetes mellitus lead to reduced ability of ...
Chapter 9a
Figure 9a.1: Measurement and diagnostic characteristics of the ankle–brachia...
Chapter 9b
Figure 9b.1: Flowchart for referral to a specialist.
Chapter 9c
Figure 9c.1: Pathophysiology of cerebrovascular disease in diabetes. RAAS, r...
Figure 9c.2: Spectrum of cerebrovascular accident (CVA) presentation. TIA, t...
Chapter 10a
Figure 10a.1: Fundus photographs showing: (a) non‐proliferative diabetic ret...
Figure 10a.2: Focused history to help guide ophthalmic investigation and man...
Figure 10a.3: Summary of treatment for diabetic retinopathy. NPDR, non‐proli...
Chapter 10b
Figure 10b.1: Prognosis of chronic kidney disease (CKD) by glomerular filtra...
Chapter 10c
Figure 10c.1: Algorithm for approaching pain management [49]. ALA, alpha‐lip...
Chapter 11a
Figure 11a.1: Age‐related vascular changes predispose to the developm...
Figure 11a.2: Escalation of blood pressure control based on category. (a) Fi...
Chapter 11b
Figure 11b.1: Synergistic effects of ageing and diabetes on dyslipidaemia, i...
Figure 11b.2: Suggested lipid‐lowering therapy in older people with diabetes...
Chapter 12a
Figure 12a.1: Pathogenesis of hyperglycaemic crisis in older people with dia...
Figure 12a.2: Management of hyperglycaemic crisis in older people with diabe...
Chapter 12b
Figure 12b.1: Characteristics of hypoglycaemia in older people with diabetes...
Figure 12b.2: AVOID‐HYPOS acronym in older people with diabetes mellitus.
Chapter 13b
Figure 13b.1: Diabetes and the older person.
Chapter 14
Figure 14.1: Feeding patterns in different populations and suggested blood g...
Chapter 15
Figure 15.1: Aetiology and pathogenesis of sexual dysfunction in older peopl...
Figure 15.2: Management of sexual dysfunction in older people with diabetes....
Chapter 16a
Figure 16a.1: Effects of diabetes mellitus (DM) on frailty. Diabetes leads t...
Figure 16a.2: Effects of frailty on diabetes. Frailty increases adverse outc...
Chapter 16b
Figure 16b.1: Impact of multimorbidity on diabetes management. Early interve...
Chapter 16c
Figure 16c.1: Characteristics and management of type 1 diabetes mellitus in ...
Chapter 16d
Figure 16d.1: Effects of cognitive decline.
Chapter 16e
Figure 16e.1: Relationship between ageing, diabetes mellitus and depression....
Figure 16e.2: Management of depression in older people with diabetes mellitu...
Chapter 16f
Figure 16f.1: (a) Typical neuropathic ulcer. (b) Ischaemic toe.
Figure 16f.2: 10 g monofilament test: (a) 10 sites, (b) 5 sites.
Figure 16f.3: Treatment of diabetic foot infection. IV, intravenous; MRSA, m...
Chapter 16g
Figure 16g.1: Acanthosis nigricans.
Figure 16g.2: Necrobiosis lipoidica.
Figure 16g.3: Diabetic dermopathy.
Figure 16g.4: Bullous eruption of diabetes.
Figure 16g.5: Cellulitis of left leg.
Figure 16g.6: Oral candidiasis.
Figure 16g.7: Candida intertrigo.
Figure 16g.8: Genital candidiasis.
Figure 16g.9: Onychomycosis.
Chapter 16h
Figure 16h.1: Falls assessment and management algorithm in older people with...
Figure 16h.2: Fracture risk assessment algorithm in older people with diabet...
Chapter 16i
Figure 16i.1: Patient‐related and health care system‐related interventions t...
Chapter 16j
Figure 16j.1: Potential roles of technology in the care of older adults with...
Figure 16j.2: Key issues for the effective and equitable implementation of t...
Chapter 16k
Figure 16k.1: Contents of a comprehensive annual review in older people with...
Figure 16k.2: A template for annual review for older people with diabetes. A...
Chapter 16l
Figure 16l.1: Factors leading to oral complications in diabetes and preventa...
Chapter 16m
Figure 16m.1: Algorithm of therapeutic options for pain control in older peo...
Figure 16m.2: Multidimensional approach for prevention of chronic pain in ol...
Chapter 17
Figure 17.1: Steps to consider deintensification in older people with type 2...
Chapter 18
Figure 18.1: Algorithm for de‐escalation of therapies at end of life.
Figure 18.2 Algorithm for managing glucose with once‐daily steroid therapy. ...
Guide
Cover Page
Table of Contents
Title Page
Copyright Page
Contributors
Foreword
Preface
About the Companion Website
Characteristics and Care Needs
Begin Reading
Answers to Clinical Practice Questions
Index
WILEY END USER LICENSE AGREEMENT
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Care of Older People with Diabetes: A Manual for Healthcare Practice
Edited by
Alan J. SinclairAhmed H. Abdelhafiz
This edition first published 2025© 2025 John Wiley & Sons Ltd
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Contributors
Ahmed H. AbdelhafizDepartment of Geriatric Medicine, Rotherham General HospitalRotherham, UK
Abdiazizi YusufDepartment of Geriatric Medicine, Rotherham General HospitalRotherham, UK
Nachiketa AcharyaDirectorate of Ophthalmology, Royal Hallamshire Hospital, SheffieldTeaching Hospitals NHS Trust, Sheffield, UK
Nali AhmedDepartment of Geriatric Medicine, Rotherham GeneralHospital, Rotherham, UK
Ali AliDepartment of Geriatrics and Neurosciences, Royal HallamshireHospital, Sheffield Teaching Hospitals NHS Foundation Trust, andthe University of Sheffield, Sheffield, UK
Nandkishor V. AthavaleDepartment of Geriatric Medicine, Rotherham GeneralHospital, Rotherham, UK
Srikanth BellaryDiabetes and Endocrinology, University Hospitals NHS TrustBirmingham, Birmingham, UKMetabolic Medicine, School of Biological Sciences, Aston University,Birmingham, UK
Isabelle Bourdel‐MarchassonCenter for Magnetic Resonance of Biological Systems, Universityof Bordeaux, Bordeaux, FranceGerontological Department, University Hospital ofBordeaux, Bordeaux, France
Marta Castro‐RodríguezGeriatric Medicine Department, University Hospital of GetafeMadrid, Spain
Antoine ChristiaensClinical Pharmacy and Pharmacoepidemiology research groupLouvain Drug Research Institute, Université catholiquede Louvain, Brussels, BelgiumFund for Scientific Research, Brussels, Belgium
Tali Cukierman‐YaffeCenter For Successful Aging With Diabetes, Division of Endocrinologyand Metabolism, Sheba Medical Center, Ramat Gan, IsraelEpidemiology Department, School of Public Health, Faculty ofMedicine, Herczeg Institute on Ageing, Tel‐Aviv University, TelAviv, Israel
Aastha DubalDivision of Endocrinology and Metabolism, University of NorthCarolina at Chapel Hill, Chapel Hill, NC, USA
Mohsen El KossiNephrology Department, Doncaster Royal InfirmaryDoncaster, UK
Demelza EmmertonDepartment of Geriatric Medicine, Rotherham General HospitalRotherham, UK
Angus ForbesFlorence Nightingale Faculty of Nursing and MidwiferyKing's College London, London, UK
June JamesLeicester Diabetes Centre, University Hospitals of Leicester NHSTrust, Leicester, UK
Anna KahkoskaDivision of Endocrinology and Metabolism, University of NorthCarolina at Chapel Hill, Chapel Hill, NC, USADepartment of Nutrition, Gillings School of Global Public HealthUniversity of North Carolina at Chapel Hill, Chapel Hill NC, USAUNC Center for Aging and Health, University of North Carolina atChapel Hill, Chapel Hill, NC, USA
Archith KamathPrincess Alexandra Eye Pavilion, NHS Lothian, Edinburgh, UK
Nahian KaziDepartment of Geriatric Medicine, Rotherham General HospitalRotherham, UK
Grace KeeganDermatology Department, Rotherham General HospitalRotherham, UK
Julie LewisPrimary and Community Care, Betsi Cadwaladr UniversityHealth Board, Bangor, UK
Sarah MahmoudDermatology Department, Rotherham General Hospital Rotherham, UK
Arshad MajidDepartment of Geriatrics and Neurosciences, Royal HallamshireHospital, Sheffield Teaching Hospitals NHS Foundation Trust, andthe University of Sheffield, Sheffield, UK
Giuseppe MalteseSchool of Cardiovascular Medicine and Sciences, King’s CollegeLondon, London, UKDepartment of Diabetes and Endocrinology, Epsom and St HelierUniversity Hospitals, Surrey, UK
Puja MerwahaDepartment of Geriatric Medicine, Rotherham General HospitalRotherham, UK
Ann MiddletonPerson living with diabetesDiabetes UK Research Steering Group, Droitwich Spa, UK
Solomon MuzuluDepartment of Diabetes and Endocrinology, Rotherham GeneralHospital, Rotherham, UK
Lynne ReedmanDUET Diabetes Ltd, Cambridge, UK
Leocadio Rodríguez‐MañasGeriatric Medicine Department, University Hospital of GetafeMadrid, Spain
Rihan SaidDepartment of Diabetes and Endocrinology, Rotherham GeneralHospital, Rotherham, UK
Rubí E. Sandoval‐SantoyoGeriatric Medicine Department, University Hospital of GetafeMadrid, Spain
Pann Ei Hnynn SiSheffield Kidney Institute, Sheffield Teaching HospitalsSheffield, UK
Alan J. SinclairKing's College London, London, UKFoundation for Diabetes Research in Older PeopleDroitwich Spa, UK
Abubakhr SubkhanDepartment of Geriatrics and Neurosciences, Royal HallamshireHospital, Sheffield Teaching Hospitals NHS Foundation Trust, andthe University of Sheffield, Sheffield, UK
Alex M. SummerbellLeeds Teaching Hospitals NHS Trust, Leeds, UK
Sarah L. SyDivision of Geriatric Medicine, Department of Medicine, Universityof British Columbia, Vancouver, BC, Canada
Mitra TavakoliExeter Centre of Excellence for Diabetes ResearchNational Institute for Health and Care ResearchUniversity of Exeter Medical School, Exeter, UK
Josh WeinsteinDepartment of Health Policy and Management, GillingsSchool of Global Public Health, University of NorthCarolina at Chapel Hill, Chapel Hill, NC, USA
Ruth S. WeinstockDivision of Endocrinology, Diabetes and MetabolismDepartment of Medicine, SUNY Upstate MedicalUniversity, Syracuse, NY, USA
Kirsty WinkleyFlorence Nightingale Faculty of Nursing and MidwiferyKing's College London, London, UK
Sara‐Louise WylieGeneral Practice, Clinical Commissioning Group, Sheffield, UK
Grace ZamanDepartment of Nutrition and Dietetics, Rotherham General HospitalRotherham, UK
Foreword
Although we all agree that longevity is one of the most important achievements of modern societies, an ageing population remains one of the main challenges facing medicine in the twenty‐first century, because of its associated increased risk of chronic diseases and disability. Diabetes, a common illness in older adults, can cause severe complications, leading to loss of physical and cognitive function and premature death. A prompt diagnosis and appropriate management, through both pharmacological and lifestyle interventions, are essential in the control of the disease and its impact. In this perspective, this Manual provides the reader with an accessible, updated, practical source of consultation, written by outstanding authors of international repute, who bring a wealth of clinical experience and scientific expertise in their chapters. It is intended for diabetologists, geriatricians and general practitioners, but it is also a resource not easily obtained elsewhere for all members of the healthcare team who care for older people with diabetes, including nurses, dietitians and other paramedical staff, as well as students in these various disciplines.
A specific chapter is devoted to comprehensive geriatric assessment, the multidimensional diagnostic process focused on determining the medical, psychological and functional capacity of the older patient, which allows a targeted, coordinated and integrated plan for interventions. The treatment goal for patients with diabetes at advanced age is not just survival but maintaining function, reducing complications and improving quality of life, and all these aspects are discussed extensively in dedicated sessions.
I sincerely congratulate the editors and the authors of the individual chapters for the outstanding contributions they have made, as I am confident that this Manual will prove to be an invaluable reference guide on the care of older people with diabetes.
Stefania Maggi, MD, MPH, PhDResearch Director CNR Aging Branch‐IN ItalyMember, Diabetes Special Interest Group for Older People,International Diabetes Federation 11th Edition Atlas GroupPast President, European Geriatric Medicine Society
Preface
We are delighted to present this Manual as a natural development after four editions of the textbook, Diabetes in Old Age. We felt it was important, if not essential, to produce a clinician‐friendly book (manual) that has more practical examples of management and less detailed literature of each subject area.
This Manual provides a general introduction to the domains of geriatric diabetes and establishes the key aims of diabetes care and its related priorities. The Manual comprises over 30 chapters and covers a wide range of topics from epidemiology, screening for diabetes, treatment strategies, complications (both microvascular, macrovascular), metabolic emergencies, inpatient care and management of diabetes in care homes. There are also other important topics, including frailty, foot care and avoiding hospitalisation. In this first edition, we have included areas dealing with technology, deintensification of treatment and the end of life.
In this first edition of the Manual, we have assembled a list of distinguished international, local and regional authors working full‐time in clinical practice. This combination provides the right amount of insight and expertise that is warranted in the pursuit of unravelling the complexities of geriatric diabetes. The generalist and the specialist should both benefit from this guidance, which should aid rational and effective decision making in everyday clinical scenarios involved in the diabetes care of the older person.
Management of geriatric diabetes can be challenging, particularly if we consider those with significant renal impairment or cardiovascular disease, with or without frailty, as well those with other medical comorbidities that have contributed to functional loss, disability and reduced life expectancy. Metabolic target or goal setting is limited by lack of randomised controlled trials of interventions in diabetes care of older people, but the guidance put forward in this Manual has synthesised the data, extrapolated from younger counterparts where necessary, and provided an additional expert viewpoint.
In the book, you will find key messages listed at the start of each chapter and clinical practice questions at the end of the chapter; these elements provide examples of clinical issues in management and how they should be addressed. Ten key references are included in the printed book; a full reference list is available online.
We hope you enjoy reading this Manual of Diabetes Care for Older People and that it will stimulate you to seek a more in‐depth review of the subject in due course.
A. J. SinclairA. H. AbdelhafizApril 2024
Acknowledgements
We would like to thank Caroline Sinclair for her devoted clerical and administrative contributions to this Manual.
We would like to thank Wiley‐Blackwell publishers and the managing editors, Moyuri Handique and Harini Arumugam, for supporting this work, particularly in the transition from a textbook format to a Manual.
About the Companion Website
This book is accompanied by a companion website:
www.wiley.com/go/sinclair/1e
The website includes:
Full list of References for each chapters
Multiple Choice Questions
Case Studies
1Epidemiology and Pathophysiology
Sarah L. Sy
Division of Geriatric Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
Key Points
Diabetes is common in older adults (age
≥
65 years).
The development of type 2 diabetes in older adults is multifactorial.
Lifestyle and environmental factors are strong diabetes risk factors.
Older adults with diabetes are at risk of hypoglycaemia due to changes in glucose counter‐regulation. Hypoglycaemia should be avoided in this population.
Introduction
Diabetes mellitus is a chronic medical condition and a major global public health issue that affects millions of people worldwide. It can lead to micro‐ and macrovascular complications, increased morbidity, reduced life expectancy and significant healthcare expenditure [1]. There is an association between increasing age and the development of diabetes, and its prevalence is highest for older adults (age ≥ 65 years) [1]. This population is heterogenous with varying levels of complexity, geriatric syndromes, functional status and life expectancy. In this chapter, the epidemiology and pathophysiology of diabetes in older adults are discussed.
Epidemiology
In 2019, there were nearly 136 million people worldwide between the ages of 65 and 99 years living with diabetes. This number is anticipated to rise to 195 million by 2030 and 276 million by 2045, based on projections from the International Diabetes Federation (IDF) Diabetes Atlas [2].
The IDF has organised the world map into seven regions for epidemiology research: North America and the Caribbean, South and Central America, Middle East and North Africa, Europe, Western Pacific, South‐East Asia and Africa. In 2019, the highest diabetes prevalences in older adults were in the North America and the Caribbean, and Middle East and North Africa regions, at 27.0% and 24.2%, respectively. The Africa and South‐East Asia regions had the lowest diabetes prevalence in older adults [2].
Diabetes prevalences among older men and women were similar across the regions, apart from a few exceptions. In North America and the Caribbean, men had higher rates of diabetes (31.0%) compared with women (23.6%). In contrast, in South and Central America, rates of diabetes in women were higher (24.6%) compared with men (20.3%) [2]. In terms of socioeconomic status, high‐income countries tended to have a higher diabetes prevalence in older adults compared with middle‐ and lower‐income countries [1, 2]. This trend is likely driven by urbanisation. China, the United States of America and India are countries with the largest populations of older adults with diabetes [2].
Recent studies have shown that diabetes prevalence tends to peak between the ages of 75 and 79 years and that type 2 diabetes is the most common type, accounting for approximately 96% of cases [3]. Several risk factors have been identified as strong contributors to the development of type 2 diabetes, in order of highest risk: obesity, diet, environmental and occupational exposures, and tobacco use [3].
With respect to cost, diabetes care has significant healthcare expenditure. In 2021, it is estimated that US$966 billion were spent globally for the management of diabetes in individuals between the ages of 20 and 79 years [1]. A large proportion of the cost was incurred in the North America and the Caribbean region (US$415 billion) and the greatest amount of spending was for men between ages 60 and 69 years (US$132.5 billion) [1]. Unfortunately, there are limited amounts of health expenditure data on individuals above the age of 80 years.
Pathophysiology of Diabetes in Older Adults
The majority of older adults with diabetes will have type 2 diabetes. In contrast, type 1 diabetes is an autoimmune disease that presents in younger patients due to destruction of beta islet cells and lack of insulin secretion [4]. There is a small subgroup of patients who share overlapping characteristics between type 1 and type 2 diabetes and present later in adulthood (age ≥ 30 years). These individuals have latent autoimmune diabetes in adults (LADA) or type 1.5 diabetes, and have diabetes‐associated antibodies. They usually do not require insulin until six months after diagnosis [5].
The development of type 2 diabetes in older adults is a result of age‐related alterations in glucose metabolism [4]. There are several other factors, such as genetics, lifestyle and environmental changes, inflammation and comorbidities, that contribute to the development of diabetes (Figure 1.1).
There are several contributing factors to hyperglycaemia in older adults, which leads to an imbalance of insulin secretion and insulin resistance and, ultimately, the development of type 2 diabetes. Age‐related decreased beta cell mass and function results in reduced insulin secretion in response to glucose. Genetic predisposition increases an individual's risk of developing diabetes. Lifestyle factors such as diets high in simple sugars and saturated fats lead to increased adiposity, which further increases insulin resistance. A lack of physical activity contributes to a loss of lean muscle mass and decreased insulin sensitivity. Chronic inflammation interferes with insulin signalling pathways thereby increasing insulin resistance. Finally, there are comorbidities and medications that will alter insulin secretion and/or increase insulin resistance.
Age‐related Alterations in Glucose Metabolism
With ageing, hyperglycaemia primarily stems from impaired beta cell function and poor adaptation to insulin resistance [6]. Beta cell mass and proliferation decrease with age, and there is reduced beta cell sensitivity to glucose [7, 8]. Studies have demonstrated that insulin secretion in response to glucose is diminished in older individuals compared with younger individuals with similar insulin resistance [7]. There was previously a debate as to whether increased insulin resistance and decreased insulin sensitivity were due to the ageing process. However, recent studies have shown that age alone does not increase insulin resistance and that factors such as lifestyle, obesity, lean body mass and sarcopenia are major contributors. Similarly, insulin sensitivity worsens due to increased adiposity and loss of lean muscle mass rather than age alone [6].
Figure 1.1: Development of type 2 diabetes in older adults.
There are significant age‐related physiological changes that occur in response to hypoglycaemia. In normal and younger individuals, glucagon is secreted by pancreatic alpha cells in response to hypoglycaemia to stimulate liver gluconeogenesis. If the glucagon response is decreased, then the epinephrine response becomes important. When a hypoglycaemia episode becomes prolonged, growth hormone and cortisol are subsequently secreted [9]. In older adults, the response of both glucagon and growth hormone are impaired during hypoglycaemia. Studies have revealed that the glucagon response is dampened in older adults with diabetes for decreasing blood glucose levels whereas epinephrine and cortisol responses increase [10]. As a result, older adults with diabetes will often have little warning of autonomic and neuroglycopenic symptoms at levels of glucose that would usually elicit symptoms in younger patients. It has also been shown that reaction time is slower in older adults during hypoglycaemia, so they may not be able to act quickly to correct their low blood sugar to the normal level [10].
Genetics
There is a strong genetic component to the development of type 2 diabetes [7]. Older adults with a family history of diabetes are at higher likelihood of developing the condition as they age [8]. However, specific genes leading to the development of diabetes in older age have not been identified. There are also certain ethnic groups that have a higher predisposition to developing diabetes [1].
Lifestyle and Environmental Factors
A diet high in saturated fats and simple sugars, and low in complex carbohydrates and fibre increases the risk of developing diabetes [11, 12]. In addition, diets that incorporate ultra‐processed foods (e.g. foods that contain food additives, or undergo multiple physical, biological or chemical processing) have been shown to increase the risk of diabetes [13]. There have been small studies investigating supplementation of vitamins C and E, magnesium and zinc in improving glycaemic control; however, the benefits are not entirely clear [4].
