Diabetes in Old Age E-Book
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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
This new edition of the popular and market-leading Diabetes in Old Age features up-to-date and comprehensive information about the key aspects of managing older people with diabetes, predominantly type 2 diabetes.
With a strong evidence-based focus throughout, the entire range of issues surrounding diabetes and its many complications are covered, each with a clear focus on how they relate directly to the older patient. Varying approaches to optimizing diabetes care in the community, primary care and secondary care health care arenas are presented, and the importance of comprehensive functional assessment is emphasized. Coverage of areas unique to an ageing population of older people with diabetes such as falls management, frailty and sarcopenia, and cognitive dysfunction form a key cornerstone of the book. In every chapter, best practice points and key learning outcomes are provided, as well as published evidence bases for each major conclusion.
Diabetes in Old Age, 4th edition is essential reading for diabetologists and endocrinologists, diabetes specialist nurses, primary care physicians, general physicians and geriatricians, podiatrists and dieticians with an interest in diabetes, as well as all health professionals engaged in the delivery of diabetes care to older people.
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Seitenzahl: 1786
Veröffentlichungsjahr: 2017
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Table of Contents
Cover
Title Page
Preface
Foreword
Nourishing the soul
The challenge for the profession
Interpreting data
Depression
Demographics and disease
Valediction
List of contributors
SECTION A: Pathophysiology, screening and diagnosis
CHAPTER 1: Pathophysiology of diabetes in older people
1.1 Introduction
1.2 Diet and diabetes in the elderly
1.3 Other factors
1.4 Metabolic alterations
1.5 Molecular biology studies
1.6 Glucose counter-regulation
1.7 Conclusions
Acknowledgments
References
CHAPTER 2: Type 1 diabetes in older age
2.1 Introduction
2.2 Goals in the management of type 1 diabetes in older adults
2.3 Complications and co-morbidities
2.4 Hypoglycemia
2.5 Multidisciplinary team approach
2.6 Long-term care
2.7 Conclusion
References
CHAPTER 3: Preventative strategies
3.1 Introduction
3.2 Diabetes and cardiovascular disease
3.3 Trials to prevent or delay progression from impaired glucose tolerance to diabetes
3.4 Diabetes prevention trials using lifestyle modification programs
3.5 The Da Qing study
3.6 The Finnish Diabetes Prevention Study
3.7 The Diabetes Prevention Program/Diabetes Prevention Program Outcomes Study
3.8 Translation of clinical trial results into clinical practice
References
CHAPTER 4: Diagnosis and screening
4.1 Introduction
4.2 Definition of being old
4.3 Definition of diabetes
4.4 Why investigate diabetes? Diagnostic objectives
4.5 How to recognize diabetes mellitus: Diagnostic tools
4.6 Diagnostic criteria
4.7 Diagnostic approach
4.8 Screening
References
CHAPTER 5: Assessment procedures including comprehensive geriatric assessment
5.1 Diabetes in the aging population
5.2 Geriatric syndromes in an aging population
5.3 CGA and the geriatrics approach to diabetes
5.4 Conclusion
References
SECTION B: Vascular risk factors and complications
CHAPTER 6: Peripheral arterial disease
6.1 Introduction
6.2 Epidemiology of PAD
6.3 Pathophysiology
6.4 Clinical presentation
6.5 Diagnostic methods
6.6 Treatment
6.7 Conclusions
References
CHAPTER 7: Coronary heart disease
7.1 Introduction
7.2 Effect of aging and diabetes on the cardiovascular system
7.3 Epidemiology of CHD
7.4 Cardiovascular risk
7.5 Prevention and management of CHD
7.6 Conclusion
References
CHAPTER 8: Chronic kidney disease related to diabetes in older patients
8.1 Introduction
8.2 Relevant epidemiological information and forms of presentation
8.3 Pathophysiological mechanisms involved in diabetic kidney disease
8.4 Metabolic alterations, particularly hyperglycemia
8.5 Conclusion
References
CHAPTER 9: Visual loss in people with diabetes in old age
9.1 Introductions and background
9.2 Causes of visual impairment
9.3 Conclusions
References
CHAPTER 10: Diabetes foot disease
10.1 Introduction
10.2 Foot disease in older people
10.3 Risk factors for foot disease
10.4 Diabetic neuropathy
10.5 Charcot’s neuropathy
10.6 Peripheral arterial disease
10.7 PAD and foot ulcer healing
10.8 Other risk factors
10.9 Classification of diabetic foot ulcers
10.10 Assessment of foot at risk
10.11 Principles of management
10.12 Treatment of diabetic foot ulcers
10.13 Control of infection
10.14 Improvement in wound condition
10.15 Surgery
10.16 Conclusion
References
CHAPTER 11: Diabetes, neuropathy, and old age
11.1 Introduction
11.2 Frequency of neuropathy development
11.3 Types of diabetic peripheral neuropathy
11.4 Diagnosis and evaluation
11.5 Management
11.6 Summary
References
CHAPTER 12: Sensory disabilities in people with diabetes
12.1 Introduction
12.2 The five senses
12.3 Prevent sensory disability
12.4 Seeing
12.5 Hearing
12.6 Smelling and tasting (olfaction and gustation)
12.7 Impaired bodily sensation
12.8 Medication and sensory impairment
12.9 Sensory assessment
12.10 Conclusions
References
CHAPTER 13: Sexual health and wellbeing
13.1 Why is sexuality important in older age?
13.2 What sexual problems do we see associated with diabetes in aging?
13.3 Impact of aging in men and women
13.4 Hormones and aging in men
13.5 Diabetes and sexuality in women
13.6 Cardiovascular drugs and sexual function in men and women
13.7 Osteoporosis, frailty, recurrent falls, and muscle strength
13.8 Cognitive function
13.9 Mood and depression
13.10 Testosterone and Alzheimer’s disease
13.11 Testosterone and quality of life
13.12 Long-term safety of testosterone therapy
13.13 Effects of androgen ablation therapy
13.14 Conclusions
References
CHAPTER 14: eHealth and diabetes
14.1 Introduction
14.2 An overview of ICT solutions for managing chronic conditions
14.3 Diabetes management apps: strengths and weaknesses
14.4 Diabetes and older people: looking for a novel approach
14.5 Conclusion
References
SECTION C: Treatment and care issues
CHAPTER 15: Insulin resistance and the metabolic syndrome
15.1 Introduction
15.2 Insulin physiology and metabolic regulation
15.3 Insulin action: Relation to aging
15.4 Implications of insulin resistance for cardiometabolic disease
15.5 Clinical research methods for assessing insulin action
15.6 Studies of insulin action in older people
15.7 Insulin resistance in clinical practice
15.8 Metabolic syndrome: clinical definitions
15.9 Utility of the metabolic syndrome in clinical practice
15.10 Prevalence of the metabolic syndrome
15.11 Pathogenesis of the metabolic syndrome
15.12 Overweight and obesity
15.13 Role of insulin resistance
15.14 Emerging role of insulin resistance and the metabolic syndrome in age-related disorders
15.15 Controversies in prevention and therapy of the metabolic syndrome
References
CHAPTER 16: Diabetes and functional limitation: The emergence of frailty and disability
16.1 Introduction
16.2 Functional limitation and diabetes: early background studies
16.3 Diabetes and frailty
16.4 Diabetes and disability
16.5 Functional assessment in varying clinical sectors
16.6 Conclusions
References
CHAPTER 17: Metabolic decompensation in older people
17.1 Introduction
17.2 Hypoglycemia
17.3 Diabetic ketoacidosis and hyperosmolar hyperglycemic state in the elderly
17.4 Pathogenesis of DKA and HHS
17.5 Diagnosis of DKA and HHS
17.6 Conclusion
References
CHAPTER 18: Nutrition management
18.1 Introduction
18.2 Basis of nutrition support
18.3 Nutrition and normal aging
18.4 Under- and malnutrition in older people
18.5 Over-nutrition and obesity in older people
18.6 Nutrition assessment
18.7 Brief review of nutritional guidelines
18.8 Current dietary recommendations: Applications to older people with diabetes
18.9 Energy intake: Carbohydrates and fats
18.10 Activity and exercise
18.11 Protein
18.12 Fiber
18.13 Sodium
18.14 Alcohol
18.15 Vitamins and minerals
18.16 Specific mineral and vitamin deficiencies
18.17 Other vitamins and minerals
18.18 Oral nutrition supplements
18.19 Prebiotics and probiotics
18.20 Artificial nutrition
18.21 Is artificial nutritional support necessary?
18.22 Delivery routes for artificial nutritional
18.23 Enteral tube feeding
18.24 Composition of specialist feeds to manage hyperglycemia
18.25 Administering medicines with enteral feeding
18.26 Complications of enteral nutrition
18.27 Parenteral nutrition
18.28 Ethical issues
18.29 Oral health, swallowing, and dysphagia
18.30 Pressure ulcers and the diabetic foot
18.31 Summary
Acknowledgments
References
CHAPTER 19: Physical exercise management
19.1 Introduction
19.2 The effects of exercise interventions on glycemic control in older people
19.3 The effects of endurance training
19.4 The effects of resistance training
19.5 The effects of combined resistance and endurance training
19.6 Functional capacity in older diabetic patients
19.7 Resistance training improves muscle strength, power, and functional capacity in older people with diabetes
19.8 High-velocity resistance training in older patients with diabetes
19.9 Endurance training and cardiovascular function in older patients with diabetes
19.10 Diabetes, cognitive impairment, and exercise
19.11 Conclusions: Special considerations when prescribing exercise in older type 2 diabetic patients
References
CHAPTER 20: Medicines, pharmacovigilance, and the importance of undertaking comprehensive assessments and regular medicine reviews
20.1 Introduction
20.2 Medicine-related vulnerability and older people
20.3 Polypharmacy
20.4 Pharmacovigilance
20.5 Common medicine-related issues in older people
20.6 Medicine adherence
20.12 Antipsychotic, antihypertensive, and lipid- and glucose-lowering medicines
20.13 Infrequent blood glucose testing
20.14 Frailty and cognitive changes
20.15 Falls risk
20.16 Health professionals, people with diabetes, and/or family medicine-related beliefs and attitudes
20.17 Strategies that can help reduce medicine-related adverse events
20.18 The five rights of administering medicines
20.19 Medicine reviews and risk assessments
20.20 Medicine dose aids
20.21 Technology and apps
20.22 Medicine environment
20.23 Summary
References
CHAPTER 21: Glucose-lowering drugs
21.1 Introduction
21.2 Insulin-sensitizing drugs
21.3 Insulin secretagogues
21.4 Other oral glucose-lowering drug options
21.5 Oral glucose-lowering drugs in development
21.6 Conclusions
References
CHAPTER 22: Insulin therapy
22.1 Introduction
22.2 Indications for insulin therapy
22.3 Advantages and disadvantages of insulin therapy
22.4 Barriers to insulin therapy
22.5 Goals of insulin therapy
22.6 Initiation of insulin therapy
22.7 Physiologic insulin secretion
22.8 Insulin regimens
22.9 Insulin therapy in care homes
22.10 Insulin therapy in diabetic patients with dementia
22.11 Insulin therapy in tube feeding
22.12 Special considerations
22.13 Conclusion
References
CHAPTER 23: Hypertension in older diabetic patients
23.1 Introduction and background
23.2 Prevalence and impact
23.3 Normal blood pressure and the definition of hypertension
23.4 Hypertension in diabetic older persons
23.5 Measurement of blood pressure
23.6 Goals of management
23.7 Initiation of therapy
23.8 Non-pharmacological management
23.9 Pharmacological management
23.10 Compliance with treatment and monitoring
23.11 Special situations of hypertension in diabetes
References
CHAPTER 24: Hypoglycemia
24.1 Introduction
24.2 Epidemiology and risks of hypoglycemia
24.3 Altered physiological response to hypoglycemia with aging
24.4 Hypoglycemic unawareness
24.5 Risk factors for hypoglycemia in aging
24.6 Clinical implications of hypoglycemia
24.7 Glycemic control and hypoglycemia in aging
24.8 HbA1c and hypoglycemia in aging
24.9 Role of treatment modalities
24.10 Conclusions
Referencess
CHAPTER 25: Diabetes in care homes
25.1 Introduction
25.2 The UK as a model of care home reform
25.3 Epidemiology
25.4 Complications and co-morbidity
25.5 Common management problems
25.6 Organization of diabetes care in residential settings
25.7 Improving care
25.8 Nutrition in older residents with diabetes
25.9 Responsibility of physicians
25.10 Multidisciplinary diabetes care
25.11 Nursing care
25.12 Foot care
25.13 Eye care
25.14 Assessing the efficacy and efficiency of diabetes care
25.15 What care homes need to provide
25.16 What needs to be provided in near-patient healthcare settings
25.17 Conclusion
Acknowledgments
References
CHAPTER 26: Primary and community care of diabetes in older people
26.1 Introduction
26.2 Definition of primary care
26.3 The shift of diabetes care from the hospital to the community
26.4 The primary care diabetes team
26.5 Individualizing management
26.6 Glycemic targets
26.7 Lifestyle modification
26.8 Pharmacotherapy
26.9 Screening for microvascular complications
26.10 Smoking cessation
26.11 Treatment of hypertension
26.12 Treatment of dyslipidemia
26.13 Aspirin therapy
26.14 Co-morbidities and special circumstances
26.15 Falls
26.16 Frailty
26.17 Urinary incontinence
26.18 Concordance with recommended treatment
26.19 Loneliness and social isolation
26.20 Nursing home patients
26.21 Preventive health care in older people: another perspective
26.22 Conclusions
Acknowledgments
References
CHAPTER 27: Inpatient diabetes care and admissions avoidance in older people with diabetes
27.1 Introduction
27.2 Diabetes admissions from the care home population
27.3 Reducing diabetes admissions: A whole-system approach
27.4 Diabetes medication
27.5 Hyperglycemia
27.6 Conclusions
References
SECTION D: Management of associated complications
CHAPTER 28: Diabetes and co-morbidities
28.1 Introduction
28.2 Obstructive sleep apnea
28.3 Fatty liver disease
28.4 Cancer
28.5 Fractures
28.6 Type 2 diabetes and the lower urinary tract
28.7 Hearing impairment
28.8 Periodontal disease
28.9 Conclusion
References
CHAPTER 29: Diabetes and cognitive dysfunction
29.1 Introduction
29.2 Background evidence of association between diabetes and cognitive dysfunction
29.3 Background evidence of the relationship between cognitive dysfunction and glycemic control
29.4 The importance of detecting cognitive dysfunction
29.5 Methods of detection
29.6 Influence on diabetes self-care
29.7 The importance of excluding depression
29.8 Further investigations
29.9 Recent developments
29.10 Conclusions
Acknowledgement
CHAPTER 30: Mood disorders
30.1 Introduction
30.2 Depression
30.3 Anxiety
30.4 Distress
30.5 Conclusion
Key points
References
CHAPTER 31: Falls and diabetes
31.1 Introduction
31.2 Falls: A major public health problem
31.3 Diabetes: An independent risk factor for falls
31.4 Other risk factors for falls in older adults with diabetes
31.5 Assessment of falls in outpatient diabetes clinics
References
CHAPTER 32: Managing pain
32.1 Introduction
32.2 What is pain?
32.3 Categories of pain
32.4 Prevalence of pain in older people
32.5 Barriers to pain management
32.6 Common types of pain in older people
32.7 Some diabetes-specific types of pain
32.8 Painful diabetic neuropathy
32.9 Pressure ulcers and wound pain
32.10 Managing pain
32.11 Pain tools
32.12 Observation
32.13 Pharmaceutical treatment
32.14 Non-medicine options
32.15 Involving the older person in pain management
32.16 Communicating the pain management plan
32.17 Pain management in aged-care homes
32.18 Summary
References
CHAPTER 33: Palliative and end-of-life care
33.1 Introduction
33.2 Making decisions about end-of-life care: clinical and ethical dilemmas
33.3 Key management strategies
33.4 Pain management
33.5 Glycemic targets
33.6 Monitoring blood glucose
33.7 Hyperglycemia
33.8 Hypoglycemia
33.9 Medicine management
33.10 Type 1 diabetes
33.11 Type 2 diabetes
33.12 Complementary and alternative therapies
33.13 Nutrition and hydration
33.14 Diabetogenic medicines
33.15 Managing corticosteroid-induced diabetes in palliative and end-of-life care
33.16 Supporting family/carers
33.17 Advanced care plans and withdrawing treatment
33.18 Diabetes education
33.19 Spiritual needs
33.20 Summary
References
SECTION E: Optimizing diabetes care in older people
CHAPTER 34: Diabetes education and the older adult
34.1 Introduction
34.2 Phases of living with diabetes
34.3 Educational assessment of factors associated with diabetes self-care
34.4 Diabetes educational and behavioral support interventions
34.5 Summary
References
CHAPTER 35: Supporting the family and informal carers
35.1 Introduction
35.2 Who are carers?
35.3 What do carers do?
35.4 What effect can caring have on the carer?
35.5 What do carers want?
35.6 What are the benefits for carers?
Acknowledgments
References
CHAPTER 36: Public health issues and community impact
36.1 Introduction
36.2 Diabetes as a public health priority
36.3 Heterogeneity of diabetes in the old
36.4 Epidemiology
36.5 Prevention
36.6 Putting it into practice: An agenda for action
36.7 Summary
References
CHAPTER 37: Providing cost-effective diabetes care
37.1 Introduction
37.2 Current and future costs of diabetes
37.3 Prevalence of pre-diabetes and diabetes prevention
37.4 Principles of cost-effectiveness analysis
37.5 Cost-effectiveness of diabetes prevention
37.6 Cost-effectiveness of specific components of diabetes care
37.7 Cost-effectiveness of new approaches to care management and coordination of care
References
CHAPTER 38: Clinical trials in older people
38.1 Overview of clinical trials
38.2 Clinical trials for older subjects
38.3 Differential aspects of clinical trials in elderly subjects
Further reading
Index
End User License Agreement
List of Tables
Chapter 02
Table 2.1 Characteristics of older patients with type 1 or type 2 diabetes.
Table 2.2 Therapy approach and glycemic targets for type 1 diabetes in older people.
Chapter 03
Table 3.1 Summary of results of major randomized controlled trials of medications and lifestyle interventions to prevent the development of type 2 diabetes mellitus in people with impaired glucose tolerance.
Chapter 04
Table 4.1 Diagnostic criteria of glucose metabolism abnormalities.
Chapter 05
Table 5.1 Medical domain.
Table 5.2 Functional domain.
Table 5.3 Psychological/mental domain.
Table 5.4 Social domain.
Chapter 06
Table 6.1 Fontaine’s stages.
Chapter 07
Table 7.1 Summary of recent diabetes studies [94–97].
Chapter 08
Table 8.1 Pathophysiological mechanisms implicated in diabetic nephropathy.
Table 8.2 Chronic kidney disease stages based on eGFR measurements (adapted from [145]).
Table 8.3 The 2009 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline (adapted from [146]).
Table 8.4 Data from three key studies in type 2 diabetes showing diverse interventions with different levels of urinary protein loss.
Table 8.5 Foods low in sodium, potassium and phosphorus.
Chapter 10
Table 10.1 PEDIS classification system for foot ulcers [33].
Table 10.2 Neuropathy disability score sheet [34].
Chapter 11
Table 11.1 Symptoms associated with diabetic autonomic neuropathy.
Table 11.2 A summary of some of the medications used to treat pain in people with diabetic neuropathy.
Chapter 12
Table 12.1 Estimated numbers of people living with disorders that can impair vision (RNIB sight loss data tool).
Chapter 13
Table 13.1 Outcome of therapy with long-acting testosterone undecanoate in a population of men with type 2 diabetes and hypogonadism (BLAST) [68].
Table 13.2 FSFI scores in women with diabetes, obesity, and hypothyroidism versus controls [71].
Table 13.3 Sexual problems associated with co-morbid conditions in women [72].
Chapter 15
Table 15.1 Physiological and pathological states associated with whole-body insulin resistance.
Table 15.2 Clinical disorders in which insulin resistance is implicated in pathogenesis
a
[4].
Table 15.3 Investigative techniques for the assessment of insulin action in humans [387].
Table 15.4 Components of the metabolic syndrome [4].
Table 15.5 NCEP ATP III clinical criteria for the metabolic syndrome [71].
Table 15.6 IDF clinical criteria for the metabolic syndrome [38].
Chapter 16
Table 16.1 Risk of death in older people with diabetes mellitus: after adjustment, only age, sex and frailty remain in the predictive equation.
Table 16.2 Benefits of comprehensive geriatric assessment.
Table 16.3 Instruments for evaluating frailty and its components and/or associated areas.
Table 16.4 Future research questions: diabetes and functional limitation.
Chapter 17
Table 17.1 The main features of diabetic ketoacidosis (DKA) and hyperglycaemic state (HHS) in older people.
Chapter 18
Table 18.1 Overview of the pathophysiology of malnutrition.
Table 18.2 Common methods used to undertake nutrition screening.
Table 18.3 Mnemonic ‘Meals on Wheels’ [11].
Table 18.4 Chronic diseases and medicines that contribute to malnutrition in older people (social factors such as ability to shop, social isolation, food beliefs and experiences, financial status, nutrition knowledge also have a role).
Table 18.5 Essential criteria for diagnosing malnutrition in older people.
Chapter 19
Table 19.1 Summary of some studies that investigated the effects of resistance, endurance or combined resistance and endurance training in the elderly with type 2 diabetes.
Chapter 20
Table 20.1 Factors that can influence glucose-lowering medicine risks and benefits in older people with diabetes (adapted from the Australian Medicines Handbook [5] and Dunning and Sinclair [6]).
Table 20.2 Examples of some commonly prescribed medicines that can increase or lower blood glucose.
Chapter 21
Table 21.1 Classes of glucose-lowering agents (with insulin as a comparator) and associated characteristics.
Table 21.2 Profiles of three commonly used DPP-4 inhibitors.
Table 21.3 Examples of novel glucose-lowering drugs in development for the treatment of type 2 diabetes.
Chapter 22
Table 22.1 Comparison between insulin regimens.
Chapter 23
Table 23.1 DASH eating plan.
Chapter 24
Table 24.1 Common hypoglycemia symptoms in older adults.
Chapter 25
Table 25.1 Some estimates of diabetes prevalence among older care home residents.
Table 25.2 Management problems in care homes.
Table 25.3 Outcome measures for use in care home diabetes care.
Chapter 26
Table 26.1 Strategy for improving medication adherence in older people with diabetes.
Chapter 27
Table 27.1 NPSA recommendations for reducing insulin errors (2010).
Table 27.2 10 key steps to ensure safe and timely discharge.
Table 27.3 Potential obstacles to achieving optimal glycemic control in hospital.
Table 27.4 ThinkGlucose: patient assessment tool and referral criteria.
Table 27.5 Types of discharge category.
Table 27.6 Roles and responsibilities of hospital staff.
Chapter 28
Table 28.1 Common conditions present in older people with diabetes.
Table 28.2 Summary of metformin trials in adult patients with non-alcoholic fatty liver disease/non-alcoholic steatohepatitis.
Chapter 29
Table 29.1 Background to the relationship between diabetes and cognitive disorders.
Table 29.2 Benefits of early recognition of cognitive dysfunction in diabetes.
Chapter 31
Table 31.1 Risk factors for falls and possible interventions to modify them.
Chapter 32
Table 32.1 Pain descriptors adapted from the ISAP taxonomy [4], the American Geriatrics Society [6], the Australian Pain Society [3, 51] and the British Pain Society [5, 39].
Table 32.2 Some behavioral signs of pain that can be detected on careful observation and noting changes in the behaviors listed under relevant column subheadings in the table [51] (it is important to check assumptions that the observed behavior is a result of pain).
Chapter 33
Table 33.1 Common hypoglycemia risk factors for older people with diabetes receiving palliative care and at the end of life: the more risk factors the person has the greater their risk of hypoglycemia.
Table 33.2 Some medicines commonly used in palliative and cancer care that can cause, exacerbate or contribute to the underlying cause of symptoms.
Table 33.3 Some issues to consider when prescribing and monitoring commonly used glucose-lowering medicines during palliative and end-of-life care.
Chapter 34
Table 34.1 Important areas to consider in the educational assessment.
Table 34.2 Tips and strategies to accommodate sensory loss in diabetes education.
Table 34.3 Low literacy diabetes education resources.
Table 34.4 Steps for helping patients set self-care goals.
Chapter 35
Table 35.1 Overview of the care that caregivers take responsibility for delivering.
Table 35.2 Risk factors for carer psychological distress adapted from Shah
et al.
[10] and Carey
et al.
[74].
Table 35.3 What do carers want?
Table 35.4 Potential benefits of networking and supported informal care.
Chapter 38
Table 38.1 Description of publications by groups of 100 articles.
Table 38.2 Possible strategies to improve the participation of older people in clinical trials.
List of Illustrations
Chapter 01
Figure 1.1 Factors that contribute to the high prevalence of diabetes in the elderly.
Figure 1.2 Fasting hepatic glucose production in relation to fasting glucose levels in healthy elderly controls and elderly patients with diabetes. Hepatic glucose production was measured by infusing radioactive glucose tracers.
Figure 1.3 Glucose-induced insulin release in healthy elderly controls and elderly patients with diabetes. Insulin values were measured at glucose levels approximately 5 mmol/l above fasting levels.
Figure 1.4 Insulin-mediated glucose disposal rates in healthy elderly controls and elderly patients with diabetes. Glucose disposal rates were measured utilizing the euglycemic clamp technique. In this technique, insulin is infused to achieve levels occurring after a meal, and glucose is infused simultaneously to prevent hypoglycemia.
Figure 1.5 Insulin-mediated blood flow in obese middle-aged controls and obese elderly controls and patients with diabetes. Blood flow was measured in the calf during euglycemic clamp studies utilizing venous occlusion plethysmography.
Figure 1.6 Glucose effectiveness in elderly controls and patients with diabetes. During these studies, insulin secretion was suppressed by infusing the somatostatin analogue octreotide. Glucose was then infused to assess glucose disposal in the absence of insulin.
Figure 1.7 Glucagon and growth hormone (GH) responses to hypoglycemia in healthy young, healthy old, and elderly patients with diabetes. Controlled hypoglycemia was induced using the glucose clamp technique. Glucose values at which hormone levels were measured are shown on the top
x
-axis.
Chapter 03
Figure 3.1 Diabetes incidence by age group in the Diabetes Prevention Program.
Figure 3.2 Cumulative incidence of diabetes over 10 years of follow-up in subjects age 60 years or older at randomization in the Diabetes Prevention Program Outcomes Study.
Chapter 04
Figure 4.1 Principal features of the elderly: the cocktail of the senescence.
Figure 4.2 Practical clinical approach in the diagnosis of diabetes mellitus in the elderly. HbA1c, hemoglobin A1c; FPG, fasting plasma glucose; GSR, globular sedimentation rate; CRP, C-reactive protein; ADA, American Diabetes Association; WHO, World Health Organization.
Chapter 06
Figure 6.1 The evolution of the atherosclerosis.
Figure 6.2 The ankle-braquial index.
Chapter 07
Figure 7.1 The synergistic effects of aging and diabetes on atherosclerosis. The synergistic effect of aging combined with diabetes promotes a procoagulant, proliferative, and pro-inflammatory state inducing atherosclerosis with increased vasoconstriction and reduced vasodilatation. AGE, advanced glycation products.
Chapter 08
Figure 8.1 Reported prevalence of CKD in adult diabetic patients.
Figure 8.2 Pathophysiological mechanisms in diabetic kidney disease.
Chapter 13
Figure 13.1 UK changes in sexual activity with age (Natsal-3) [3].
Figure 13.2 Reasons why couples cease sexual activity by age (Natsal-3) [3].
Figure 13.3 Association of depression and diabetes complications: A meta-analysis [62].
Figure 13.4 Factors related to diabetes which may affect female sexuality.
Chapter 14
Figure 14.1 Factors involved in clinical decision-making for older people with diabetes with therapeutic options.
Figure 14.2 Proposed architecture for remotely managing older adults with diabetes.
Chapter 16
Figure 16.1 Factors affecting treatment decisions and associated therapeutic options [56].
Figure 16.2 Ageing and diabetes sarcopenia: relationship with lower limb performance [41]. T2DM, type 2 diabetes mellitus.
Figure 16.3 The management of diabetes in older people.
Chapter 17
Figure 17.1 Management of patients with DKA and HHS.
Chapter 18
Figure 18.1 Association between BMI and mortality as a function of age in 8428 hospitalized patients. Reproduced from [32].
Chapter 19
Figure 19.1 Total abdominal fat and insulin sensitivity at pretraining and after a 16-week strength training period for each subject and mean values. **
p
< 0.01 and ***
p
< 0.001 vs the corresponding pretraining value.
Chapter 21
Figure 21.1 Renal tubular reabsorption of glucose. T2DM, type 2 diabetes mellitus; SGLT2, sodium-glucose co-transporter-2.
Chapter 22
Figure 22.1 Initiation of insulin regimens in older people with diabetes.
Chapter 24
Figure 24.1 Hierarchy of responses to hypoglycaemia in non-diabetic humans.
Chapter 26
Figure 26.1 Healthcare professionals involved in the care of older people with diabetes in the community.
Chapter 27
Figure 27.1 National Diabetes Audit 2011–2012 England and Wales, Health and Social Care Information Centre, showing prevalence of (a) type 1 and (b) type 2 diabetes according to age and gender.
Chapter 28
Figure 28.1 Association between obstructive sleep apnea and metabolic abnormalities.
Figure 28.2 Diabetes and osteoblastic activity. BMP, bone morphogenetic protein; TGF-β, transforming growth factor β; BMPR, bone morphogenetic protein receptor; IL-6, interleukin 6; IL-1, interleukin-1; IL6R, receptor IL-6 receptor; PTH, parathyroid hormone; PTHR, PTH receptor; TNT, neurotransmitter; HTR2β, 5-hydroxytryptamine receptor 2 β; I, insulin; IR, insulin receptor; LRP, low-density lipoprotein receptor related protein; FZD, frizzled; TNF, tumor necrosis factor; TNFR, TNF receptor; JAK: janus kinase; STAT, signal transducers and activators of transcription; AP-1, activator protein 1; ERK, extracellular signal regulated kinase; MAPK, mitogen activated protein kinase; RUNX2, runt related transcription factor 2; PKA, protein kinase A; PKA, protein kinase C; β-cat, β catenin; GSK3b, glycogen synthase kinase 3b; SMURF, SMAD ubiquitylation regulatory factor; MGP, matrix gla protein; OC, osteocalcin; OSX, osterix; OPG, osteoprotegerin; DKK-1, Dickkopf related protein 1; Sost, sclerostin; TWSG1, twisted gremlin; Ang-II: angiotensin-II; AGE, advance glycation end product; GRB2, growth factor receptor bound protein.
Figure 28.3 Diabetes and osteoclastic activity. MCP, monocyte chemoattractant protein; IgG, immunoglobulin G; NFAT, nuclear factor of activated T cells; ROS, reactive oxygen species; PLCγ, phospholipase Cγ; M-CSF, macrophage colony stimulating factor; PPARγ, activates transcription factors peroxisome proliferator activated receptor γ; HIF1α, hypoxia inducible factor 1 α; FcγR, Fc receptor γ; IL-6, interleukin 6; CCR2, CC chemokine receptor 2; mTOR, mammalian target of rapamycin; OPG, osteoprotegerin; ERK, extracellular signal regulated kinase; JNK, JUN N terminal kinase; TRAP, tartrate-resistant acid phosphatase; CSK, cathepsin K; MMP, matrix metalloproteinase; CA2, carbonic anhydrase 2; GC, glucocorticoid.
Chapter 29
Figure 29.1 Scheme for the detection of cognitive dysfunction in type 2 diabetes mellitus.
Chapter 30
Figure 30.1 Interaction between diabetes and mood disorders: Diabetes and mood disorder share common risk factors and have a bidirectional relationship. Diabetes leads to development of mood disorders and mood disorders worsen diabetes control setting a vicious circle. HPAA, hypothalamic pituitary adrenal axis.
Chapter 31
Figure 31.1 The greatest potentially modifiable risk factors for falling are gait impairment, reduced balance, and weakness. Gait, posture, balance, and strength must be covered in the multidimensional assessment. Currently, multiple devices are available from simple ones such a chronometer (a) or dynamometer (b); new technological devices are being developed to make these evaluations most accurate. Posturography (c) and GaitRite (d, two photos) are more sophisticated devices.
Figure 31.2 If after considering general advice the high risk of falls persists, patients must be referred to a falls and fractures clinic for a multidimensional assessment.
Chapter 34
Figure 34.1 Mean HbA1c levels over time for older versus middle-aged adults participating in randomized controlled diabetes education study: (a) all participants, (b) structured cognitive behavioral intervention group education, (c) standard group education (attention control), (d) individual education (control). White circles, younger adults; black squares, older adults.
Chapter 37
Figure 37.1 Cost-effectiveness plane.
Chapter 38
Figure 38.1 The search strategy for clinical trials.
Guide
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Diabetes in Old Age
EDITED BY
Alan J. Sinclair
Diabetes Frail Ltd, and University of Aston, Birmingham, UK
Trisha Dunning
Deakin University, Geelong, Australia
Leocadio Rodríguez Mañas
Hospital Universitario de Getafe, Madrid, Spain
Medha Munshi
Beth Israel Deaconess Medical Center, Harvard University, USA
FOURTH EDITION
This edition first published [2017] © [1995, 2001, 2009, 2017] by [John Wiley & Sons Ltd]
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Names: Sinclair, Alan (Alan J.), editor. | Dunning, Trisha, editor. | Mañas, Leocadio Rodríguez, editor. | Munshi, Medha N., editor.Title: Diabetes in old age / edited by Alan J. Sinclair, Trisha Dunning, Leocadio Rodríguez Mañas, Medha Munshi.Description: Fourth edition. | Chichester, West Sussex, UK ; Hoboken, NJ : Wiley-Blackwell, 2017. | Includes bibliographical references and index.Identifiers: LCCN 2016040281| ISBN 9781118954591 (hardback) | ISBN 9781118954607 (adobe PDF) | ISBN 9781118954614 (ePub)Subjects: | MESH: Diabetes Mellitus | AgedClassification: LCC RC660.75 | NLM WK 810 | DDC 618.97/6462–dc23LC record available at https://lccn.loc.gov/2016040281
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Preface
Diabetes in Old Age, 4th Edition
The primary purpose of this book is to promote high-quality diabetes care for all older people irrespective of their health or social care setting. This brings with it the equally important need to ensure their wellbeing, quality of life, and an acceptable level of physical and cognitive functioning.
Older people also have a fundamental right to expect this care to be delivered in a compassionate and effective way using, where possible, all modern treatments and technology. With this view in mind, we decided at an early stage of the preparation of this book that individual contributions should be provided by active investigators in the field, many of whom are leading international authorities, rather than by armchair physicians and clinicians. Our expert contributors come from the USA, Europe, Australia, Canada, India, Mexico, and South America.
We have also tried to establish a balance between diabetes care in community settings and care in hospital or care homes. All these aspects and more are covered. We have included a “Key messages” section in each chapter and have limited the number of references cited where possible in an attempt to cite more recent work.
This book has been written to appeal to general physicians, diabetologists, geriatricians, hospital-based and community nurses, diabetes specialist nurses, social care staff, commissioners of health and social services, policy makers, and other allied professional staff and stakeholders.
This edition gains from the inclusion as new editors three highly distinguished clinical scientists, Trisha Dunning, Medha Munshi, and Leocadio Rodriguez Manas, who have worked tirelessly with Alan J. Sinclair to produce this book.
Finally, we wish to acknowledge the administrative support of Caroline Sinclair.
Alan J. Sinclair, Medha Munshi, Leocadio Rodriguez Manas, and Trisha Dunning
Foreword
The cognoscenti, the small cadre of experts on diabetes in older people, will skip this foreword and dive right into the individual chapters. There they will find many treasures related to clinical science and clinical care, as well as historical vignettes and current controversies related to diabetes in aging patients.
You, by reading this foreword in a book on diabetes in old age, are marking yourselves as non-expert but you are clearly ahead of your medical colleagues. You are recognizing that the excellent textbooks on diabetes and excellent textbooks on geriatric medicine, though they cover medical care of the older patient, typically fall short in dealing with the older patient with diabetes.
These textbooks mirror the state of affairs in medical care today. When I was a young physician, I was impressed that excellent internists provided excellent care for their patients, including very good diabetes management. My impression now is that very good internists continue to provide very good care, except for diabetes where the care often is only mediocre. Many endocrinologists, formerly excellent in diabetes, are also falling further and further back from the cutting edge of diabetes care. This is especially sad because we now know more than ever the importance of good management and have better tools with which to approach the desired goals. The gap between “excellent” and “actual” widens as the patient’s age increases.
In this essay, I plan to inspire you, to help guide you into a highly satisfying professional path, a path that will please you, as well as enhance your value to your patients and to your medical community. The rest of this book is filled with instructional material that you will find very useful. My goal is to provide an overarching view from the top of the mountain.
Nourishing the soul
Champions seek new challenges, set new goals. For mountain climbers and cellists, surgeons and swimmers, dancers and authors, striving for excellence channels energies and rejuvenates the self. The physician who adopts the mindset of a champion helps his or her patients, helps other health care professionals with their patients and nourishes his or her own soul. At this time in medicine, when physician burnout is epidemic, nourishment for the soul can be life-saving. In the USA, where the pension systems are in disarray and large debts have been piled up to pay for schooling, physicians will be working many years past the hallowed 65. The best preparation for the long journey is passion in one’s professional pursuit. As an internist, or endocrinologist, or geriatrician, join me in exploring the attractions of becoming skilled in the care of diabetes of the old.
When I entered the profession fifty years ago, antibiotics were routing many infectious diseases. The ancient aphorism “If you know syphilis, you know all of medicine” was being re-modelled; syphilis was replaced by diabetes.
I propose a new model: “If you know diabetes in old age, you know all of medicine”.
The challenge for the profession
Increasingly, medicine in general is benefiting from the introduction of protocols and algorithms. While improving care, these also shrink the intellectual distance between the physician, the physician’s assistant and the nurse. I am guessing that a 37-year-old professor of computer science with type 1 diabetes can probably manage well with a little help from a diabetes educator and an occasional visit to a physician. Recall the World War II pharmacist’s mate who in the pre-antibiotic area successfully removed an inflamed appendix from a crew member of his submarine submerged beneath the waters of the Pacific.
Advancing age brings growing complexity. Elderly patients with diabetes need continuous input from skilled physicians. For these physicians, protocols and algorithms are the starting point but the real plan needs multiple modifications, surveillance, balancing of competing priorities, and skilled navigation of poorly charted waters. It demands professional skills at their best.
Interpreting data
Multi-centre trials, the foundation of therapeutics today, are typically performed on younger patients. With the basic and clinical science in the background, the data from widely heralded multi-centre trials (with patients who are typically younger and less complicated) provide a basis but not a recipe for care of the elderly patient. Advanced age and other exclusionary criteria, including medications, make extrapolations to older people more tenuous. The loud “microphones” supported by pharmaceutical company coffers often fill the air with information that is misleading for older patients.
Laboratory standards are based on younger populations. Data in the elderly are much sparser. Even when the mean and median for a lab test remain unchanged, the splay typically increases so that higher and lower values that are “normal” for an older patient are easily labelled as pathological.
New medications are largely tested on younger, less complicated patients. Data among older patients are sparse. Many side effects of drugs emerge gradually in the years after their introduction. The catalogue of side effects among older complex patients emerge more slowly. The sparseness of data dictates that new drugs should be avoided in older patients, except on the very rare occasion when the new drug is a very substantial advance and other drugs cannot meet the need.
Adverse drug interactions between two drugs are identified slowly. Many remain undetected. Typical elderly patients take many medications, exponentially increasing the likelihood of adverse drug interactions and, equally, making their detection most difficult.
Depression
Advancing age as well as medications and multiple medical conditions are associated with depression. The link between diabetes and depression has received a lot of attention recently. Growing evidence that depression impacts negatively on physical health mandates that depression, so common in older people, be detected and treated energetically.
In dealing with depression, especially in the older patient, recall:
Depression without sadness is easy to miss.
Screening instruments are helpful.
Personalized rationalizations of the healthcare professional (“If I were 82 and living alone, I would also feel that way …”) can obscure the correct diagnosis and management.
Drugs as well as endocrine diseases and other disorders are common aetiologies of depression that is reversible.
When medication and psychotherapy fail, ECT (electroconvulsive therapy), is an excellent therapeutic choice to consider.
With ageing, suicide rates rise sharply, especially among white males. Living alone and having firearms in the home each add to the risk.
Demographics and disease
The population is being enriched progressively with patients who are over 65. They are living longer. The so-called old-old are a rapidly growing group. Objective data to guide the physician require ever longer lines of extrapolation, demanding more of the physician’s judgment. The incidence and prevalence of diabetes increase with age. Ageing brings out diabetes; diabetes accelerates biological ageing and onset of other pathology. These processes corrode cognition.
Ageing in our Society: The universal reverence, or at least respect, for the elderly that held sway worldwide since the beginning of human memory, has been replaced in the industrialized world of today with a wide range of negative attitudes, mostly undeserved. In their care for the elderly, physicians and their teammates in care will be energized by recalling the widely appreciated positive features of a majority of the elderly:
Every older patient can be improved in some way by an encounter with a professional.
Typically, older people are appreciative of the care and express their appreciation.
Their expectations for improvement are realistically tempered.
They are individually “more unique”.
“More unique” is a phrase that will galvanize to action legions of amateur grammarians all over the English-speaking world. They will reflexly remind me that unique indicates one-of-a-kind and therefore no comparator is permitted. Biology and I will prove them wrong. Let’s start with a fertilized egg that is just dividing to generate a pair of monozygotic twins. They are not identical and progressively diverge, distancing one biological self from the other. All humans do the same. The extremely similar looking zygotes, and highly similar looking newborns progressively diverge, biologically, sociologically and medically, to the delight and amazement of the skilled physician and other health care providers. Like snowflakes, Rembrandt paintings, precious gemstones, and leaves from a single tree, blessedly, there are no sames among older patients with diabetes.
Valediction
With a little luck, it is likely that you, in your lifetime, will never lack for food for your body. Much more at risk, and therefore more to be guarded, is the supply of nourishment for your professional soul.
Jesse Roth MD, D.H.C., FACPInvestigator & Head, Laboratory of Diabetes and Diabetes-Related Disorders,Feinstein Institute for Medical Research, Northwell Health (formerly North Shore-LIJ Health System);Professor of Medicine, Hofstra Northwell School of Medicine;Professor of Medicine, Albert Einstein College of Medicine, Yeshiva University;Former Director of Intramural Research (“Scientific Director”)NIH's National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda;Former Lublin Professor of Medicine and Geriatrician-in-Chief,Johns Hopkins University School of Medicine, Baltimore.
List of contributors
Ahmed H. AbdelhafizConsultant Physician and Honorary Senior Clinical LecturerDepartment of Elderly MedicineRotherham General HospitalRotherhamUK
Belinda AllanConsultant DiabetologistHull and East Yorkshire NHS TrustHullUK
Michelangela BarbieriDepartment of Medical, Surgical, Neurological, Metabolic and Geriatric SciencesSecond University of NaplesNaplesItaly
Srikanth BellaryConsultant DiabetologistHeart of England NHS Foundation Trust and Senior Lecturer Metabolic MedicineAston UniversityBirminghamUK
Elizabeth A. BeverlyAssistant ProfessorOhio University Heritage College of Osteopathic MedicineAthensOhioUSA
Isabelle Bourdel-MarchassonCHU BordeauxClinical GerontologyBordeauxFrance
Cristina Alonso BouzónThe Geriatric ServiceGetafe University HospitalMadridSpain
Eduardo Lusa CadoreDepartment of Physical EducationFederal University of Rio Grande do SulPorto AlegreBrazil
A. ChikaraUniversity College of Medical SciencesNew DelhiIndia
Chia-Hung ChouDepartment of MedicineUniversity of ChicagoChicagoUSA
Marie DanetGRECCAD ClinicalMiami VA Healthcare SystemUSA
Francisco del PozoCentro de Tecnología BiomédicaUniversidad Politécncia de MadridSpain
Ketan DhatariyaConsultant DiabetologistNorfolk and Norwich University Hospitals NHS TrustNorwichUK
Jennifer DineenDepartment of NeurologyBeth Israel Deaconess Medical CenterBostonUSA
Trisha DunningChair in Nursing and DirectorCentre for Nursing and Allied Health ResearchDeakin UniversityGeelongAustralia
Hermes FlorezGRECCAD ClinicalMiami VA Healthcare SystemUSA
Roger GadsbyPrinciple Teaching FellowWarwick Medical SchoolUniversity of WarwickCoventryUK
Christopher GibbonsDepartment of NeurologyBeth Israel Deaconess Medical CenterBostonUSA
Ashish GoelUniversity College of Medical SciencesNew DelhiIndia
Geoffrey I. HackettFormer Professor of Men's HealthUniversity of Bedfordshire and Consultant in Urology/AndrologyGood Hope HospitalSutton ColdfieldUK
Rowan HillsonFormer National Clinical Director for Diabetes EnglandUK
Edward S. HortonSenior InvestigatorJoslin Diabetes CenterProfessor of MedicineHarvard Medical SchoolBostonUSA
Elbert S. HuangDepartment of MedicineUniversity of ChicagoChicagoUSA
Felipe InserraCo-Director of Master on Vascular Mechanics and High Blood PressureAustral UniversityBuenos AiresArgentina
Mikel IzquierdoDepartment of Health SciencesPublic University of NavarreTudelaNavarre, Spain
N. JainUniversity College of Medical SciencesNew DelhiIndia
Carol JairamDiabetes Inpatient Specialist NurseImperial College Healthcare NHS TrustLondon, UK
Mark KennedyCorio Medical ClinicVictoriaAustralia
Andrew J. KrentzProfil Institute for Clinical ResearchChula VistaCaliforniaUSA
Olga LaosaThe Geriatric ServiceGetafe University HospitalMadridSpain
Marta Checa LopezThe Geriatric ServiceGetafe University HospitalMadridSpain
Leocadio Rodríguez MañasThe Geriatric ServiceGetafe University HospitalMadridSpain
Jorge ManzarbeitiaThe Geriatric ServiceGetafe University HospitalMadridSpain
Graydon S. MeneillyDivision of Geriatric MedicineDepartment of MedicineThe University of British ColumbiaVancouverCanada
Medha MunshiAssociate Professor of Medicine and Director of Joslin Geriatric Diabetes ProgramsBeth Israel Deaconess Medical CenterHarvard UniversityUSA
Giuseppe PaolissoDepartment of Medical, Surgical, Neurological, Metabolic and Geriatric SciencesSecond University of NaplesNaplesItaly
Laura PedrazaThe Geriatric ServiceGetafe University HospitalMadridSpain
Ignacio Peinado-MartínezFundación para la Investigación BiomédicaGetafe University HospitalMadridSpainandCentro de Tecnología BiomédicaUniversidad Politécncia de MadridSpain
Luis Miguel Gutiérrez RobledoDirector GeneralInstituto Nacional de GeriatríaSan Jerónimo LídiceMéxico
Marta Castro RodríguezThe Geriatric ServiceGetafe University HospitalMadridSpain
Mike SampsonConsultant DiabetologistNorfolk and Norwich University Hospitals NHS TrustNorwichUK
Peter H. ScanlonConsultant OphthalmologistGloucestershire Eye UnitCheltenhamGloucestershireUK
Angelo ScuteriHospital San Raffaele PisanaIstituto Ricovero e Cura a Carattere SceintificoRome,Italy
Isaac SinayAdvisor for the Diabetic Unit of the Cardiovascular Institute of Buenos AiresBuenos AiresArgentina
Alan J. SinclairDirectorFoundation for Diabetes Research in Older PeopleDiabetes Frail LtdandUniversity of AstonBirminghamUK
Arlene SmaldoneAssociate ProfessorColumbia University School of NursingNew York, USA
Willy Marcos ValenciaGRECCAD ClinicalMiami VA Healthcare SystemUSA
Elena Villalba-MoraFundación para la Investigación BiomédicaGetafe University HospitalMadridSpainandCentro de Tecnología BiomédicaUniversidad Politécncia de MadridMadridSpain
Esther WaldenDiabetes Inpatient Specialist NurseNorfolk and Norwich University Hospitals NHS TrustNorwichUK
Katie WeingerInvestigatorBehavioral ResearchJoslin Diabetes CenterandAssociate Professor of PsychiatryHarvard Medical SchoolBostonUSA
SECTION APathophysiology, screening and diagnosis
CHAPTER 1Pathophysiology of diabetes in older people
Graydon S. Meneilly
Division of Geriatric Medicine, Department of Medicine, The University of British Columbia, Vancouver, Canada
KEY MESSAGES
Lifestyle factors play a major role in diabetes in the elderly.
Diabetes in the elderly is metabolically distinct.
Elderly patients with diabetes have an increase incidence of severe or fatal hypoglycemia.
1.1 Introduction
Numerous studies have been conducted to investigate the pathogenesis of type 2 diabetes [1]. Unfortunately, elderly patients were systematically excluded from these protocols. We have more recently started to study, in a systematic fashion, the pathophysiological alterations that occur in elderly patients with diabetes. These studies, the details of which will be reviewed in the following sections, suggest that there are many ways in which diabetes in the elderly is unique. Some of the factors that contribute to the high prevalence of diabetes in the elderly are shown schematically in Figure 1.1.
Figure 1.1 Factors that contribute to the high prevalence of diabetes in the elderly.
Reproduced with permission from Halter, J.B., Carbohydrate metabolism, in: E.J. Masoro (ed.), Handbook of Physiology, Volume on Aging. New York, Oxford University Press Inc., 1995, p. 119.
1.1.1 Genetic factors
There are several lines of evidence which suggest that there is a strong genetic component to diabetes in the elderly, although the specific genes responsible have yet to be defined [2]. If you have a family history of type 2 diabetes, you are much more likely to develop the disease as you age [3]. Diabetes is much more common in the elderly in certain ethnic groups [4], while the likelihood that an elderly identical twin will develop diabetes if their sibling is affected is over 80%. Even in elderly identical twins discordant for type 2 diabetes, the unaffected siblings clearly have evidence of abnormal glucose metabolism [5].
1.1.2 Age-related changes in carbohydrate metabolism
The progressive alterations in glucose metabolism that occur with age explain why genetically susceptible older individuals may not develop diabetes until late in life. Pathogenic mechanisms which contribute to the glucose intolerance of aging include alterations in glucose-induced insulin release and resistance to insulin-mediated glucose disposal [6]. Early investigations suggested that glucose-induced insulin release was normal in the elderly. However, more recent studies enrolling large numbers of carefully characterized healthy young and old subjects have demonstrated definable alterations in glucose-induced insulin release in the aged [6, 7]. Part of the reason for the decrease in insulin secretion is an impairment in islet mass and reduced β-cell proliferation [8]. In addition, the magnitude of the decrement in insulin secretion is more apparent in response to oral than to intravenous glucose [6]. This may be due, in part, to a decreased β-cell response to the incretin hormones (see below). As with many hormones, insulin is secreted in a pulsatile fashion. Normal aging is associated with subtle alterations in pulsatile insulin release, which further contribute to age-related changes in glucose metabolism [9]. Elevated levels of proinsulin, which suggest disordered insulin processing, predict the subsequent development of type 2 diabetes in elderly subjects [10]. Thus, it is clear that alterations in glucose-induced insulin release are an important component of the changes in carbohydrate metabolism with aging. However, the most important pathogenic mechanism underlying the glucose intolerance of aging is resistance to insulin-mediated glucose disposal [2, 6, 11]. Debate persists as to whether the insulin resistance of the elderly is intrinsic to the aging process itself, or is the result of lifestyle factors commonly associated with aging. The consensus of opinion is that the aging process itself is the most important cause of insulin resistance, although lifestyle changes are clearly an important contributing factor. The molecular and cellular changes contributing to insulin resistance are detailed below.
