European Diabetes Working Party for Older People 2011 Clinical Guidelines for Type 2 Diabetes Mellitus. Executive SummaryA Report of the European Diabetes Working Party for Older People (EDWPOP) Revision Group on Clinical Practice Guidelines for Type 2 Diabetes Mellitus
Introduction
This Executive Summary of the Clinical Guidelines provides an opportunity to summarise the interpretation of relevant clinical trial evidence for older people with diabetes. They are intended to support clinical decisions in older people with diabetes and the primary focus is enhancing high quality diabetes care by the use of best available evidence. Where possible, recommendations which have a cost-effective component will be employed.
The original European Diabetes Working Party for Older People (EDWPOP) was established in December 2000 to ensure that older people in societies across the European Union have consistent and high quality diabetes care throughout their lives. It developed from the Elderly Diabetes Working Group (Chair: Professor A J Sinclair, UK) of the St Vincent Declaration Primary Care Diabetes Group chaired by Dr Paul Cromme (Netherlands).
Modern diabetes care systems for older people require integrated care between general practitioners, hospital specialists, and other members of the healthcare team. These should have a multi-dimensional approach with an emphasis on prevention of diabetes and its complications, early intervention for vascular disease, and assessment of disability due to limb problems, eye disease, stroke, and other causes.
Although management of diabetes in older people can be relatively straightforward especially when patients have no other co-morbidities and when vascular complications are absent. In many cases, however, special issues arise which increase the complexity of management and lead to difficult clinical decision-making.
Variations in clinical practice are common in most healthcare systems resulting in inequalities of care. For older people with diabetes, this may be manifest as lack of access to services, inadequate specialist provision, poorer clinical outcomes and patient and family dissatisfaction. Our response to these concerns has been to develop Clinical Guidelines for older patients with type 2 diabetes mellitus based on the best available scientific and clinical trial evidence.
We anticipated a series of possible advantages for developing the guidelines and these have been summarised in Table 1. Other benefits of this approach include: (a) provide an up-to-date evidenced-based approach to practical clinical decision-making for older adults with type 2 diabetes of 70 years and over; and (b) provide a user-friendly set of recommendations to aid clinical decision-making in primary, community-based and secondary care settings.
Little, if any, published work exists which examines the ethical and moral dimensions of providing diabetes care for older people. Issues which might pose specific problems include aims and strategies of care, patients’ compliance, and risks of hypoglycaemia, choice of priorities, cost-effectiveness, and the presence of dementia or depression. Decision-making needs to reflect consideration of quality of life, life expectancy, cognitive and physical skills and the presence or otherwise of frailty. In the full set of Guidelines launched in 2004, those sections where ethical and/or moral issues are apparent, these have been highlighted and discussed, and practical advice provided.
In preparing the original full version EDWPOP identified various primary areas of concern and produced a series of target areas for concerted action (Table 2) [1], [2], [3], [4], [5], [6], [7]. These were based on common but important clinical issues relevant to most people with diabetes, but, in addition, other areas were identified which were deemed to satisfy a series of additional criteria: each has a significant impact on the lives of older people with diabetes and their families; in each case, some supporting evidence was available but careful scrutiny by an experienced review group would be necessary to derive an appropriate grade of recommendation; for each targeted area either existing Guidelines for adult diabetes had failed to discuss or specific guidance was thought necessary.
The lack of a sufficient clinical evidence base for establishing recommendations on best practice was recognised and highlighted by the absence of any large-scale intervention studies in older people with type 2 diabetes, no substantial evidence of benefit for glucose or lipid lowering, no evidence of large studies in diabetic residents of care homes, and no evidence to recommend a particular care model.
This extensive literature review has revealed numerous gaps in our knowledge of diabetes in older adults. In several Sections of the full Guideline (but not in this document) the Working party has tried to identify important research areas which might be addressed by the diabetes research community in the form of a randomised controlled trial or some form of epidemiological research.
Section snippets
Further developments of clinical guidelines
The original comprehensive version of Clinical Guidelines represents an important step in highlighting the special needs of older people with diabetes mellitus. A first draft of the Guidelines were presented at the 18th International Diabetes Federation (IDF) Congress in Paris, France, 24–29th August 2003, and later in Florence, Italy at the 2nd Congress of the European Union Geriatric Medicine Society (EUGMS), 27–29th August 2003. A complete version then underwent critical review by an
Recommendations for enhancing the practice and quality of diabetes care
Screening and early diagnosis may prevent progression of undetected vascular complications: Level of evidence 1+, Grade of recommendation (A) Overall improved metabolic control will reduce cardiovascular risk: Level of evidence 1+, Grade of recommendation (A) Improved screening for maculopathy and cataracts will reduce visual impairment and blind registrations: Level of evidence 2+, Grade of recommendation (C) An integrated approach
Managing cardiovascular risk [31–36]
- 1.
At initial assessment, all older patients aged less than 85 years with diabetes should have a cardiovascular risk assessment undertaken. Evidence level 1+, Grade of recommendation A.
- 2.
All older patients with type 2 diabetes aged less than 85 years should have a review and discussion of modifiable cardiovascular risk factors and be offered advice on smoking cessation. Evidence level 2++, Grade of recommendation B.
- 3.
The ten-year risk of developing symptomatic cardiovascular disease should be
Recommendations for care home diabetes [53–56]
- 1.
In view of the high rate of undiagnosed diabetes in care home residents, at the time of admission to a care home, each resident requires to be screened for the presence of diabetes. Evidence level 2++, Grade of recommendation B.
- 2.
At the time of admission to care home, each resident with diabetes should be comprehensively assessed for the presence of functional loss as they are at higher risk of progression of disability. Evidence level 2+, Grade of recommendation B.
- 3.
Residents on insulin
Diabetic foot disease [57–59]
- 1.
All older patients with type 2 diabetes should receive foot care education and instruction to self-inspect by suitable health care professionals. Evidence level 1++, Grade of recommendation A.
- 2.
All older patients with type 2 diabetes should receive an annual (minimum frequency) inspection (including vascular and neurological examination) of their feet by a health care professional to detect risk factors for ulceration. Evidence level 2+, Grade of recommendation C.
- 3.
Use of a 10-g monofilament or
Other good clinical practice points
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Healthcare providers should address the following issues in older patients with diabetes and their carers:
- –
The need for well structured shared care protocols with agreements on management of new cases, hospital admission criteria, access to specialist services, and follow-up criteria.
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To avoid excessive carer burden, support is available in the areas of education, access to medical and nursing care, financial assistance, transport facilities and networking with other carers and support groups.
- –
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Aknowledgment
Supported by RETICEF (Red Temática de Investigacion Cooperativa envejecimiento y Fragilidad) (RD06/0013), Instituto de Salud Carlos III, Ministerio de Ciencia e Innovación, Spain and Institute for Diabetes in Old People (IDOP), UK.
Conflicts statement of interest
No potential conflicts of interest relevant to this article have been reported by any of the authors.
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- et al.
Survival as a function of HbA1c in people with type 2 diabetes: a retrospective cohort study
Lancet
(2010) - et al.
Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II)
J Vasc Surg
(2007) - et al.
Trends in the quality of care for elderly people with type 2 diabetes: the need for improvements in safety and quality (the 2001 and 2007 Entred Surveys)
Diabetes Metab
(2011)
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