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The prevalence of diabetes mellitus is increasing, and its epidemiology is shifting towards old age because of increased life expectancies. As a result, diabetes mellitus is increasingly becoming a disease of older rather than middle age. The increased prevalence of co-morbidities associated with ageing, combined with the increased prevalence of geriatric syndromes that lead to physical and mental disabilities and frailty, contributes to the complexity of managing diabetes in elderly individuals. Taking into account the heterogeneous functional status, co-morbidities, frailty and life expectancy of older people, therapeutic interventions and glycaemic targets should be individualized, considering individuals' preferences and putting quality of life at the heart of their care plans.

Objective: Intermittently scanned continuous glucose monitoring (isCGM) has revolutionised the care of people with diabetes but its uptake and benefits in older adults are not well known. We examined the impact of isCGM (Freestyle Libre, FSL) on glycaemic outcomes in younger (⩽65 years) and older adults (>65 years) with diabetes.Design and methods: In total, 2260 adult patients registered on the Libreview account at University Hospitals Birmingham NHS Foundation Trust, UK, were included. Inclusion criteria: all patients with type 1 and type 2 diabetes aged >18 years, use of isCGM >6 months, scanning at least 6 times/day. Demographics, diabetes history and glycaemic outcomes (time in range (TIR), time above range and time below range (TBR), estimated HbA1c, HbA1c at start and at end of study) were collected by accessing electronic patient records and Libreview. Outcomes were compared between age groups ⩽65 or >65 years old.Results: Most patients were of Caucasian ethnicity (⩽65 years 68%, >65 years 73%) and had type 1 diabetes. Mean duration of diabetes was 19.5 years (range 0–65 years) and 34.5 years (range 0–79 years) for ⩽65 and >65 years, respectively. Only a quarter of those ⩽65 years achieved (219/943; 23.2%) their age specific TIR target compared to 69% (78/113) of those >65 years cohort, while 70.1% (663/946) of ⩽65 years and 40.7% (46/113) of >65 years achieved their age-specific TBR target. When the less strict ⩽65 years TBR target was applied, 75% (85/113) of >65 years cohort achieved this.Conclusion: FSL use was associated with improved glycaemic outcomes across all age groups. Individualised targets may be needed to improve TBR in those aged >65 years.

Frailty is a newly emerging complication of diabetes in older people and increasingly recognised in national and international clinical guidelines. However, frailty remains less clearly defined and frail older people with diabetes are rarely characterised. The general recommendation of clinical guidelines is to aim for a relaxed glycaemic control, mainly to avoid hypoglycaemia, in this often-vulnerable group of patients. With increasing age and development of frailty, body composition changes are characterised by an increase in visceral adipose tissue and a decrease in body muscle mass. Depending on the overall body weight, differential loss of muscle fibre types and body adipose/muscle tissue ratio, the presence of any associated frailty can be seen as a spectrum of metabolic phenotypes that vary in insulin resistance of which we have defined two specific phenotypes. The sarcopenic obese (SO) frail phenotype with increased visceral fat and increased insulin resistance on one side of spectrum and the anorexic malnourished (AM) frail phenotype with significant muscle loss and reduced insulin resistance on the other. In view of these varying metabolic phenotypes, the choice of hypoglycaemic therapy, glycaemic targets and overall goals of therapy are likely to be different. In the SO phenotype, weight-limiting hypoglycaemic agents, especially the new agents of GLP-1RA and SGLT-2 inhibitors, should be considered early on in therapy due to their benefits on weight reduction and ability to achieve tight glycaemic control where the focus will be on the reduction of cardiovascular risk. In the AM phenotype, weight-neutral agents or insulin therapy should be considered early on due to their benefits of limiting further weight loss and the possible anabolic effects of insulin. Here, the goals of therapy will be a combination of relaxed glycaemic control and avoidance of hypoglycaemia; and the focus will be on maintenance of a good quality of life. Future research is still required to develop novel hypoglycaemic agents with a positive effect on body composition in frailty and improvements in clinical outcomes.

How do older patients with diabetes present? What are the common complications? What are the goals of treatment? IN OLDER PEOPLE, DIABETES IS A DISABLING DISEASE DUE TO THE ASSOCIATED [...]

To compare the performance of eight frailty instruments to identify relevant adverse outcomes for older people across different settings over a 12 month follow‐up. Observational longitudinal prospective study of people aged 75 + years enrolled in different settings (acute geriatric wards, geriatric clinic, primary care clinics, and nursing homes) across five European cities. Frailty was assessed using the following: Frailty Phenotype, SHARE‐FI, 5‐item Frailty Trait Scale (FTS‐5), 3‐item FTS (FTS‐3), FRAIL scale, 35‐item Frailty Index (FI‐35), Gérontopôle Frailty Screening Tool, and Clinical Frailty Scale. Adverse outcomes ascertained at follow‐up were as follows: falls, hospitalization, increase in limitation in basic (BADL) and instrumental activities of daily living (IADL), and mortality. Sensitivity, specificity, and capacity to predict adverse outcomes in logistic regressions by each instrument above age, gender, and multimorbidity were calculated. A total of 996 individuals were followed (mean age 82.2 SD 5.5 years, 61.3% female). In geriatric wards, the FI‐35 (69.1%) and the FTS‐5 (67.9%) showed good sensitivity to predict death and good specificity to predict BADL worsening (70.3% and 69.8%, respectively). The FI‐35 also showed good sensitivity to predict BADL worsening (74.6%). In nursing homes, the FI‐35 and the FTSs predicted mortality and BADL worsening with a sensitivity > 73.9%. In geriatric clinic, the FI‐35, the FTS‐5, and the FRAIL scale obtained specificities > 85% to predict BADL worsening. No instrument achieved high enough sensitivity nor specificity in primary care. All the instruments predict the risk for all the outcomes in the whole sample after adjusting for age, gender, and multimorbidity. The associations of these instruments that remained significant by setting were for BADL worsening in geriatric wards [FI‐35 OR = 5.94 (2.69–13.14), FTS‐3 = 3.87 (1.76–8.48)], nursing homes [FI‐35 = 4.88 (1.54–15.44), FTS‐5 = 3.20 (1.61–6.38), FTS‐3 = 2.31 (1.27–4.21), FRAIL scale = 1.91 (1.05–3.48)], and geriatric clinic [FRAIL scale = 4.48 (1.73–11.58), FI‐35 = 3.30 (1.55–7.00)]; for IADL worsening in primary care [FTS‐5 = 3.99 (1.14–13.89)] and geriatric clinic [FI‐35 = 3.42 (1.56–7.49), FRAIL scale = 3.27 (1.21–8.86)]; for hospitalizations in primary care [FI‐35 = 3.04 (1.25–7.39)]; and for falls in geriatric clinic [FI‐35 = 2.21 (1.01–4.84)]. No single assessment instrument performs the best for all settings and outcomes. While in inpatients several commonly used frailty instruments showed good sensitivities (mainly for mortality and BADL worsening) but usually poor specificities, the contrary happened in geriatric clinic. None of the instruments showed a good performance in primary care. The FI‐35 and the FTS‐5 showed the best profile among the instruments assessed.

In Brief Clinicians who manage older people with diabetes require special skills if they wish to provide high-quality care. Their approach is influenced by a multitude of factors, such as [...]

OBJECTIVE--The aim of this systematic review was to determine the benefits of nutritional support in patients with type 1 or type 2 diabetes. RESEARCH DESIGN AND METHODS--Studies utilizing an enteral [...]

Insulin signalling declines with increasing age and impacts skeletal muscle function and longevity in animal models. Our aim was to assess the relationships between insulin resistance (IR) and frailty and mortality in a unique community-dwelling cohort of older people. 991 non-diabetic subjects from the Toledo Study of Healthy Ageing (TSHA) cohort were included. IR was estimated by the homeostasis model assessment index (HOMA-IR) at baseline while frailty was determined by frailty phenotype (FP) and Frailty Trait Scale (FTS) at baseline and after 5-year follow-up. Deaths were also determined. Multivariate regression models were used to analyze the effects of HOMA-IR on outcomes. Age, gender, BMI, education level, cardio- and cerebro-vascular disease, glomerular filtration rate, and disability were included as potential confounding variables in progressive adjustment models. IR determined as increasing log HOMA-IR was inversely associated with risk of mortality. The association remained significant for all adjustment models (HR: 0.64–0.69). When we analyzed survival curves, the higher the HOMA-IR tertile, the lower the mortality rate (highest vs lowest tertile, p = 0.0082). In contrast, IR increased the risk of incident frailty determined by FP (OR 1.81 [1.14–2.87]) as well as deterioration of frailty status determined by worsening in FTS score (OR 1.28 [1.01–1.63]) at 5-year follow-up. In non-diabetic older subjects, IR significantly increases the risk for frailty and functional decline but decreased the risk of death at 5-year follow-up. This finding raises the need of assessing the effect of biomarkers on different outcomes before establishing their role as biomarkers of aging.

OBJECTIVE--To explore the nature of functional impairment in older people with diabetes. RESEARCH DESIGN AND METHODS--A population-based case-control study with detailed assessment of diabetes and functional status was undertaken. RESULTS--Altogether, [...]

Older adults with diabetes are heterogeneous in their medical, functional, and cognitive status, and require careful individualisation of their treatment regimens. However, in the absence of detailed information from clinical trials involving older people with varying characteristics, there is little evidence-based guidance, which is a notable limitation of current approaches to care. It is important to recognise that older people with diabetes might vary in their profiles according to age category, functional health, presence of frailty, and comorbidity profiles. In addition, all older adults with diabetes require an individualised approach to care, ranging from robust individuals to those residing in care homes with a short life expectancy, those requiring palliative care, or those requiring end-of-life management. In this Review, our multidisciplinary team of experts describes the current evidence in several important areas in geriatric diabetes, and outlines key research gaps and research questions in each of these areas with the aim to develop evidence-based recommendations to improve the outcomes of interest in older adults.

Type 2 diabetes and cognitive dysfunction are highly prevalent disorders worldwide. Although type 2 diabetes is associated with an increased risk of dementia, awareness of the link between the two conditions is poor, and few recommendations are available to guide clinicians about how to approach cognitive dysfunction in people with diabetes. Clinical guidelines in diabetes have only recently begun to emphasise the importance of cognitive impairment in diabetes and its management. This Series paper aims to synthesise knowledge about the link between diabetes and cognitive dysfunction, issues pertaining to screening and diagnosis of cognitive impairment and dementia in those with type 2 diabetes, management of diabetes in people with cognitive dysfunction (accounting for age and frailty), and emerging therapies for prevention. A conceptual framework for approaching screening and diagnosis is included, and future research directions to guide the field forward are suggested.

Aging is associated with body composition changes that lead to glucose intolerance and increased risk of diabetes. The incidence of diabetes increases with aging and the prevalence has increased because of the increased life expectancy of the population. Lifestyle modifications through nutrition and exercise in combination with medications are the main components of diabetes management. The potential benefits of nutrition and exercise intervention in older people with diabetes are enormous. Nutrition and exercise training are feasible even in frail older people living in care homes, and should take into considerations individual circumstances, cultural factors, and ethnic preferences.

The objective is to formulate clinical practice guidelines for the treatment of diabetes in older adults.

The prevalence of diabetes mellitus is increasing, and its epidemiology is shifting towards old age because of increased life expectancies. As a result, diabetes mellitus is increasingly becoming a disease of older rather than middle age. The increased prevalence of co-morbidities associated with ageing, combined with the increased prevalence of geriatric syndromes that lead to physical and mental disabilities, contributes to the complexity of managing diabetes in the elderly. Taking into account the heterogeneous functional status, co-morbidities and life expectancy of older people, therapeutic interventions and glycaemic targets should be individualized, considering patients’ preferences and putting quality of life at the heart of their care plans.

ALAN J. SINCLAIR, MD, FRCP [1] ROGER GADSBY, MB [2] SUE PENFOLD, MB [5] SIMON C.M. CROXSON, MD, FRCP [3] ANTONY J. BAYER, MB [4] OBJECTIVE -- To determine the [...]

Glycaemic targets for older people have been revised in recent years because of concern that more stringent targets are associated with increased mortality. We aimed to investigate the association between glycaemic control (mean HbA1c) and variability (variability of HbA1cover time) and mortality in older people with diabetes.

This paper discusses some of key issues that need to be considered when caring for older people with diabetes living in care homes. It refers to but does not reproduce diabetes management information available in diabetes clinical guidelines such as Sinclair et al. [Diabetes mellitus in older people position statement on behalf of the International Association of Gerontology and Geriatrics (IAGG) and the European Diabetes Working Party for Older People (EDWOP) and the International Task force Experts in Diabetes. J Am Med Dir Assoc. 2012;13:497–502], International Diabetes Federation (IDF) [Global guideline for managing older people with type 2 diabetes. 2013. Available from www.idf.org] and Dunning et al. [2013. Available from http://www.adma.org.au/clearinghouse/doc_details/133-the-mckellar-guidelines-for-managing-older-people-with-diabetes-in-residential-and-other-care-settings_9dec2013.html] guidelines. It does address care issues such as sexual health and wellbeing and companion animals that are rarely, if ever, described in clinical guidelines, yet they are essential to the quality of life and psychological wellbeing of many older people with and those without diabetes.

Scientists from the US, UK and several other countries met in 1997 to discuss opportunities for research collaboration. The meeting was sponsored by the American and British Geriatric Societies. Some areas for potential collaboration include research on incontinence, hip fracture, and dementia. Additional meetings may be held to standardize research techniques, identify research priorities, develop an infrastructure for carrying out megatrials and creating transatlantic fellowships and scholarships.

Diabetes mellitus is a highly prevalent chronic disease, with an associated heavy personal and public health burden of disability, morbidity and mortality. The focus of care for older patients with diabetes is prevention of functional decline, with early intervention rather than attempting to recover function later. Diabetes doubles the risk of frailty. An important contributor towards physical frailty is sarcopaenia, which manifests as an age-related loss of skeletal muscle volume and power. Frailty is not an inevitable consequence of the ageing process; it is a dynamic and potentially reversible condition that highlights the importance of early recognition and intervention. In this review, we examine the evidence for linking diabetes to frailty and sarcopaenia and how the emergence of these conditions should lead to changes in clinician behaviour in terms of assessment of function and goal setting. High-quality, focused research in this area is now mandatory.

Diabetes mellitus is a disabling, chronic cardiovascular and medical disease with a tremendous health, social and economic burden in our ageing communities. It has a prevalence of 10% to 30% in people older than 65 years of age, and more than half of all subjects with diabetes in the United States are older than 60 years of age.

Many are losing out by default Diabetes is common in elderly British people, with a prevalence of between 3% and 6%.[1 2] Elderly (mainly noninsulin dependent) diabetic patients therefore represent [...]

SUMMARY Diabetes phenotype in old age is characterized by increased prevalence of co-morbidities, geriatric syndromes and frailty. Interaction between geriatric syndromes and diabetes will have a synergistic effect to worsen adverse outcomes such as increased vascular complications, disability and hospitalization. Risk factors for hospitalizations include hypoglycemia, poor glycemic control, infections and acute exacerbation of the associated co-morbidities or geriatric syndromes. A large proportion of hospitalizations are preventable. Integrated care system between primary and secondary care to provide a holistic care for older people with diabetes with a focus on early and effective interventions, maintaining functional status and autonomy and promoting a good quality of life and well-being for each patient are warranted as part of any strategy to reduce hospitalization.

Used correctly insulin can be a life-saving intervention but deaths through errors have led to the implementation of new laws. Why failure to safely prescribe and administer the drug can lead to fatalities.

ObjectiveTo determine whether a multicomponent intervention based on physical activity with technological support and nutritional counselling prevents mobility disability in older adults with physical frailty and sarcopenia.DesignEvaluator blinded, randomised controlled trial.Setting16 clinical sites across 11 European countries, January 2016 to 31 October 2019.Participants1519 community dwelling men and women aged 70 years or older with physical frailty and sarcopenia, operationalised as the co-occurrence of low functional status, defined as a short physical performance battery (SPPB) score of 3 to 9, low appendicular lean mass, and ability to independently walk 400 m. 760 participants were randomised to a multicomponent intervention and 759 received education on healthy ageing (controls).InterventionsThe multicomponent intervention comprised moderate intensity physical activity twice weekly at a centre and up to four times weekly at home. Actimetry data were used to tailor the intervention. Participants also received personalised nutritional counselling. Control participants received education on healthy ageing once a month. Interventions and follow-up lasted for up to 36 months.Main outcome measuresThe primary outcome was mobility disability (inability to independently walk 400 m in <15 minutes). Persistent mobility disability (inability to walk 400 m on two consecutive occasions) and changes from baseline to 24 and 36 months in physical performance, muscle strength, and appendicular lean mass were analysed as pre-planned secondary outcomes. Primary comparisons were conducted in participants with baseline SPPB scores of 3-7 (n=1205). Those with SPPB scores of 8 or 9 (n=314) were analysed separately for exploratory purposes.ResultsMean age of the 1519 participants (1088 women) was 78.9 (standard deviation 5.8) years. The average follow-up was 26.4 (SD 9.5) months. Among participants with SPPB scores of 3-7, mobility disability occurred in 283/605 (46.8%) assigned to the multicomponent intervention and 316/600 (52.7%) controls (hazard ratio 0.78, 95% confidence interval 0.67 to 0.92; P=0.005). Persistent mobility disability occurred in 127/605 (21.0%) participants assigned to the multicomponent intervention and 150/600 (25.0%) controls (0.79, 0.62 to 1.01; P=0.06). The between group difference in SPPB score was 0.8 points (95% confidence interval 0.5 to 1.1 points; P<0.001) and 1.0 point (95% confidence interval 0.5 to 1.6 points; P<0.001) in favour of the multicomponent intervention at 24 and 36 months, respectively. The decline in handgrip strength at 24 months was smaller in women assigned to the multicomponent intervention than to control (0.9 kg, 95% confidence interval 0.1 to 1.6 kg; P=0.028). Women in the multicomponent intervention arm lost 0.24 kg and 0.49 kg less appendicular lean mass than controls at 24 months (95% confidence interval 0.10 to 0.39 kg; P<0.001) and 36 months (0.26 to 0.73 kg; P<0.001), respectively. Serious adverse events occurred in 237/605 (39.2%) participants assigned to the multicomponent intervention and 216/600 (36.0%) controls (risk ratio 1.09, 95% confidence interval 0.94 to 1.26). In participants with SPPB scores of 8 or 9, mobility disability occurred in 46/155 (29.7%) in the multicomponent intervention and 38/159 (23.9%) controls (hazard ratio 1.25, 95% confidence interval 0.79 to 1.95; P=0.34).ConclusionsA multicomponent intervention was associated with a reduction in the incidence of mobility disability in older adults with physical frailty and sarcopenia and SPPB scores of 3-7. Physical frailty and sarcopenia may be targeted to preserve mobility in vulnerable older people.Trial registrationClinicalTrials.gov NCT02582138.

The prevalence of diabetes mellitus is increasing and the epidemiology is shifting towards old age due to the increased life expectancy. As a result, diabetes mellitus is increasingly becoming a disease of older age rather than middle age. Care for older people with diabetes presents unique challenges. The increased prevalence of co-morbidities associated with ageing combined with the increased prevalence of geriatric syndromes contributes to the complexity of managing diabetes in the elderly. Taking into account the heterogeneous functional status, co-morbidities and life expectancy of older people, therapeutic interventions and glycaemic targets should be individualized, considering patients' preferences and putting quality of life at the heart of their care plans. This chapter addresses the key areas for the care of older people with diabetes and their complex needs.

Several reports have indicated that point mutations of the mitochondrial DNA (mtDNA) contribute to the pathogenesis of Alzheimer's disease (AD). However, other groups have failed to find similar associations between these mutations and AD. A recent report described a set of mutations in the mtDNA encoded cytochrome oxidase genes which may account for 20% of all AD cases. We screened brain tissue from 65 AD patients for each of these previously reported mtDNA mutations but were unable to find an increased incidence of any of them in our AD sample. However, one patient with a mutation in the APP gene did harbour a novel mtDNA mutation (G to C at position 5705 in the tRNAAsngene) that might have contributed to the very early onset of dementia in this individual. The role of mtDNA mutations in the pathogenesis of AD remains unclear, but they do not appear to be primary causes but may contribute to the onset of the disease.

The aim of this study was to investigate the effects of preconditioning on amino acid neurotransmitter release, induced by hypoxia/hypoglycaemia, from rat brain cortical slices. Tissue, perfused with artificial cerebrospinal fluid (aCSF) at 37°C with zero glucose and gassed with 95% nitrogen and 5% carbon dioxide, showed a fivefold increase in glutamate release with little effect on γ-aminobutyric acid (GABA) release. Preconditioning, with three 5-min periods of hypoxia/hypoglycaemia preceding continuous hypoxia/hypoglycaemia, significantly decreased glutamate release whilst significantly elevating GABA release. These results suggest that GABA may reduce the release of glutamate and consequently decrease the neurotoxic effects of glutamate.