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Over the past two decades there has been a substantial rise in the adoption of diabetes therapeutic technology among children, adolescents and younger adults with type 1 diabetes, and its use is now also advocated for older individuals. Older people with diabetes are more prone to experience hypoglycaemia because of numerous predisposing factors and are at higher risk of hypoglycaemic events requiring third-party assistance as well as other adverse sequelae. Hypoglycaemia may also have long-term consequences, including cognitive impairment, frailty and disability. Diabetes in older people is often characterised by marked glucose variability related to age-associated changes such as variable appetite and levels of physical activity, comorbidities and polypharmacotherapy. Preventing hypoglycaemia and mitigating glucose excursions may have considerable positive impacts on physical and cognitive function and general well-being and may even prevent or improve frailty. Technology for older people includes continuous glucose monitoring systems, insulin pumps, automated insulin delivery systems and smart insulin pens. Clinical trials and real-world studies have shown that older people with diabetes benefit from technology in terms of glucose management, reductions in hypoglycaemic events, emergency department attendance and hospital admissions, and improvement in quality of life. However, ageing may bring physical impairments and other challenges that hinder the use of technology. Healthcare professionals should identify older adults with diabetes who may benefit from therapeutic technology and then adopt an individualised approach to education and follow-up for individuals and their caregivers. Future research should explore the impact of diabetes technology on outcomes relevant to older people with diabetes. [ABSTRACT FROM AUTHOR]

We present an executive summary of a guideline for management of type 2 diabetes mellitus in primary care written by the European Geriatric Medicine Society, the European Diabetes Working Party for Older People with contributions from primary care practitioners and participation of a patient's advocate. This consensus document relies where possible on evidence-based recommendations and expert opinions in the fields where evidences are lacking. The full text includes 4 parts: a general strategy based on comprehensive assessment to enhance quality and individualised care plan, treatments decision guidance, management of complications, and care in case of special conditions. Screening for frailty and cognitive impairment is recommended as well as a comprehensive assessment all health conditions are concerned, including end of life situations. The full text is available online at the following address: essential_steps_inprimary_care_in_older_people_with_diabetes_-_EuGMS-EDWPOP___3_.pdf. [ABSTRACT FROM AUTHOR]

An interview with Professor Alan Sinclair, discussing the impact of frailty on diabetes and vice versa, emphasizing how both conditions can lead to functional impairment, disability, increased mortality, hospitalizations, and institutionalization; it also explores potential interventions, including glucose lowering, nutritional interventions, and continuous glucose monitoring (CGM), to improve outcomes for patients with diabetes and frailty.

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. [ABSTRACT FROM AUTHOR]

Introduction: Frail older people with diabetes often present with or develop walking impairments, in part due to lower-limb sensory-motor neuropathy. Several studies suggest a possible improvement of balance control using somatosensory stimulation. We undertook a novel randomized control trial, the aim of which was to observe whether use of this device for 1 month improves walking speed as measured in the 10-m fast walking speed test standardized to body size at month 1 (M1) (FWS). Secondary outcomes were the differences between intervention (VS) and control (C) in the 10-m normal walking speed test, step length, short physical performance battery, timed up and go test, and posturographic measures. Methods: Subjects were aged ≥ 70 years and had had type 2 diabetes for at least 2 years. The intervention (VS) at home consisted of 22-min daily vibrating sequences with noise intensity set at 90% of the tactile threshold for each foot. The same device was used in group C but noise was set to 0. Compliance was retrieved from the device. Results: Among 56 subjects, 27 were in the VS group and 29 in the C group; 35 subjects were frail, 15 were prefrail ,and 6 were non-frail. Bilateral neuropathy was present in 17 subjects. More than half of sessions were done in 36 subjects with no discernible difference according to intervention. At M1 there were no discernible differences in FWS between the groups [VS: 0.96 (0.53) cm s−1 cm−1, C: 0.94 (0.47) cm s−1 cm−1]. There were also no discernible differences in other outcomes, irrespective of the presence of bilateral neuropathy. Conclusion: In a cohort of frail, prefrail, or non-frail older subjects with diabetes, a 1-month intervention using a vibrating insole device did not alter measures of walking speed and related measures. Larger studies with longer term and different stimulation protocols are required to test this hypothesis more fully. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Prognosis and appropriate treatment goals for older adults with diabetes vary greatly according to frailty. It is now recognised that changes may be needed to diabetes management in some older people. Whilst there is clear guidance on the evaluation of frailty and subsequent target setting for people living with frailty, there remains a lack of formal guidance for healthcare professionals in how to achieve these targets. The management of older adults with type 2 diabetes is complicated by comorbidities, shortened life expectancy and exaggerated consequences of adverse effects from treatment. In particular, older adults are more prone to hypoglycaemia and are more vulnerable to its consequences, including falls, fractures, hospitalisation, cardiovascular events and all-cause mortality. Thus, assessment of frailty should be a routine component of a diabetes review for all older adults, and glycaemic targets and therapeutic choices should be modified accordingly. Evidence suggests that over-treatment of older adults with type 2 diabetes is common, with many having had their regimens intensified over preceding years when they were in better health, or during more recent acute hospital admissions when their blood glucose levels might have been atypically high, and nutritional intake may vary. In addition, assistance in taking medications, as often occurs in later life following implementation of community care strategies or admittance to a care home, may dramatically improve treatment adherence, leading to a fall in glycated haemoglobin (HbA1c) levels. As a person with diabetes gets older, simplification, switching or de-escalation of the therapeutic regimen may be necessary, depending on their level of frailty and HbA1c levels. Consideration should be given, in particular, to de-escalation of therapies that may induce hypoglycaemia, such as sulphonylureas and shorter-acting insulins. We discuss the use of available glucose-lowering therapies in older adults and recommend simple glycaemic management algorithms according to their level of frailty. [ABSTRACT FROM AUTHOR]

This statement addresses the need to provide clinically relevant and practical guidance for long-term care staff working in care homes and other stakeholders engaged in the care of residents who require consideration for dexamethasone and oxygen therapy. It had been provided following a series of consensus discussions between the EDWPOP and the EuGMS in January and February 2021. Its main aim is to minimise morbidity and mortality from serious acute illnesses including COVID-19 requiring these treatments within the long-term care sector. [ABSTRACT FROM AUTHOR]

Key summary points: Aim: To summarize the prevalence of diabetes in people with sarcopenia (and vice versa) through a meta-analytic approach of available observational studies. Findings: In this work, we have presented the findings of the first full methodological systematic review and meta-analysis of observational studies exploring the relationship between diabetes and sarcopenia. Our findings overall emphasize the reciprocal relationship between diabetes and sarcopenia in terms of risk of occurrence, that is sarcopenia increases the risk of diabetes being present and vice versa. Message: This study provides support for further research into the prognosis of people with both diabetes and sarcopenia and the value of interventional strategies in sarcopenia to minimize adverse outcomes such as premature death, hospitalization, and disability. Purpose: Sarcopenia and diabetes are two common conditions in older people. Some recent literature has proposed that these two conditions can be associated. However, to date, no attempt has been made to collate this literature. Therefore, we aimed to summarize the prevalence of sarcopenia in diabetes (and vice versa) and the prevalence of sarcopenia in people with diabetes complications, through a systematic review and meta-analysis. Methods: Two authors searched major electronic databases from inception until March 2019 for case control/cross-sectional/longitudinal studies investigating sarcopenia and diabetes. The strength of the reciprocal associations between sarcopenia and diabetes was assessed through odds ratios (ORs) with 95% confidence intervals (CIs), adjusted for potential confounders, where possible. Results: From 953 potential eligible articles, 20 were included in the systematic review, with 17 providing data for meta-analysis. Overall, 54,676 participants were included (mean age = 65.4 years). Diabetic participants had an increased prevalence of sarcopenia compared to controls (n = 10; OR = 1.635; 95% CI 1.204–2.220; p = 0.002; I2 = 67%), whilst, after adjusting for potential confounders, sarcopenia was associated with an increased odds of having diabetes (OR = 2.067; 95% CI 1.396–3.624; p < 0.0001; I2 = 0%). In 1868 diabetic participants with a complication, there was an increased prevalence of sarcopenia (OR = 2.446; 95% CI 1.839–3.254; p < 0.0001; I2 = 0%), as compared with those with no complication. Very limited data existed regarding studies with a longitudinal design. Conclusions: Our study suggests a bidirectional association between diabetes and sarcopenia, particularly when diabetic complications are present. [ABSTRACT FROM AUTHOR]

The sustainability of health and social care systems is threatened by a growing population of older persons with heterogeneous needs related to multimorbidity, frailty, and increased risk of functional impairment. Since disability is difficult to reverse in old age and is extremely burdensome for individuals and society, novel strategies should be devised to preserve adequate levels of function and independence in late life. The development of mobility disability, an early event in the disablement process, precedes and predicts more severe forms of inability. Its prevention is, therefore, critical to impede the transition to overt disability. For this reason, the Sarcopenia and Physical fRailty IN older people: multi-componenT Treatment strategies (SPRINTT) project is conducting a randomized controlled trial (RCT) to test a multicomponent intervention (MCI) specifically designed to prevent mobility disability in high-risk older persons. SPRINTT is a phase III, multicenter RCT aimed at comparing the efficacy of a MCI, based on long-term structured physical activity, nutritional counseling/dietary intervention, and an information and communication technology intervention, versus a healthy aging lifestyle education program designed to prevent mobility disability in 1500 older persons with physical frailty and sarcopenia who will be followed for up to 36 months. The primary outcome of the SPRINTT trial is mobility disability, operationalized as the inability to walk for 400 m within 15 min, without sitting, help of another person, or the use of a walker. Secondary outcomes include changes in muscle mass and strength, persistent mobility disability, falls and injurious falls, disability in activities of daily living, nutritional status, cognition, mood, the use of healthcare resources, cost-effectiveness analysis, quality of life, and mortality rate. SPRINTT results are expected to promote significant advancements in the management of frail older persons at high risk of disability from both clinical and regulatory perspectives. The findings are also projected to pave the way for major investments in the field of disability prevention in old age. [ABSTRACT FROM AUTHOR]

The authors reflect on the choice of using insulin therapy for treating type 2 diabetes. They explores the economic factors on using the said therapy, in which they mention that drug budget of insulin analogues lead to the existence of debate concerning the value for money and the clinical benefits of the therapy. The state that analogue insulin must be reserved to patient with particular needs and add that healthcare system must decide on how to manage escalating costs for diabetes drugs.

The aim of this study was to investigate the effects of bilobalide, the postulated active constituent of Ginkgo biloba, on the release of glutamate elicited by hypoxia/hypoglycemia. Cortical slices were prepared from rat brain and perfused with normal artificial cerebrospinal fluid (aCSF) or aCSF made hypoxic by gassing with nitrogen, and hypoglycemic by removal of glucose. The perfusate was assayed for glutamate by HPLC. After 30 minutes, perfusion with hypoxic/hypoglycemic aCSF glutamate levels in the perfusate were increased approximately 5-fold. Bilobalide at 1, 10, and 100 μM, when perfused together with hypoxic/hypoglycemic aCSF, significantly reduced the release of glutamate. This study suggests that the reported neuroprotective properties of bilobalide may, in part, be mediated through its ability to reduce glutamate efflux, thus leading to a decrease in the excitotoxic effects of this neurotransmitter. [ABSTRACT FROM AUTHOR]

The authors discuss the impact of diabetes complication which requires particular management approaches. Topics include the Frailty model for diabetes was described a different approach to older people with diabetes who develop frailty, the benefits of glycaemia treatment with dipeptidyl peptidase 4 (DPP4) inhibitors, and the association of sarcopenia, a loss of muscle tissue, with diabetes.