Rationale and methods of the multicenter randomised trial of a heart failure management programme among geriatric patients (HF-Geriatrics) Evaluation of a web-based tool in screening for medication-related problems in community-dwelling older adults. Pharmaceutical care of elderly patients with poorly controlled type 2 diabetes mellitus: a randomized controlled trial Lifestyle intervention for type 2 diabetes patients – trial protocol of The Copenhagen Type 2 Diabetes Rehabilitation Project A controlled trial of a nursing-centered intervention in hospitalized elderly medical patients: the Yale Geriatric Care Program. Cognitive behavioural therapy in elderly type 2 diabetes patients with minor depression or mild major depression: study protocol of a randomized controlled trial (MIND-DIA) A Substudy Protocol of the Hypertension in the Very Elderly Trial Assessing Cognitive Decline and Dementia Incidence (HYVET-COG) Long-term multiple risk factor interventions in Japanese elderly diabetic patients: the Japanese Elderly Diabetes Intervention Trial--study design, baseline characteristics and effects of intervention. Pharmacist-Led Group Medical Appointments for the Management of Type 2 Diabetes with Comorbid Depression in Older Adults Pharmacologic Therapy for Type 2 Diabetes: Synopsis of the 2017 American Diabetes Association Standards of Medical Care in Diabetes Improved diabetes control in the elderly delays global cognitive decline Exercise training for rehabilitation and secondary prevention of falls in geriatric patients with a history of injurious falls. Effect of a geriatric consultation team on functional status of elderly hospitalized patients. A randomized, controlled clinical trial. Medication Use and Adherence Among Elderly Medicare Beneficiaries With Diabetes Enrolled in Part D and Retiree Health Plans An interdisciplinary geriatric consultation service: a controlled trial. Effects of Concomitant Administration of a Dipeptidyl Peptidase-4 Inhibitor in Japanese Patients with Type 2 Diabetes Showing Relatively Good Glycemic Control Under Treatment with a Sodium Glucose Co-Transporter 2 Inhibitor. Addressing the needs of patients with multiple chronic illnesses: the case of diabetes and depression.
Background Disease management programmes ( DMPs ) have been shown to reduce hospital readmissions and mortality in adults with heart failure ( HF ) , but their effectiveness in elderly patients or in those with major comorbidity is unknown . The Multicenter R and omised Trial of a Heart Failure Management Programme among Geriatric Patients ( HF-Geriatrics ) assesses the effectiveness of a DMP in elderly patients with HF and major comorbidity . Methods / Design Clinical trial in 700 patients aged ≥ 75 years admitted with a primary diagnosis of HF in the acute care unit of eight geriatric services in Spain . Each patient should meet at least one of the following comorbidty criteria : Charlson index ≥ 3 , dependence in ≥ 2 activities of daily living , treatment with ≥ 5 drugs , active treatment for ≥ 3 diseases , recent emergency hospitalization , severe visual or hearing loss , cognitive impairment , Parkinson 's disease , diabetes mellitus , chronic obstructive pulmonary disease ( COPD ) , anaemia , or constitutional syndrome . Half of the patients will be r and omly assigned to a 1-year DMP led by a case manager and the other half to usual care . The DMP consists of an educational programme for patients and caregivers on the management of HF , COPD ( knowledge of the disease , smoking cessation , immunizations , use of inhaled medication , recognition of exacerbations ) , diabetes ( knowledge of the disease , symptoms of hyperglycaemia and hypoglycaemia , self-adjustment of insulin , foot care ) and depression ( knowledge of the disease , diagnosis and treatment ) . It also includes close monitoring of the symptoms of decompensation and optimisation of treatment compliance . The main outcome variables are quality of life , hospital readmissions , and overall mortality during a 12-month follow-up . Discussion The physiological changes , lower life expectancy , comorbidity and low health literacy associated with aging may influence the effectiveness of DMPs in HF . The HF-Geriatrics study will provide direct evidence on the effect of a DMP in elderly patients with HF and high comorbidty , and will reduce the need to extrapolate the results of clinical trials in adults to elderly patients .Trial registration ( Clinical Trials.gov number , NCT01076465 ) OBJECTIVE The primary objective was to evaluate the effectiveness of a Web-based program , Monitor-Rx , in identifying older adults at risk for drug-related geriatric syndromes or inappropriate medicines . DESIGN This prospect i ve pilot study compared medication related risks generated by the Web-based program with those identified by a certified geriatric pharmacist ( CGP ) . SETTING Wisconsin-based community pharmacy serving primarily older adults . PARTICIPANTS 29 community-dwelling older adults ( mean age : 81.6 years , mean daily medications : 11.7 ) . INTERVENTIONS Each participant received a complete medication history , including self-identified geriatric syndromes . Each participant 's demographic information and medications were entered into Monitor-Rx and concurrently review ed by a CGP . MAIN OUTCOME MEASURES Number of potentially inappropriate medications ( PIMs ) , anticholinergic medicines , and identified geriatric syndromes . RESULTS All participants were identified as at risk for falls by Monitor-Rx and the CGP . Significant medication-related risks identified were urinary incontinence , cognition/memory , nutrition , and dental care . Monitor-Rx identified more participants at risk for geriatric syndromes than the CGP ; however , PIMs were identified more frequently by the CGP . Twenty-six participants self-identified at least one geriatric syndrome . Prevalence of anticholinergic use was more than 75 % . CONCLUSIONS In the participants screened , Monitor-Rx was successful at identifying those with a high risk of drug-related geriatric syndromes . An interview was also important to clarify use of the PIM and to identify whether at-risk participants were actually experiencing the drug related geriatric syndromes . Use of the Web-based tool does not supplant the experience of a well-trained geriatric pharmacist and the professional judgment that comes with that experience Background Care of the elderly with diabetes is more complicated than that for other age groups . The elderly and /or those with multiple comorbidities are often excluded from r and omized controlled trials of treatments for diabetes . The heterogeneity of health status of the elderly also increases the difficulty in diabetes care ; therefore , diabetes care for the elderly should be individualized . Motivated patients educated about diabetes benefit the most from collaborating with a multidisciplinary patient-care team . A pharmacist is an important team member by serving as an educator , coach , healthcare manager , and pharmaceutical care provider . Objective To evaluate the effects of pharmaceutical care on glycemic control of ambulatory elderly patients with type 2 diabetes . Setting A 421-bed district hospital in Nantou City , Taiwan . Method We conducted a r and omized controlled clinical trial involving 100 patients with type 2 diabetes with poor glycemic control ( HbA1c levels of ≥9.0 % ) aged ≥65 years over 6 months . Participants were r and omly assigned to a st and ard-care ( control , n = 50 ) or pharmaceutical-care ( intervention , n = 50 ) group . Pharmaceutical care was provided by a certified diabetes-educator pharmacist who identified and resolved drug-related problems and established a procedure for consultations pertaining to medication . The Mann – Whitney test was used to evaluate nonparametric quantitative data . Statistical significance was defined as P < 0.05 . Main outcome measure The change in the mean HbA1c level from the baseline to the next level within 6 months after recruiting . Results Nonparametric data ( Mann – Whitney test ) showed that the mean HbA1c level significantly decreased ( 0.83 % ) after 6 months for the intervention group compared with an increase of 0.43 % for the control group ( P ≤ 0.001 ) . Medical expenses between groups did not significantly differ ( −624.06 vs. −418.7 , P = 0.767 ) . There was no significant difference in hospitalization rates between groups . Conclusion The pharmacist intervention program provided pharmaceutical services that improved long-term , safe control of blood sugar levels for ambulatory elderly patients with diabetes and did not increase medical expenses Background Current guidelines recommend education , physical activity and changes in diet for type 2 diabetes patients , yet the composition and organization of non-pharmacological care are still controversial . Therefore , it is very important that programmes aim ing to improve non-pharmacological treatment of type 2 diabetes are developed and evaluated . The Copenhagen Type 2 Diabetes Rehabilitation Project aims to evaluate the effectiveness of a new group-based lifestyle rehabilitation programme in a Health Care Centre in primary care . Methods / Design The group-based diabetes rehabilitation programme consists of empowerment-based education , supervised exercise and dietary intervention . The effectiveness of this multi-disciplinary intervention is compared with conventional individual counselling in a Diabetes Outpatient Clinic and evaluated in a prospect i ve and r and omized controlled trial . During the recruitment period of 18 months 180 type 2 diabetes patients will be r and omized to the intervention group and the  control group . Effects on glycaemic control , quality of life , self-rated diabetes symptoms , body composition , blood pressure , lipids , insulin resistance , beta-cell function and physical fitness will be examined after 6 , 12 and 24 months . Discussion The Copenhagen Type 2 Diabetes Rehabilitation Project evaluates a multi-disciplinary non-pharmacological intervention programme in a primary care setting and provides important information about how to organize non-pharmacological care for type 2 diabetes patients .Trail Registration Clinical Trials.gov registration number : NCT00284609 OBJECTIVE To test the effectiveness of a nursing-centered intervention to prevent functional decline among hospitalized elderly medical patients . DESIGN Prospect i ve cohort study with stratified and matched cohort analyses . SETTING General medicine wards of a university teaching hospital . PATIENTS Two hundred sixteen patients aged > or = 70 years ( 85 intervention and 131 control patients ) . INTERVENTION The intervention included identification and surveillance of frail older patients , twice-weekly rounds of the Geriatric Care Team , and a nursing-centered educational program . MAIN OUTCOME MEASURE Functional decline , defined as a net decline in five activities of daily living ( ADLs ) . RESULTS In stratified analyses , the intervention result ed in a beneficial effect with a relative risk of 0.82 ( 95 % confidence interval [ CI ] 0.54 to 1.24 ) in patients ( n = 106 ) with one of four geriatric target conditions at baseline ( eg , delirium , functional impairment , incontinence , and pressure sores ) . The intervention had no effect in patients without target conditions at baseline ( n = 110 ) ; thus , this subgroup was excluded from further analyses . When patients were matched on number of target conditions and risk for functional decline at baseline ( n = 66 ) , the intervention result ed in a significant beneficial effect , with a reduction in functional decline from 64 % in controls to 41 % in the intervention group , for a relative risk of 0.64 ( 95 % CI , 0.43 to 0.96 ) . The intervention group had significantly less decline in ADL score and in individual ADLs than control subjects . Specific interventions aim ed at maximizing function , such as physical therapy , were received more often by intervention patients ; however , the beneficial effects of the intervention were achieved without increasing per-day hospital costs . CONCLUSIONS The intervention appears effective to decrease functional decline in targeted elderly hospitalized medical patients Background The global prevalence of diabetes among adults will be 6.4 % in 2010 and will increase to 7.7 % by 2030 . Diabetes doubles the odds of depression , and 9 % of patients with diabetes are affected by depressive disorders . When sub clinical depression is included , the proportion of patients who have clinical ly relevant depressive symptoms increases to 26 % . In patients aged over 65 years , the interaction of diabetes and depression has predicted increased mortality , complications , disability , and earlier occurrence of all of these adverse outcomes . These deleterious effects were observed even in minor depression , where the risk of mortality within 7 years was 4.9 times higher compared with diabetes patients who did not have depressive symptoms . In this paper we describe the design and methods of the Minor Depression and Diabetes trial , a clinical trial within the ' Competence Network for Diabetes mellitus ' , which is funded by the German Federal Ministry of Education and Research . Methods / Design Patients ' inclusion criteria are : Type 2 diabetes mellitus , 65 to 85 years of age , 3 to 6 depressive symptoms ( minor depression or mild major depression ) . Our aim is to compare the efficacy of diabetes-specific cognitive behavioural therapy adapted for the elderly vs. intensified treatment as usual vs. a guided self-help intervention regarding improvement of health related quality of life as the primary outcome . The trial will be conducted as a multicentre , open , observer-blinded , parallel group ( 3 groups ) r and omized controlled trial . Patients will be r and omized to one of the three treatment conditions . After 12 weeks of open-label therapy in all treatment conditions , both group interventions will be reduced to one session per month during the one-year long-term phase of the trial . At the one-year follow-up , all groups will be re-examined regarding the primary and secondary parameters , for example reduction of depressive symptoms , prevention of moderate/severe major depression , improvement of glycaemic control , mortality , and cost effectiveness . Depending on additional funding , the sample will be continuously observed as a prospect i ve cohort ; the primary outcome will be changed to mortality for all subsequent follow-up measurements .Trial registration Current Controlled Trials Register ( IS RCT N58007098 ) Background and objective R and omised , controlled trials and population studies have suggested a link between hypertension and the development of dementia ( vascular dementia and Alzheimer ’s disease ) although the results are not conclusive . The very elderly are at highest risk for both hypertension and dementia but have been underrepresented in studies to date . The Hypertension in the Very Elderly Trial ( HYVET ) , an international , r and omised , double-blind , placebo-controlled trial of antihypertensive medication for those ≥80 years of age , is currently underway . The protocol for the assessment of cognitive decline and detection of incident dementia cases is described in this article . The objective of this protocol is to determine whether treatment of hypertension in this very elderly group affects the incidence of dementia and decline in cognitive function during the period of the HYVET trial . Methods Cognitive function in all HYVET trial participants is assessed at baseline and annually thereafter using the Mini-Mental State Examination ( MMSE ) . An MMSE score that decreases more than three points per year or decreases to < 24 prompts further investigation for possible incident dementia . This includes use of the Diagnostic and Statistical Manual-IV criteria , the modified Hachinski scale and CT scanning . In cases where a CT scan can not be obtained the full Hachinski scale is used . Additional information is provided when available from the clock drawing test and Geriatric Depression Scale . Data are also gathered from all trial participants with regard to education , blood pressure , alcohol use , co-morbidities and concomitant treatments . At the end of the trial , changes in cognitive function and incident dementia cases will be compared in those receiving active treatment ( indapamide slow-release ± perindopril ) and those receiving matching placebo . Results The protocol has been applied successfully and the data collection phase is underway . Discussion Previous population studies have been unable to study antihyperten-sive use in a controlled manner and r and omised , controlled trials suggest a positive or mixed picture regarding an association between use of antihyperten-sive therapy and reduction in incident cognitive decline and /or dementia . No such trial has yet been performed exclusively in subjects ≥80 years of age with hypertension . The HYVET trial is placebo controlled and while investigating the cardiovascular effect of treatment also assesses cognitive function and quality of life in both the placebo and actively treated arms of the trial . The HYVET cognitive sub study trial ( HYVET-COG ) design has been successfully applied and the instruments chosen appear to be appropriate , valid and pragmatic . Conclusion HYVET-COG provides the first opportunity to examine the effect of antihypertensive treatment on incident dementia in a high-risk very elderly population AIM To evaluate long-term , multiple risk factor intervention on physical , psychological and mental prognosis , and development of complications and cardiovascular disease in elderly type 2 diabetes patients . METHODS Our r and omized , controlled , multicenter , prospect i ve intervention trial included 1173 elderly type 2 diabetes patients who were enrolled from 39 Japanese institutions and r and omized to an intensive or conservative treatment group .  Glycemic control , dyslipidemia , hypertension , obesity , diabetic complications and atherosclerotic disease were measured annually . Instrumental activity of daily living , cognitive impairment , depressive symptoms and diabetes burden were assessed at baseline and 3 years . RESULTS There was no significant difference in clinical or cognitive parameters at baseline between the two groups . The prevalence of low activities of daily living , depressive symptoms and cognitive impairment was 13 % , 28 % and 4 % , respectively , and was similar in the two groups . A small , but significant difference in HbA1c between the two groups was observed at 1 year after the start of intervention ( 7.9 % vs 8.1 % , P < 0.05 ) , although this significant difference was not observed after the second year . With the exception of coronary revascularization , there was no significant difference in fatal or non-fatal events between the two groups . Composite events were also similar in the two groups . CONCLUSIONS This study showed no significant differences in fatal or non-fatal events  between intensive and conventional treatment . The present study might clarify whether treatment of risk factors influences function and quality of life in elderly diabetic patients Background : : Depression is associated with poor glycemic control , increased number of microvascular and macrovascular complications , functional impairment , mortality , and 4.5 times higher total health care costs in patients with diabetes .  Shared medical appointments ( SMAs ) may be an effective method to attain national guideline recommendations for glycemic control in diabetes for patients with depression through peer support , counseling , problem solving , and improved access to care . Objective : To test the efficacy as assessed by attainment of a hemoglobin A1c ( A1C ) < 7 % of pharmacistted group SMA visits , Veterans Affairs Multidisciplinary Education in Diabetes and Intervention for Cardiac Risk Reduction in Depression ( VA-MEDIC-D ) , in patients with type 2 diabetes mellitus . Methods : This was a r and omized controlled trial of VA-MEDIC-D added to st and ard care versus st and ard care alone in depressed patients with diabetes with A1C > 6.5 % .  VA-MEDIC-D consisted of 4 once-weekly , 2-hour sessions followed by 5 monthly 90-minute group sessions . Each SMA session consisted of multidisciplinary education and pharmacist-led behavioral and pharmacologic interventions for diabetes , lipids , smoking , and blood pressure . No pharmacologic interventions for depression were provided . The change in the proportion of participants who achieved an A1C < 7 % at 6 months was compared . Results : Compared to st and ard care ( n = 44 ) , a lower proportion of patients in VA-MEDIC-D ( n = 44 ) had systolic blood pressure ( SBP ) < 130 mm Hg at baseline , but were similar in other cardiovascular risk factors and psychiatric comorbidity . The change in the proportion of participants achieving an A1C < 7 % was greater in the VA-MEDIC-D arm than in the st and ard care arm ( 29.6 % vs 11.9 % ) , with odds ratio 3.6 ( 95 % CI 1.1 to 12.3 ) . VA-MEDIC-D participants also achieved significant reductions in SBP , low-density lipoprotein cholesterol , and non – high-density lipoprotein ( HDL ) cholesterol from baseline , whereas significant reductions were attained only in non – HDL cholesterol with st and ard care . There was no significant change in depressive symptoms for either arm . Conclusions : Pharmacist-led group SMA visits are efficacious in attainment of glycemic control in patients with diabetes and depression without change in depression symptoms The American Diabetes Association ( ADA ) first released its St and ards of Medical Care in Diabetes for health professionals in 1989 . These practice guidelines provide an extensive set of evidence -based recommendations that are up date d annually for the diagnosis and management of patients with diabetes . The 2017 St and ards cover all aspects of patient care ( 1 ) ; this guideline synopsis focuses on pharmacologic approaches for patients with type 2 diabetes . Guideline Development and Evidence Grading To develop the 2017 St and ards , the ADA Professional Practice Committee , which comprises physicians , adult and pediatric endocrinologists , diabetes educators , registered dietitians , epidemiologists , and public health experts , systematic ally search ed MEDLINE from 1 January 2016 ( date of last previous search ) to November 2016 . The committee revised recommendations based on the new evidence or , in some cases , to clarify prior ones or match the strength of the wording to the strength of the evidence . It also solicited feedback from the larger clinical community . The recommendations are rated as A , B , C , or E. Those with an A rating are based on large , well- design ed , multicenter clinical trials or high- quality meta-analyses . Recommendations with lower- quality evidence may be equally important and are based on well-conducted cohort studies ( B rating ) or uncontrolled studies ( C rating ) . Those assigned an E rating are consensus recommendations for which there is no evidence from clinical trials , in which clinical trials may be impractical , or in which there is conflicting evidence . The ADA funds development of the St and ards from its general revenues with no industry support or involvement . Details on the methodology , information about the committee members and their conflict-of-interest disclosures , and the complete St and ards can be downloaded at professional.diabetes.org/annals . Pharmacologic Therapy for Type 2 Diabetes : Recommendations Metformin , if not contraindicated and if tolerated , is the preferred initial pharmacologic agent for the treatment of type 2 diabetes ( A rating ) . Long-term use of metformin may be associated with biochemical vitamin B12 deficiency , and periodic measurement of vitamin B12 levels should be considered in patients treated with metformin , especially those with anemia or peripheral neuropathy ( B rating ) . Providers should consider initiating insulin therapy ( with or without additional agents ) in patients with newly diagnosed type 2 diabetes who are symptomatic , have a hemoglobin A1c ( HbA1c ) level of 10 % or greater , or have a blood glucose level of 16.7 mmol/L ( 300 mg/dL ) or greater ( E rating ) . If noninsulin monotherapy at the maximum tolerated dose does not achieve or maintain the HbA1c target after 3 months , adding a second oral agent , a glucagon-like peptide-1 (GLP-1)receptor agonist , or basal insulin should be considered ( A rating ) . For patients with type 2 diabetes who are not achieving glycemic goals , insulin therapy should be instituted without delay ( B rating ) . A patient-centered approach should be used to guide the choice of pharmacologic agents ( E rating ) . Initial Treatment Approach : Metformin Metformin monotherapy should be initiated at the time of diagnosis of type 2 diabetes for most patients unless there are contraindications . It is effective , safe , and inexpensive and may reduce the risk for cardiovascular events and death ( 2 ) . A large meta- analysis ( 3 ) supports the use of metformin monotherapy as first-line therapy . It may be safely used in patients with an estimated glomerular filtration rate as low as 30 mL/min/1.73 m2 ( 4 ) ; the U.S. label of metformin was recently revised to reflect its safety in patients with an estimated glomerular filtration rate of 30 mL/min/1.73 m2 or greater ( 5 ) . Gastrointestinal side effects are common in patients receiving metformin . In the authors ' experience , these side effects can be reduced if metformin monotherapy is started at a dose of 500 mg once or twice daily with food and titrated gradually to the maximum effective dose ( 2 g/d ) . Patients should be advised to stop taking their medication if they experience nausea , vomiting , or dehydration . The Diabetes Prevention Program Outcomes Study found that long-term users of metformin may develop vitamin B12 deficiency . Periodic testing of vitamin B12 levels should be considered in metformin users , especially those with anemia or peripheral neuropathy ( 6 ) . Using Pharmacotherapies Other Than or in Addition to Metformin If the patient does not tolerate or has a contraindication to metformin , another option should be considered . The ADA/European Association for the Study of Diabetes position statement ( 7 ) recommends a patient-centered approach , including assessment of efficacy , hypoglycemia risk , effect on weight , side effects , cost , and patient preferences . A table detailing characteristics of all available glucose-lowering agents in the United States that may guide individualized treatment choices is available in section 8 of the St and ards ( 8) . Tables 1 and 2 depict the costs of antihyperglycemic agents that were extracted from the Red Book ( 9 ) . With so many choices , patients and providers should be able to find a mutually agreeable treatment option . Table 1 . Median Monthly Cost of Maximum Approved Daily Dose of Noninsulin Glucose-Lowering Agents in the United States * Table 2 . Median Cost of Insulins  in the United States , Calculated as the AWP per 1000 Units of Specified Dosage Form/Product * For patients with an HbA1c level of 9 % or greater who are not acutely symptomatic , initiation of dual combination therapy ( Figure 1 ) should be considered to more quickly achieve the target HbA1c level . If the patient has a r and om glucose level of 16.7 mmol/L ( 300 mg/dL ) or greater or an HbA1c level of 10 % or greater and has acute symptoms of polyuria , polydipsia , or weight loss , combination therapy that includes insulin should be considered ( Figure 2 ) . Figure 1 . Antihyperglycemic therapy for type 2 diabetes : general recommendations . The order in the chart was determined by historical availability and the route of administration , with injectables to the right ; it is not meant to denote any specific preference . Potential sequences of antihyperglycemic therapy for patients with type 2 diabetes are displayed , with the usual transition moving vertically from top to bottom ( although horizontal movement within therapy stages is also possible , depending on the circumstances ) . Adapted with permission from Inzucchi and colleagues ( 7 ) . DPP-4-i= dipeptidyl peptidase-4 inhibitor ; GI= gastrointestinal ; GLP-1-RA= glucagon-like peptide-1receptor agonist ; GU= genitourinary ; HbA1c= hemoglobin A1c ; HF= heart failure ; SGLT-2-i= sodiumglucose contransporter-2 inhibitor . * See Dieuzeide and colleagues ( 21 ) for description of efficacy and cost categorizations . Usually a basal insulin ( such as neutral protamine Hagedorn , glargine , detemir , or degludec ) . Figure 2 . Combination injectable therapy for type 2 diabetes . Adapted with permission from Inzucchi and colleagues ( 7 ) . GLP-1-RA= glucagon-like peptide-1receptor agonist ; HbA1c= hemoglobin A1c ; SMBG= self-monitored blood glucose . Assessing Response and Deciding to Intensify Therapy Providers should assess whether the HbA1c target has been achieved within approximately 3 months of therapy initiation ( Figure 1 ) ; if it has not , therapy should be intensified ( Figure 2 ) . They should use shared decision making and a patient-centered approach when selecting a second agent . Potential combination therapies include a sulfonylurea , thiazolidinedione , dipeptidyl peptidase-4 ( DPP-4 ) inhibitor , sodiumglucose contransporter-2 ( SGLT-2 ) inhibitor , GLP-1receptor agonist , or basal insulin . Insulin should also be considered as part of any combination regimen for patients with severe hyperglycemia , especially if symptoms or catabolic features ( such as weight loss or ketosis ) are present . Patients should be reassessed within 3 months for achievement of the HbA1c target . Recent Evidence From Cardiovascular Outcomes Trials Major cardiovascular outcomes trials have studied patients with type 2 diabetes and established cardiovascular disease , including EMPA-REG ( Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients ) ( 10 ) and the LEADER ( Liraglutide Effect and Action in Diabetes : Evaluation of Cardiovascular Outcome Results ) trial ( 11 ) . These 2 studies found that , compared with placebo and st and ard treatment , empagliflozin and liraglutide reduced composite outcomes for myocardial infa rct ion , stroke , and cardiovascular death in population s in which most , if not all , patients had established atherosclerotic cardiovascular disease . Whether other agents in the same class as empagliflozin and liraglutide have similar benefits , and whether the treatments benefit patients at lower risk for cardiovascular disease , is unknown . Cardiovascular outcomes trial data for the DPP-4 inhibitors sitagliptin ( 12 ) , saxagliptin ( 13 ) , and alogliptin ( 14 ) showed no statistically significant differences in rates of major cardiovascular events between treatment and placebo groups . Recent Warnings About Pharmacotherapies In May 2015 , the U.S. Food and Drug Administration ( FDA ) issued a warning that SGLT-2 inhibitors may lead to ketoacidosis in the absence of significant hyperglycemia ( termed euglycemic diabetic ketoacidosis ) . Patients who develop symptoms of ketoacidosis  , which may include dyspnea , nausea , vomiting , and abdominal pain  , should stop taking SGLT-2 inhibitors and immediately seek medical attention ( 15 ) . In April 2016 , the FDA also warned that the DPP-4 inhibitors saxagliptin and alogliptin may increase the risk for heart failure , especially in patients with preexisting heart failure or renal impairment ( 16 ) . Insulin Therapy Diabetes is a progressive condition , and many patients with type 2 diabetes eventually require and benefit from insulin therapy . Early patient education about expected disease progression Objectives To examine whether improved diabetes control is related to better cognitive outcomes . Design R and omized control trial . Setting A r and omized trial of telemedicine vs. usual care in elderly persons with type 2 diabetes . Participants Participants were 2169 persons 55 years and older with type 2 diabetes from New York City and Upstate New York . InterventionThe diabetes case management intervention was implemented by a diabetes nurse , via a telemedicine unit in the participant ’s home , and in coordination with the primary care physician . Measurements Hemoglobin A1c ( HbA1c ) , systolic blood pressure ( SBP ) , and low density lipoprotein cholesterol ( LDL ) , were measured at a baseline visit and at up to 5 annual follow-up visits . Global cognition was measured at those visits with the Comprehensive Assessment and Referral Evaluation ( CARE ) . Result In mixed models the intervention was related to slower global cognitive decline in the intervention group ( p = 0.01 ) . Improvements in HbA1c ( p = 0.03 ) , but not SBP or LDL , mediated the effect of the intervention on cognitive decline . Conclusion Improved diabetes control in the elderly following existing guidelines through a telemedicine intervention was associated with less global cognitive decline . The main mediator of this effect seemed to be improvements in HbA1c OBJECTIVE To determine the safety and efficacy of an exercise protocol design ed to improve strength , mobility , and balance and to reduce subsequent falls in geriatric patients with a history of injurious falls . DESIGN A r and omized controlled 3-month intervention trial , with an additional 3-month follow-up . SETTING Out-patient geriatric rehabilitation unit . PARTICIPANTS Fifty-seven female geriatric patients ( mean age 82 + /- 4.8 years ; range 75 - 90 ) admitted to acute care or inpatient rehabilitation with a history of recurrent or injurious falls including patients with acute fall-related fracture . INTERVENTION Ambulatory training of strength , functional performance , and balance 3 times per week for 3 months . Patients of the control group attended a placebo group 3 times a week for 3 months . Both groups received an identical physiotherapeutic treatment 2 times a week , in which strengthening and balance training were excluded . MEASUREMENTS Strength , functional ability , motor function , psychological parameters , and fall rates were assessed by st and ardized protocol s at the beginning ( T1 ) and the end ( T2 ) of intervention . Patients were followed up for 3 months after the intervention ( T3 ) . RESULTS No training-related medical problems occurred in the study group . Forty-five patients ( 79 % ) completed all assessment s after the intervention and follow-up period . Adherence was excellent in both groups ( intervention 85.4 + /- 27.8 % vs control 84.2 + /- 29.3 % ) . The patients in the intervention group increased strength , functional motor performance , and balance significantly . Fall-related behavioral and emotional restrictions were reduced significantly . Improvements persisted during the 3-month follow-up with only moderate losses . For patients of the control group , no change in strength , functional performance , or emotional status could be documented during intervention and follow-up . Fall incidence was reduced nonsignificantly by 25 % in the intervention group compared with the control group ( RR:0.753 CI:0.455 - 1.245 ) . CONCLUSIONS Progressive resistance training and progressive functional training are safe and effective methods of increasing strength and functional performance and reducing fall-related behavioral and emotional restrictions during ambulant rehabilitation in frail , high-risk geriatric patients with a history of injurious falls STUDY OBJECTIVE To evaluate the impact of a geriatric consultation team on the functional status of hospitalized elderly patients . DESIGN R and omized controlled clinical trial . SETTING University-affiliated referral Veterans Administration Medical Center . PATIENTS One hundred and seventy-eight hospitalized elderly men 75 years or older admitted to medical , surgical , and psychiatry services , but excluding patients admitted to intensive care units . INTERVENTION Eighty-eight intervention group patients received multidimensional evaluation by an interdisciplinary geriatric consultation team composed of a faculty geriatrician , geriatrics fellow , geriatric clinical nurse specialist , and a social worker trained in geriatrics . Results of the evaluation , including problem identification and recommendations , were given to the patients ' physicians . Ninety control group patients received only usual care . MEASUREMENTS AND MAIN RESULTS Intervention and control groups were comparable initially . The major outcome variable was the Index of Independence in the Activities of Daily Living ( ADL ) ( Katz ) . Thirty-nine percent of the total study population was functionally independent on admission , 27 % required assistance with one to three ADL , 22 % required assistance with four to six ADL , and 12 % were completely dependent . Many patients remained unchanged from admission to discharge : intervention group , 38 % ; control group , 39 % . In the intervention group , 34 % improved and 28 % declined ; in the control group , 26 % improved and 36 % declined . Although these changes reflected a trend toward greater improvement in the intervention group , the results were not statistically significant . CONCLUSIONS Among elderly patients entering an acute-care hospital , approximately 60 % had some degree of , and one third had serious functional disability . Such patients are at risk for further decline during hospitalization . A geriatric consultation team was unable to alter the degree of functional decline . Geriatric units or consultation teams may have to offer direct preventive or restorative services in addition to advice if improvements are to be made Background Employer-based retiree drug benefits have long been viewed as the gold st and ard of drug coverage for elderly Medicare beneficiaries . The question for policy makers is whether beneficiaries enrolled in Part D plans exhibit drug utilization patterns comparable with those seen in retiree plans . Objective To compare utilization patterns for antidiabetic agents , renin-angiotensin-aldosterone system inhibitors , and antihyperlipidemics by elderly Medicare beneficiaries with diabetes enrolled in Medicare prescription drug plans ( PDPs ) and retiree health plans ( RHPs ) . Methods A r and om 5 % sample ( N=45,613 ) of elderly diabetic patients with continuous 2006 PDP enrollment was selected from Medicare files and compared with a similar sample of elderly RHP enrollees from MarketScan ( N=211,919 ) on any use , duration of therapy , and medication possession ratio for each drug class . Adjusted comparisons were made on sample s ( N=16,859 each ) using propensity score matching . Results Drug utilization and adherence rates were high in both groups . In propensity score adjusted comparisons , prevalence rates for PDP enrollees were within 2.2 % of the level of RHP enrollees for antidiabetic agents and renin-angiotensin-aldosterone system inhibitors , but differed sharply for antihyperlipidemics ( 61 % vs. 69 % ; P<0.0001 ) . There were no clinical ly meaningful differences between PDP and RHP enrollees in duration of therapy or medication possession ratio for any drug class . Conclusion When otherwise similar Medicare beneficiaries with diabetes have drug coverage , the source of benefits has little effect on use and adherence with most ( but not all ) drugs recommended in diabetes guidelines The structure and function of a newly created interdisciplinary Geriatric Consultation Team ( GCT ) are described . The GCT was introduced on a single medical unit , where consultations were given to 46 consecutive patients aged 75 years and over . The GCT patients had , on the average , 5.5 illnesses and were receiving 3.7 medications .  Anemia ( 50 per cent ) , were hypoalbuminemia ( 65 per cent ) , and elevated blood urea nitrogen ( BUN ) ( 58 per cent ) were frequent . Functional assessment showed frequent dependence on others for assistance with ambulation ( 59 per cent ) , transfers ( 54 per cent ) , and dressing ( 52 per cent ) ; cognitive impairment was found in 52 per cent and clinical depression in 11 per cent of the patients . In comparison with control units , the GCT increased use of physical therapy by 357 per cent , occupational therapy by 390 per cent , and speech therapy by 300 per cent without increasing length of stay . In comparison with control subjects , GCT patients had no decrease in hospital readmission rates ( 43 per cent ) over 10.5 months of follow up . It was concluded that a GCT in an acute-care hospital promotes geriatrics , teaches interdisciplinary teamwork , improves awareness of functional problems of patients , and increases use of rehabilitative services , but does not decrease the high rate of readmission of hospitalized geriatric patients We conducted this study to determine whether additional administration of a dipeptidyl peptidase-4 ( DPP-4 ) inhibitor might provide further improvement of the glycemic control in Japanese type 2 diabetes patients showing relatively good glycemic control under treatment with a sodium glucose co-transporter 2 ( SGLT2 ) inhibitor . Five SGLT2 inhibitor ( luseogliflozin , dapagliflozin , tofogliflozin , empagliflozin and canagliflozin ) preparations and five DPP-4 inhibitor ( sitagliptin , vildagliptin , alogliptin , anagliptin and linagliptin ) preparations were used . The results showed that monotherapy with SGLT2 inhibitor produced significant decreases of the body weight and BMI , hemoglobin A1c ( HbA1c ) also decreased , but not to a significant extent . However , decreases of the serum aspartate aminotransferase ( AST ) , alanine aminotransferase ( ALT ) , γ-glutamyltransferase ( γ-GTP ) and uric acid were observed in this group . On the other h and , in type 2 diabetes patients treated concomitantly with a DPP-4 inhibitor and SGLT2 inhibitor , significant decrease of the HbA1c was observed , indicating the favorable effect of the concomitant therapy . The body weight and BMI decreased . As for the serum lipid profile , elevation of the serum HDL-cholesterol ( HDL-C ) was observed . Furthermore , AST , ALT , γ-GTP and uric acid decreased in the combined treatment group . Then , the therapeutic responses to concurrent administration with SGLT2 inhibitor of each of the 5 individual DPP-4 inhibitors used in this study were analyzed . The results showed that concomitant administration of sitagliptin , a DPP-4 inhibitor , with the SGLT2 inhibitor yielded the best results in terms of the lowering of the HbA1c and improvement of the serum lipid profile OBJECTIVES To review the literature on comorbid depression and diabetes ( DM/D ) and present a conceptual framework for integrating depression management with diabetes care in a managed care environment . STUDY DESIGN Literature review . RESULTS Depression affects diabetes management by 1 ) directly affecting patients ' health-related quality of life , 2 ) reducing physical activity levels , 3 ) limiting adherence to self-care regimens , and 4 ) impairing patients ' ability to communicate effectively with clinicians . Small r and omized trials suggest that both antidepressant medication and cognitive behavioral therapies ( CBTs ) or related approaches may improve not only DM/D patients ' depressive symptoms , but their physical health as well . CONCLUSIONS An effective DM/D management strategy should include the following elements : 1 ) systematic identification of DM/D patients and quality -of-care review s , 2 ) proactive patient monitoring between outpatient encounters , 3 ) intensive efforts to coordinate treatment across providers , 4 ) increased access to CBT or related therapies addressing patients ' depressive symptoms and diabetes self care , and 5 ) an emphasis on promoting physical activity to address both depressive symptoms and physiologic dysregulation . The conceptual framework developed for the care of DM/D patients offers general insights into the management of patients with multiple chronic medical
Telemedicine interventions can improve communication and connection between older patients and their providers , and improve glycemic control .
Summary A systematic review confirmed the efficacy and safety of metformin as first-line therapy of type 2 diabetes in the older adult , but multiple reports highlighted the risk for vitamin B12 deficiency .
R and omized controlled trials showed the efficacy and safety of antihyperglycemic agents in the elderly , including some with longer duration and lesser risk for hypoglycemia .
R and omized clinical trials showed cardiovascular protection with SGLT-2i ( empagliflozin , canagliflozin ) and GLP-1RA ( liraglutide , semaglutide ) .
Purpose of Review The current approach to diabetes in the elderly incorporates components from the comprehensive geriatric approach .
The most up date d guidelines from the American Diabetes Association reflect influence from the consensus made in 2012 with the American Geriatrics Society .
Notably , the framework included the evaluation for geriatric syndromes ( falls and urinary incontinence ) , functional and cognitive abilities .
The goal for this review is to provide an up date d summary of treatment strategies for community-dwelling older adults .
Recent Findings Findings on cardiovascular protection with sodium-glucose co-transporter 2 inhibitors ( SGLT-2i ) and some glucagon-like peptide 1 receptor agonists ( GLP-1RA ) support their use for older patients with diabetes .
Functional medicine concepts can offer additional adjuvant strategies to support the therapeutic interventions and management of diabetes in the elderly .
The most current guidelines recommend addressing for geriatric syndromes , physical and cognitive function in the elderly , in order to individualize targets and therapeutic strategies .