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1.  Management of Type 2 Diabetes in Older People 
Diabetes Therapy  2013;4(1):13-26.
The prevalence of diabetes is increasing due to aging of the population and increasing obesity. In the developed world, there is an epidemiologic shift from diabetes being a disease of middle age to being a disease of older people due to increased life expectancy. In old age, diabetes is associated with high comorbidity burden and increased prevalence of geriatric syndromes in addition to the traditional vascular complications. Therefore, comprehensive geriatric assessment should be performed on initial diagnosis of diabetes. Due to the heterogeneous nature of older people with diabetes and variations in their functional status, comorbidities, and life expectancy, therapeutic interventions, and glycemic targets should be individualized taking into consideration patients’ preferences and putting quality of life at the heart of their care plans.
doi:10.1007/s13300-013-0020-4
PMCID: PMC3687094  PMID: 23605454
Diabetes mellitus; Geriatric assessment; Glycemic targets; Older people; Management; Type 2 diabetes
2.  Factors associated with initiation of antihyperglycaemic medication in UK patients with newly diagnosed type 2 diabetes 
Aim
To assess the factors associated with antihyperglycaemic medication initiation in UK patients with newly diagnosed type 2 diabetes.
Methods
In a retrospective cohort study, patients with newly diagnosed type 2 diabetes were identified during the index period of 2003-2005. Eligible patients were ≥ 30 years old at the date of the first observed diabetes diagnosis (referred to as index date) and had at least 2 years of follow-up medical history (N = 9,158). Initiation of antihyperglycaemic medication (i.e., treatment) was assessed in the 2-year period following the index date. Adjusted Cox regression models were used to examine the association between time to medication initiation and patient age and other factors.
Results
Mean (SD) HbA1c at diagnosis was 8.1% (2.3). Overall, 51% of patients initiated antihyperglycaemic medication within 2 years (65%, 55%, 46% and 40% for patients in the 30- < 45, 45- < 65, 65- < 75, 75+ age groups, respectively). Among the treated patients, median (25th, 75th percentile) time to treatment initiation was 63 (8, 257) days. Of the patients with HbA1c ≥ 7.5% at diagnosis, 87% initiated treatment within 2 years. These patients with a higher HbA1c also had shorter time to treatment initiation (adjusted hazard ratio (HR) = 2.44 [95% confidence interval (CI): 1.61, 3.70]; p < 0.0001). Increasing age (in years) was negatively associated with time to treatment initiation (HR = 0.98 [95% CI: 0.97, 0.99]; p < 0.001). Factors significantly associated with shorter time to treatment initiation included female gender and use of cardiovascular medications at baseline or initiated during follow up.
Conclusions
In this UK cohort of patients with newly diagnosed type 2 diabetes, only 51% had antihyperglycaemic medication initiated over a 2-year period following diagnosis. Older patients were significantly less likely to have been prescribed antihyperglycaemic medications. Elevated HbA1c was the strongest factor associated with initiating antihyperglycaemic medication in these patients.
doi:10.1186/1472-6823-12-1
PMCID: PMC3353844  PMID: 22397700
Clinical inertia; Age; Type 2 diabetes mellitus; Antihyperglycaemic medication
3.  An evaluation of the effectiveness of a multi-modal intervention in frail and pre-frail older people with type 2 diabetes - the MID-Frail study: study protocol for a randomised controlled trial 
Trials  2014;15:34.
Background
Diabetes, a highly prevalent, chronic disease, is associated with increasing frailty and functional decline in older people, with concomitant personal, social, and public health implications. We describe the rationale and methods of the multi-modal intervention in diabetes in frailty (MID-Frail) study.
Methods/Design
The MID-Frail study is an open, randomised, multicentre study, with random allocation by clusters (each trial site) to a usual care group or an intervention group. A total of 1,718 subjects will be randomised with each site enrolling on average 14 or 15 subjects. The primary objective of the study is to evaluate, in comparison with usual clinical practice, the effectiveness of a multi-modal intervention (specific clinical targets, education, diet, and resistance training exercise) in frail and pre-frail subjects aged ≥70 years with type 2 diabetes in terms of the difference in function 2 years post-randomisation. Difference in function will be measured by changes in a summary ordinal score on the short physical performance battery (SPPB) of at least one point. Secondary outcomes include daily activities, economic evaluation, and quality of life.
Discussion
The MID-Frail study will provide evidence on the clinical, functional, social, and economic impact of a multi-modal approach in frail and pre-frail older people with type 2 diabetes.
Trial registration
ClinicalTrials.gov: NCT01654341.
doi:10.1186/1745-6215-15-34
PMCID: PMC3917538  PMID: 24456998
Multi-modal intervention; Frail; Pre-frail; Type 2 diabetes
4.  Hypoglycaemia in residential care homes 
Hypoglycaemia is the most common metabolic complication occurring in older people with type 2 diabetes. Limited data are available about prevalence of diabetes or its complications in care homes. However, the prevalence of residents with diabetes in care homes seems to be significant. There is high level of disability, dependency, and polypharmacy among residents in these settings. Hypoglycaemia is both an important adverse reaction of treatment and an outcome measure. This study reviews the relevant literature and reports a case of hypoglycaemia to demonstrate the causes of hypoglycaemia, characteristics of these patients, and the complexity of their problems.
doi:10.3399/bjgp09X394860
PMCID: PMC2605531  PMID: 19105916
elderly; homes for the aged; hypoglycemia
5.  Use of short-acting insulin aspart in managing older people with diabetes 
Type 2 diabetes mellitus affects 5.9% of the world adult population, with older people and some ethnic groups disproportionately affected. Treatment of older people with diabetes differs in many ways from that in younger adults since the majority have type 2 disease and are at particular risk of macrovascular rather than disabling microvascular disease. Insulin therapy, the most effective of diabetes medications, can reduce any level of elevated HBA1c if used in adequate doses. However, some clinicians are often reluctant to initiate insulin therapy in older people with diabetes mainly out of their concerns about adverse reactions to insulin, particularly hypoglycemia. There is evidence suggesting that insulin aspart appears to act similarly to regular human insulin in older people with type 2 diabetes mellitus. Insulin aspart can be used in the treatment of older people with diabetes, but this should be individualized. There is evidence that it improves postprandial glucose control, improves long-term metabolic control, reduces risk of major nocturnal hypoglycemia and increases patient satisfaction compared with soluble insulin.
PMCID: PMC2685239  PMID: 19503780
older people; diabetes; insulin aspart; hypoglycemia
7.  Reasons given by general practitioners for non-treatment decisions in younger and older patients with newly diagnosed type 2 diabetes mellitus in the United Kingdom: a survey study 
Background
Older patients with newly diagnosed type 2 diabetes mellitus are less likely to receive antihyperglycaemic therapy compared to their younger counterparts. The purpose of this study was to assess the reasons of general practitioners (GPs) for not treating younger and older patients with newly diagnosed type 2 diabetes mellitus with antihyperglycaemic agents.
Methods
In a survey conducted between November 2009 and January 2010, 358 GPs from the United Kingdom selected reasons for not initiating antihyperglycaemic therapy in younger (< 65 years) and older (≥65 years) patients with newly diagnosed type 2 diabetes mellitus and untreated with any antihyperglycaemic agent for at least six months following diagnosis. Thirty-six potential reasons were classified into four major categories: Mild hyperglycaemia, Factors related to antihyperglycaemic agents, Comorbidities and polypharmacy, and Patient-related reasons. Reasons for non-treatment were compared between younger (n = 1, 023) and older (n = 1, 005) patients.
Results
Non-treatment reasons related to Mild hyperglycaemia were selected more often by GPs for both younger (88%) and older (86%) patients than those in other categories. For older patients, Factors related to antihyperglycaemic agents (46% vs. 38%) and Comorbidities and polypharmacy (33% vs. 19%), both including safety-related issues, were selected significantly (p < 0.001) more often by GPs. No between-group difference was observed for the Patient-related reasons category. The GP-reported HbA1c threshold for initiating antihyperglycaemic therapy was significantly (p < 0.001) lower for younger patients (mean ± standard deviation: 7.3% ± 0.7) compared to older patients (7.5% ± 0.9).
Conclusions
GPs selected reasons related to Mild hyperglycaemia for non-treatment of their untreated patients with newly diagnosed type 2 diabetes mellitus, despite nearly one-third of these patients having their most recent HbA1c value ≥7%. The findings further suggest that safety-related issues may influence the non-treatment of older patients with type 2 diabetes mellitus.
doi:10.1186/1472-6823-11-17
PMCID: PMC3219572  PMID: 22035104

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