Applying evidence to improve diabetes care for older people

Sinclair AJ, Abdelhafiz AH, Forbes A, Munshi M (2018) Evidence-based diabetes care for older people with Type 2 diabetes: a critical review. Diabet Med Nov 8 [Epub ahead of print]

• Although diabetes confers a considerable burden on older people, who often present clinicians with complex management challenges, there is currently a relatively small evidence base on which to guide treatment, and this may have a negative impact on outcomes.
• In this review, the authors review the small but growing evidence base and advise on a comprehensive treatment scheme for: glucose lowering; blood pressure, lipid and frailty management; and lifestyle interventions in older people.
• A flow diagram outlining the development of complex illness scenarios that can occur in older people with diabetes is provided. It moves through normal glucose handling, subclinical and clinical type 2 diabetes (including delayed diagnosis) and high-risk health state, as well as providing dynamic modulation of goals by decade. 
• The first detailed algorithm for developing individualised care plans for this patient group is provided, with assessment and treatment phases.
• The authors advise that efforts be made to provide older people who have diabetes with individualised care, taking into consideration different functional and comorbid categories and duration of diabetes. A safer, risk-stratification approach with proactive monitoring is advocated for those who are frail or have a high comorbidity burden.
• A call is made for more high-quality trials to further knowledge about the best way in which to manage this vulnerable patient group.

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