Treating diabetes in the very old: an intersocietary consensus document| JOURNAL OF GERONTOLOGY AND GERIATRICS

Abstract

In the oldest old diabetes mellitus (DM) qualifies as a difficult to treat condition due to the impact of multimorbidity, the risk of adverse drug reactions and drug-drug interaction, sensory impairment and other causes of complexity. Thus, a thorough multidomain assessment is mandatory to have a comprehensive view of the patient’s health status and to define a hierarchy of needs as well as to tailor the path of care. Accordingly, the philosophy and the practical implementation of comprehensive geriatric assessment should be shared among general practitioner and different specialists caring for the older diabetic patient, and a multidisciplinary approach is desirable for difficult to manage conditions. Special attention should be paid to frequently overlooked threats such as drug-drug interactions, cognitive deficits potentially limiting the adherence to the therapy, destabilizing events such as major surgery. In this monograph, the main areas of interest for an optimal pharmacological and non pharmacological treatment of the oldest diabetic patient are discussed by a multispecialistic team. While individual sections have individual authors, all of them have been jointly revised by the full panel of authors and a truly shared version has been achieved. This guarantees for the present text representing an integrated multicultural approach to a topic of primary importance in Geriatrics.

It is well established that diabetes mellitus (DM) is an age-related condition. Its prevalence, in fact, in Italy is about 7% in the 55-64 year-old group, 14% in the 65-74 year-old one, and 20% in those over 75 year of age (). Clearly then, a relevant percentage of DM patients fall into the geriatric age group, a population facing the problems of multimorbidity, polypharmacy, frailty and disability, all variables which contribute to an individual’s overall health status and quality of life.

Given these premises, the management of DM in the elderly patients must necessarily be based on a personalized strategy taking into consideration important factors such as: the possibility of guaranteeing a full compliance with the therapeutic regimen, the risk of drug-drug interactions and adverse drug reactions, to mention just a few.

Starting out with a multidimensional assessment seems then the best path to an opportune therapeutic approach, which is frequently based on non-pharmacologic measures. Hence the need of a multidimensional geriatric assessment carried out by a team of specialists and consultants examining the patient’s physical and cognitive function, as well as psychological and social characteristics. Interestingly, the rapidly expanding armamentarium of antidiabetic drugs, some with pleiotropic beneficial effects, have facilitated the effort to tailor the therapeutic regimen to the individual needs, although in-depth knowledge and expertise are required.

These are the considerations that have led to this inter-societies initiative aiming to explore selected topics of interest regarding diabetes management in the very old. Unfortunately, the evidence that is presently available applies for the most part to adult or older-adult diabetic patients, while there is a paucity of data regarding DM management in the very old. Here we have made every effort to identify those few studies in the literature on this topic and to present practical recommendations that are based on good clinical practice and the principles already developed for a wide geriatric population.

The final product should thus be considered a guide to action rather than a to-do list. We hope that this short monograph will help the reader broaden her/his view of the very old DM patient by providing crucial information about selected items of interest, by highlighting the multiple medical and non-medical determinants of health and, in particular, by providing a conceptual framework for clinical reasoning. Despite the important limitations that we have acknowledged, we trust that this work will help the reader, whatever is her/his specialty or responsibility may be, to optimize his/her approach to the very old DM patient.

Participating Societies and Scientific Institutions, in alphabetical order:

1. CNR – Consiglio Nazionale delle Ricerche: National Research Council
2. ISS – Istituto Superiore di Sanità: Italian National Institute of Health
3. SID – Società Italiana di Diabetologia: Italian Society of Diabetology
4. SIGG – Società Italiana di Gerontologia e Geriatria: Italian Society of Gerontology and Geriatrics
5. SIMG – Società Italiana di Medicina Generale e delle Cure Primarie: Italian Society of General Medicine and Primary Care.