Guidelines for improving the care of the older person with diabetes mellitus.

BACKGROUND AND SIGNIFICANCE iabetes mellitus (DM) is highly prevalent and increasing in persons aged 65 and older, particularly among racial and ethnic minorities. Estimates have placed the proportion of adults aged 65 to 74 with physician-diagnosed DM at nearly 25% in some ethnic groups. 1 Estimates from the Centers for Disease Control and Prevention indicate that, in 1998, 12.7% of persons aged 70 and older had a diagnosis of DM, up from 11.6% in 1990. 2 There are also large numbers of older adults, almost 11% of the U.S. population aged 60 to 74, with undiagnosed DM. 1 Older persons with DM have higher rates of premature death, functional disability, and coexisting illnesses such as hypertension, coronary heart disease (CHD), and stroke 3,4 than do those without DM. Older adults with DM are also at greater risk than other older persons for several common geriatric syndromes, such as depression, 5,6 cognitive impairment, 7 urinary incontinence, 8 injurious falls, 9–11 and persistent pain. 12,13 Although there are numerous evidence-based guidelines for DM, few guidelines are specifically targeted toward the needs of older persons 14 and help clinicians prioritize care for the heterogeneous population of older adults they may see in their practices. Moreover, the main emphasis of most DM guidelines is on intensive blood glucose control and prevention of microvascular complications. Although control of hyperglycemia is important, in older persons with DM, greater reduction in morbidity and mortality may result from control of cardiovascular risk factors than from tight glycemic control. Additionally, little is known about how well providers of health care for older persons with DM adhere to recommendations for the screening and treatment of common geriatric syndromes, such as depression, injurious falls, urinary incontinence, cognitive impairment, chronic pain, and polypharmacy, which are more prevalent with DM and may significantly influence quality of life. Although interventions to reduce the incidence of geriatric syndromes and to ameliorate their symptoms have been studied in general populations of older adults, few studies have focused on the identification and treatment of these common syndromes in older adults with DM. Moreover, because conditions such as cognitive impairment, polypharmacy, and injurious falls may interfere with the provision of appropriate DM care, the identification and management of these syndromes may enhance the effectiveness of DM management for the busy primary care provider. The purpose of this guideline is to improve the care of older persons with DM by providing a set of evidencebased recommendations that include DM-specific recommendations individualized to persons with DM who are aged 65 and older and recommendations for the screening and detection of geriatric syndromes. Table 1 summarizes the components of care included in the guidelines and the number of randomized controlled trials (RCTs) and systematic evidence reviews that were evaluated for the care recommendations.