Elsevier

Diabetes & Metabolism

Volume 37, Supplement 3, November 2011, Pages S27-S38
Diabetes & Metabolism

European Diabetes Working Party for Older People 2011 Clinical Guidelines for Type 2 Diabetes Mellitus. Executive SummaryA Report of the European Diabetes Working Party for Older People (EDWPOP) Revision Group on Clinical Practice Guidelines for Type 2 Diabetes Mellitus

https://doi.org/10.1016/S1262-3636(11)70962-4Get rights and content

Abstract

Aim

The Clinical Guidelines provide an opportunity to summarise the interpretation of relevant clinical trial evidence for older people with diabetes. They are intended to support clinical decisions in older people with diabetes and the primary focus is enhancing high quality diabetes care by the use of best available evidence.

Methods

The principles used for developing the recommendations are drawn from the Scottish Intercollegiate Guidelines Network (SIGN) based in Edinburgh, Scotland. Using SIGN 50, the Guidelines developer's handbook, each reviewer evaluated relevant and appropriate studies which have attempted to answer key clinical questions identified by the Working Party. Searches were generally limited to English language citations over the previous 15 years but the wide experience and multinational nature of the Working party ensured that citations in Italian, French Spanish, and German were considered if relevant. All relevant published articles were identified from the following databases: Embase, Medline/PubMed, Cochrane Trials Register, Cinahl, and Science Citation. Hand searching of 13 key major peer-reviewed journals was undertaken by two reviewers and included the Lancet, Diabetes, Diabetologia, Diabetes Care, Diabetes and Metabolism, British Medical Journal, New England Journal of Medicine, and the Journal of the American Medical Association.

Results

Key evidenced-based recommendations were made in 18 clinical domains of interest and Good Clinical Practice points identified. A glucose-lowering algorithm has been provided for frail older patients with diabetes.

Conclusion

We have provided an up-to-date evidenced-based approach to practical clinical decision-making for older adults with type 2 diabetes of 70 years and over. We have included a user-friendly set of recommendations to aid clinical decision-making in primary, community-based and secondary care settings.

Résumé

Recommandations pour la pratique clinique 2011 du Groupe de travail européen du Diabète de type 2 de la personne âgée. Synthèse

Objectif

Ces recommandations cliniques sont l’occasion de faire la synthèse des résultats apportés par les essais cliniques pertinents pour les personnes âgées atteintes de diabète de type 2. Elles sont destinées à soutenir les décisions thérapeutiques chez les personnes âgées diabétiques et leur objectif principal est de promouvoir une prise en charge de haute qualité fondée sur les meilleures preuves disponibles.

Méthodes

Les principes qui ont permis de développer les recommandations sont issus du Scottish Intercollegiate Guidelines Network (SIGN) localisé à Edimbourg en Écosse. À l’aide de la procédure SIGN 50, chaque lecteur a recensé et évalué les études pertinentes ayant tenté de répondre aux questions cliniques clés identifiées par le groupe de travail. Les recherches ont été limitées en général aux publications écrites en anglais mais la nature multinationale du groupe de travail garantit que les publications en italien, français, espagnol et allemand ont pu être prises en compte si elles étaient pertinentes. Tous les articles publiés au cours des 15 dernières années ont été identifiés dans les bases de données suivantes : Embase, Medline/PubMed, Cochrane Trials Register, Cinahl, and Science Citation. Une recherche manuelle a été réalisée par deux lecteurs critiques dans les 13 principaux journaux pour le thème: Lancet, Diabetes, Diabetologia, Diabetes Care, Diabetes and Metabolism, British Medical Journal, New England Journal of Medicine, and the Journal of the American Medical Association.

Résultats

Les recommandations clés fondées sur les preuves ont été établies dans 18 domaines cliniques et des points de bonne pratique clinique ont été identifiés. Un algorithme de correction de la glycémie pour le sujet âgé fragile est fourni.

Conclusions

Nous avons mis à disposition une approche actualisée fonée sur les preuves de la prise de décision clinique pour les personnes âgées de plus de 70 ans atteinte d’un diabète de type 2. Nous avons produit un jeu convivial de recommandations pour l’aide à la décision pour les soins primaires au domicile ou pour les structures de soins secondaires.

Introduction

This Executive Summary of the Clinical Guidelines provides an opportunity to summarise the interpretation of relevant clinical trial evidence for older people with diabetes. They are intended to support clinical decisions in older people with diabetes and the primary focus is enhancing high quality diabetes care by the use of best available evidence. Where possible, recommendations which have a cost-effective component will be employed.

The original European Diabetes Working Party for Older People (EDWPOP) was established in December 2000 to ensure that older people in societies across the European Union have consistent and high quality diabetes care throughout their lives. It developed from the Elderly Diabetes Working Group (Chair: Professor A J Sinclair, UK) of the St Vincent Declaration Primary Care Diabetes Group chaired by Dr Paul Cromme (Netherlands).

Modern diabetes care systems for older people require integrated care between general practitioners, hospital specialists, and other members of the healthcare team. These should have a multi-dimensional approach with an emphasis on prevention of diabetes and its complications, early intervention for vascular disease, and assessment of disability due to limb problems, eye disease, stroke, and other causes.

Although management of diabetes in older people can be relatively straightforward especially when patients have no other co-morbidities and when vascular complications are absent. In many cases, however, special issues arise which increase the complexity of management and lead to difficult clinical decision-making.

Variations in clinical practice are common in most healthcare systems resulting in inequalities of care. For older people with diabetes, this may be manifest as lack of access to services, inadequate specialist provision, poorer clinical outcomes and patient and family dissatisfaction. Our response to these concerns has been to develop Clinical Guidelines for older patients with type 2 diabetes mellitus based on the best available scientific and clinical trial evidence.

We anticipated a series of possible advantages for developing the guidelines and these have been summarised in Table 1. Other benefits of this approach include: (a) provide an up-to-date evidenced-based approach to practical clinical decision-making for older adults with type 2 diabetes of 70 years and over; and (b) provide a user-friendly set of recommendations to aid clinical decision-making in primary, community-based and secondary care settings.

Little, if any, published work exists which examines the ethical and moral dimensions of providing diabetes care for older people. Issues which might pose specific problems include aims and strategies of care, patients’ compliance, and risks of hypoglycaemia, choice of priorities, cost-effectiveness, and the presence of dementia or depression. Decision-making needs to reflect consideration of quality of life, life expectancy, cognitive and physical skills and the presence or otherwise of frailty. In the full set of Guidelines launched in 2004, those sections where ethical and/or moral issues are apparent, these have been highlighted and discussed, and practical advice provided.

In preparing the original full version EDWPOP identified various primary areas of concern and produced a series of target areas for concerted action (Table 2) [1], [2], [3], [4], [5], [6], [7]. These were based on common but important clinical issues relevant to most people with diabetes, but, in addition, other areas were identified which were deemed to satisfy a series of additional criteria: each has a significant impact on the lives of older people with diabetes and their families; in each case, some supporting evidence was available but careful scrutiny by an experienced review group would be necessary to derive an appropriate grade of recommendation; for each targeted area either existing Guidelines for adult diabetes had failed to discuss or specific guidance was thought necessary.

The lack of a sufficient clinical evidence base for establishing recommendations on best practice was recognised and highlighted by the absence of any large-scale intervention studies in older people with type 2 diabetes, no substantial evidence of benefit for glucose or lipid lowering, no evidence of large studies in diabetic residents of care homes, and no evidence to recommend a particular care model.

This extensive literature review has revealed numerous gaps in our knowledge of diabetes in older adults. In several Sections of the full Guideline (but not in this document) the Working party has tried to identify important research areas which might be addressed by the diabetes research community in the form of a randomised controlled trial or some form of epidemiological research.

Section snippets

Further developments of clinical guidelines

The original comprehensive version of Clinical Guidelines represents an important step in highlighting the special needs of older people with diabetes mellitus. A first draft of the Guidelines were presented at the 18th International Diabetes Federation (IDF) Congress in Paris, France, 24–29th August 2003, and later in Florence, Italy at the 2nd Congress of the European Union Geriatric Medicine Society (EUGMS), 27–29th August 2003. A complete version then underwent critical review by an

Recommendations for enhancing the practice and quality of diabetes care

Table 3 Rationale for High Quality Diabetes Care for Older People.

Screening and early diagnosis may prevent progression of undetected vascular complications: Level of evidence 1+, Grade of recommendation (A)
Overall improved metabolic control will reduce cardiovascular risk: Level of evidence 1+, Grade of recommendation (A)
Improved screening for maculopathy and cataracts will reduce visual impairment and blind registrations: Level of evidence 2+, Grade of recommendation (C)
An integrated approach

Managing cardiovascular risk [31–36]

  • 1.

    At initial assessment, all older patients aged less than 85 years with diabetes should have a cardiovascular risk assessment undertaken. Evidence level 1+, Grade of recommendation A.

  • 2.

    All older patients with type 2 diabetes aged less than 85 years should have a review and discussion of modifiable cardiovascular risk factors and be offered advice on smoking cessation. Evidence level 2++, Grade of recommendation B.

  • 3.

    The ten-year risk of developing symptomatic cardiovascular disease should be

Recommendations for care home diabetes [53–56]

  • 1.

    In view of the high rate of undiagnosed diabetes in care home residents, at the time of admission to a care home, each resident requires to be screened for the presence of diabetes. Evidence level 2++, Grade of recommendation B.

  • 2.

    At the time of admission to care home, each resident with diabetes should be comprehensively assessed for the presence of functional loss as they are at higher risk of progression of disability. Evidence level 2+, Grade of recommendation B.

  • 3.

    Residents on insulin

Diabetic foot disease [57–59]

  • 1.

    All older patients with type 2 diabetes should receive foot care education and instruction to self-inspect by suitable health care professionals. Evidence level 1++, Grade of recommendation A.

  • 2.

    All older patients with type 2 diabetes should receive an annual (minimum frequency) inspection (including vascular and neurological examination) of their feet by a health care professional to detect risk factors for ulceration. Evidence level 2+, Grade of recommendation C.

  • 3.

    Use of a 10-g monofilament or

Other good clinical practice points

  • Healthcare providers should address the following issues in older patients with diabetes and their carers:

    • The need for well structured shared care protocols with agreements on management of new cases, hospital admission criteria, access to specialist services, and follow-up criteria.

    • To avoid excessive carer burden, support is available in the areas of education, access to medical and nursing care, financial assistance, transport facilities and networking with other carers and support groups.

Aknowledgment

Supported by RETICEF (Red Temática de Investigacion Cooperativa envejecimiento y Fragilidad) (RD06/0013), Instituto de Salud Carlos III, Ministerio de Ciencia e Innovación, Spain and Institute for Diabetes in Old People (IDOP), UK.

Conflicts statement of interest

No potential conflicts of interest relevant to this article have been reported by any of the authors.

Cited by (0)

View full text