Guidelines for Improving the Care of the
Older Person with Diabetes Mellitus

California Healthcare Foundation/American Geriatrics Society Panel on ImprovingCare for Elders with Diabetes BACKGROUND AND SIGNIFICANCE
mon geriatric syndromes, such as depression, injurious iabetes mellitus (DM) is highly prevalent and increas- falls, urinary incontinence, cognitive impairment, chronic Ding in persons aged 65 and older, particularly among pain, and polypharmacy, which are more prevalent with racial and ethnic minorities. Estimates have placed the DM and may significantly influence quality of life. Al- proportion of adults aged 65 to 74 with physician-diagnosed though interventions to reduce the incidence of geriatric DM at nearly 25% in some ethnic groups.1 Estimates from syndromes and to ameliorate their symptoms have been the Centers for Disease Control and Prevention indicate studied in general populations of older adults, few studies that, in 1998, 12.7% of persons aged 70 and older had a have focused on the identification and treatment of these diagnosis of DM, up from 11.6% in 1990.2 There are also common syndromes in older adults with DM. Moreover, large numbers of older adults, almost 11% of the U.S.
because conditions such as cognitive impairment, poly- population aged 60 to 74, with undiagnosed DM.1 pharmacy, and injurious falls may interfere with the provi- Older persons with DM have higher rates of prema- sion of appropriate DM care, the identification and man- ture death, functional disability, and coexisting illnesses agement of these syndromes may enhance the effectiveness such as hypertension, coronary heart disease (CHD), and of DM management for the busy primary care provider.
stroke3,4 than do those without DM. Older adults with The purpose of this guideline is to improve the care of DM are also at greater risk than other older persons for older persons with DM by providing a set of evidence- several common geriatric syndromes, such as depression,5,6 based recommendations that include DM-specific recom- cognitive impairment,7 urinary incontinence,8 injurious mendations individualized to persons with DM who are aged falls,9–11 and persistent pain.12,13 Although there are numer- 65 and older and recommendations for the screening and de- ous evidence-based guidelines for DM, few guidelines are tection of geriatric syndromes. Table 1 summarizes the com- specifically targeted toward the needs of older persons14 ponents of care included in the guidelines and the number of and help clinicians prioritize care for the heterogeneous randomized controlled trials (RCTs) and systematic evidence population of older adults they may see in their practices.
reviews that were evaluated for the care recommendations.
Moreover, the main emphasis of most DM guidelines is onintensive blood glucose control and prevention of micro- IMPORTANCE OF INDIVIDUALIZED GOAL-
vascular complications. Although control of hyperglyce- SETTING IN DIABETES MELLITUS CARE
mia is important, in older persons with DM, greater reduc-tion in morbidity and mortality may result from control of The goals of DM care in older adults, as in younger per- cardiovascular risk factors than from tight glycemic con- sons, include control of hyperglycemia and its symptoms; trol. Additionally, little is known about how well providers prevention, evaluation, and treatment of macrovascular and of health care for older persons with DM adhere to microvascular complications of DM; DM self-management recommendations for the screening and treatment of com- through education; and maintenance or improvement ofgeneral health status. Although these goals are similar inolder and younger persons, the care of older adults with This guideline was developed and written under the auspices of the DM is complicated by their clinical and functional hetero- California Healthcare Foundation/American Geriatrics Society (AGS) Panel geneity. Some older persons developed DM in middle age on Improving Care of Elders with Diabetes and approved by the AGS Board and face years of comorbidity; others who are newly diag- nosed may have had years of undiagnosed comorbidity or This work was supported in part by the California Healthcare Foundation Grant 01–1287.
few complications from the disease. Some older adults The development of this guideline was supported by the California with DM are frail and have other underlying chronic con- Healthcare Foundation’s Program for Elders in Managed Care and an ditions, substantial DM-related comorbidity, or limited unrestricted educational grant from Aventis Pharmaceuticals.
physical or cognitive functioning, but other older persons Address correspondence to Elvy Ickowicz, MPH, Associate Director, with DM have little comorbidity and are active. Life expect- Professional and Public Education, American Geriatrics Society, 350 Fifth ancies are also highly variable for this population. Clinicians Avenue, Suite 801, New York, NY 10118. E-mail: eickowicz@americangeriatrics.org caring for older adults with DM must take this heteroge- 2003 by the American Geriatrics Society AMERICAN GERIATRICS SOCIETY
For older persons, whose life expectancy may be Table 1. Evidence Evaluated for Each Component of
shorter than the time needed to benefit from an interven- Diabetes Care
tion, a key clinical issue is the expected time horizon forbenefit from specific interventions. Clinical trials have demonstrated that approximately 8 years are needed be- fore the benefits of glycemic control are reflected in a re- duction in microvascular complications such as diabetic retinopathy or renal disease18–20 and that only 2 to 3 years are required to see benefits from better control of blood pressure and lipids.21–25 For this reason, this guideline places special emphasis on domains particularly important to the reduction of macrovascular endpoints for persons with DM—blood pressure management, aspirin therapy, and lipid management—for which data from RCTs and systematic reviews provide strong evidence in favor of in- tensive treatment. It is likely that there is an association between moderate glycemic control and enhancement of wound healing, reduction of symptoms associated with hyperglycemia such as polyuria and fatigue, and possibly maximization of cognitive function. However, the avail- able data suggest that many of these shorter-term benefits may be achieved with less-aggressive glycemic targets than those recommended in most of the national DM Quality of life is another important consideration in caring for older adults with DM. Although several inter-ventions have been found to significantly reduce morbidity neity into consideration when setting and prioritizing and mortality, it is clear that the potential benefits may be associated with reduced quality of life in older adults, par- Diabetes mellitus education is another important ele- ticularly for those with chronic conditions. Specifically, ment of care for older adults with DM and their caregivers.
complicated, costly, or uncomfortable treatment regimens Many clinicians are able to impart self-management skills may result in deleterious side effects, reduction in adher- in the primary care setting. Others find the primary care ence to recommended therapies, and a decrement in over- appointment to be too brief to provide education that ade- all well-being. The possible effects on quality of life should quately addresses elements that are critical in the coordi- be taken into account in any treatment plan.
nation of treatment and self-management that personswith DM need. For many patients, particularly those who APPLYING THE EVIDENCE TO THE CARE OF
are clinically complex, referral to a DM educator for one- OLDER PATIENTS WITH DIABETES MELLITUS:
on-one counseling or group classes, a comprehensive DM THE DIFFICULTIES
management program, or specialty physician care may im- Solid evidence supports the effectiveness of several compo- prove control. It is important to note that annual DM self- nents of DM care, including control of glycemia, lipids, management training is a covered benefit under Medicare and blood pressure; aspirin use; smoking cessation; appro- Part B (http://www.medicare.gov). Diabetes mellitus edu- priate eye and foot care; and prevention and management cation programs may be particularly important when ad- of nephropathy. Nevertheless, very few of the data sup- dressing the needs of persons with DM from minority and porting these interventions were obtained from research immigrant communities. There are many well-established studies of older persons. Although it is likely that many DM curricula that are appropriate for the needs of culturally guidelines can be generalized to many older adults with and linguistically diverse populations.15–17 An additional DM, intensive management of all these conditions simulta- element of DM education and self-management training neously may not be feasible for a proportion of older pa- that is important for the frail or cognitively impaired older tients, and clinicians may have to prioritize reduction of patient, persons with limited English proficiency, and ra- some risks over others. Moreover, it is clear that there may cial and ethnic minorities is the involvement and education be some groups of older persons with DM for whom ag- of family members or caregivers. Patients and, in some gressive management of these conditions will not provide cases, family members and caregivers should have their the same benefit as observed for younger persons; that is, knowledge and information needs assessed and have edu- for some, aggressive management can instead result in cational efforts tailored to these needs. Finally, it is impor- harm, such as episodes of hypoglycemia with tight blood tant to note that regular reassessment of treatment goals sugar control or hypotension with aggressive blood pres- and management skills is integral to DM education and that reinforcement may be necessary to make and sustain Among the unanswered questions that need to be sys- behavior change. This is particularly true for older adults, tematically addressed are: when and how to prioritize in- whose functional and cognitive status may change over terventions targeting blood pressure, glycemia, elevated lipids, and aspirin use, and how to stratify older adults by DIABETES GUIDELINES FOR OLDER PEOPLE
their likelihood of risk or benefit from intensive therapies.
older adult with DM presents with new-onset or recurrent For some older persons with DM without significant func- depression, medications should be evaluated to determine tional disability, all or most of the guidelines may be ap- whether any of them are associated with depression. If propriate, but for other, frail older adults with DM and a therapy is initiated, targeted symptoms should be identi- high burden of comorbid conditions, short life expectancy, or significant difficulty adhering to treatment recommen-dations, choices between therapies may have to be made.
Cognitive Impairment
Instead of treating these patients by using aggressive target Older adults with DM are at increased risk for cognitive levels for blood pressure, lipids, or glucose, the clinician impairment.7 Unrecognized cognitive impairment may in- may instead choose therapeutic goals to enhance quality of terfere with the patient’s ability to implement lifestyle life, treating symptoms associated with DM and its related modifications and take medications recommended by the conditions and addressing common geriatric syndromes clinician. Therefore, it is important that the clinician screen such as polypharmacy, depression, urinary incontinence, for cognitive impairment during the initial evaluation pe- riod and with any change in the patient’s clinical status,particularly if increased difficulty with self-care and self- RATIONALE FOR THE INCLUSION
management is noted. A variety of validated screening OF SPECIFIC GERIATRIC SYNDROMES
tools exist for assessing cognitive impairment. Caregivers Six geriatric syndromes were selected for inclusion in these can be a valuable source of information as well. Involve- DM guidelines. Syndromes were included if there was ment of a caregiver in DM education and management can population-based evidence that the specific syndrome was be critical to the successful management of the cognitively more prevalent in persons with DM or, in the absence of clear prevalence estimates, there was a strong pathophysi-ological reason to believe that persons with DM might be Urinary Incontinence
at greater risk for the syndrome or expert consensus that Older women with DM are at increased risk for urinary the syndrome should be included. Because of a paucity of incontinence.8,31 A targeted history and physical examina- RCT evidence supporting screening recommendations in tion should be performed, focusing on conditions associ- any age group, most of the recommendations to screen for ated with older age or DM. Examples are polyuria (glyco- common treatable geriatric syndromes in older persons suria), neurogenic bladder, fecal impaction, prolapse, with DM are based on expert opinion. The guidelines take cystoceles, atrophic vaginitis, vaginal candidiasis, and uri- into consideration the logistical complexity of providing nary tract infection, which can cause or exacerbate urinary comprehensive care to all older persons with DM by using a window of time that is 3 to 6 months into the initialevaluation. Throughout the guideline, this window is re- Injurious Falls
ferred to as the “initial evaluation period.” Falls by older adults are associated with high rates of mor-bidity, mortality, and functional decline.32–34 Older persons Polypharmacy
with DM are at increased risk for injurious falls.9–11,35 Pos- Older adults with DM are at risk for drug side effects and sible risk factors for injurious falls in older persons with DM drug-drug and drug-disease interactions. Polypharmacy is include high rates of frailty and functional disability, visual a major problem for older adults with DM, who may re- impairment, peripheral neuropathy, hypoglycemia, and quire several medications to manage glycemia, hyperlipi- polypharmacy.11,36 Older persons with DM should therefore demia, hypertension, and other associated conditions. In be screened for their risk for falls and for opportunities to addition, drug therapy for DM and comorbid illness can prevent their falling (see the American Geriatrics Society be costly for some patients. Clinicians should perform a (AGS) guideline for falls prevention in older persons).34 careful review of each medication currently being used bythe patient during the initial visit and at each subsequent visit and document whether the patient is taking each Older adults with DM are at risk for neuropathic pain, and medication properly. All drugs identified during the initial those with pain are often undertreated.12,13 Older adults review and each new drug prescribed should have clear with DM should be screened for persistent pain by using a documentation of the indication in the record, and pa- targeted history and physical examination. If there is evi- tients and their caregivers should receive information de- dence of persistent pain in an older adult with DM, further scribing the expected benefits, risks, and potential side evaluation should be performed, appropriate therapy should be offered, and the patient should be monitored, as recom-mended by the AGS guideline on persistent pain.37 Depression
Older adults with DM are at increased risk for depression,
and there is evidence of underdetection and undertreat- AND METHODS
ment in the primary care setting.26,27 On initial presenta- These guidelines were developed in the following stages: tion of an older adult with DM, the clinician should assess review of existing guidelines and literature on each topic, the patient for symptoms of depression using a single construction of evidence tables that summarized the data screening question or consider using a standardized screen- from RCTs on each topic, modification of existing guide- ing tool such as the Geriatric Depression Scale, the Beck lines and development of new guidelines, and review and Depression Inventory, or Zung’s Mood Scale.28–30 If an revision by members of the expert panel. For all domains, AMERICAN GERIATRICS SOCIETY
existing evidence and guidelines from sources such as theCochrane Collaboration, the American Diabetes Associa- Table 2. Key to Designations of Quality and Strength of
tion (ADA), the AGS, Assessing Care of Vulnerable Elders, Evidence
the American Association of Clinical Endocrinologists, and the Adult Treatment Panel III report from the Na-tional Cholesterol Education Program were reviewed. Fo- cused searches of the English language literature were per- formed using PubMed and the references listed in the papers and guidelines reviewed. For most of the topic clinical trial without randomization, from areas reviewed, limited data that were specific to older adults with DM were found, but for some of the domains studies, from multiple time-seriesstudies, or from dramatic results in under consideration, there were data from studies of older persons or of persons of all ages with DM, and for a num- ber of these, it was reasonable to extrapolate the findings based on clinical experience, descriptive to older adults with DM. Evidence tables (available at http://www.americangeriatrics.org) that summarize data from RCTs were created. Existing guidelines were subse- quently modified, and new guidelines were developed on the basis of this literature review. A national advisory panel consisting of general internists, family practitioners, Moderate evidence to support the use of a geriatricians, endocrinologists, health services researchers, and certified DM educators, among whom were members of the ADA, the Department of Veterans Affairs, the Cen- Poor evidence to support or to reject the ters for Medicare and Medicaid Services, the California Peer Review Organization, the Centers for Disease Con- trol and Prevention, the American Association of Family Practitioners, and the National Institute of Diabetes and Digestive and Kidney Diseases then evaluated the candi- This work was not meant to be an exhaustive review of DM care for the older adult; rather, these guidelines focus on the most important aspects of care for older adults with DM because they differ significantly from or deserve specialemphasis in comparison with the care provided to youngerpersons with DM. Some areas of DM care are beyond the may be a reason that targeted outcomes are not achieved.
scope of these guidelines and are not addressed in the guide- The clinician should review the feasibility of medication lines. In this document, it is recommended that primary care dosing and costs. Efforts should be made to keep care sim- providers screen older adults with DM for a number of the ple and inexpensive through such practices as single daily established geriatric syndromes, but for treatment recom- dosing of drugs (or, when this is not feasible, twice daily mendations, readers are referred to guidelines from the dosing). If there is evidence of difficulty with adherence to ADA, AGS, and other sources used in these guidelines.
a regimen that cannot or should not be simplified, a physi- The guidelines were reviewed by the expert panel, cian, pharmacist, DM educator, or other healthcare practi- who used the ratings for quality and strength of evidence tioner should provide counseling of the patients, family described in Table 2. Some of the guidelines are based on members, and caregivers; aids such as pill-dosing dispens- clinical experience and the consensus of members of the ers should be suggested or offered; and efforts should be made to simplify other aspects of care.
If these target outcomes are not being achieved, then THE GUIDELINES
clinicians should consider referral to a specialist experi- General Guiding Principles for the Care
enced in the care of older persons. Among the specialists of Older Adults with Diabetes Mellitus
who may assist with the management of these conditionsare endocrinologists or diabetologists, geriatricians, hyper- Clinicians should establish, in collaboration with patients tension specialists, mental health specialists, DM educa- or caregivers, specific goals of care or target outcomes for persons with DM. Such targets should be identified anddocumented for all aspects of care, such as management of hypertension, hyperlipidemia, hyperglycemia, mood dis- 1. The older adult who has DM (and is not on other order if present, and screening and treatment of geriatric anticoagulant therapy and does not have any con- syndromes if present. These targets or goals of treatment traindications to aspirin) should be offered daily as- should be identified and documented in the medical record.
If goals of care are not being met, then the patient should be evaluated for contributing causes. Difficulty Several RCTs38–40 and systematic reviews41,42 have with adherence to medications or to lifestyle modification shown an association between aspirin use and reduction in
acute myocardial infarction (MI) and other cardiovascular 2. Because older adults may have reduced tolerance for events, as well as reduction in cardiovascular mortality for blood pressure reduction, hypertension should be older adults and persons with DM. The dose of aspirin treated gradually to avoid complications. (IIIA) used in these studies ranges from 75 mg to 325 mg. A There are no data on the optimal time intervals over meta-analysis found no evidence that a daily dose of 1,000 which blood pressure should be lowered. Expert consen- mg or more was more effective than a 75-mg daily dose.42 sus suggests that blood pressure in older patients with hy- pertension should be lowered gradually to avoid complica-tions. An initial goal to lower systolic blood pressure by no more than 20 mmHg is prudent. If that goal is met and 1. The older adult who has DM and smokes should be well tolerated, then further steps to achieve target blood assessed for willingness to quit and should be of- pressure can be considered as needed. (Source guideline: 4) fered counseling and pharmacological interventions 3. The older adult who has DM and hypertension should be offered pharmacological and behavioral Approximately 12% of persons with DM aged 65 and interventions to lower blood pressure within 3 months older smoke. Of people with DM, smokers have a higher if systolic blood pressure is 140 to 160 mmHg or dia- risk than nonsmokers of morbidity and premature death,43 stolic blood pressure is 90 to 100 mmHg or within 1 but within 2 to 3 years of smoking cessation, the former month if blood pressure is greater than 160/100 smoker’s risk of CHD appears to decline to levels compa- rable with that of persons who never smoked.44 Although There are no data on the optimal timing for initiation several RCTs and systematic reviews have demonstrated of treatment for hypertension, but expert opinion supports the effectiveness of counseling and pharmacological inter- the recommendation that the severity of blood pressure el- ventions for smoking cessation in the general population, evation should influence the urgency of initiating therapy.
only two small studies have evaluated smoking cessation programs in persons with DM, with equivocal results.45,46Nonetheless, the detrimental effects of smoking are clear, Medication
and substantial benefit may be obtained through smoking 4. The older adult with DM who is on an ACE inhibi- cessation, for older adults and for persons with DM.
tor or ARB should have renal function and serum potassium levels monitored within 1 to 2 weeks ofinitiation of therapy, with each dose increase, and at Hypertension
General Recommendations
Although one specific medication for managing blood 1. If an older adult has DM and requires medical pressure in older adults with DM is not recommended, therapy for hypertension, then the target blood special attention should be paid to some commonly used pressure should be less than 140/80 if it is toler- medications. ACE inhibitors have been associated with a ated. (IA) Epidemiologic evidence shows that low- reduction in renal function. One RCT found that a moder- ering blood pressure to less than 130/80 may pro- ate dose of ACE inhibitor (i.e., captopril 75 mg/d, enala- pril 10 mg/d, or lisinopril 10 mg/d) is significantly associ-ated with the development of hyperkalemia.59 Additionally, There is strong evidence from a number of RCTs that a prospective study found a significant increase in serum drug therapy for blood pressure management reduces car- potassium in patients with type 2 DM on captopril com- diovascular events and mortality in middle-aged and older pared with those on other antihypertensive medications,60 adults. Several studies included large numbers of older par- and data from several uncontrolled studies suggest that ticipants or persons with DM.22,47–57 In the majority of these older adults are more susceptible to the reductions in renal studies, target blood pressure levels were less than 140/90 function that are related to ACE inhibitors.61 (Source mmHg, but other studies conducted primarily in younger adults found a reduction in cardiovascular endpoints using a 5. The older adult with DM who is prescribed a thiaz- target of less than 150/8022,48,50 or systolic blood pressure ide or loop diuretic should have electrolytes checked less than 160 mmHg.21 The Appropriate Blood Pressure within 1 to 2 weeks of initiation of therapy or of an Control in Diabetes (ABCD) study found that intensive con- increase in dosage and at least yearly. (IIIA) trol (blood pressure approximately 128/75) in normotensivepatients with type 2 DM slows the progression of diabetic No studies have evaluated the effect of monitoring nephropathy and retinopathy.57 (Source guidelines: 2, 4) electrolytes or appropriate monitoring intervals in persons Recent evidence comparing classes of antihypertensive using diuretics. However one RCT found that the use of medications for persons with DM indicates that many, thiazide diuretics is associated with hypokalemia and ven- such as diuretics, angiotensin-converting enzyme (ACE) tricular arrhythmias,62 and a case-control study found that inhibitors, beta-blockers, and calcium channel blockers, hypertensive patients on higher doses of thiazide diuretics have comparable effectiveness in reducing cardiovascular have an increased risk of cardiac arrest.63 These data sug- morbidity and mortality.48,58 There are also data to suggest gest that monitoring of potassium levels at the initiation of that angiotensin-receptor blockers (ARBs) have cardiovas- therapy and at regular intervals reduces the risk of hy- cular and renal benefit for persons with DM.53 pokalemia and its complications. (Source guideline: 11)
Glycemic Control
depending on the individual’s functional and cogni-tive abilities. The schedule should be based on the General Recommendations
goals of care, target A1C levels, the potential for 1. For older persons, target hemoglobin A (A1C) modifying therapy, and the individual’s risk for hy- should be individualized. A reasonable goal for A1C in relatively healthy adults with good functional sta- Self-monitoring of blood glucose is a key component tus is 7% or lower. For frail older adults, persons of the management of type 1 DM.64 Self-monitoring for with life expectancy of less than 5 years, and others persons with type 2 DM who are on insulin is recom- in whom the risks of intensive glycemic control ap- mended on the basis of expert opinion.67 In a systematic pear to outweigh the benefits, a less stringent target review of 11 studies that evaluated self-monitoring in per- sons treated with diet or hypoglycemic medications (six Lowering A1C is one goal of a DM treatment pro- randomized trials and five observational studies), only one gram,18,64,65 but there are no clinical trial data on the mac- found an improvement in glycemic control associated with rovascular and microvascular consequences of intensive self-monitoring.69 However, expert opinion strongly sug- glycemic control in older adults. Epidemiological analysis gests that long-term outcomes will be enhanced when self- of data from the United Kingdom Prospective Diabetes monitoring is combined with review of blood glucose levels Study (UKPDS), an RCT of persons in late middle age and appropriate adjustment of therapy to attain target levels with incident type 2 DM and minimal comorbidity, found of glycemic control. In addition, epidemiological evidence a 1% reduction in A1C to be associated with a 37% de- suggests that frail older adults with DM are at increased cline in microvascular complications and a 21% reduction risk for hypoglycemic coma.70 Expert consensus suggests in risk of any endpoint related to DM.18,66 Therefore, older that self-monitoring may reduce the risk of serious hypogly- adults who are in good health and those who already have cemia in older adults with DM who use insulin or oral microvascular complications are likely to benefit the most antidiabetic agents. The optimal frequency and timing of self-monitoring is not known. The ADA recommends that Nevertheless, the risks of intensive glycemic control, these “should be dictated by the particular needs and goals including hypoglycemia, polypharmacy, and drug-drug of the patients” and that frequency should be increased and drug-disease interactions, may significantly alter the with any modification of therapy.67 (Source guidelines: 2, risk-benefit equation. For frail older adults, persons with limited life expectancy, and others in whom the risks of in- 4. The management plan for the older adult with DM tensive glycemic control appear to outweigh the potential who has severe or frequent hypoglycemia should be benefits, a less-stringent target than the ADA general rec- evaluated; the patient should be offered referral to a ommendation, such as 8.0%, is appropriate.
DM educator, endocrinologist, or diabetologist; and According to ADA recommendations,67 the quality of the patient and any caregivers should have more- evidence is level I for lowering A1C in younger persons frequent contacts with the healthcare team (e.g., phy- (approximately younger than 65), level II for A1C goal of sicians, certified DM educators, pharmacists, nurse 7% or less, and level III for applying less stringent goals to case manager) while therapy is being readjusted. (IIB) some older adults and those with limited life expectancy.
(Source guidelines: 2, 4) Epidemiological evidence suggests that frail older adults are at higher risk for serious hypoglycemia than are Monitoring
healthier, more-functional older adults.70,71 One small 2. The older adult who has DM and whose individual RCT found that automated health assessment calls to pa- targets are not being met should have his or her A1C tients with follow-up phone calls from a nurse signifi- levels measured at least every 6 months and more cantly reduced the risk of hypoglycemia in patients with frequently, as needed or indicated. For persons with DM on oral antidiabetic medications (adjusted difference stable A1C over several years, measurement every in number of symptoms Ϫ0.5, P ϭ .001). This study, with a mean age of 56 for participants in the interventionarm, excluded persons aged 75 and older. Older adults Monitoring blood glucose levels is necessary for en- with DM who have frequent or severe episodes of hy- hancing glycemic control. No clinical trials have evaluated poglycemia are likely to benefit from more-intensive man- the effect on outcomes of routine measurement of A1C in agement to determine the precipitants of hypoglycemia persons with type 2 DM. One RCT conducted in Den- and to attempt to reduce the risk of recurrence. (Source mark found that measuring and reporting A1C four times a year in persons with type 1 DM was associated withlower A1C levels and fewer hospitalizations (absolute risk Medications
reduction 11%) at 1 year than in persons whose A1C lev- 5. If an older adult is prescribed an oral antidiabetic els were not reported.68 More-frequent monitoring may be agent, then chlorpropamide should not be used.
appropriate for persons for whom achievement of intensive glycemic control is clinically indicated (e.g., symptomatic pa-tients with elevated A1C levels). (Source guidelines: 4, 11) Chlorpropamide has a prolonged half-life, particu- larly in older adults. It is associated with increased risk for 3. For the older adult with DM, a schedule for self- hypoglycemia,73,74 and this risk increases with age.75,76 monitoring of blood glucose should be considered, DIABETES GUIDELINES FOR OLDER PEOPLE
6. Older diabetic men with a serum creatinine of 1.5 100 to 129 mg/dL, medical nutrition therapy (MNT) mg/dL or greater and older diabetic women with a and increased physical activity are recommended; serum creatinine of 1.4 mg/dL or greater and older lipid status should be checked at least annually, diabetic patients of either sex with creatinine clear- and response to therapy should be monitored. If ance that indicates reduced renal function should an LDL of 100 or lower is not achieved in 6 not use metformin because of the increased risk of months, then pharmacological therapy should be 7. The older adult with DM who receives metformin 130 mg/dL or greater, pharmacological therapy is should have serum creatinine measured at least annu- required in addition to lifestyle modification; lipid ally and with any increase in dose, but for individuals status should be checked at least annually, and re- aged 80 years or older or those who have reduced sponse to therapy should be monitored. (IIIB) muscle mass, a timed urine collection should be ob- The evidence presented in Lipid Recommendation 1 tained for measurement of creatinine clearance. (IIB) argues for making efforts to lower LDL cholesterol and Lactic acidosis, a rare but serious complication of supports pharmacological interventions (e.g., the use of metformin use, is more common in the presence of im- lipid-lowering agents). Expert opinion supports the selec- paired renal function.77,78 Because aging is associated with tion of specific LDL levels as prompts for specific actions.
reduced renal function, older adults with type 2 DM on MNT, enhanced physical activity, and weight loss have metformin should undergo regular monitoring of renal also been shown to play a role in improving cardiovascular function, and patients with serum creatinine levels above risk profiles in older adults with DM. Eleven RCTs have the upper limit of normal for their age should not receive evaluated MNT96–103 or MNT and physical activity104–106 in metformin.79 There are no data on the frequency of the the clinical management of dyslipidemia in older adults timed urine collection. Additionally, metformin should be withheld before initiating radiological studies, and renal It is recommended that goals for HDL and triglycer- function should be reevaluated after such procedures be- ides also be consistent with ADA recommendations of fore metformin is reinstituted. (Source guideline: 2) HDL greater than 40 mg/dL and triglycerides lower than150 mg/dL.67 Older adults with normal or nearly normal LDL cholesterol and low HDL or elevated triglyceridesshould be offered a fibrate in addition to MNT.
General Recommendations
There are no data to support the length of the interval 1. For the older adult with DM who has dyslipidemia, during which lipid levels should be checked. Expert con- efforts should be made to correct the lipid abnor- sensus suggests that persons with low-risk lipid values malities if feasible after overall health status is con- (LDL Ͻ100 mg/dL, HDL Ͼ40 mg/dL, triglycerides Ͻ150 mg/dL) on an initial assessment may have lipids checkedevery 2 years; persons with moderate or higher-risk lipid Epidemiological evidence suggests that persons with levels should have their lipids evaluated at least annually DM without prior MI have similar elevated risk of MI as and more frequently if targets are not being met.67 (Source persons without DM who have had an MI.24 Persons with DM have high rates of lipid abnormalities that contributeto this cardiovascular risk: high low-density lipoprotein Monitoring
(LDL), low high-density lipoprotein (HDL), and high tri- 3. The older adult with DM who is newly prescribed ni- glycerides. Evidence supports the use of lipid-lowering acin or a statin or who has an increase in the current agents and therapies to increase HDL in older adults with dose of niacin or statin should have alanine amino- DM. Several RCTs and meta-analyses have shown that a transferase level measured within 12 weeks of initia- reduction in LDL cholesterol reduces the risk of cardiovas- tion of the new medication or dose change. (IIIB) cular events in older adults and persons with DM. The 4. The older adult with DM who is taking a fibrate beneficial effects of lowering LDL have been demonstrated should have an annual evaluation of liver enzymes.
with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins).23,80–91 Despite this evidence, there aredata to suggest that rates of prescribing of statins in older Data describing the benefit of monitoring liver func- adults are suboptimal and that, even when they are pre- tion for patients using lipid-lowering medications are lim- scribed, there is poor adherence to these medications.92,93 ited. Clinical trials suggest that the use of statins or fi- Data on the effect of HDL and triglyceride levels in older brates is associated with elevations in liver transaminases adults with DM are limited. In men with DM (mean age in some patients, but RCT evidence from studies of per- 65) whose primary abnormality is low HDL, the use of fi- sons with type 2 DM found no increase in liver enzymes brates has been found to be associated with an increase in 12 weeks after initiation of therapy with a statin.
HDL levels, a fall in triglyceride levels, and a reduction in RCT comparing older adults (aged 50–70) and younger rates of cardiovascular events.94,95 (Source guidelines: 1, 4) persons taking niacin, which excluded persons with DM,found no significant difference in frequency of liver func- 2. When the older adult with DM has an LDL choles- tion test abnormalities between the two age groups.108 There is no clinical trial evidence supporting the inter- 100 mg/dL or less, lipid status should be rechecked vals at which monitoring of liver enzymes should occur.
Foot Care
1. The older adult who has new-onset DM should have The older adult who has DM should have a careful foot an initial screening dilated-eye examination per- examination at least annually to check skin integrity and formed by an eye-care specialist with funduscopy to determine whether there is bony deformity, loss of sen- sation, or decreased perfusion and more frequently if thereis evidence of any of these findings. (IIIA) Two RCTs have shown that detection and treatment There are no RCT data to support examination of the of diabetic retinopathy reduces the progression of dia- feet at regular intervals to prevent lower-extremity ulcer- betic eye disease and visual loss.109,110 Evidence suggests ation or amputation, but a randomized trial of an inter- that sensitivity of screening for diabetic retinopathy is vention consisting of patient and provider foot-care educa- highest among eye-care specialists.111,112 (Source guide- tion and a team approach to foot care found an increase in rates of foot examinations at routine office visits and a re- 2. The older adult who has DM and who is at high risk duction in serious foot lesions (odds ratio (OR) ϭ 0.41, P ϭ for eye disease (symptoms of eye disease present; ev- .05).116 In addition, several uncontrolled studies have idence of retinopathy, glaucoma, or cataracts on an found a reduction in rates of amputation after implemen- initial dilated-eye examination or subsequent exami- tation of comprehensive foot-care programs.117 nations during the prior 2 years; A1C Ն8.0%; type Regular foot examinations permit identification of di- 1 DM; or blood pressure Ն140/80) on the prior ex- abetic neuropathy and foot lesions and may in turn prevent amination should have a screening dilated-eye exam- progression to ulcers and amputation, but there are no data ination performed by an eye-care specialist with fun- to support the optimal interval for evaluation. Most current duscopy training at least annually. Persons at lower recommendations specify that the foot examination should risk may have a dilated-eye examination at least ev- be done at all nonurgent outpatient visits.
Quality of evidence is level II for more frequent exami- nations for persons at high risk for foot problems and level Data from the UKPDS indicates that incidence of III for routine annual screening. (Source guidelines: 2, 4).
retinopathy is associated with, among other things, levelof glycemic control over the prior 6 years and higher Nephropathy
blood pressure and that the progression of retinopathy is 1. A test for the presence of microalbumin should be associated with older age, male sex, and hyperglyce- performed at diagnosis in patients with type 2 DM.
mia.113 Few patients with type 2 DM without diabetic After the initial screening and in the absence of pre- retinopathy on baseline examination were found to re- viously demonstrated macro- or microalbuminuria, a quire photocoagulation during the subsequent 3 to 6 test for the presence of microalbumin should be per- years (0.2% and 1.1%, respectively), whereas persons formed annually. (IIIA) (Source guideline: 4) with microaneurysms in one eye at initial evaluationwere found to need photocoagulation at rates of 0.0% Diabetes Mellitus Education
and 1.9% at 3 and 6 years, and those with microaneu- 1. Persons with DM, and, if appropriate, family mem- rysms in both eyes were found to need photocoagulation bers and caregivers, should be given the following at rates of 1.2% and 3.6% at 3 and 6 years. Persons information about hypo- and hyperglycemia at diag- with more severe retinopathy required photocoagulation nosis, with reassessment and reinforcement periodi- at significantly higher rates, 15.3% and 25.2% at 3 and 6 years. At 12 years, the study reported significant dif- ferences in time to photocoagulation between persons with and without diabetic retinopathy at baseline (P Ͻ .001).114 Notably, this analysis did not record or exam- ine the prevalence of other common treatable age-related (v) when to notify a member of the healthcare eye disorders, such as glaucoma, cataract, and macular degeneration, which are also more common among per-sons with DM.
RCT evidence from middle-aged and older adults sug- Decision analytic models suggest that screening for gests that multidisciplinary interventions that provide edu- diabetic retinopathy is cost-effective. However in persons cation on medication use, monitoring, and recognizing at low risk for retinopathy, annual screening is not cost- hypo- and hyperglycemia can significantly improve glyce- effective in comparison with less-frequent screening in- tervals.115 There is consensus among experts that data 2. The monitoring technique of the older adult with from previous examinations, DM-related considerations, DM who self-monitors blood glucose levels should and blood pressure should all be considered when deter- mining the need for photocoagulation. It is important tonote that none of the existing decision analytic models Self-monitoring blood glucose (SMBG) was an impor- for the timing of eye care have taken into consideration tant component of two RCTs of education programs for the potential health benefits of detecting other age- middle-aged and older adults that found improved glyce- related vision problems, such as cataract, glaucoma, and mic control in the intervention arms of the studies.119,120 In uncorrected refractive errors in older adults with DM.
addition, one carefully conducted meta-analysis of educa- tion programs for adults (younger and older) found SMBG DIABETES GUIDELINES FOR OLDER PEOPLE
instruction to have a significant positive effect on adher- scriptions are lacking, two RCTs118,119 investigated the ef- ence to a prescribed regimen (seven studies, effect size ϭ fect of DM education programs that included education ϩ0.49 (standard deviation (SD) ϭ 0.41)).121 Finally, one on medication use in middle-aged and older adults and well-conducted RCT found that a single 30-minute session found that the programs had a significant effect on glyce- of instruction on SMBG significantly decreased measurement mic control. Additionally, a meta-analysis of 153 studies errors in comparison with 30 minutes of self-instruction us- involving adults of various ages indicated that one-on-one ing the directions included with an SMBG device (P Ͻ interventions significantly improved medication adher- .01).122 Nevertheless, there are no clinical trials that evalu- ate the benefit of reviewing SMBG technique on DM out- 6. The older adult who has DM and any caregiver should receive education about risk factors for foot 3. The older adult who has DM should be evaluated ulcers and amputation. Physical ability to provide regularly for level of physical activity and should be proper foot care should be evaluated, with reassess- informed about the benefits of exercise and available ment and reinforcement periodically as needed. (IB) Older adults are at higher risk for conditions that may Evidence from RCTs indicates that increased physical reduce the ability to conduct proper foot surveillance and activity in combination with nutrition education can sig- care (e.g., cognitive impairment, visual impairment, os- nificantly reduce weight and enhance blood pressure, teoarthritis, and other physical limitations in functioning lipid, and glycemic control.104–106 Two of these RCTs104,105 that prevent movement). One RCT that evaluated a multi- dealt specifically with older adults (aged 55 and 60 and disciplinary intervention that included patient education older, respectively), but some older persons are too func- on foot care for middle-aged and older adults (mean age tionally or cognitively impaired to successfully increase 59) found lower rates of serious foot lesions (OR ϭ 0.41; their level of physical activity. (Source guideline: 4) P ϭ .05).116 Another RCT found that patients of variousages exposed to an educational program on foot care ex- 4. The older adult with DM should be evaluated regu- perienced lower rates of amputation (P ϭ .03) and ulcer- larly for diet and nutritional status and, if appropri- ation (P ϭ .005).126 (Source guidelines: 2, 4) ate, should be offered referral for culturally appro-priate MNT and counseled on the content of his or Depression
her diet (e.g., intake of high-cholesterol foods and 1. The older adult who has DM is at increased risk for appropriate intake of carbohydrates) and on the po- major depression and should be screened for depres- tential benefits of weight reduction. (IA) sion during the initial evaluation period (first 3 Eight RCTs96–103 have evaluated dietary education or months) and if there is any unexplained decline in MNT in the clinical management of older adults with DM and found that they can significantly improve weight, On initial presentation of an older adult with DM, the blood pressure, lipid levels, and glycemic control. Most of clinician should assess the patient for symptoms of depres- these RCTs focused primarily on middle-aged adults, but sion using a two-question screen or consider using a stan- one103 specifically targeted adults aged 65 and older and dardized screening tool, such as the Geriatric Depression produced results similar to the others. Data on the effect Scale.28,127 This tool is available in several languages (http:// of weight loss on morbidity and mortality in older adults www.stanford.edu/~yesavage/GDS.html).
with DM are limited; thus, weight reduction may not be Depression is more common in persons with DM6,128 an appropriate goal in all cases. (Source guidelines: 2, 4) and may impede DM self-management.129 One recent ret- 5. The older adult with DM who is prescribed a new rospective study found that, controlling for age, sex, and medication and any caregiver should receive educa- race/ethnicity, older adults with DM were significantly tion about the purpose of the drug, how to take it, more likely to develop major depression than other older the common side effects, and important adverse re- adults and that depressed older adults with DM in- actions, with reassessment and reinforcement peri- curred higher non-mental health costs than those who are not depressed.130 Older adults have high rates of under-diagnosis and undertreatment of their depressive symptoms, There is evidence that older persons may receive inad- with fewer then 10% of depressed older adults and fewer equate information about their medications. Package in- than 5% of older adults with high levels of depressive serts that accompany prescription medications often do symptoms receiving antidepressant medications.26,27 not meet the readability needs of older adults, with many The data on the relationship between screening for de- printed on poor quality paper and in small fonts.123 Fur- pression in the clinical setting and patient outcomes are thermore, language and health literacy can be barriers to mixed. One RCT found that middle-aged patients screened obtaining vital information about side effects and adverse with a single question or a longer survey were significantly reactions from package inserts or labels because many are more likely to recover from depression, but mean im- written solely in English or in a form easily misunderstood provement in depressive symptoms was not significantly by patients. In one study, interviews with 325 older adults different from the control group.131 Another partially ran- revealed that 39% could not read their medication labels domized controlled trial found no improvement in depres- and 67% did not fully understand the labels.124 Although sion in patients aged 70 and older who were screened by trials directly testing the effects of education on new pre- office staff before their initial visit.132 It is important to AMERICAN GERIATRICS SOCIETY
note that recent studies have demonstrated poorer out- presents with depression, falls, cognitive impair- comes of DM care for patients with unrecognized depres- ment, or urinary incontinence should be reviewed.
sion.133–136 Therefore, screening and treatment of depression may influence outcomes of DM care in older persons.
Epidemiological evidence shows that medications may contribute to or exacerbate geriatric syndromes, alone or 2. The older adult with DM who presents with new- through drug-drug or drug-disease interactions. Medica- onset or a recurrence of depression should be treated tions, particularly those with sedating effects, are regularly or referred within 2 weeks of presentation, or sooner cited as a risk factor for falls.141–144 Medication use is also if the patient is a danger to himself or herself, unless cited as a potential cause of depression and may compli- there is documentation that the patient has im- cate its treatment.145,146 Many medications (especially se- dating medications) have been associated with cognitiveimpairment (delirium or dementia) in older patients.147–151 There is evidence from two carefully conducted meta- Urinary incontinence has been linked to some specific analyses of RCTs that pharmacological and psychological medications and to drug-drug interaction and polyphar- treatment of older adults (aged 55 and older) is effective in macy, particularly in women.152–155 Finally, adverse drug reducing depressive symptoms.137,138 One systematic re- reactions have been implicated in failure to thrive in older view of RCTs shows the same benefit for people with adults, resulting in functional decline, depression, and physical illnesses.139 There are no RCT data on the optimal malnutrition.156 One RCT found that the withdrawal of timing of referral or implementation of treatment in older psychotropic medications leads to a significant reduction adults. The quality and strength of evidence is IA for under- in the risk of falling;157 therefore, the quality of evidence is taking clinical intervention but IIIB for the timing of referral or treatment. For persons who show evidence of substanceabuse or dependence, initiation of therapy for depressionmay wait until he or she is in a drug- or alcohol-free state.
If therapy is initiated, targeted symptoms should be identi- Cognitive Impairment
fied and documented in the record. (Source guideline: 11) 1. The clinician should assess the older adult with DM for cognitive impairment using a standardized screen- 3. The older adult who has received therapy for depres- ing instrument during the initial evaluation period sion should be evaluated for improvement in target and with any significant decline in clinical status. In- symptoms within 6 weeks of the initiation of ther- creased difficulty with self-care should be considered Evaluation of the effectiveness of therapies for depres- Diabetes mellitus, particularly type 2, has been associ- sion is critical to managing the disease. Because there is ev- ated with decreased cognitive function in older adults, man- idence of inadequate treatment once therapy is initiated ifested as decreased memory, learning, or verbal skills.7,158–165 for depression in older adults,26,27 persons who receive Two case-control studies159,165 found significant differences therapy for depression should be reassessed to see whether in cognitive function between older adults with and with- there has been a noticeable improvement in target symp- out DM using the Mini-Mental State Examination toms, and efforts should be made to modify therapy ap- (MMSE),166 demonstrating that a short formal cognitive propriately. No evidence is available on the optimal time assessment like the MMSE can detect impairment in older to evaluate treatment effectiveness. Six weeks was identi- fied as the interval for evaluating therapy for depression One case-control study found that older adults with because antidepressant medications frequently work dur- DM who scored below 24 points on the MMSE are more ing this time period. (Source guidelines: 3, 5, 11) likely to have been hospitalized in the last year.165 There-fore, it is important to be aware of a patient’s cognitive Polypharmacy
function when prescribing treatments and to note difficul- 1. The older adult who has DM should be advised to ties with participating in DM self-care that could be an indi- maintain an updated medication list for review by cator of a change in cognitive status. (Source guideline: 11) 2. If there is evidence of cognitive impairment in an Older adults with DM are at risk for drug side effects older adult with DM and delirium has been ex- and drug-drug interactions. The availability of an updated cluded as a cause, then an initial evaluation designed medication list that includes nonprescription drugs allows to identify reversible conditions that may potentially the clinician to evaluate the need for current medications, cause or exacerbate cognitive impairment should be the potential for drug-drug and drug-disease interactions, performed promptly after diagnosis and with any and ways to enhance medication adherence.
significant change in clinical status. (IIIA) One RCT found that reviewing a medication list can improve patient care for older adults by significantly de- Recent American Academy of Neurology guidelines creasing inappropriate prescribing (P Ͻ .001 at 12 months recommend screening older adults with evidence of cogni- after initiation of the intervention).140 (Source guideline: tive impairment for depression, vitamin B deficiency, and hypothyroidism; structural neuroimaging to identify le-sions is also recommended for those recently diagnosed.167 2. The medication list of an older adult with DM who As noted above, medications can also affect cognitive DIABETES GUIDELINES FOR OLDER PEOPLE
function, so a review of the medication list should be per- tients with the use of pharmacological or behavioral inter- formed if there is evidence of cognitive impairment (see Epidemiological evidence has found that cognitive im- Injurious Falls
pairment is associated with DM and that hyperglycemia 1. The older adult who has DM should be asked about may be a treatable cause of cognitive impairment.162 One prospective pre/post study found that older adults with 2. If an older adult presents with evidence of falls, the untreated type 2 DM who were treated with an oral hy- clinician should document a basic falls evaluation, poglycemic agent for a minimum of 2 weeks (mean fasting including an assessment of injuries and examination glucose before treatment Ϯ standard deviation ϭ 13.8 Ϯ of potentially reversible causes of the falls (e.g., med- 1.2 mmol/L, mean after treatment ϭ 8.4 Ϯ .4 mmol/L) had significantly (P Ͻ .05) improved scores on a variety oftests of cognitive function after treatment.168 A nonran- No RCTs have assessed the efficacy of screening for domized controlled trial found similar results in treated falls, but evidence from one RCT indicates that using falls versus untreated older adults with type 2 DM and found as a target condition for comprehensive geriatric assess- an association between treatment of glycemia and im- ment is associated with reduced functional decline.172 Falls provement in memory and learning, particularly verbal frequently go unreported and undetected and may be asso- ciated with reversible factors. Five RCTs provide evidencethat exercise programs can reduce the rates of falls by Urinary Incontinence
older adults.175–179 As noted above, psychotropic medica-tions have been associated with falls in epidemiological 1. The older adult who has DM should be evaluated analyses, and one RCT found that their withdrawal can for symptoms of urinary incontinence during annual also lead to a significant reduction in the risk of falling.157 Interventions involving home visits to assess safety have Evidence suggests that women with DM are at higher had mixed results. Two RCTs suggest that home visits can risk than the general population for urinary inconti- reduce the rate of falls in older people,180,181 but six others nence.8,31 The risk factors for urinary incontinence that are did not find a significant reduction in falls with home vis- more common in older adults with DM include polyuria, its.95,182–186 The AGS Guideline for the Prevention of Falls overflow secondary to neurogenic bladder and autonomic in Older Persons34 provides further recommendations on insufficiency, urinary tract infection, candida vaginitis, and fecal impaction due to autonomic insufficiency. Uri-nary incontinence is commonly unreported by patients and undetected by providers, but its effect may be pro- 1. The older adult who has DM should be assessed found, and it may be associated with social isolation, de- during the initial evaluation period for evidence of pression, falls, and fractures.170,171 No RCT evidence indi- cates that routine inquiry about urinary incontinence will Older adults with DM are at risk for neuropathic pain, result in enhanced detection and treatment or improved and those with pain are often undertreated.12,13 Many older outcomes, but evidence from one RCT indicates that using adults are reluctant to report pain unprompted and may re- urinary incontinence as a target condition for comprehen- main reluctant even when asked (although using alterna- sive geriatric assessment is associated with reduced func- tive terms, such as aching or discomfort or other culturally tional decline.172 There is also no evidence in the literature appropriate terminology may be helpful). In many in- that supports a specific screening interval at which evalua- stances, pain can be successfully treated when it is re- tion for urinary incontinence should take place. Although ported.37 A quantitative systematic review of RCTs of anti- the evidence supporting this recommendation is level III depressants or anticonvulsants for the treatment of (expert opinion), because of the profound negative effect diabetic neuropathy found both drug classes to be effec- of underdiagnosis and undertreatment of this condition on tive in reducing pain associated with the neuropathy.187 quality of life, it is given an importance rating of level A.
Older adults with DM should be screened for persis- tent pain by the use of a targeted history and physical ex- 2. If there is evidence of urinary incontinence in the amination. If there is evidence of persistent pain in an evaluation of an older adult with DM, then an eval- older adult with DM, further evaluation should be per- uation designed to identify treatable causes of uri- formed, appropriate therapy offered, and patients moni- nary incontinence should be pursued. (IIIB) tored, as recommended by the AGS guidelines, The Man-agement of Persistent Pain.37 (Source guidelines: 11, 14) Among the reversible or treatable causes of urinary in- continence in older adults in general are urinary tract in- WRITING COMMITTEE
fection, urine retention, fecal impaction, restricted mobil- Arleen F. Brown, MD, PhD, and Carol M. Mangione, ity, and use of certain medications.173,174 Other conditions MD, MSPH, were cochairpersons of the writing commit- that may contribute to urinary incontinence and are asso- tee for this guideline. Committee members included (in al- ciated with older age and DM include polyuria (glyco- phabetical order) Debra Saliba, MD, MPH, and Catherine suria), neurogenic bladder, prolapse, cystoceles, atrophic A. Sarkisian, MD, MSPH, for the California Healthcare vaginitis, and vaginal candidiasis. In addition, urinary in- Foundation/American Geriatrics Society Panel on Improv- continence itself can be successfully treated in many pa- ing Care for Older Persons with Diabetes.
Novartis, Merck Medco, Janssen, and Lilly; has received The California Healthcare Foundation/American Geriat- grants from Pharmacia, Novartis, Lilly, and Takeda; and rics Society (AGS) Panel on Improving the Care for Older is a member of the Speaker’s Bureau for Merck, Pharma- Persons with Diabetes includes: Carol M. Mangione, MD, cia, and Novartis; and Dr. Albright is a paid consultant for MSPH (Co-Chair) and Arleen F. Brown, MD, PhD (Co- Chair), Catherine A. Sarkisian, MD, MSPH: David Geffen SOURCE GUIDELINES
School of Medicine at UCLA, Los Angeles, CA; DebraSaliba, MD, MPH: VA Greater Los Angeles, Los Angeles, 1. American Association of Clinical Endocrinologists.
CA; Ann L. Albright, PhD, RD: University of California, AACE medical guidelines for clinical practice for the San Francisco/California Department of Health Services, diagnosis and treatment of dyslipidemia and preven- San Francisco, CA; Caroline S. Blaum, MD, MS, Jeffrey B.
tion of atherogenesis. Endocr Pract 2000;6:162–213.
Halter, MD: Department of Internal Medicine, University 2. American Association of Clinical Endocrinologists.
of Michigan, Ann Arbor, MI; Samuel C. Durso, MD: The AACE medical guidelines for the management Johns Hopkins University School Medicine, Baltimore, of diabetes mellitus: The AACE system of intensive MD; Michael M. Engelgau, MD, MS: Centers for Disease diabetes self-management—2002 update. Endocr Control and Prevention, Atlanta, GA; Martha M. Funnell, MD, RN, CDE: Michigan Diabetes Research and Training 3. Agency for Health Care Policy and Research. Uri- Center, Ann Arbor, MI; Sanford A. Garfield, PhD: Na- nary Incontinence in Adults: Acute and Chronic Man- tional Institutes of Health/National Institute of Diabetes agement. Rockville, MD: U.S. Department of Health and Digestive and Kidney Diseases, Bethesda, MD; Anto- and Human Services, 1996 March. Report No. 96– nio Linares, MD: CMRI; Mark E. Molitch, MD: The Fein- 0682. (Clinical Practice Guideline Number 2.) berg School of Medicine, Northwestern University, Chi- 4. American Diabetes Association. Standards of medi- cago, IL; Jeffrey M. Newman, MD, MPH: University of cal care for patients with diabetes mellitus. Diabetes California, San Francisco, San Francisco, CA; Leonard Pogach, MD, MBA: New Jersey HealthCare System, East 5. American Medical Directors Association. Pharmaco- Orange, NJ; Anthony E. Ranno, PharmD: University of therapy Companion to the Depression Clinical Prac- Nebraska Medical Center, Omaha, NE; Joe V. Selby, MD, tice Guideline. Columbia, MD: American Medical MPH: Kaiser Permanente, Oakland, CA.
6. American Society of Health-System Pharmacists. ASHP ACKNOWLEDGMENTS
therapeutic guidelines on angiotensin-converting- Research services and administrative support were pro- enzyme inhibitors in patients with left ventricular dys- vided by Phuong Tran, JD, Jennifer K. Gulick, MA, and function. Am J Health Syst Pharm 1997;54:299–313.
Kristen Mukae of the Division of General Internal Medi- 7. Diabetes Control Program. Massachusetts Guide- cine and Health Services Research, David Geffen School of lines for Adult Diabetes Care. Boston, MA: Massa- Medicine at UCLA, Los Angeles, CA. Additional adminis- chusetts Department of Public Health, 2001.
trative support was provided by Elvy Ickowicz, MPH: De- 8. Joslin Diabetes Center [On-line]. Available: http:// partment of Professional Education and Special Projects, American Geriatrics Society, New York, NY. Editorial ser- 9. National Diabetes Education Program. Guiding Prin- vices were provided by Barbara B. Reitt, PhD, ELS(D), Reitt ciples for Diabetes Care [On-line]. Available: http:// ndep.nih.gov/materials/ pubs /guiding- principles/provider.htm 1999.
Peer Review
10. Piven ML. Detection of depression in the cognitively The following organizations provided peer review of a intact older adult. J Gerontol Nurs 2001;27:8–14.
preliminary draft of this guideline: American Academy of 11. Shekelle PG, MacLean CH, Morton SC et al.
Family Physicians, American College of Clinical Phar- ACOVE Quality Indicators. Ann Intern Med 2001; macy, American College of Physicians, American Diabetes Association, American Association of Clinical Endocrinol- 12. University of Michigan Health System. Screening and ogists, American Society of Consultant Pharmacists, and Management of Diabetes (Report No. 936–9771).
Society of General Internal Medicine.
Ann Arbor, MI: University of Michigan, 2000.
Drs. Mangione, Brown, Engelgau, Durso, Sarkisian, Linares,
Newman, Pogach, and Saliba have all indicated that they 13. American Geriatrics Society, British Geriatrics Soci- have no financial relationship with any pharmaceutical ety, and American Academy of Orthopaedic Sur- company; Dr. Funnell has served as a consultant to Aven- geons Panel on Falls Prevention. Guideline for the tis Pharmaceuticals, Inlight Communications, Novo Nord- prevention of falls in older persons. J Am Geriatr So- isk, Takeda, and Pfizer; Dr. Ranno is a member of the Speakers’ Bureau for Merck, Novartis, and Pfizer; Dr.
14. American Geriatrics Society Panel on The Manage- Halter served as a paid consultant for Design Write, Inc.
ment of Persistent Pain in Older Adults. The man- and Novartis and has received grants from Novo Nordisk; agement of persistent pain in older persons. AGS Dr. Blaum has served on the Speaker’s Bureau for Panel on Persistent Pain in Older Persons. J Am Pfizer; Dr. Molitch is a paid consultant for Pharmacia, Geriatr Soc 2002;50(Suppl. 6):S205–S224.
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Comptroller General of the United States United St ates General Accounting Office Washingto n, DC 20548 Decision Matter of: GlaxoSmithKline File: Frank M. Rapoport, Esq., Alison L. Doyle, Esq., and David M. Glynn, Esq., McKenna Long & Aldridge, for the protester. Maura C. Brown, Esq., Department of Veterans Affairs, for the agency. Charles W. Morrow, Esq.,

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