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Diabetes Management in Older Adults: Seeing the Forest for the Trees
ARTICLE IN PRESS Can J Diabetes xxx (2015) 1–2
Contents lists available at ScienceDirect
Canadian Journal of Diabetes journal homepage: w w w. c a n a d i a n j o u r n a l o f d i a b e t e s . c o m
Diabetes Management in Older Adults: Seeing the Forest for the Trees Diana Sherifali RN, PhD, CDE a,b,* a b
School of Nursing, McMaster University, Hamilton, Ontario, Canada Diabetes Care and Research Program, Hamilton Health Sciences, Hamilton, Ontario, Canada
a r t i c l e i n f o Article history: Received 27 June 2015 Received in revised form 30 July 2015 Accepted 4 August 2015
Diabetes is a burdensome chronic disease that affects older adults disproportionately. The Public Health Agency of Canada estimates that approximately 18% of adults aged 65 years of age and older have diabetes, and 21% of adults aged 70 years and older have diabetes (1). The unique and heterogeneous group comprising older adults presents challenges in the management of diabetes and its complications. The clinical management of diabetes has become increasingly difficult, straining even the most advanced and highquality healthcare systems (2). Thus, clinical guidelines to address diabetes management and education for diabetes in older adults are necessary. Over the past several years, 3 leading diabetes organizations, the American Diabetes Association (ADA), the Canadian Diabetes Association (CDA) and the International Diabetes Federation (IDF), published their respective guidelines for the management of diabetes in older adults; all 3 were met with some degree of applause, debate, confusion and appreciation. All 3 reported their respective recommendations for various aspects of diabetes management in older adults, including clinical management and glucose, blood pressure and cholesterol targets, as well as recommendations for education and psychosocial well-being (3–5).
Guideline Process There were important differences in the development processes of each respective guideline. Each guideline is discussed briefly in relation to the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument’s 6 domains: 1) scope and purpose; 2) stakeholder involvement; 3) rigour of development; 4) clarification of presentation; 5) applicability and 6) editorial independence (6). The ADA created its consensus report, titled Diabetes in Older Adults, during a 2012 consensus development conference that * Address for correspondence: Diana Sherifali RN, PhD, CDE, HSC-3N28F, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada. E-mail address: [email protected]
also included expert presentations. The scope, purpose and interprofessional healthcare provider stakeholder involvement were noted. It was also apparent throughout the consensus report that up-to-date research evidence was considered; however, the development of recommendations (i.e. grading of evidence and linking of recommendations to evidence) and the applicability of recommendations were not distinguishable (3). Finally, there was no mention of a process or procedure to update the consensus report and recommendations (3). The CDA and an expert committee developed a chapter titled Diabetes in the Elderly within the 2013 Clinical Practice Guidelines. The 2013 CDA guidelines in their entirety followed the domains in the AGREE II instrument, with clear scope and purpose statements as well as interprofessional healthcare stakeholder and patient involvement. More specifically, each of the 10 recommendations in the guideline for diabetes in the elderly is graded according to the level of evidence to support the recommendation, with transparent linkages and suggestions for application. Although not explicitly mentioned, the CDA does update the guidelines every 5 years, with increasingly concerted efforts to maintain editorial independence and the recording of conflicts of interests by guideline developers (7). Finally, the IDF developed its guidelines, Managing Older People with Type 2 Diabetes, in 2013, following the launch of the 2012 IDF guidelines for the management of type 2 diabetes. Recognizing the gap in management recommendations for older people in the 2012 guideline, an international group of healthcare professionals was assembled to create a guideline document to assist clinicians with the management of diabetes in older people. To that end, the scope and purpose of the guideline were evident; however, patient representation or involvement in the guideline development is not clear (5). Like the ADA, the IDF constructed the guideline through a consensus writing process using up-to-date research evidence. However, the IDF guideline does not provide insight regarding the development of recommendations (5). The clarity of presentation and applicability across the heterogeneous population that comprises older people makes this guideline easy to comprehend and easily accessible. Finally, the IDF does intend to update the guideline every
1499-2671 © 2015 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjd.2015.08.004
ARTICLE IN PRESS 2
D. Sherifali / Can J Diabetes xxx (2015) 1–2
Table 1 Guideline recommendations for key clinical outcomes from the Canadian Diabetes Association (CDA), American Diabetes Association (ADA) and International Diabetes Federation (IDF) Measure
ADA
CDA
IDF
A1C
Healthy: <7.5% Complex/intermediate: <8.0% Very complex/poor health: <8.5%
Healthy: ≤7% Frail≤: 8.5%
Blood pressure
Healthy: <140/80 mm Hg Complex/intermediate: <140/80 mm Hg Very complex/poor health: <150/90 mm Hg
<130/80 mm Hg
LDL-C
<70 mg/dL <1.8 mmol/L
<70 mg/dL
Functionally independent: 7.0% to7.5% Functionally dependent: 7.0% to 8.0% Sublevel frail: <8.5% Sublevel dementia: <8.5% End of life: avoid symptomatic hyperglycemia Functionally independent: <140/80 mm Hg Functionally dependent: <140/80 mm Hg Sublevel frail: <150/90 mm Hg Sublevel dementia: <140/80 mm Hg End of life: strict BP may not be necessary <2.0 mmol/L and adjusted based on CVD risk
Note: Adapted from Meneilly, 2013 (4); adapted from ADA (3), CDA (4), IDF (5). A1C, glycated hemoglobin; CVD, cardiovascular disease; LDL-C, low-density lipoprotein cholesterol.
5 years and has a clear duality-of-interest statement for the guidelines working group (5).
Defining the Population It is interesting that all 3 guidelines make important distinctions regarding the population of interest they address. The ADA identifies older adults as those 65 years of age or older; the CDA similarly defines its population using the same chronologic age (3,4). Conversely, although the IDF acknowledges varying definitions for older adults, the guideline working group articulates that older adults are aged 70 years and older (5). All organizations note the limitations of using chronologic age only to define older adults; thus, a function or frailty assessment was used to further triage recommendations for this heterogeneous and complex population. The ADA describes a 3-level framework: 1) healthy; 2) complex/intermediate (i.e. presence of comorbid conditions that require medications or lifestyle management, such as cancer, arthritis, depression, hypertension, etc.); and 3) very complex/poor health (i.e. presence of a single end-stage disease that causes significant symptoms, impairment of functional status or reduction in life expectancy (3). Although the CDA refers to a 9-item frailty scale (1 = very fit to 9 = terminally ill) created and validated by Moorhouse and colleagues (8), it dichotomizes the concept of healthy or frail in anyone at 6 (i.e. moderately frail) or greater as being frail, thus suggesting less stringent target parameters for clinical recommendations (4). Finally, the IDF refers to multiple definitions and assessments of frailty and triages their recommendations into 3 levels: 1) functionally independent (i.e. lives alone, has minimal support and has diabetes as the main medical issue); 2) functionally dependent (i.e. community dwelling, experiencing some loss of function, additional medical or social support needed) and includes sublevels for frailty and dementia and 3) end-of-life care (i.e. life expectancy reduced to less than 1 year) (5). Recommendations and implications A summary of all 3 guideline recommendations for clinical measures, such as glycated hemoglobin (A1C), blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) are presented in the Table 1. Each organization recommends different targets for A1C, BP and LDL-C levels and delineates less stringent targets based on interpretations of functional decline or frailty, with the CDA offering more intensive targets for A1C and BP levels, whereas the ADA and IDF follow similar targets for A1C and BP levels. One could argue
that the differences across all 3 guidelines are due to the process of searching for evidence and appraising and integrating the evidence to support each recommendation. Although it is easy to point out the differences, can we see the forest for the trees? First, recognition should be given to the ADA, CDA and IDF for addressing the need for guidelines for the management of diabetes in older adults. It is well known that diabetes in older adults presents significant challenges to the individuals living with the disease, to their families, to healthcare providers and to the healthcare system; these respective guidelines are the foundational steps needed to further our understanding of diabetes care. Second, with the development of such guidelines and consensus statements, gaps and opportunities are identified due to the paucity of existing evidence to answer important clinical questions. The ADA, CDA and IDF clearly articulate opportunities for future innovations related to diabetes in older adults and encourage the clinical and scientific communities to act on those opportunities. Finally, although one could get lost in the minutia of each recommendation, or the trees, it is vitally important to see the forest. Specifically, when reviewing each respective guideline, we are reminded to see the whole individual, including the complex interplay of comorbid conditions, psychosocial well-being, functional status, safety, life expectancy and the individual’s needs (3–5). References 1. Public Health Agency of Canada. Diabetes in Canada; Facts and figures from a public health perspective 2009. http://www.phac-aspc.gc.ca/cd-mc/publications/ diabetes-diabete/facts-figures-faits-chiffres-2011/chap1-eng.php#Pre, 2011 Accessed June 9, 2015. 2. Sinclair A, Morley J, Rodriguez-Manas L, et al. Diabetes mellitus in older people: Position statement on behalf of the International Association of Gerontology and Geriatrics, the European Diabetes Working Party for Older People, and the International Task Force of Experts in Diabetes. J Am Med Dir Assoc 2012;13:497– 502. 3. Kirkman S, Broscoe V, Clark N, et al. Diabetes in older adults: A consensus report. J Am Geriatr Soc 2012;60:2342–56. 4. Meneilly G, Knip A, Tessier D, Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes 2013;37(Suppl. 1):S184–90. 5. International Diabetes Federation. IDF Global Guideline for Managing Older People with Type 2 Diabetes 2013. http://www.idf.org/sites/default/files/ IDF%20Guideline%20for%20Older%20People.pdf, 2013. Accessed June 8, 2015. 6. Brouwers M, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. AGREE II: Advancing guideline development, reporting and evaluation in healthcare. Can Med Assoc J 2010;182:E839–42. 7. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes 2013;37(Suppl. 1):S1–212. 8. Moorhouse P, Rockwood K. Frailty and its quantitative clinical evaluation. J R Coll Physicians Edinb 2012;42:333–40.
Contents lists available at ScienceDirect
Canadian Journal of Diabetes journal homepage: w w w. c a n a d i a n j o u r n a l o f d i a b e t e s . c o m
Diabetes Management in Older Adults: Seeing the Forest for the Trees Diana Sherifali RN, PhD, CDE a,b,* a b
School of Nursing, McMaster University, Hamilton, Ontario, Canada Diabetes Care and Research Program, Hamilton Health Sciences, Hamilton, Ontario, Canada
a r t i c l e i n f o Article history: Received 27 June 2015 Received in revised form 30 July 2015 Accepted 4 August 2015
Diabetes is a burdensome chronic disease that affects older adults disproportionately. The Public Health Agency of Canada estimates that approximately 18% of adults aged 65 years of age and older have diabetes, and 21% of adults aged 70 years and older have diabetes (1). The unique and heterogeneous group comprising older adults presents challenges in the management of diabetes and its complications. The clinical management of diabetes has become increasingly difficult, straining even the most advanced and highquality healthcare systems (2). Thus, clinical guidelines to address diabetes management and education for diabetes in older adults are necessary. Over the past several years, 3 leading diabetes organizations, the American Diabetes Association (ADA), the Canadian Diabetes Association (CDA) and the International Diabetes Federation (IDF), published their respective guidelines for the management of diabetes in older adults; all 3 were met with some degree of applause, debate, confusion and appreciation. All 3 reported their respective recommendations for various aspects of diabetes management in older adults, including clinical management and glucose, blood pressure and cholesterol targets, as well as recommendations for education and psychosocial well-being (3–5).
Guideline Process There were important differences in the development processes of each respective guideline. Each guideline is discussed briefly in relation to the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument’s 6 domains: 1) scope and purpose; 2) stakeholder involvement; 3) rigour of development; 4) clarification of presentation; 5) applicability and 6) editorial independence (6). The ADA created its consensus report, titled Diabetes in Older Adults, during a 2012 consensus development conference that * Address for correspondence: Diana Sherifali RN, PhD, CDE, HSC-3N28F, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada. E-mail address: [email protected]
also included expert presentations. The scope, purpose and interprofessional healthcare provider stakeholder involvement were noted. It was also apparent throughout the consensus report that up-to-date research evidence was considered; however, the development of recommendations (i.e. grading of evidence and linking of recommendations to evidence) and the applicability of recommendations were not distinguishable (3). Finally, there was no mention of a process or procedure to update the consensus report and recommendations (3). The CDA and an expert committee developed a chapter titled Diabetes in the Elderly within the 2013 Clinical Practice Guidelines. The 2013 CDA guidelines in their entirety followed the domains in the AGREE II instrument, with clear scope and purpose statements as well as interprofessional healthcare stakeholder and patient involvement. More specifically, each of the 10 recommendations in the guideline for diabetes in the elderly is graded according to the level of evidence to support the recommendation, with transparent linkages and suggestions for application. Although not explicitly mentioned, the CDA does update the guidelines every 5 years, with increasingly concerted efforts to maintain editorial independence and the recording of conflicts of interests by guideline developers (7). Finally, the IDF developed its guidelines, Managing Older People with Type 2 Diabetes, in 2013, following the launch of the 2012 IDF guidelines for the management of type 2 diabetes. Recognizing the gap in management recommendations for older people in the 2012 guideline, an international group of healthcare professionals was assembled to create a guideline document to assist clinicians with the management of diabetes in older people. To that end, the scope and purpose of the guideline were evident; however, patient representation or involvement in the guideline development is not clear (5). Like the ADA, the IDF constructed the guideline through a consensus writing process using up-to-date research evidence. However, the IDF guideline does not provide insight regarding the development of recommendations (5). The clarity of presentation and applicability across the heterogeneous population that comprises older people makes this guideline easy to comprehend and easily accessible. Finally, the IDF does intend to update the guideline every
1499-2671 © 2015 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjd.2015.08.004
ARTICLE IN PRESS 2
D. Sherifali / Can J Diabetes xxx (2015) 1–2
Table 1 Guideline recommendations for key clinical outcomes from the Canadian Diabetes Association (CDA), American Diabetes Association (ADA) and International Diabetes Federation (IDF) Measure
ADA
CDA
IDF
A1C
Healthy: <7.5% Complex/intermediate: <8.0% Very complex/poor health: <8.5%
Healthy: ≤7% Frail≤: 8.5%
Blood pressure
Healthy: <140/80 mm Hg Complex/intermediate: <140/80 mm Hg Very complex/poor health: <150/90 mm Hg
<130/80 mm Hg
LDL-C
<70 mg/dL <1.8 mmol/L
<70 mg/dL
Functionally independent: 7.0% to7.5% Functionally dependent: 7.0% to 8.0% Sublevel frail: <8.5% Sublevel dementia: <8.5% End of life: avoid symptomatic hyperglycemia Functionally independent: <140/80 mm Hg Functionally dependent: <140/80 mm Hg Sublevel frail: <150/90 mm Hg Sublevel dementia: <140/80 mm Hg End of life: strict BP may not be necessary <2.0 mmol/L and adjusted based on CVD risk
Note: Adapted from Meneilly, 2013 (4); adapted from ADA (3), CDA (4), IDF (5). A1C, glycated hemoglobin; CVD, cardiovascular disease; LDL-C, low-density lipoprotein cholesterol.
5 years and has a clear duality-of-interest statement for the guidelines working group (5).
Defining the Population It is interesting that all 3 guidelines make important distinctions regarding the population of interest they address. The ADA identifies older adults as those 65 years of age or older; the CDA similarly defines its population using the same chronologic age (3,4). Conversely, although the IDF acknowledges varying definitions for older adults, the guideline working group articulates that older adults are aged 70 years and older (5). All organizations note the limitations of using chronologic age only to define older adults; thus, a function or frailty assessment was used to further triage recommendations for this heterogeneous and complex population. The ADA describes a 3-level framework: 1) healthy; 2) complex/intermediate (i.e. presence of comorbid conditions that require medications or lifestyle management, such as cancer, arthritis, depression, hypertension, etc.); and 3) very complex/poor health (i.e. presence of a single end-stage disease that causes significant symptoms, impairment of functional status or reduction in life expectancy (3). Although the CDA refers to a 9-item frailty scale (1 = very fit to 9 = terminally ill) created and validated by Moorhouse and colleagues (8), it dichotomizes the concept of healthy or frail in anyone at 6 (i.e. moderately frail) or greater as being frail, thus suggesting less stringent target parameters for clinical recommendations (4). Finally, the IDF refers to multiple definitions and assessments of frailty and triages their recommendations into 3 levels: 1) functionally independent (i.e. lives alone, has minimal support and has diabetes as the main medical issue); 2) functionally dependent (i.e. community dwelling, experiencing some loss of function, additional medical or social support needed) and includes sublevels for frailty and dementia and 3) end-of-life care (i.e. life expectancy reduced to less than 1 year) (5). Recommendations and implications A summary of all 3 guideline recommendations for clinical measures, such as glycated hemoglobin (A1C), blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) are presented in the Table 1. Each organization recommends different targets for A1C, BP and LDL-C levels and delineates less stringent targets based on interpretations of functional decline or frailty, with the CDA offering more intensive targets for A1C and BP levels, whereas the ADA and IDF follow similar targets for A1C and BP levels. One could argue
that the differences across all 3 guidelines are due to the process of searching for evidence and appraising and integrating the evidence to support each recommendation. Although it is easy to point out the differences, can we see the forest for the trees? First, recognition should be given to the ADA, CDA and IDF for addressing the need for guidelines for the management of diabetes in older adults. It is well known that diabetes in older adults presents significant challenges to the individuals living with the disease, to their families, to healthcare providers and to the healthcare system; these respective guidelines are the foundational steps needed to further our understanding of diabetes care. Second, with the development of such guidelines and consensus statements, gaps and opportunities are identified due to the paucity of existing evidence to answer important clinical questions. The ADA, CDA and IDF clearly articulate opportunities for future innovations related to diabetes in older adults and encourage the clinical and scientific communities to act on those opportunities. Finally, although one could get lost in the minutia of each recommendation, or the trees, it is vitally important to see the forest. Specifically, when reviewing each respective guideline, we are reminded to see the whole individual, including the complex interplay of comorbid conditions, psychosocial well-being, functional status, safety, life expectancy and the individual’s needs (3–5). References 1. Public Health Agency of Canada. Diabetes in Canada; Facts and figures from a public health perspective 2009. http://www.phac-aspc.gc.ca/cd-mc/publications/ diabetes-diabete/facts-figures-faits-chiffres-2011/chap1-eng.php#Pre, 2011 Accessed June 9, 2015. 2. Sinclair A, Morley J, Rodriguez-Manas L, et al. Diabetes mellitus in older people: Position statement on behalf of the International Association of Gerontology and Geriatrics, the European Diabetes Working Party for Older People, and the International Task Force of Experts in Diabetes. J Am Med Dir Assoc 2012;13:497– 502. 3. Kirkman S, Broscoe V, Clark N, et al. Diabetes in older adults: A consensus report. J Am Geriatr Soc 2012;60:2342–56. 4. Meneilly G, Knip A, Tessier D, Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes 2013;37(Suppl. 1):S184–90. 5. International Diabetes Federation. IDF Global Guideline for Managing Older People with Type 2 Diabetes 2013. http://www.idf.org/sites/default/files/ IDF%20Guideline%20for%20Older%20People.pdf, 2013. Accessed June 8, 2015. 6. Brouwers M, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. AGREE II: Advancing guideline development, reporting and evaluation in healthcare. Can Med Assoc J 2010;182:E839–42. 7. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes 2013;37(Suppl. 1):S1–212. 8. Moorhouse P, Rockwood K. Frailty and its quantitative clinical evaluation. J R Coll Physicians Edinb 2012;42:333–40.