Treatment of Type 2 Diabetes in the Elderly

As the number of older adults increases in the United States and worldwide, management of patients with multiple coexisting chronic diseases has become a critical component in health care. Management of diabetes is particularly challenging in this population due to significant risks of microvascular and macrovascular diseases on the one hand, and complications of the treatment strategies (e.g., hypoglycemia) with intensive control on the other hand. To provide a balanced approach to diabetes in the elderly, a comprehensive and holistic strategy, with consideration of overall health, functional status, psychosocial environment, financial resources and, finally but most importantly, quality of life is needed. Understanding the unique challenges faced by older adults with diabetes and issues pertaining to antidiabetes medications with aging is an important first step in the direction of better and tailored care of this burgeoning population.     

Coronavirus Disease 2019 in Geriatrics and Long-Term Care: The ABCDs of COVID-19

The pandemic of coronavirus disease of 2019 (COVID-19) is having a global impact unseen since the 1918 worldwide influenza epidemic. All aspects of life have changed dramatically for now. The group most susceptible to COVID-19 are older adults and those with chronic underlying medical disorders. The population residing in long-term care facilities generally are those who are both old and have multiple comorbidities. In this article we provide information, insights, and recommended approaches to COVID-19 in the long-term facility setting. Because the situation is fluid and changing rapidly, readers are encouraged to access frequently the resources cited in this article. J Am Geriatr Soc 68:912–917, 2020     

远程自助监控和危急预警系统对老年慢性病的应用价值

随着社会老龄化和慢性疾病的发展,远程自助监控和危急预警逐渐成为一种新的医疗模式。远程自助监控系统可用于健康监测、疾病诊断、咨询、教育、老年慢性病管理、长期护理以及转诊和连续医疗,尤其可用于慢性心力衰竭和慢性糖尿病的治疗。危急预警可有效救治患者突发急性病,满足老年人护理需求并解决医疗资源配置不合理的问题。本文综述了远程自助监控和危急预警系统对老年人慢性病的应用价值。     

Addressing the aging crisis in U.S. criminal justice health care

The U.S. criminal justice population is aging at a significantly more rapid rate than the overall U.S. population, with the population of older adults in prison having more than tripled since 1990. This increase is at the root of a prison healthcare crisis that is spilling into communities and public healthcare systems because nearly 95% of prisoners are eventually released. The graying prison population is also straining state and local budgets. In prison, older prisoners cost approximately three times as much as younger prisoners to incarcerate, largely because of healthcare costs. In the community, older former prisoners present the least risk of recidivism yet are vulnerable to serious and costly social and medical challenges such as housing instability, poor employability, multiple chronic health conditions, and health-related mortality; however older current and former prisoners are largely ignored in the current geriatrics evidence base. Knowledge about the health, functional, and cognitive status of older prisoners is limited, with even less known about risk factors for long-term poor health outcomes during and after incarceration. This article provides an overview of aging in the criminal justice system. It then describes how geriatric models of care could be adapted to address the mounting older prisoner healthcare crisis and identifies areas where additional research is needed to explore prison-specific models of care for older adults.     

Health and Health Care System for Older Persons

Thailand has now reached a new demographic turning point with the advent of an ageing society. Improvements in the health care system and technology advancement over recent decades mean that Thais can now enjoy better health in old age than previously. Life expectancy at birth for the Thai population has been increasing steadily, and there has been an improvement among older persons in all aspects of health behaviors. Even though the majority of Thai elderly are sufficiently healthy to take care of themselves, there are an increasing number of elderly people who have difficulty with essential daily activities, leading to problems with disability and dependency. Non communicable diseases such as hypertension, diabetes mellitus, dyslipidemia, osteoarthritis, cardio-cerebrovascular diseases and tumor are some of the major health problems confronting older Thais. Due a higher incidence of illness and chronic conditions as compared to young people, the elderly typically require different types of care and health services. As Thailand becomes an ageing society, health services and proper care systems specifically for the elderly group need to be prepared and well established. Given the far greater likelihood of chronic conditions and disabilities among older persons compared to the rest of population, pressures on long-term care facilities and services will increase enormously. The issue of ageing should be given a high priority in both local and national government agendas. All sectors should be involved in adjusting care systems and programs to accommodate the rapid growth of older persons and the relative balance of age groups within the population. It will be crucial for the health sectors to provide services oriented towards geriatric and long-term care issues.     

Elderly long-term care in Korea

The national mandatory elderly long-term care insurance (LTCI) was established in Korea in July 2008. One year after introduction of the LTCI, 5.2% of the elderly population aged 65 years and older were beneficiaries. The applicant's caregiver(s) submit an application form along with a statement of a doctor's medical opinion to the National Health Insurance Corporation, after which one or two National Health Insurance Corporation staff members (either a nurse or social worker) visit the applicant's house to evaluate their physical and mental status.The majority of beneficiaries are reported to have one or more chronic conditions. The problem is that national LTCI and national medical insurance are separate now in Korea. However, it is almost impossible to separate long-term care and health care. Even though long-term care facilities contract physicians or hospitals to have physicians visit care facilities regularly, the reward for these physicians is not satisfactory and sometimes they work without pay. Furthermore, contracted physicians cannot properly manage the elderly in long-term care facilities because they are not legally allowed to provide any medical services to long-term care facilities except for prescribing medicine.The efficient linkage of long-term care and health care is a big task in Korea that is under discussion by full-time physicians working for long-term care facilities.     

Cognitive and psychosocial aspects of caring for elderly patients with diabetes

The population is aging in the United States as well as worldwide. The prevalence of diabetes increases with increasing age. To provide optimal care to older adults with diabetes, unique psychosocial barriers need to be considered by medical providers. Unlike in younger adults, cognitive dysfunction/dementia and depressive mood disorders are common coexisting conditions in older adults with diabetes. This article reviews recent literature on epidemiology and clinical implications of cognitive and psychosocial dysfunctions in older patients with diabetes. This article focuses on cognitive dysfunctions, dementia, depression, and other psychosocial stresses, and their implications in the care of older adults with diabetes.     

Update in Geriatric Medicine

INTRODUCTION  

With an aging population, internists will provide care to a growing number of older adults, a population at risk of developing multiple chronic medical conditions and geriatric syndromes. For this update in geriatric medicine, we highlight recent key articles focused on preventive strategies and lifestyle changes that reduce the burden of disease and functional decline in older adults.     

Health care for older persons: a country profile-Korea

The Korean healthcare system is faced with a crisis caused by rapidly changing social values tending toward westernization, increasing insurance benefit requests for elder health care, financial instability of the National Health Insurance (NHI) program, and a lack of social infrastructure for the elderly. The demand for health care for the elderly has increased markedly, because of a rapidly aging population, growing female participation in the labor market, elevated expectations for health care, and a change in the pattern of medical conditions in the elderly from acute illness to chronic disability. NHI lacks the finances to meet the benefit request for long-term care (LTC). Only 0.39% of the elderly can be accommodated in LTC beds. Consequently, the chronically disabled elderly overflow to acute care beds in general hospitals, which places an undue burden on the already strained NHI system in terms of longer stays and higher cost of treatment in hospitals compared with care specific to the elderly in LTC facilities. It is clear that the Korean healthcare system does not have the facilities to meet such challenges and is in a state of disorder. Korea has failed to predict and prepare for population needs before they arise, including financing and the development of appropriate care models, particularly concerning the adequate provision of LTC. This paper advocates the necessity of international discussion of the prospects for developing health care for aging populations and encourages the sharing of differing national experiences concerning care for the elderly.     

Managing complexity in chronic care: an overview of the VA state-of-the-art (SOTA) conference

INTRODUCTION: The aging of the population and the increasing prevalence of multiple chronic illnesses, along with multiplying options for clinical management, pose great challenges to both the Veterans Health Administration (VHA) and the broader US health care system. Developing effective and efficient health care for persons with complex and multiple medical conditions is a national priority. Therefore, research in this area is critically important. In 2006, the VHA Health Services Research and Development Service held a state-of-the-Art (SOTA) conference titled "Managing Complexity in Chronic Care" to clarify our current understanding of the management of complex chronic conditions and suggest directions for research to better address this important problem. OBJECTIVE: This article provides an overview of the major findings from that conference, including major presentations, summaries of the workgroup deliberations, and a list of research topics that were thought to be of highest importance to advancing our ability to provide medical care for persons with complex chronic care needs.     

Long-term care of the aging population with intellectual and developmental disabilities

The aging population with intellectual and developmental disabilities (I/DD) deserves appropriate health care and social support. This population poses unique medical and social challenges to the multidisciplinary team that provides care. In the past, long-term care (LTC) facilities played an essential role in the livelihood of this population. The likelihood that the geriatric LTC system must prepare for adequately caring for this population is high. This article conveys the need to prepare for the inclusion of the growing aging population with I/DD into long-term care with the general elderly population in the near future.     

Diabetes and Employment

Uncomplicated diabetes does not require any adjustment regarding employment, but those with complications should undergo detailed assessment to determine safety and effectiveness to perform duties. Though there is no such guidance in India, the American Diabetes Association (ADA) adopted a position statement that any person with diabetes, whether insulin treated or non-insulin treated, should be eligible for any employment for which he/she is otherwise qualified. Patients suffering from diabetes should be assessed individually, and after reviewing medical and treatment history, medical fitness to the job should be assigned. Maintenance of proper medical documentation and use of screening guidelines are a must. For this to be implemented properly, one needs state and national laws. A health care professional (HCP) treating the employee though preferred should have expertise in treating diabetes. If there is a disagreement between the opinions of physicians, an independent opinion from a HCP with clinical expertise in diabetes should be taken. An employer should not enquire about an employee’s condition till a job has been offered and can only do so if it is not safe or poses a threat to his health and also if expert opinion and medical documentation suggest so. Screening guidelines, though not used in India but regularly used in Western countries, can be used in evaluation. Safety risks should be assessed individually—recurrent hypoglycemia, not a single episode, may pose a risk whereas hyperglycemia and chronic complications though may not pose immediate risk should be assessed separately. Periodic safety assessments should be done. Jobs requiring operating firearms or running dangerous machinery may have safety concerns with patients having severe hypoglycemia or those on insulin or secretagogues. Hypoglycemia usually can be effectively prevented or self-treated by ingestion of glucose. Severe hypoglycemia requiring assistance may pose a risk; even if it is a single incidence, one has to be followed up properly and investigated to find out its cause. In recurrent severe hypoglycemia, as episodes cannot be explained, it is a risk for the employee himself as well as the public. Hyperglycemia leading to chronic complications is only relevant when it interferes with the performance in actual jobs. Self-monitored blood glucose measurements over a period of time give actual information and should be evaluated by a HCP with expertise in diabetes. Multiple incidents of severe hypoglycemia may pose a problem in high-risk occupations, and the factors responsible should be properly evaluated. Hypoglycemia unawareness increases the risk of a sudden episode of severe hypoglycemia and should be treated with changes in diabetes management. Chronic complications may pose a risk in some jobs, but if not present, possible future development should not be taken into consideration. The tools that do not accurately reflect the current state of diabetes like urine glucose and HbA1C should not be used. The term uncontrolled diabetes should also not be used as it is not well defined. A few accommodations are required at a job for diabetes patients to be able to perform their work responsibilities effectively and safely: testing blood glucose at regular intervals, administering insulin as and when required with proper storage facilities, access to snacks, and a flexible work schedule to accommodate needs and modifications if required for chronic complications.     

Barriers to the effective use of capillary blood glucose monitoring in extended care facilities

Elderly residents of extended care facilities have an increased prevalence of diabetes compared with age-matched individuals living in the community, and are more prone to uncontrolled hyperglycemia and hypoglycemia. Capillary blood glucose monitoring can provide essential data for managing patients with diabetes, yet blood glucose monitoring is not used consistently by many institutions that provide long-term care. Among the barriers to its use are a perceived lack of validity, a perceived or actual lack of reliability, a failure by staff to use monitoring results consistently, a belief that good control is not necessary for the elderly, and the cost. Educational programs need to be offered to extended care facilities emphasizing the significance of glucose monitoring in the management of diabetes in elderly patients.     

Treatment of chronic heart failure in long-term care facilities: implications of recent heart failure guidelines recommendations

Use of angiotensin-converting enzyme inhibitor in heart failure with left ventricular systolic dysfunction has revolutionized management of heart failure and resulted in several national heart failure guidelines. However, studies have documented underutilization of these life saving drugs. Subsequently, results of other randomized clinical trials revealed the beneficial effects of angiotensin receptor blockers, beta-blockers, and spironolactone in heart failure with systolic dysfunction, which prompted several other guidelines. However, all these guidelines were primarily restricted to systolic dysfunction. Heart failure is as much a geriatric syndrome as it is a cardiac. Most heart failure patients are older adults. About half of the heart failure in older adults is not associated with left ventricular systolic dysfunction. Two recent heart failure guidelines, from the European Society of Cardiology and the American College of Cardiology/American Heart Association, published respectively in September and December 2001 included recommendations for patients with preserved left ventricular systolic function and other special populations, including older adults and those at end of life. The purpose of this article is to review the relevance of these two guidelines to heart failure patients living in long-term care facilities. As our population is aging, more heart failure patients are expected to live in long-term care facilities. Appropriate evaluation and management of these patients are essential to improve quality of heart failure care in the coming decades.     

新型冠状病毒肺炎疫情期间糖尿病基层管理专家建议

自2019年12月以来,我国发生新型冠状病毒肺炎(COVID-19)疫情。糖尿病患者COVID-19感染风险增高,且预后差。COVID-19疫情期间,基层医疗在糖尿病预防和血糖控制管理方面面临严峻挑战。中国糖尿病专家、基层医疗服务提供者和公共卫生管理者提出专家建议,旨在提高全国基层医疗卫生机构在COVID-19疫情期间的临床诊治能力并提供标准化的基本公共卫生和医疗服务。本建议的主要内容包括管理的基本要求、健康管理的工作流程、转诊、治疗和长期随访。     

In defense of a department of geriatrics

Departmental status for geriatrics offers many advantages, all of which are related to strengthening academic and clinical programs in aging. The training programs and the content of medical school curriculum in geriatrics remain inadequate under the current structures. A department of geriatrics can provide a stronger faculty base and allow effective interaction with other departments (including but not limited to internal medicine) that need geriatric training. A department of geriatrics also focuses on a model of care that involves working closely with other disciplines, such as nursing and social work. This interdisciplinary model helps expert providers work efficiently throughout the spectrum of care, strengthening continuity. The department can include other medical specialists, such as family practitioners, psychiatrists, and physiatrists, who work with caregivers and patients throughout a course of treatment to manage chronic illness and help maintain and enhance function and independence as long as possible. Comprehensive care and proper care management also substantially benefit institutions by expanding the patient population, reducing length of stay, and avoiding unnecessary hospitalization of older patients through effective discharge planning and transitional care. This requires strong relationships with long-term care providers, a characteristic strength of geriatricians. Although not all research in aging needs to be housed in a department of geriatric medicine, the presence of a critical mass of basic and clinical researchers creates an environment that can stimulate new initiatives and attract external funding. Additional research bridging basic translational and clinical phases relevant to the elderly population is best encouraged by maintaining relationships with other basic science and clinical departments.     

对老年糖尿病更应给予高度关注

老年人群糖尿病发病率高,起病隐匿,往往多病并存、应用多种药物且容易忘记服药,对于高血糖、低血糖的敏感性和反应能力都差,严重的低血糖和高血糖都会引起严重事件。老年的年龄跨度大,个体差异明显,医疗保障水平、经济承受能力以及自我管理能力差别极大。因此,临床上对于老年糖尿病需要高度重视：及早筛查、及早诊断、及早治疗和科学安全治疗;注意治疗的个体化,包括达标值的个体化和选用降糖药物的个体化;重视系统化管理。