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though nearly 80&#37; of patients have non-cardiovascular comorbidities<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; In fact&#44; DM increases the risk of not only cardiovascular disease&#44; but also of kidney injury&#44; nontraumatic amputations&#44; blindness&#44; and psychiatric symptoms<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;10</span></a>&#46; In the specific case of elderly patients&#44; it increases functional disability&#44; sarcopenia&#44; cognitive impairment&#44; depression&#44; urinary incontinence&#44; falls&#44; and chronic pain<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Clinical practice guidelines have been published which offer specific recommendations for this population&#44; given the complexity of DM2 management when there are determinants such as comorbidities and age<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;11&#8211;13</span></a>&#46; Nevertheless&#44; the manner in which guidelines are followed and complied with is not always optimal and can jeopardize clinical outcomes<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#8211;18</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">This study aims to analyze the knowledge&#44; barriers&#44; and attitudes in the management of elderly patients with DM2 and&#47;or comorbidities among primary care &#40;PC&#41; and hospital care &#40;HC&#41; specialists&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">This study is a national&#44; multicenter project based on a mixed Delphi method&#47;opinion&#44; attitude&#44; and behavior &#40;OAB&#41; survey&#46; The OAB questions help expand upon the reasons underlying agreement or disagreement and go more in depth on the reasons why participants chose a specific option on the Delphi survey&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Data were collected in two phases &#40;waves&#41; by means of anonymous online questionnaires&#46; The first wave of surveys was conducted in February and March 2020 and the second in May and June 2020&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The participants selected were PC and HC physicians whose routine practice included DM2 management&#46; They were selected by means of non-probability sampling by clusters according to proportional geographical distribution and population criteria&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The mixed survey was designed by a scientific committee&#46; It included a total of 25 Delphi-style statements and 13 OAB questions&#46; Of these&#44; the results of 12 statements and seven OAB questions focused on the determining role of comorbidities and old age in the management of patients with DM2 are presented&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The method used to predetermine the sample was a 95&#37; confidence interval for a proportion of a finite population&#46; The final sample size yielded a precision of &#177;5&#37; for a 95&#37; confidence interval&#46; With a reference population of 46&#44;934&#44;628 inhabitants and 3055 PC centers&#44; a representative sample of 300 physicians &#40;PC and HC&#41; from different regions of Spain was calculated&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The level of agreement on the Delphi statements was evaluated via a five-point Likert scale and was analyzed through two approaches&#58; consensus measure &#40;CNS&#41; by means of the Tastle technique<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> and the consolidation of five Likert scale categories into three &#40;disagree&#44; neutral&#44; and agree&#41;&#46; The threshold of consensus on the Delphi statements was a CNS&#8239;&#8805;&#8239;0&#46;7&#46; Statements which did not have a high degree of consensus &#40;CNS&#8239;&#8805;&#8239;0&#46;8&#41; in the first wave were reevaluated in a second wave by the modification or inversion of the statement&#8217;s wording&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">OAB questions were able to be answered either through single-choice&#44; multiple-choice&#44; or rating scale responses&#46; For OAB questions which were single- or multiple-choice&#44; the percentage each answer received was calculated and for questions with a rating scale&#44; the median was calculated&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The Mann-Whitney <span class="elsevierStyleItalic">U</span> test and <span class="elsevierStyleItalic">p</span> value were used to evaluate differences between the responses from PC and HC specialists&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Participants</span><p id="par0065" class="elsevierStylePara elsevierViewall">A total of 296 physicians participated in the first wave and 293 participated in the second wave&#58; 211 belonged to PC&#44; 80 to HC&#44; and 2 did not report their specialty&#46; In terms of age&#44; 21&#46;6&#37; of participants were younger than 46 years of age&#44; 31&#37; were between 46 and 55 years of age&#44; and 47&#46;7&#37; were older than 55 years of age&#46; In terms of sex&#44; 65&#46;5&#37; were men&#46; A total of 67&#46;9&#37; had been practicing medicine for 20 years or more&#46; A total of 74&#46;4&#37; of participants stated that they followed clinical practice guidelines recommendations for the diagnosis of and follow-up on patients with DM2&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results of the Delphi statements</span><p id="par0070" class="elsevierStylePara elsevierViewall">After the second wave&#44; consensus was achieved on the 12 statements presented and the CNS was 0&#46;8 or greater on nine of them &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; When the responses were consolidated into three categories&#44; similar results were obtained in terms of percentage &#40;Appendix <a class="elsevierStyleCrossRef" href="#sec0065">A</a>&#44; Fig&#46; 1&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">A total of 86&#46;3&#37; of participants considered that comorbidities affect a patient&#8217;s capacity for self-care&#46; A total of 86&#46;9&#37; agreed that severe psychiatric disorders condition antidiabetic treatment&#46; A total of 72&#46;2&#37; considered the assessment of cognitive capabilities and psychological symptoms to be as important as the rest of comorbidities and determinants &#40;Appendix <a class="elsevierStyleCrossRef" href="#sec0065">A</a>&#44; Fig&#46; 1a&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">A total of 79&#46;7&#37; of participants agreed that a lack of treatment deintensification is a form of therapeutic inertia with possible repercussions for the patient&#46; The level of agreement was 90&#46;7&#37; on the individualization of glycemic control targets based on biological&#44; psychological&#44; and social characteristics and 90&#37; on classification according to frailty for choosing glycemic control targets in elderly patients&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">A total of 75&#46;6&#37; agreed that DM2 is a predisposing factor for the onset of sarcopenia&#46; A total of 81&#46;8&#37; of participants considered the deintensification of antidiabetic treatment and treatment for other cardiovascular risk factors necessary in patients over 80 years of age&#46; A total of 88&#46;3&#37; affirmed that cognitive impairment conditioned the choice of treatment strategy &#40;Appendix <a class="elsevierStyleCrossRef" href="#sec0065">A</a>&#44; Fig&#46; 1b&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Comparison of responses from primary care vs&#46; hospital care</span><p id="par0090" class="elsevierStylePara elsevierViewall">There was greater agreement among HC physicians that comorbidity affects patient&#8217;s capacity for self-care &#40;95&#46;0&#37; vs&#46; 82&#46;9&#37;&#41; &#40;Appendix <a class="elsevierStyleCrossRef" href="#sec0065">A</a>&#44; Fig&#46; 1a&#41;&#46; HC physicians showed greater agreement on the notion that a lack of deintensification is a form of therapeutic inertia &#40;88&#46;8&#37; vs&#46; 76&#46;3&#37;&#41;&#59; on classifying older adults as frail when choosing glycemic control targets &#40;96&#46;3&#37; vs&#46; 87&#46;7&#37;&#41;&#59; on the notion that DM2 is a predisposing factor to sarcopenia &#40;86&#46;3&#37; vs&#46; 71&#46;6&#37;&#41;&#59; and on evaluating whether the deintensification of antidiabetic treatment and treatment for the control of cardiovascular risk factors is appropriate in patients older than 80 years of age &#40;90&#46;0&#37; vs&#46; 78&#46;7&#37;&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The percentage of agreement on the consideration that the available clinical guidelines provide practical&#44; useful recommendations for the specific evaluation of individuals with DM2 and frailty was significantly greater among participants from PC than those from HC &#40;79&#46;1&#37; vs&#46; 72&#46;5&#37;&#41; &#40;Appendix <a class="elsevierStyleCrossRef" href="#sec0065">A</a>&#44; Fig&#46; 1b&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results of the opinion&#44; attitude&#44; and behavior survey</span><p id="par0100" class="elsevierStylePara elsevierViewall">The onset of intolerable side effects&#44; the presence of frailty&#44; and the high risk of having hypoglycemic episodes were considered reasons for deintensification by more than 80&#37; of participants &#40;Appendix <a class="elsevierStyleCrossRef" href="#sec0065">A</a>&#44; Fig&#46; 2&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Sixty percent of participants considered a patient&#8217;s determinants and comorbidities to be determining factors when it comes to taking a different approach whereas 37&#37; considered biological age to be more important&#59; only 3&#37; stated that they took chronological age into account &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>a&#41;&#46; Forty-two percent of participants defined elderly patients as those over 80 years of age whereas 39&#37; chose 75 years of age &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>b&#41;&#46; The most important determinants for individualizing glycemic control targets and treatment were a high degree of comorbidity&#44; frailty&#44; risk of hypoglycemia&#44; and cognitive impairment &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>c&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">The most significant factors for defining frailty were functional decline&#44; a high degree of comorbidity&#44; cognitive impairment&#44; and limited life expectancy &#40;Appendix <a class="elsevierStyleCrossRef" href="#sec0065">A</a>&#44; Fig&#46; 3&#41;&#46; None of the tools proposed for evaluating frailty had been used by more than 25&#37; of participants&#46; In fact&#44; more than 50&#37; of professionals stated they did not know of the FRAIL tool or the Fried criteria &#40;Appendix <a class="elsevierStyleCrossRef" href="#sec0065">A</a>&#44; Fig&#46; 4a&#41;&#46; The most used tools for evaluating sarcopenia were a subjective evaluation of muscle mass and strength and the determination of anthropometric measurements &#40;Appendix <a class="elsevierStyleCrossRef" href="#sec0065">A</a>&#44; Fig&#46; 4b&#41;&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0115" class="elsevierStylePara elsevierViewall">The data from our study show a high level of agreement among clinicians who attend to patients with DM2 regarding the importance of considering comorbidities in the management of DM2&#46; In recent years&#44; international clinical recommendations on DM2 management have mainly focused on the presence of established cardiovascular disease&#44; which affects approximately 20&#37; of the population with DM2<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46; However&#44; psychiatric problems are very prevalent in the population with DM2<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9&#44;21</span></a> and have been associated with a worse prognosis&#44; treatment compliance<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#8211;24</span></a>&#44; quality of life<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a>&#44; and clinical outcomes<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> and even with an increase in mortality<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;27</span></a>&#46; Similar issues arise with cognitive impairment<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;28</span></a>&#46; Despite this&#44; 27&#46;7&#37; of participants did not believe that an assessment of a patient&#8217;s psychological or cognitive condition to be as important as the rest of comorbidities and determinants of DM2&#46; Likewise&#44; 13&#37; did not believe that psychiatric disorders could condition antidiabetic treatment&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Elderly patients with DM2 are at greater risk of severe hypoglycemic episodes and associated hospitalization<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30</span></a>&#46; Given that among elderly patients&#44; hypoglycemic episodes have been associated with a greater incidence of cognitive impairment&#44; falls&#44; fractures&#44; stroke&#44; and even greater mortality&#44; clinical practice guidelines establish that avoiding hypoglycemic episodes must be priority therapeutic objective in these patients<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;11&#44;12</span></a>&#46; Setting more flexible glycemic control targets than in the general population is recommended<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;31</span></a>&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Despite these recommendations&#44; only 38&#46;9&#37; and 28&#46;7&#37; of physicians establish these targets in patients considered elderly and frail&#44; respectively<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a>&#46; In a recent Spanish study&#44; 25&#46;9&#37; of patients were at severe risk of hypoglycemia and the majority received secretagogues or insulin<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a>&#44; despite the fact that treatment with antidiabetic agents with a low risk for hypoglycemia &#40;metformin and dipeptidyl peptidase-4 inhibitors&#41; is recommended in elderly patients<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">A total of 79&#46;7&#37; of those surveyed in this study believed that not deintensifying treatment in patients in whom no benefits have been demonstrated is a form of treatment inertia with possible repercussions and that whether antidiabetic treatment deintensification is appropriate must be evaluated in patients older than 80 years of age&#46; However&#44; in our setting&#44; overtreatment of DM2 has been described as common among elderly patients<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a>&#46; Studies in the United States of America confirm that the majority of elderly adults in average or poor health condition are subject to strict glycemic control and potentially overtreated<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a>&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The definition of an elderly patient varies according to treatment guidelines for these patients&#58; 75 years<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#44; 70 years<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>&#44; or even 65 years in guidelines from the USA<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#46; This disparity is reflected among the study participants&#44; though the most common response was 75&#8211;80 years of age&#46; Even still&#44; and as has been observed in other studies conducted in our setting<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a>&#44; chronological age was not considered to be a very important determinant in the approach to elderly patients&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">In this study&#44; the level of agreement on determining frailty for choosing glycemic control targets was especially high&#44; especially among physicians who work in a hospital setting&#46; Functional decline&#44; a high degree of comorbidity&#44; and cognitive impairment were the most valued factors in determining frailty&#46; Despite the fact there are specific guidelines on the management of frail patients with DM<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> or that it is included on guidelines on elderly patients<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;12</span></a>&#44; 22&#46;7&#37; of participants declared they did not know about or did not agree with recommendations in this regard&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Sarcopenia can lead to lower uptake of glucose in the muscle&#44; hyperglycemia and hyperinsulinemia&#44; and lastly&#44; to the onset of DM<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;36</span></a>&#46; Likewise&#44; DM2 is also a predisposing factor for the onset of sarcopenia<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a>&#46; Sarcopenia has been associated with greater progression of age-related functional limitation and even with a reduction in life expectancy<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a>&#46; However&#44; 24&#46;4&#37; of participants did not agree that DM2 was a predisposing factor for the onset of sarcopenia&#44; especially those in PC&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Our study found a low level of use of tools for evaluating frailty &#40;&#60;25&#37;&#41; and a high degree of lack of awareness of tests such as the FRAIL tool or the Fried criteria &#40;&#62;50&#37;&#41;&#46; In regard to sarcopenia&#44; this work has also observed a low level of use of these aforementioned tests&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The results obtained in this study coincide with the most current guidelines on the importance of designing a treatment plan and setting glycemic control targets based on the comorbidities&#44; functional and cognitive capacity&#44; mood disorders&#44; and social support of elderly patients&#46; In addition&#44; room for improvement was noted regarding the integration of psychiatric symptoms and cognitive capacities into a comprehensive assessment of patients with DM2&#59; the deintensification of antidiabetic treatment to meet more flexible targets set for elderly&#44; frail patients&#59; and the dissemination of specific guidelines on the management of these patients and the use of tools for evaluating frailty and sarcopenia&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">This study has certain limitations&#46; First&#44; the sample of participants was selected&#44; though this is a characteristic linked to Delphi studies&#44; as they intend to include experts on the subject&#46; Second&#44; the use of closed responses to OAB questions may introduce bias for having left out other response options&#46; However&#44; those considered the most important or common according to the scientific committee&#39;s judgment were included&#46; In addition&#44; the decision to include more options or use an open-text field would have made the questionnaire too long and possibly lead to a wide range of responses&#46; Lastly&#44; it is possible that interpretation of the statements or response options may have varied according to each participant&#46; In any case&#44; the questionnaire was reviewed by experts who belong to both PC and HC&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conclusions</span><p id="par0165" class="elsevierStylePara elsevierViewall">This study observed a high level of agreement on the evaluation and treatment of elderly patients with DM2 and&#47;or comorbidities among participating specialists&#44; with some differences between PC and HC physicians&#46; It is important to conduct a comprehensive assessment of these patients in order to individualize treatment and reduce the risk of hypoglycemia&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Room for improvement was noted on aspects such as the evaluation of psychiatric symptoms and cognitive capacity&#44; the deintensification of antidiabetic treatment and flexibility of glycemic control targets&#44; the dissemination of specific guidelines&#44; and the evaluation of frailty and sarcopenia in the management of elderly or frail patients&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflicts of interest</span><p id="par0175" class="elsevierStylePara elsevierViewall">Francesc Xavier Cos has provided consulting services and served as a speaker for AstraZeneca&#44; Boehringer Ingelheim&#44; Eli Lilly&#44; Novartis&#44; Novo Nordisk&#44; and Sanofi and has participated as an investigator on studies funded by AstraZeneca&#44; Novartis&#44; Sanofi&#44; and Boehringer Ingelheim&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Ricardo G&#243;mez-Huelgas has provided consulting services&#44; served as a speaker&#44; and participated as an investigator in studies funded by Boehringer Ingelheim&#44; Eli Lilly&#44; Novo Nordisk&#44; Sanofi&#44; AstraZeneca&#44; MSD&#44; Janssen&#44; and Esteve&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Fernando G&#243;mez-Peralta has provided consulting services for Abbott&#44; AstraZeneca&#44; Esteve&#44; Novartis&#44; Novo Nordisk&#44; and Sanofi and participated as an investigator in studies funded by Boehringer Ingelheim&#44; Eli Lilly&#44; Novo Nordisk&#44; and Sanofi&#46; He has served as a speaker for Abbott&#44; AstraZeneca&#44; Boehringer Ingelheim&#44; Bristol Myers Squibb&#44; Eli Lilly&#44; Esteve&#44; Novartis&#44; Novo Nordisk&#44; and Sanofi&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Funding</span><p id="par0190" class="elsevierStylePara elsevierViewall">This work was funded by <span class="elsevierStyleGrantSponsor" id="gs0005">ESTEVE Pharmaceuticals&#44; S&#46;A&#46;&#44; Spain</span>&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">This work aims to explore attitudes regarding the management of elderly or frail patients with type 2 diabetes mellitus in the routine clinical practice of a multidisciplinary group of physicians in Spain&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A mixed survey was used that included both Delphi and opinion&#44; attitude&#44; and behaviour &#40;OAB&#41; questions&#46; Perceptions in primary care &#40;n&#8239;&#61;&#8239;211&#41; and hospital care &#40;n&#8239;&#61;&#8239;80&#41; were compared&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Consensus was obtained on all statements&#46; Eighty-seven percent of participants considered that severe psychiatric disorders conditioned antidiabetic treatment and 72&#37; that a psychocognitive assessment is as relevant as the assessment of other comorbidities&#46; Hospital care physicians more frequently considered that comorbidity affects self-care &#40;95&#46;0&#37; vs&#46; 82&#46;9&#37;&#41;&#44; that a lack of de-intensification is a form of therapeutic inertia &#40;88&#46;8&#37; vs&#46; 76&#46;3&#37;&#41;&#44; that classifying older adults as frail is fundamental to choosing targets &#40;96&#46;3&#37; vs&#46; 87&#46;7&#37;&#41;&#44; that de-intensification of antidiabetic treatment and control of cardiovascular risk factors should be considered in those over 80 years of age &#40;90&#46;0&#37; vs&#46; 78&#46;7&#37;&#41;&#44; and that type 2 diabetes mellitus predisposes patients to sarcopenia &#40;86&#46;3&#37; vs&#46; 71&#46;6&#37;&#41;&#46; The usefulness of clinical guidelines was more highly valued among primary care participants &#40;79&#46;1&#37; vs&#46; 72&#46;5&#37;&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">There is room for improvement on several aspects of managing elderly or frail patients with type 2 diabetes mellitus&#44; including inertia in treatment de-intensification&#44; conducting a psychocognitive assessment&#44; or the identification of frailty and sarcopenia&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objectives"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Explorar actitudes en la pr&#225;ctica cl&#237;nica habitual de un grupo multidisciplinar de m&#233;dicos en Espa&#241;a en el manejo de pacientes de edad avanzada o fr&#225;giles con diabetes mellitus tipo 2&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Se utiliz&#243; una encuesta mixta tipo Delphi y preguntas de opini&#243;n&#44; actitud y comportamiento&#46; Se compararon las percepciones en atenci&#243;n primaria &#40;n&#8239;&#61;&#8239;211&#41; y en atenci&#243;n hospitalaria &#40;n&#8239;&#61;&#8239;80&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Se obtuvo consenso en todos los enunciados&#46; El 87&#37; de participantes consider&#243; que los trastornos psiqui&#225;tricos graves condicionan el tratamiento antidiab&#233;tico y el 72&#37;&#44; que la evaluaci&#243;n psicocognitiva es tan relevante como la del resto de comorbilidades&#46; Los m&#233;dicos de atenci&#243;n hospitalaria consideraron con mayor frecuencia que la comorbilidad afecta al autocuidado &#40;95&#44;0&#37; vs&#46; 82&#44;9&#37;&#41;&#44; que la ausencia de desintensificaci&#243;n es una forma de inercia terap&#233;utica &#40;88&#44;8&#37; vs&#46; 76&#44;3&#37;&#41;&#44; que clasificar al adulto mayor como fr&#225;gil es fundamental para elegir objetivos &#40;96&#44;3&#37; vs&#46; 87&#44;7&#37;&#41;&#44; que debe valorarse la desintensificaci&#243;n del tratamiento antidiab&#233;tico y el control de factores de riesgo cardiovascular en mayores de 80 a&#241;os &#40;90&#44;0&#37; vs&#46; 78&#44;7&#37;&#41; y que la diabetes mellitus tipo 2 predispone a la sarcopenia &#40;86&#46;3&#37; vs&#46; 71&#44;6&#37;&#41;&#46; La utilidad de las gu&#237;as cl&#237;nicas fue m&#225;s valorada entre los participantes de atenci&#243;n primaria &#40;79&#44;1&#37; vs&#46; 72&#44;5&#37;&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Existen aspectos susceptibles de mejora en el manejo de pacientes de edad avanzada o fr&#225;giles con diabetes mellitus tipo 2&#58; la inercia en la desintensificaci&#243;n del tratamiento&#44; la evaluaci&#243;n psicocognitiva&#44; o la identificaci&#243;n de fragilidad y sarcopenia&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivos"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "M&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; G&#243;mez-Huelgas R&#44; G&#243;mez-Peralta F&#44; Cos FX&#46; Evaluaci&#243;n de conocimientos&#44; barreras y actitudes en el manejo de la diabetes tipo 2 en pacientes de edad avanzada&#58; estudio Delphi en atenci&#243;n primaria y hospitalaria&#46; Rev Clin Esp&#46; 2022&#59;222&#58;385&#8211;392&#46;</p>"
      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0205" class="elsevierStylePara elsevierViewall">The following is Supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0065"
          ]
        ]
      ]
    ]
    "multimedia" => array:3 [
      0 => array:8 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 3449
            "Ancho" => 2177
            "Tamanyo" => 614523
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        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0005"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Questions about opinions&#44; attitudes&#44; and behaviors about determinants in the management of elderly patients &#40;n&#8239;&#61;&#8239;296&#41;&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">a&#41; In your clinical practice&#44; do you approach elderly patients with DM2 differently&#63; b&#41; In your clinical practice&#44; from what age do you consider a patient to be elderly&#63; c&#41; What importance do you place on the following factors as possible determinants for the individualization of targets and drug treatment&#63;</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">CVD&#58; cardiovascular disease&#59; DM2&#58; diabetes mellitus type 2&#59; UK&#47;NA&#58; unknown&#47;not answered&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0010"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">CNS&#58; consensus measure&#59; DM2&#58; type 2 diabetes mellitus&#59; COPD&#58; chronic obstructive pulmonary disease&#59; CVRF&#58; cardiovascular risk factors&#59; MW-<span class="elsevierStyleItalic">p</span>&#58; <span class="elsevierStyleItalic">p</span> value of the Mann-Whitney <span class="elsevierStyleItalic">U</span> test&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Statements&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CNS &#40;n&#8239;&#61;&#8239;291&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CNS PC &#40;n&#8239;&#61;&#8239;211&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CNS HC &#40;n&#8239;&#61;&#8239;80&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">MW-<span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Management of patients with comorbidities and determinants</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#46; The evaluation of cognitive capacities and psychological symptoms in patients with DM2 &#40;distress&#44; depression&#44; anxiety&#44; eating disorders&#41; is as important as the rest of comorbidities and determinants&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;396&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#46; Comorbidity affects a patient&#8217;s capacity for self-care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&#46; The coexistence of severe psychiatric disorders in patients with DM2 conditions antidiabetic treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;168&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>4&#46; Patients with DM2-COPD who receive medium- or high-dose glucocorticoids as treatment for flare-ups of their lung disease must be specifically screened for glucocorticoid-induced hyperglycemia &#40;self-measurement of capillary blood glucose&#41; and adjustments of hyperglycemia treatment must be evaluated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;021&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Management of elderly patients</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>5&#46; A lack of treatment deintensification in cases in which no benefits have been demonstrated is a form of therapeutic inertia that can have repercussions on the patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;78&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;035&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>6&#46; In elderly patients with DM2&#44; glycemic control targets must be individualized based on their biological&#44; psychological&#44; and social characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;024&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>7&#46; The classification of elderly adults with DM2 as frail is fundamental in choosing glycemic control targets&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;85&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">0&#46;90&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>8&#46; The available clinical guidelines provide practical&#44; useful recommendations for the specific evaluation of individuals with DM2 and frailty&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;78&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;79&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;74&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;025&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>9&#46; In elderly patients&#44; DM2 is a predisposing factor to the onset of sarcopenia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;77&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">0&#46;82&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;008&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>10&#46; In elderly patients over 80 years of age with DM2&#44; it is necessary to evaluate if deprescribing&#47;deintensifying antidiabetic treatment and treatment for the control of CVRF is appropriate&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;79&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>11&#46; Treating hypertension provides benefits even in patients with DM2 who are very elderly&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>12&#46; The fact that a patient with DM2 has some type of cognitive impairment &#40;from a mild cognitive disorder to dementia&#41; conditions the choice of treatment strategy&nbsp;\t\t\t\t\t\t\n
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Original article
Evaluation of knowledge, barriers, and attitudes in the management of type 2 diabetes in elderly patients: A Delphi study on primary and hospital care
Evaluación de conocimientos, barreras y actitudes en el manejo de la diabetes tipo 2 en pacientes de edad avanzada: estudio Delphi en atención primaria y hospitalaria
R. Gómez-Huelgasa,b, F. Gómez-Peraltac,
Corresponding author
fgomezperalta@gmail.com

Corresponding author.
, F.X. Cosd,e,f
a Servicio de Medicina Interna, Hospital Regional Universitario, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), Málaga, Spain
b CIBER Fisiopatología de Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, Madrid, Spain
c Unidad de Endocrinología y Nutrición, Hospital General de Segovia, Segovia, Spain
d Medicina Familiar y Comunitaria, Fundación Instituto Universitario para la Investigación en Atención Primaria de Salud Jordi Gol i Gurina (IDIAPJGol), Innovation Officer, Institut Català de la Salut, Centro de Atención Primaria Sant Martí de Provençals, Barcelona, Spain
e Innovation Officer, Institut Català de la Salut
f Centro de Atención Primaria Sant Martí de Provençals, Barcelona, Spain
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Questions about opinions&#44; attitudes&#44; and behaviors about determinants in the management of elderly patients &#40;n&#8239;&#61;&#8239;296&#41;&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">a&#41; In your clinical practice&#44; do you approach elderly patients with DM2 differently&#63; b&#41; In your clinical practice&#44; from what age do you consider a patient to be elderly&#63; c&#41; What importance do you place on the following factors as possible determinants for the individualization of targets and drug treatment&#63;</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">CVD&#58; cardiovascular disease&#59; DM2&#58; diabetes mellitus type 2&#59; UK&#47;NA&#58; unknown&#47;not answered&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Type 2 diabetes mellitus &#40;DM2&#41; is a disease closely linked to aging&#59; its prevalence increases with age<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; In Spain&#44; two-thirds of patients with DM &#40;of which more than 90&#37; have DM2&#41; are older than 65 years of age<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and more than one-third of the population over 75 years of age meets the diagnostic criteria for DM<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">International clinical recommendations on the management of DM2 focus on the presence of established cardiovascular disease&#44; though nearly 80&#37; of patients have non-cardiovascular comorbidities<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; In fact&#44; DM increases the risk of not only cardiovascular disease&#44; but also of kidney injury&#44; nontraumatic amputations&#44; blindness&#44; and psychiatric symptoms<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;10</span></a>&#46; In the specific case of elderly patients&#44; it increases functional disability&#44; sarcopenia&#44; cognitive impairment&#44; depression&#44; urinary incontinence&#44; falls&#44; and chronic pain<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Clinical practice guidelines have been published which offer specific recommendations for this population&#44; given the complexity of DM2 management when there are determinants such as comorbidities and age<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;11&#8211;13</span></a>&#46; Nevertheless&#44; the manner in which guidelines are followed and complied with is not always optimal and can jeopardize clinical outcomes<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#8211;18</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">This study aims to analyze the knowledge&#44; barriers&#44; and attitudes in the management of elderly patients with DM2 and&#47;or comorbidities among primary care &#40;PC&#41; and hospital care &#40;HC&#41; specialists&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">This study is a national&#44; multicenter project based on a mixed Delphi method&#47;opinion&#44; attitude&#44; and behavior &#40;OAB&#41; survey&#46; The OAB questions help expand upon the reasons underlying agreement or disagreement and go more in depth on the reasons why participants chose a specific option on the Delphi survey&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Data were collected in two phases &#40;waves&#41; by means of anonymous online questionnaires&#46; The first wave of surveys was conducted in February and March 2020 and the second in May and June 2020&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The participants selected were PC and HC physicians whose routine practice included DM2 management&#46; They were selected by means of non-probability sampling by clusters according to proportional geographical distribution and population criteria&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The mixed survey was designed by a scientific committee&#46; It included a total of 25 Delphi-style statements and 13 OAB questions&#46; Of these&#44; the results of 12 statements and seven OAB questions focused on the determining role of comorbidities and old age in the management of patients with DM2 are presented&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The method used to predetermine the sample was a 95&#37; confidence interval for a proportion of a finite population&#46; The final sample size yielded a precision of &#177;5&#37; for a 95&#37; confidence interval&#46; With a reference population of 46&#44;934&#44;628 inhabitants and 3055 PC centers&#44; a representative sample of 300 physicians &#40;PC and HC&#41; from different regions of Spain was calculated&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The level of agreement on the Delphi statements was evaluated via a five-point Likert scale and was analyzed through two approaches&#58; consensus measure &#40;CNS&#41; by means of the Tastle technique<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> and the consolidation of five Likert scale categories into three &#40;disagree&#44; neutral&#44; and agree&#41;&#46; The threshold of consensus on the Delphi statements was a CNS&#8239;&#8805;&#8239;0&#46;7&#46; Statements which did not have a high degree of consensus &#40;CNS&#8239;&#8805;&#8239;0&#46;8&#41; in the first wave were reevaluated in a second wave by the modification or inversion of the statement&#8217;s wording&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">OAB questions were able to be answered either through single-choice&#44; multiple-choice&#44; or rating scale responses&#46; For OAB questions which were single- or multiple-choice&#44; the percentage each answer received was calculated and for questions with a rating scale&#44; the median was calculated&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The Mann-Whitney <span class="elsevierStyleItalic">U</span> test and <span class="elsevierStyleItalic">p</span> value were used to evaluate differences between the responses from PC and HC specialists&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Participants</span><p id="par0065" class="elsevierStylePara elsevierViewall">A total of 296 physicians participated in the first wave and 293 participated in the second wave&#58; 211 belonged to PC&#44; 80 to HC&#44; and 2 did not report their specialty&#46; In terms of age&#44; 21&#46;6&#37; of participants were younger than 46 years of age&#44; 31&#37; were between 46 and 55 years of age&#44; and 47&#46;7&#37; were older than 55 years of age&#46; In terms of sex&#44; 65&#46;5&#37; were men&#46; A total of 67&#46;9&#37; had been practicing medicine for 20 years or more&#46; A total of 74&#46;4&#37; of participants stated that they followed clinical practice guidelines recommendations for the diagnosis of and follow-up on patients with DM2&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results of the Delphi statements</span><p id="par0070" class="elsevierStylePara elsevierViewall">After the second wave&#44; consensus was achieved on the 12 statements presented and the CNS was 0&#46;8 or greater on nine of them &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; When the responses were consolidated into three categories&#44; similar results were obtained in terms of percentage &#40;Appendix <a class="elsevierStyleCrossRef" href="#sec0065">A</a>&#44; Fig&#46; 1&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">A total of 86&#46;3&#37; of participants considered that comorbidities affect a patient&#8217;s capacity for self-care&#46; A total of 86&#46;9&#37; agreed that severe psychiatric disorders condition antidiabetic treatment&#46; A total of 72&#46;2&#37; considered the assessment of cognitive capabilities and psychological symptoms to be as important as the rest of comorbidities and determinants &#40;Appendix <a class="elsevierStyleCrossRef" href="#sec0065">A</a>&#44; Fig&#46; 1a&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">A total of 79&#46;7&#37; of participants agreed that a lack of treatment deintensification is a form of therapeutic inertia with possible repercussions for the patient&#46; The level of agreement was 90&#46;7&#37; on the individualization of glycemic control targets based on biological&#44; psychological&#44; and social characteristics and 90&#37; on classification according to frailty for choosing glycemic control targets in elderly patients&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">A total of 75&#46;6&#37; agreed that DM2 is a predisposing factor for the onset of sarcopenia&#46; A total of 81&#46;8&#37; of participants considered the deintensification of antidiabetic treatment and treatment for other cardiovascular risk factors necessary in patients over 80 years of age&#46; A total of 88&#46;3&#37; affirmed that cognitive impairment conditioned the choice of treatment strategy &#40;Appendix <a class="elsevierStyleCrossRef" href="#sec0065">A</a>&#44; Fig&#46; 1b&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Comparison of responses from primary care vs&#46; hospital care</span><p id="par0090" class="elsevierStylePara elsevierViewall">There was greater agreement among HC physicians that comorbidity affects patient&#8217;s capacity for self-care &#40;95&#46;0&#37; vs&#46; 82&#46;9&#37;&#41; &#40;Appendix <a class="elsevierStyleCrossRef" href="#sec0065">A</a>&#44; Fig&#46; 1a&#41;&#46; HC physicians showed greater agreement on the notion that a lack of deintensification is a form of therapeutic inertia &#40;88&#46;8&#37; vs&#46; 76&#46;3&#37;&#41;&#59; on classifying older adults as frail when choosing glycemic control targets &#40;96&#46;3&#37; vs&#46; 87&#46;7&#37;&#41;&#59; on the notion that DM2 is a predisposing factor to sarcopenia &#40;86&#46;3&#37; vs&#46; 71&#46;6&#37;&#41;&#59; and on evaluating whether the deintensification of antidiabetic treatment and treatment for the control of cardiovascular risk factors is appropriate in patients older than 80 years of age &#40;90&#46;0&#37; vs&#46; 78&#46;7&#37;&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The percentage of agreement on the consideration that the available clinical guidelines provide practical&#44; useful recommendations for the specific evaluation of individuals with DM2 and frailty was significantly greater among participants from PC than those from HC &#40;79&#46;1&#37; vs&#46; 72&#46;5&#37;&#41; &#40;Appendix <a class="elsevierStyleCrossRef" href="#sec0065">A</a>&#44; Fig&#46; 1b&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results of the opinion&#44; attitude&#44; and behavior survey</span><p id="par0100" class="elsevierStylePara elsevierViewall">The onset of intolerable side effects&#44; the presence of frailty&#44; and the high risk of having hypoglycemic episodes were considered reasons for deintensification by more than 80&#37; of participants &#40;Appendix <a class="elsevierStyleCrossRef" href="#sec0065">A</a>&#44; Fig&#46; 2&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Sixty percent of participants considered a patient&#8217;s determinants and comorbidities to be determining factors when it comes to taking a different approach whereas 37&#37; considered biological age to be more important&#59; only 3&#37; stated that they took chronological age into account &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>a&#41;&#46; Forty-two percent of participants defined elderly patients as those over 80 years of age whereas 39&#37; chose 75 years of age &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>b&#41;&#46; The most important determinants for individualizing glycemic control targets and treatment were a high degree of comorbidity&#44; frailty&#44; risk of hypoglycemia&#44; and cognitive impairment &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>c&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">The most significant factors for defining frailty were functional decline&#44; a high degree of comorbidity&#44; cognitive impairment&#44; and limited life expectancy &#40;Appendix <a class="elsevierStyleCrossRef" href="#sec0065">A</a>&#44; Fig&#46; 3&#41;&#46; None of the tools proposed for evaluating frailty had been used by more than 25&#37; of participants&#46; In fact&#44; more than 50&#37; of professionals stated they did not know of the FRAIL tool or the Fried criteria &#40;Appendix <a class="elsevierStyleCrossRef" href="#sec0065">A</a>&#44; Fig&#46; 4a&#41;&#46; The most used tools for evaluating sarcopenia were a subjective evaluation of muscle mass and strength and the determination of anthropometric measurements &#40;Appendix <a class="elsevierStyleCrossRef" href="#sec0065">A</a>&#44; Fig&#46; 4b&#41;&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0115" class="elsevierStylePara elsevierViewall">The data from our study show a high level of agreement among clinicians who attend to patients with DM2 regarding the importance of considering comorbidities in the management of DM2&#46; In recent years&#44; international clinical recommendations on DM2 management have mainly focused on the presence of established cardiovascular disease&#44; which affects approximately 20&#37; of the population with DM2<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46; However&#44; psychiatric problems are very prevalent in the population with DM2<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9&#44;21</span></a> and have been associated with a worse prognosis&#44; treatment compliance<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#8211;24</span></a>&#44; quality of life<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a>&#44; and clinical outcomes<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> and even with an increase in mortality<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;27</span></a>&#46; Similar issues arise with cognitive impairment<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;28</span></a>&#46; Despite this&#44; 27&#46;7&#37; of participants did not believe that an assessment of a patient&#8217;s psychological or cognitive condition to be as important as the rest of comorbidities and determinants of DM2&#46; Likewise&#44; 13&#37; did not believe that psychiatric disorders could condition antidiabetic treatment&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Elderly patients with DM2 are at greater risk of severe hypoglycemic episodes and associated hospitalization<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29&#44;30</span></a>&#46; Given that among elderly patients&#44; hypoglycemic episodes have been associated with a greater incidence of cognitive impairment&#44; falls&#44; fractures&#44; stroke&#44; and even greater mortality&#44; clinical practice guidelines establish that avoiding hypoglycemic episodes must be priority therapeutic objective in these patients<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;11&#44;12</span></a>&#46; Setting more flexible glycemic control targets than in the general population is recommended<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;31</span></a>&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Despite these recommendations&#44; only 38&#46;9&#37; and 28&#46;7&#37; of physicians establish these targets in patients considered elderly and frail&#44; respectively<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a>&#46; In a recent Spanish study&#44; 25&#46;9&#37; of patients were at severe risk of hypoglycemia and the majority received secretagogues or insulin<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a>&#44; despite the fact that treatment with antidiabetic agents with a low risk for hypoglycemia &#40;metformin and dipeptidyl peptidase-4 inhibitors&#41; is recommended in elderly patients<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">A total of 79&#46;7&#37; of those surveyed in this study believed that not deintensifying treatment in patients in whom no benefits have been demonstrated is a form of treatment inertia with possible repercussions and that whether antidiabetic treatment deintensification is appropriate must be evaluated in patients older than 80 years of age&#46; However&#44; in our setting&#44; overtreatment of DM2 has been described as common among elderly patients<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a>&#46; Studies in the United States of America confirm that the majority of elderly adults in average or poor health condition are subject to strict glycemic control and potentially overtreated<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a>&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The definition of an elderly patient varies according to treatment guidelines for these patients&#58; 75 years<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#44; 70 years<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>&#44; or even 65 years in guidelines from the USA<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#46; This disparity is reflected among the study participants&#44; though the most common response was 75&#8211;80 years of age&#46; Even still&#44; and as has been observed in other studies conducted in our setting<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a>&#44; chronological age was not considered to be a very important determinant in the approach to elderly patients&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">In this study&#44; the level of agreement on determining frailty for choosing glycemic control targets was especially high&#44; especially among physicians who work in a hospital setting&#46; Functional decline&#44; a high degree of comorbidity&#44; and cognitive impairment were the most valued factors in determining frailty&#46; Despite the fact there are specific guidelines on the management of frail patients with DM<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> or that it is included on guidelines on elderly patients<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;12</span></a>&#44; 22&#46;7&#37; of participants declared they did not know about or did not agree with recommendations in this regard&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Sarcopenia can lead to lower uptake of glucose in the muscle&#44; hyperglycemia and hyperinsulinemia&#44; and lastly&#44; to the onset of DM<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;36</span></a>&#46; Likewise&#44; DM2 is also a predisposing factor for the onset of sarcopenia<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a>&#46; Sarcopenia has been associated with greater progression of age-related functional limitation and even with a reduction in life expectancy<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a>&#46; However&#44; 24&#46;4&#37; of participants did not agree that DM2 was a predisposing factor for the onset of sarcopenia&#44; especially those in PC&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Our study found a low level of use of tools for evaluating frailty &#40;&#60;25&#37;&#41; and a high degree of lack of awareness of tests such as the FRAIL tool or the Fried criteria &#40;&#62;50&#37;&#41;&#46; In regard to sarcopenia&#44; this work has also observed a low level of use of these aforementioned tests&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The results obtained in this study coincide with the most current guidelines on the importance of designing a treatment plan and setting glycemic control targets based on the comorbidities&#44; functional and cognitive capacity&#44; mood disorders&#44; and social support of elderly patients&#46; In addition&#44; room for improvement was noted regarding the integration of psychiatric symptoms and cognitive capacities into a comprehensive assessment of patients with DM2&#59; the deintensification of antidiabetic treatment to meet more flexible targets set for elderly&#44; frail patients&#59; and the dissemination of specific guidelines on the management of these patients and the use of tools for evaluating frailty and sarcopenia&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">This study has certain limitations&#46; First&#44; the sample of participants was selected&#44; though this is a characteristic linked to Delphi studies&#44; as they intend to include experts on the subject&#46; Second&#44; the use of closed responses to OAB questions may introduce bias for having left out other response options&#46; However&#44; those considered the most important or common according to the scientific committee&#39;s judgment were included&#46; In addition&#44; the decision to include more options or use an open-text field would have made the questionnaire too long and possibly lead to a wide range of responses&#46; Lastly&#44; it is possible that interpretation of the statements or response options may have varied according to each participant&#46; In any case&#44; the questionnaire was reviewed by experts who belong to both PC and HC&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conclusions</span><p id="par0165" class="elsevierStylePara elsevierViewall">This study observed a high level of agreement on the evaluation and treatment of elderly patients with DM2 and&#47;or comorbidities among participating specialists&#44; with some differences between PC and HC physicians&#46; It is important to conduct a comprehensive assessment of these patients in order to individualize treatment and reduce the risk of hypoglycemia&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Room for improvement was noted on aspects such as the evaluation of psychiatric symptoms and cognitive capacity&#44; the deintensification of antidiabetic treatment and flexibility of glycemic control targets&#44; the dissemination of specific guidelines&#44; and the evaluation of frailty and sarcopenia in the management of elderly or frail patients&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflicts of interest</span><p id="par0175" class="elsevierStylePara elsevierViewall">Francesc Xavier Cos has provided consulting services and served as a speaker for AstraZeneca&#44; Boehringer Ingelheim&#44; Eli Lilly&#44; Novartis&#44; Novo Nordisk&#44; and Sanofi and has participated as an investigator on studies funded by AstraZeneca&#44; Novartis&#44; Sanofi&#44; and Boehringer Ingelheim&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Ricardo G&#243;mez-Huelgas has provided consulting services&#44; served as a speaker&#44; and participated as an investigator in studies funded by Boehringer Ingelheim&#44; Eli Lilly&#44; Novo Nordisk&#44; Sanofi&#44; AstraZeneca&#44; MSD&#44; Janssen&#44; and Esteve&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Fernando G&#243;mez-Peralta has provided consulting services for Abbott&#44; AstraZeneca&#44; Esteve&#44; Novartis&#44; Novo Nordisk&#44; and Sanofi and participated as an investigator in studies funded by Boehringer Ingelheim&#44; Eli Lilly&#44; Novo Nordisk&#44; and Sanofi&#46; He has served as a speaker for Abbott&#44; AstraZeneca&#44; Boehringer Ingelheim&#44; Bristol Myers Squibb&#44; Eli Lilly&#44; Esteve&#44; Novartis&#44; Novo Nordisk&#44; and Sanofi&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Funding</span><p id="par0190" class="elsevierStylePara elsevierViewall">This work was funded by <span class="elsevierStyleGrantSponsor" id="gs0005">ESTEVE Pharmaceuticals&#44; S&#46;A&#46;&#44; Spain</span>&#46;</p></span></span>"
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              "titulo" => "Comparison of responses from primary care vs&#46; hospital care"
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              "titulo" => "Results of the opinion&#44; attitude&#44; and behavior survey"
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    "fechaAceptado" => "2021-11-23"
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            0 => "Type 2 diabetes mellitus"
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            0 => "Diabetes mellitustipo 2"
            1 => "Comorbilidades"
            2 => "Fragilidad en el paciente de edad avanzada"
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            4 => "Atenci&#243;n primaria"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">This work aims to explore attitudes regarding the management of elderly or frail patients with type 2 diabetes mellitus in the routine clinical practice of a multidisciplinary group of physicians in Spain&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A mixed survey was used that included both Delphi and opinion&#44; attitude&#44; and behaviour &#40;OAB&#41; questions&#46; Perceptions in primary care &#40;n&#8239;&#61;&#8239;211&#41; and hospital care &#40;n&#8239;&#61;&#8239;80&#41; were compared&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Consensus was obtained on all statements&#46; Eighty-seven percent of participants considered that severe psychiatric disorders conditioned antidiabetic treatment and 72&#37; that a psychocognitive assessment is as relevant as the assessment of other comorbidities&#46; Hospital care physicians more frequently considered that comorbidity affects self-care &#40;95&#46;0&#37; vs&#46; 82&#46;9&#37;&#41;&#44; that a lack of de-intensification is a form of therapeutic inertia &#40;88&#46;8&#37; vs&#46; 76&#46;3&#37;&#41;&#44; that classifying older adults as frail is fundamental to choosing targets &#40;96&#46;3&#37; vs&#46; 87&#46;7&#37;&#41;&#44; that de-intensification of antidiabetic treatment and control of cardiovascular risk factors should be considered in those over 80 years of age &#40;90&#46;0&#37; vs&#46; 78&#46;7&#37;&#41;&#44; and that type 2 diabetes mellitus predisposes patients to sarcopenia &#40;86&#46;3&#37; vs&#46; 71&#46;6&#37;&#41;&#46; The usefulness of clinical guidelines was more highly valued among primary care participants &#40;79&#46;1&#37; vs&#46; 72&#46;5&#37;&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">There is room for improvement on several aspects of managing elderly or frail patients with type 2 diabetes mellitus&#44; including inertia in treatment de-intensification&#44; conducting a psychocognitive assessment&#44; or the identification of frailty and sarcopenia&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Explorar actitudes en la pr&#225;ctica cl&#237;nica habitual de un grupo multidisciplinar de m&#233;dicos en Espa&#241;a en el manejo de pacientes de edad avanzada o fr&#225;giles con diabetes mellitus tipo 2&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Se utiliz&#243; una encuesta mixta tipo Delphi y preguntas de opini&#243;n&#44; actitud y comportamiento&#46; Se compararon las percepciones en atenci&#243;n primaria &#40;n&#8239;&#61;&#8239;211&#41; y en atenci&#243;n hospitalaria &#40;n&#8239;&#61;&#8239;80&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Se obtuvo consenso en todos los enunciados&#46; El 87&#37; de participantes consider&#243; que los trastornos psiqui&#225;tricos graves condicionan el tratamiento antidiab&#233;tico y el 72&#37;&#44; que la evaluaci&#243;n psicocognitiva es tan relevante como la del resto de comorbilidades&#46; Los m&#233;dicos de atenci&#243;n hospitalaria consideraron con mayor frecuencia que la comorbilidad afecta al autocuidado &#40;95&#44;0&#37; vs&#46; 82&#44;9&#37;&#41;&#44; que la ausencia de desintensificaci&#243;n es una forma de inercia terap&#233;utica &#40;88&#44;8&#37; vs&#46; 76&#44;3&#37;&#41;&#44; que clasificar al adulto mayor como fr&#225;gil es fundamental para elegir objetivos &#40;96&#44;3&#37; vs&#46; 87&#44;7&#37;&#41;&#44; que debe valorarse la desintensificaci&#243;n del tratamiento antidiab&#233;tico y el control de factores de riesgo cardiovascular en mayores de 80 a&#241;os &#40;90&#44;0&#37; vs&#46; 78&#44;7&#37;&#41; y que la diabetes mellitus tipo 2 predispone a la sarcopenia &#40;86&#46;3&#37; vs&#46; 71&#44;6&#37;&#41;&#46; La utilidad de las gu&#237;as cl&#237;nicas fue m&#225;s valorada entre los participantes de atenci&#243;n primaria &#40;79&#44;1&#37; vs&#46; 72&#44;5&#37;&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Existen aspectos susceptibles de mejora en el manejo de pacientes de edad avanzada o fr&#225;giles con diabetes mellitus tipo 2&#58; la inercia en la desintensificaci&#243;n del tratamiento&#44; la evaluaci&#243;n psicocognitiva&#44; o la identificaci&#243;n de fragilidad y sarcopenia&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; G&#243;mez-Huelgas R&#44; G&#243;mez-Peralta F&#44; Cos FX&#46; Evaluaci&#243;n de conocimientos&#44; barreras y actitudes en el manejo de la diabetes tipo 2 en pacientes de edad avanzada&#58; estudio Delphi en atenci&#243;n primaria y hospitalaria&#46; Rev Clin Esp&#46; 2022&#59;222&#58;385&#8211;392&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Questions about opinions&#44; attitudes&#44; and behaviors about determinants in the management of elderly patients &#40;n&#8239;&#61;&#8239;296&#41;&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">a&#41; In your clinical practice&#44; do you approach elderly patients with DM2 differently&#63; b&#41; In your clinical practice&#44; from what age do you consider a patient to be elderly&#63; c&#41; What importance do you place on the following factors as possible determinants for the individualization of targets and drug treatment&#63;</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">CVD&#58; cardiovascular disease&#59; DM2&#58; diabetes mellitus type 2&#59; UK&#47;NA&#58; unknown&#47;not answered&#46;</p>"
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          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">CNS&#58; consensus measure&#59; DM2&#58; type 2 diabetes mellitus&#59; COPD&#58; chronic obstructive pulmonary disease&#59; CVRF&#58; cardiovascular risk factors&#59; MW-<span class="elsevierStyleItalic">p</span>&#58; <span class="elsevierStyleItalic">p</span> value of the Mann-Whitney <span class="elsevierStyleItalic">U</span> test&#46;</p>"
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                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CNS &#40;n&#8239;&#61;&#8239;291&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CNS PC &#40;n&#8239;&#61;&#8239;211&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CNS HC &#40;n&#8239;&#61;&#8239;80&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">MW-<span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Management of patients with comorbidities and determinants</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1&#46; The evaluation of cognitive capacities and psychological symptoms in patients with DM2 &#40;distress&#44; depression&#44; anxiety&#44; eating disorders&#41; is as important as the rest of comorbidities and determinants&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;396&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2&#46; Comorbidity affects a patient&#8217;s capacity for self-care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>3&#46; The coexistence of severe psychiatric disorders in patients with DM2 conditions antidiabetic treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;168&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>4&#46; Patients with DM2-COPD who receive medium- or high-dose glucocorticoids as treatment for flare-ups of their lung disease must be specifically screened for glucocorticoid-induced hyperglycemia &#40;self-measurement of capillary blood glucose&#41; and adjustments of hyperglycemia treatment must be evaluated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;021&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Management of elderly patients</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>5&#46; A lack of treatment deintensification in cases in which no benefits have been demonstrated is a form of therapeutic inertia that can have repercussions on the patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;78&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;035&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>6&#46; In elderly patients with DM2&#44; glycemic control targets must be individualized based on their biological&#44; psychological&#44; and social characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;024&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>7&#46; The classification of elderly adults with DM2 as frail is fundamental in choosing glycemic control targets&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>8&#46; The available clinical guidelines provide practical&#44; useful recommendations for the specific evaluation of individuals with DM2 and frailty&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;78&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;025&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>9&#46; In elderly patients&#44; DM2 is a predisposing factor to the onset of sarcopenia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>10&#46; In elderly patients over 80 years of age with DM2&#44; it is necessary to evaluate if deprescribing&#47;deintensifying antidiabetic treatment and treatment for the control of CVRF is appropriate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>11&#46; Treating hypertension provides benefits even in patients with DM2 who are very elderly&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;116&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>12&#46; The fact that a patient with DM2 has some type of cognitive impairment &#40;from a mild cognitive disorder to dementia&#41; conditions the choice of treatment strategy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;258&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
          ]
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                      "titulo" => "Sarcopenia&#58; European consensus on definition and diagnosis&#58; report of the European Working Group on Sarcopenia in Older People"
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                          "autores" => array:6 [
                            0 => "A&#46;J&#46; Cruz-Jentoft"
                            1 => "J&#46;P&#46; Baeyens"
                            2 => "J&#46;M&#46; Bauer"
                            3 => "Y&#46; Boirie"
                            4 => "T&#46; Cederholm"
                            5 => "F&#46; Landi"
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                        "tituloSerie" => "Age Ageing&#46;"
                        "fecha" => "2010"
                        "volumen" => "39"
                        "paginaInicial" => "412"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20392703"
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        "identificador" => "xack618751"
        "titulo" => "Acknowledgments"
        "texto" => "<p id="par0195" class="elsevierStylePara elsevierViewall">The authors would especially like to thank the panel of primary care and hospital care physicians for their participation&#44; Esteve Pharmaceuticals&#44; S&#46;A&#46; for the support provided in the conduct of this study&#44; IDEMM-FARMA S&#46;L&#46; for technical and methodological support&#44; Montse Fontbot&#233; and Jemina Moret&#243; for their medical writing support&#44; and Francisco L&#243;pez for conducting the statistical analysis&#46;</p>"
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Article information
ISSN: 22548874
Original language: English
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