Diabetes in ageing: pathways for developing the evidence base for clinical guidance

Summary

Older adults with diabetes are heterogeneous in their medical, functional, and cognitive status, and require careful individualisation of their treatment regimens. However, in the absence of detailed information from clinical trials involving older people with varying characteristics, there is little evidence-based guidance, which is a notable limitation of current approaches to care. It is important to recognise that older people with diabetes might vary in their profiles according to age category, functional health, presence of frailty, and comorbidity profiles. In addition, all older adults with diabetes require an individualised approach to care, ranging from robust individuals to those residing in care homes with a short life expectancy, those requiring palliative care, or those requiring end-of-life management. In this Review, our multidisciplinary team of experts describes the current evidence in several important areas in geriatric diabetes, and outlines key research gaps and research questions in each of these areas with the aim to develop evidence-based recommendations to improve the outcomes of interest in older adults.

Introduction

Over the past decade, several diabetes organisations and societies have published position statements, guidelines, and consensus reports to guide the management of older adults with diabetes with consideration of the unique challenges that are involved.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 In addition, there have been published articles with a main focus on diabetes and older adults where the emerging science, the complexity of management, and the goals of care have been discussed¹² in varying situations, such as the presence of cognitive dysfunction¹³ or the management of inpatient hyperglycaemia.¹⁴ This literature supports the view that many factors necessitate different approaches to diabetes care in older adults compared with younger adults.

Older adults are a heterogeneous population and are frequently defined on the basis of chronological age, functional status, or the presence of comorbid conditions. This variability in definitions is seen in the studies in current literature focusing on older adults. Because of this variability, defining older adults in the context of the purpose of the study or review might be necessary. In the past decade, various guidelines and consensus reports have provided clinical recommendations based on the presence of severe comorbidities, cognitive status, and functionality, avoiding chronological age as the defining factor. The three groups of older adults with diabetes that are usually defined for the purposes of allocating recommendations are: (1) individuals in good health with little or no cognitive or functional impairment and a long life expectancy (eg, >10–15 years); (2) those who have some comorbidities and mild disabilities; and (3) those who have a high number of comorbidities or disabilities, or both, and a shorter life expectancy (eg, <5 years).

The recommendations from these guidelines offer important information for clinicians providing care for older adults with diabetes. However, older adults, particularly those who have evidence of functional loss, frailty, and cognitive impairment, are under-represented in clinical trials leading to management guidelines that rely on expert opinions only. In addition, there is little research and clinical guidance on the care of older adults with type 1 diabetes. Thus, there is an increasing and urgent need to develop evidence-based treatment recommendations for this growing population that has unique and often unmet needs. In this Review, we describe the current evidence in seven important areas in geriatric diabetes (figure), and outline key research gaps and research questions in each of these areas.