Insulin Therapy for Older Adults with Diabetes

Alissa R. Segal, PharmD, CDE, Associate Professor, Massachusetts College of Pharmacy and Health Sciences; Clinical pharmacist, Joslin Diabetes Center, Boston, Massachusetts, U.S.A.
Medha N. Munshi, MD, Assistant Professor, Harvard Medical School; Director of Joslin
Geriatric Diabetes Program, Joslin Diabetes Center; Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, U.S.A.

The aging of the population and increasing prevalence of diabetes are worldwide phenomena that require a better focus on challenges of diabetes management in older adults. We now understand the benefits of tight glycemic control and have an armament of agents to achieve such a feat. However, in an aging population, balance must be sought between the goals of glycemic control and those of overall health status, including quality of life. Insulin therapy, in particular, requires significant self-care abilities. Insulin therapy can be used safely and effectively if diabetes management plans are formulated with consideration of the clinical, functional, and psychosocial contexts of an older adult.
Key words: diabetes, older adults, insulin therapy, geriatrics, glycemic control.

The Role of Peripheral Arterial Disease in the Pathogenesis of Diabetic Foot Disease: When to Refer for Vascular Surgery

Robert J. Hinchliffe, MD, MRCS, Clinical Lecturer in Vascular Surgery, St George’s Regional Vascular Institute, St George’s Hospital and St George’s University of London, London, UK.
William Jeffcoate, FRCP, Professor, Foot Ulcer Trials Unit, Department of Diabetes and Endocrinology, Nottingham University Hospitals, City Hospital Campus, Nottingham, UK.

Individuals with ulceration of the foot should be identified and referred urgently to a specialist. Unfortunately there is little formal health care education in diabetic foot ulceration and often no specialist referral pathway. We discuss the common modes of presentation of patients with diabetes and foot ulcer. The clinical implications of a range of symptoms and signs will be explained, including the most common diagnostic pitfalls in everyday primary care practice.
Key words: diabetes, peripheral vascular disease, ulcer, vascular surgery, peripheral arterial disease, diabetic foot.

Pharmacological Treatments for Diabetes among Older Adults: An Update

Jeremy Gilbert, MD, FRCPC, Staff Endocrinologist, Toronto General Hospital, Toronto, ON.

Diabetes is a very common condition, especially among older adults. There are numerous benefits associated with improved glycemic control. However, achieving glycemic targets can be challenging, particularly for older adults with comorbidities. In recent years more oral antihyperglycemic agents have become available to better manage diabetes, and there are many pharmacological therapies currently in development. In order to select the most appropriate agent to use as monotherapy or in combination for an individual patient, it is important to be familiar with the mechanism, efficacy, safety, and cost of the various antihyperglycemic agents.
Key words: diabetes, older adults, oral antihyperglycemic agents, monotherapy, combination therapy.

Management of Hypertension among Older Adults: Where Are We Now?

Anita W. Asgar, MD, FRCPC, Interventional Cardiology Fellow, Montreal Heart Institute, Montreal, QC.
Renee L. Schiff, MD, FRCPC, Echocardiography Fellow, Montreal Heart Institute, Montreal, QC.
Reda Ibrahim, MD, CSPQ, FRCPC, Interventional Cardiologist, Montreal Heart Institute, Associate Professor of Medicine, Universite de Montreal, Montreal, QC.

Hypertension is a common health concern among older adults and constitutes an important risk factor for cardiovascular disease. Despite its prevalence, it is a constant management challenge. We review four aspects of hypertension management that have been of interest over the past year.
Key words: hypertension, diabetes, drug therapy, gender differences, resistant hypertension.

Erectile Dysfunction in Older Males: Why Not Investigate and Treat It?

Peter Pommerville, BA, MD, FRCS(C), Director of Research, Can-Med Clinical Research, Inc.; Clinical Instructor, University of British Columbia; Clinical Instructor, University of Victoria; Consulting Urologist, Vancouver Island Health Authority, Vancouver, BC.

It is estimated that 50% of men between 40 and 70 have erectile dysfunction (ED). The number of men with ED rises to 65% or greater over age 70. Despite the fact that men in this age range have significant medical comorbidities causing their ED, they have often cared for a spouse with a terminal illness. In search of companionship, they become acquainted with a woman who has just been through a similar circumstance. Therefore, it’s usual for men to have performance anxiety contributing to their ED. Proper diagnosis and assessment to determine the etiology of ED is usually done by the primary care physician, with possible follow-up by an urologist or psychiatrist if the main cause is deemed to be organic or psychological, respectively. In some cases, there is overlap as medications such as antidepressants may interfere with sexual function.
Primary care physicians, geriatricians, and allied health care professionals charged with the management of these older men should be empathetic towards their sexual health. Safe and effective treatments for ED are available to permit these couples to enjoy a healthy sexual experience in their elder years.
Key words: erectile dysfunction, diabetes, vardenafil, sildenafil, tadalafil.

Management of Diabetic Foot Ulcers

Madhuri Reddy, MD, MSc, FRCPC, Assistant Professor, Department of Medicine,
University of Toronto, Associate Editor, Geriatrics & Aging, Toronto, ON.

R. Gary Sibbald, BSc, MD, FRCPC (Med), FRCPC (Derm), MACP, DABD, Associate Professor and Director of Continuing Education, Department of Medicine, University of Toronto, Toronto, ON.

Prevention of diabetic foot wounds is of crucial importance. Diabetic foot wounds are basically pressure ulcers due to improper footwear, and therefore the most critical aspect of prevention is wearing proper shoes, checked regularly by a reputable orthotist. Once foot wounds have occurred in a person with diabetes, proper footwear continues to be
crucial. Also of importance are adequate vascular supply, treatment of infection, and surgical debridement, if necessary. All diabetic foot wounds should be probed in order to evaluate depth. If the wound probes to bone, osteomyelitis should be presumed unless proven otherwise.

Key words: diabetes, wounds, ulcers, vascular, infection.

Obesity in Older Adults

Isabelle J. Dionne, PhD, Faculty of Physical Activity and Sports, University of Sherbrooke; Research Centre on Aging, Geriatric Institute of Sherbrooke University, Sherbrooke, QC.
Martin Brochu, PhD, Faculty of Physical Activity and Sports, University of Sherbrooke; Research Centre on Aging, Geriatric Institute of Sherbrooke University, Sherbrooke, QC.

There is a high prevalence of obesity in older adults up to the age of 80. While women generally gain body weight during the menopausal transition, men tend to accumulate an excess of fat mass earlier in life for as yet unknown reasons. Consequently, an increasing proportion of older adults are now obese. Obesity’s association with metabolic diseases such as metabolic syndrome, type II diabetes, and cardiovascular disease is widely recognized. However, recent evidence shows that, in older adults, obesity is also related to functional impairment and decreased quality of life. This review addresses the actual prevalence and definition of obesity in older adults, the energy-balance equation, and the known consequences of obesity. Finally, the heterogeneity of obesity in older adults regarding its association with metabolic diseases and functional capacity will be discussed, as well as how obesity treatment should be conducted in this population.

Key words: obesity, metabolic syndrome, diabetes, weight loss, impaired functional capacity.

How New Clinical Trials May Change Cholesterol Management Guidelines

David Fitchett, MD FRCP(C), St Michael’s Hospital, University of Toronto, Toronto, ON.

As a response to recent clinical trials of low-density lipoprotein (LDL) lowering, the Adult Treatment Panel III (ATP III) has proposed new thresholds and targets for treatment. In addition, the population that is considered to benefit from LDL lowering has been extended to include the diabetic and the older patient. This article reviews the clinical trial evidence, and the new recommendations, and provides commentary with special reference to management of the older person.

Key words: cardiovascular disease, LDL cholesterol, statin therapy, older patients, diabetes.

Chronic Wound Pain in Older Adults

Madhuri Reddy, MD, MSc, FRCPC, Assistant Professor, University of Toronto, Sunnybrook and Women's College Hospital, Toronto, ON.

Chronic wound pain adversely affects quality of life and causes functional impairment in the older adult. As the population ages and the prevalence of chronic illness increases, an explosion in the number of chronic wounds is expected in both long-term care and community care. Chronic wounds have a myriad of causes and complications, and care can be complex. The most common types of chronic wounds include venous stasis ulcers, diabetic ulcers and pressure ulcers. There is a paucity of clinical trials of chronic wound pain management in the older patient. In the absence of an adequate evidence base, we present a comprehensive clinical approach to chronic wound pain management.
Key words: chronic wounds, pain, venous stasis, diabetes, pressure.