Does Lecturing Older Adults with Diabetes about a Healthy Lifestyle Work?

Carla Miller, PhD, RD, Associate Professor, Department of Human Nutrition, Ohio State University, Columbus, OH, USA.

The translation of effective treatments for obesity and diabetes management into clinical care has been slow. However, self-management education and counselling regarding diet and physical activity can improve weight, blood glucose, and lipid levels, and blood pressure control among older adults with type 2 diabetes. A collaborative approach to counselling is more effective than simply lecturing in promoting and sustaining behaviour change. The five A’s to behavioural counselling—assess, advise, agree, assist, and arrange—provide a model for care. A key component of the five A’s for counselling is the development of an action plan that specifies goals and implementation intentions for behaviour change.
Key words: type 2 diabetes mellitus, older adults, behavioural research, patient education, behavioural therapy.

A Rational Approach to the Initiation of Insulin Therapy in Older Adults

Mae Sheikh-Ali, MD, Assistant Professor of Medicine, University of Florida College of Medicine, Division of Endocrinology Diabetes and Metabolism, Department of Medicine, University of Florida College of Medicine, Jacksonville, FL, USA.
Joe M. Chehade, MD, Associate Professor of Medicine, University of Florida College of Medicine, Division of Endocrinology Diabetes and Metabolism, Department of Medicine, University of Florida College of Medicine, Jacksonville, FL, USA.

Over the past decade, eight classes of drugs have been used to treat diabetes; however, insulin remains the most effective and least costly treatment for older adults. The American Diabetes Association has recommended that the approach to drug therapy of diabetes consider insulin a first-tier therapy. Nevertheless, there is a general reluctance among physicians and patients alike to accept insulin. The initiation of insulin therapy is especially challenging in older adults, who often have multiple comorbidities and physical limitations. In this article, we present a case-based approach to the initiation of insulin therapy in older adults.
Key words: diabetes, older adults, insulin therapy, glycemic goals, antihyperglycemic agents.

Glycemic Control in Older Adults: Applying Recent Evidence to Clinical Practice

Ajay Sood, MD, Division of Clinical and Molecular Endocrinology, Case Western Reserve University School of Medicine; Louis Stokes Cleveland Veterans Affairs (VA) Medical Center, Cleveland, OH, USA.
David C. Aron, MD, MS, Division of Clinical and Molecular Endocrinology, Case Western Reserve University School of Medicine; VA Network 10 Geriatric Research, Education, and Clinical Centers, VA Health Services Research and Development Quality Enhancement Research Initiative Diabetes Clinical Coordinating Center; Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA.

Glycemic goals and the decision to intensify glycemic control among older adults with diabetes must be individualized based on comorbid conditions and the risks associated with treatment. The duration of diabetes mellitus, baseline glycosylated hemoglobin value, prior history of cardiovascular disease, and history of severe hypoglycemia are important factors to consider. This article reviews how the management of diabetes mellitus in this subgroup is changing in view of three recently reported randomized trials of intensive glycemic control.
Key words: diabetes, older adults, glycemic control, cardiovascular disease, glycemic goal.

Benefits and Risks of Oral Medications in the Treatment of Older Adults with Type 2 Diabetes

Ali A. Rizvi, MD, Professor of Medicine, Division of Endocrinology, Diabetes, and Metabolism, University of South Carolina School of Medicine, Columbia, South Carolina, USA.

Recent therapeutic advances have seen the emergence of several oral agents for type 2 diabetes, providing an opportunity for better management of the disease. Older adults may pose a special challenge because of altered drug kinetics, the presence of other medical conditions, an increased propensity to adverse reactions, and a lack of evidence-based information for clinical decision making. Consideration should be given to treatment satisfaction, side effects, and the overall risk-benefit ratio of oral medications. It is important for providers to become familiar with the medication profiles and follow a rational initiation and titration regimen tailored to the individual patient.
Key words: diabetes, older adults, hyperglycemia, oral medications, combination therapy.

Educating the Older Adult in Over-the-Counter Medication Use

Judith Glaser, DO, Resident, Physical Medicine and Rehabilitation, New York University School of Medicine, Rusk Institute of Rehabilitation Medicine, New York, NY, USA.
Lydia Rolita, MD, Instructor, Section of Geriatrics, Department of Medicine, New York University School of Medicine, Bellevue Hospital Geriatric Clinic, New York, NY, USA.

The number of over-the-counter (OTC) medications is increasing as more prescription medications are being switched to OTC status. Many older adults rely on self-management of medications to treat common medical conditions such as the common cold, pain, diarrhea, and constipation. Although OTC medications are regulated by the U.S. Food and Drug Administration and Health Canada, many people are unaware of proper dosing, side effects, adverse drug reactions, and possible medication interactions that may not be clearly labelled. This article reviews the major side effects of common OTC medications and how to recognize these adverse effects, and provides health care professionals with information to offer to older adults and their caregivers about safe OTC medication use.
Key words: over-the-counter, self-medication, older adults, side effects, patient education.

Insomnia in Older Adults with Dementia

Jason Strauss, MD, Departments of Psychiatry and Medicine, Division of Gerontology, Harvard Medical School; Beth Israel Deaconess Medical Center, Boston, MA; Hebrew Rehabilitation Center, Roslindale, MA; Cambridge Health Alliance, Cambridge, MA, USA.

Sleep disturbances are frequently seen among older adults with dementia, leading to significant distress for both patients and their caregivers. It is likely that neuronal loss in key areas of the brain contributes to sleep disturbances in this population. When evaluating older adults with dementia and insomnia, try to obtain information regarding all details of their sleep, and determine whether medical, psychiatric, or environmental factors may be contributors. In treating sleep disturbances in older adults with dementia, behavioural interventions should first be used to improve sleep hygiene. At the present time, there are not enough data to standardize recommendations for pharmacological treatment of insomnia in this population, so treatment should be guided by attempting to minimize potential side effects and interactions with other medications.
Key words: sleep, dementia, older adults, sleep hygiene, pharmacological treatment of insomnia.

Prescribing Opioids to Older Adults: A Guide to Choosing and Switching Among Them

Marc Ginsburg, RN, MScN, NP, Medical Student, University of Sint Eustatius School of Medicine, Sint Eustatius, Netherlands-Antilles.
Shawna Silver, MD, PEng, Resident, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON.
Hershl Berman, MD, FRCPC, Assistant Professor, Faculty of Medicine, University of Toronto; Staff Physician, Department of Medicine, University Health Network; Associated Medical Services Fellow in End-of-Life Care Education, University of Toronto; Centre for Innovation In Complex Care, University Health Network, Toronto, ON.

The use of opioid medications and converting among them in the older adult population can often be challenging. Physiological changes in older adults may affect metabolism and cognitive abilities. Due to renally cleared metabolites, some opioids, such as morphine, should be used with caution among older adults. Others, such as meperidine, should never be used at all. When prescribing or changing opioids, the choice of the correct formulation, appropriate counselling, and close follow-up are essential for optimal pain management and in order to prevent adverse outcomes.
Key words: opioids, pain management, older adults, analgesia, opioid conversion.

Vitamin D Deficiency in Older Adults, Part I: the Prevention of Chronic Degenerative Disease and Support of Immune Health

Aileen Burford-Mason, PhD, President, Holistic Health Research Foundation of Canada, Toronto, ON.

Accumulated research evidence suggests that vitamin D deficiency or insufficiency has profound implications for health and well-being, compromising immune responses and increasing the risk for osteoporosis, arthritis, diabetes, depression, cancer, and cardiovascular disease. Older adults, especially those who are housebound, are at increased risk for vitamin D deficiency. In addition to sun avoidance and the use of sunscreen, age, ethnicity, and obesity are risk factors for vitamin D deficiency. This article discusses the use of serum 25-hydroxyvitamin D to assess vitamin D needs and outlines current recommendations on appropriate interventions to improve vitamin D status in older adults.
Key words: vitamin D, older adults, supplements, UVB exposure, immunity.

Update in Endocarditis Prophylaxis

Jason Andrade, MD, Division of Cardiology, University of British Columbia, Department of Medicine, Vancouver, BC.
Aneez Mohamed, MD, Division of Cardiology, University of British Columbia, Department of Medicine, Vancouver, BC.
Chris Rauscher, MD, Division of Geriatric Medicine, University of British Columbia, Department of Medicine, Vancouver, BC.

Infective endocarditis (IE) is a rare but potentially devastating clinical entity with a well-delineated pathogenesis. While previously thought to be a disorder of younger individuals, older adults now represent one of the highest risk groups for the acquisition of and adverse outcomes related to IE. Prior to focusing on the updated recommendations for IE prophylaxis and the rationale behind them, we briefly review the clinical aspects of IE in the general population, as well as special considerations for older adults.
Key words: endocarditis, prophylaxis, older adults, cardiovascular disease, antibiotics.

Fitness, Falls and Older Adults

Our focus in this issue is Fitness and Falls. The benefit of regular exercise was well established with the MacArthur Foundation’s study of healthy aging in 1998,¹ but the difficulties in implementing its recommendations are twofold: how do we encourage our patients to exercise, and how do we prescribe the right kinds of exercise? These two questions are interconnected and the article “Prescribing Exercise” by Dr. Alison Mudge, Robert Mullins, and Julie Adsett offers some answers. Fractures are common sequelae of falls and one type of fracture is discussed in the article “Vertebral Compression Fractures Among Older Adults” by Dr. Simona Abid and Dr. Alexandra Papaioannou. This article is also the basis for our February CME program. I like to say that there is no such thing as a trivial fall for an older adult. Some falls result in trivial injury, but often that is poor good fortune, and a slightly different angle of fall could result in serious damage. Dr. Susan Jaglal, a noted authority in the area of falls among older adults, addresses this in her article “After the Fall: The ABCs of Fracture Prevention.”

We also have our usual collection of articles on various important areas of geriatric care. Our Cardiovascular Disease column provides an “Update in Endocarditis Prophylaxis” and is written by Dr. Jason Andrade, Dr. Aneez Mohamed, and Dr. Chris Rauscher. The changes are quite significant from previous guidelines. Our Dementia column is on “Recreational Activities to Reduce Behavioural Symptoms in Dementia” by Dr. Ann Kolanowski, Dr. Donna Fick, and Dr. Linda Buettner. This issue’s Drugs and Aging column is part one of two on “Vitamin D Deficiency in Older Adults: Implications for Improving Immune System Health and the Prevention of Chronic Degenerative Disease” by Dr. Aileen Burford-Mason. Our Palliative Care column is entitled ”Prescribing Opioids to Older Adults: A Guide to Choosing and Switching Among Them” by Marc Ginsburg, Dr. Shawna Silver, and Dr. Hershl Berman. Our Men’s Health column is “Sexuality and the Aging Couple Part II: The Aging Man” by Drs. Irwin Kuzmarov and Jerald Bain of our partner organization, the Canadian Society for the Study of the Aging Male.

This issue, the first of the new year, also sees some changes in our pages. We’ve added a new section to each article called Clinical Pearls. These short notes suggest directly implementable changes, practices that clinicians can implement in the office to improve their care of older adults. Also, in our ongoing quest for excellence, we’ve expanded our system of peer review to include not only each issue’s CME article but also all the articles on the issue theme. Starting with this issue, all the Focus articles will undergo the same rigorous peer-review process that readers have come to expect of our CME article.

Enjoy this issue,
Barry Goldlist

1. Rowe JW, Kahn RL. Successful Aging: The MacArthur Foundation Study. New York: Dell Publishing, 1998.