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Cited by 548Diabetes Treatment and ManagementDiabetes Management and ResearchPharmaceutical Practices and Patient Outcomes

Diabetes in Older Adults: A Consensus Report

Open access
Sue Kirkman, M., Briscoe, Vanessa Jones, Clark, Nathaniel, Florez, Hermes, Haas, Linda B., Halter, Jeffrey B., Huang, Elbert S., Korytkowski, Mary T. +4 more·2012·Journal of the American Geriatrics Society
DOI 10.1111/jgs.12035PMC PMC4525769
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Abstract

More than 25% of the U.S. population aged ≥ 65 years has diabetes mellitus (hereafter referred to as diabetes),1 and the aging of the overall population is a significant driver of the diabetes epidemic. Although the burden of diabetes is often described in terms of its impact on working-age adults, diabetes in older adults is linked to higher mortality, reduced functional status, and increased risk of institutionalization.2 Older adults with diabetes are at substantial risk for both acute and chronic microvascular and cardiovascular complications of the disease. Despite having the highest prevalence of diabetes of any age-group, older persons and/or those with multiple comorbidities have often been excluded from randomized controlled trials of treatments—and treatment targets—for diabetes and its associated conditions. Heterogeneity of health status of older adults (even within an age range) and the dearth of evidence from clinical trials present challenges to determining standard intervention strategies that fit all older adults. To address these issues, the American Diabetes Association (ADA) convened a Consensus Development Conference on Diabetes and Older Adults (defined as those aged ≥ 65 years) in February 2012. Following a series of scientific presentations by experts in the field, the writing group independently developed this consensus report to address the following questions: According to the most recent surveillance data, the prevalence of diabetes among U.S. adults aged ≥ 65 years varies from 22 to 33%, depending on the diagnostic criteria used. Postprandial hyperglycemia is a prominent characteristic of type 2 diabetes in older adults,3, 4 contributing to observed differences in prevalence depending on which diagnostic test is used.5 Using the hemoglobin A1C (A1C) or fasting plasma glucose (FPG) diagnostic criteria, as is currently done for national surveillance, one-third of older adults with diabetes are undiagnosed.1 The epidemic of type 2 diabetes is clearly linked to increasing rates of overweight and obesity in the U.S. population, but projections by the Centers for Disease Control and Prevention (CDC) suggest that even if diabetes incidence rates level off, the prevalence of diabetes will double in the next 20 years, in part due to the aging of the population.5 Other projections suggest that the number of cases of diagnosed diabetes in those aged ≥ 65 years will increase by 4.5-fold (compared to 3-fold in the total population) between 2005 and 2050.6 The incidence of diabetes increases with age until about age 65 years, after which both incidence and prevalence seem to level off (www.cdc.gov/diabetes/statistics). As a result, older adults with diabetes may either have incident disease (diagnosed at and after age 65 years) or long-standing diabetes with onset in middle age or earlier. Demographic and clinical characteristics of these two groups differ in a number of ways, adding to the complexity of making generalized treatment recommendations for older patients with diabetes. Older-age–onset diabetes is more common in non-Hispanic whites and is characterized by lower mean A1C and lower likelihood of insulin use than is middle-age–onset diabetes. Although a history of retinopathy is significantly more common in older adults with middle-age–onset diabetes than those with older-age onset, there is, interestingly, no difference in prevalence of cardiovascular disease (CVD) or peripheral neuropathy by age of onset.7 Older adults with diabetes have the highest rates of major lower-extremity amputation,8 myocardial infarction (MI), visual impairment, and end-stage renal disease of any age-group. Those aged ≥ 75 years have higher rates than those aged 65–74 years for most complications. Deaths from hyperglycemic crises also are significantly higher in older adults (although rates have declined markedly in the past 2 decades). Those aged ≥ 75 years also have double the rate of emergency department visits for hypoglycemia than the general population with diabetes.9 Although increasing numbers of individuals with type 1 diabetes are living into old age,10 this discussion of pathophysiology concerns type 2 diabetes—overwhelmingly the most common incident and prevalent type in older age-groups. Older adults are at high risk for the development of type 2 diabetes due to the combined effects of increasing insulin resistance and impaired pancreatic islet function with aging. Age-related insulin resistance appears to be primarily associated with adiposity, sarcopenia, and physical inactivity,11 which may partially explain the disproportionate success of the intensive lifestyle intervention in older participants in the Diabetes Prevention Program (DPP).12 However, age-related declines of pancreatic islet function4, 13 and islet proliferative capacity14, 15 have previously been described. Older adults are at high risk for both diabetes and prediabetes, with surveillance data suggesting that half of older

AI snapshot

Written from the paper’s full text.

TL;DR

This consensus report reviews epidemiology, prevention, treatment, and care of diabetes in older adults, emphasizing clinical heterogeneity and individualized goals. It concludes that evidence is limited for older and frail adults and recommends balancing treatment benefits against life expectancy, comorbidity, and functional status.

Key findings

  • Among U.S. adults over age 65, diabetes prevalence varies from 22% to 33% depending on diagnostic criteria; one-third of older adults with diabetes are undiagnosed using A1C or FPG criteria, and about half of older adults have prediabetes.
  • In the Diabetes Prevention Program, participants over age 60 had a 49% risk reduction at 10-year follow-up with lifestyle intervention versus 34% for the total cohort, but older participants did not appear to benefit from metformin.
  • ACCORD’s glucose-control arm was terminated after about 3 years because of excessive deaths in the intensive arm; older participants in both glycemic arms had approximately 50% higher rates of severe hypoglycemia than participants under age 65.
  • In 71,092 patients with type 2 diabetes aged ≥60 years, mortality had a U-shaped relationship with A1C: compared with A1C <6.0%, mortality risk was lower for A1C 6.0%–9.0% and higher at A1C ≥11.0%; risk of any endpoint became significantly higher at A1C ≥8.0%.

Methods

  • Design: consensus report and narrative review, not a primary research study; it synthesizes epidemiology, randomized trials, observational studies, and existing guidelines.
  • Data or sample: no primary sample; cited evidence includes national surveillance data, the DPP, UKPDS, ACCORD, ADVANCE, VADT, observational cohorts, and guidelines from ADA, AGS, VA/DOD, and the European Diabetes Working Party for Older People.
  • Main analysis: expert consensus synthesis with recommendations, including a framework based on Blaum et al. that classifies older patients into three health-status groups by comorbidity and functional impairment.

Limitations

  • The paper states that older and especially frail older adults have been excluded from most traditional randomized controlled trials, leaving large gaps in knowledge; there are essentially no directly applicable clinical trial data on glucose control for large segments of the older diabetes population.
  • The paper states that comparative effectiveness studies of diabetes medications in older adults are lacking, and many guideline recommendations are based on expert opinion.
  • Evident from the text: this is a consensus/narrative report without a described systematic search strategy or formal evidence-grading process, so recommendations reflect expert interpretation and may be subject to selection of cited evidence.

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Integrity signals

Registry

Crossref · 10.1111/jgs.12035

Cites

144 of 144 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 157 cited sources checked · 0 supported · 0 flagged

  • Findingcitation

    In one small study, hormonal counter-regulatory responses to hypoglycemia did not differ between older (mean age 70 years) and middle-aged (mean 51 years) people with type 2 diabetes.

    “One small study compared responses to hypoglycemic clamps in older (mean age 70 years) vs. middle-aged (mean 51 years) people with type 2 diabetes. Hormonal counter-regulatory responses to hypoglycemia did not differ between age groups, but middle-aged participants had a significant increase in autonomic and neuroglycopenic symptoms at the end of the hypoglycemic period, while older participants”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [102] Bremer JP Jauch-Chara K Hallschmid M Schmid S Schultes B Hypoglycemia unawareness in older compared with middle-aged patients with type 2 diabetes Diabetes Care 2009 32 1513 1517 19487634 PMC2713637 source

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  • Findingcitation

    In one study, polypharmacy (use of 6 or more prescription medications) was associated with increased risk of falling in older people.

    “In one study, polypharmacy (defined as use of 6 or more prescription medications) was associated with increased risk of falling in older people75.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [75] Huang ES The Association Between the Number of Prescription Medications and Incident Falls in a Multi-ethnic Population of Adult Type-2 Diabetes Patients: The Diabetes and Aging Study J Gen Intern Med 2010 25 141 146 19967465 PMC2837501 source

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  • Findingcitation

    A mean A1C of 7% was achieved and maintained for 12 months with either an insulin pump regimen or multiple daily insulin injections in otherwise healthy and functional older adults (mean age 66 years), with low rates of hypoglycemia.

    “A mean A1C of 7% was achieved and maintained for 12 months with either an insulin pump regimen or multiple daily insulin injections in otherwise healthy and functional older adults (mean age 66 years), with low rates of hypoglycemia99.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [99] Herman WH Ilag LL Johnson SL A clinical trial of continuous subcutaneous insulin infusion versus multiple daily injections in older adults with type 2 diabetes Diabetes Care 2005 28 1568 1573 15983302 source

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  • Findingcitation

    In a population analysis of Medicaid enrollees treated with insulin or sulfonylureas, incidence of serious hypoglycemia was approximately 2 per 100 person-years.

    “In a population analysis of Medicaid enrollees treated with insulin or sulfonylureas, incidence of serious hypoglycemia (defined as that leading to emergency department visit, hospitalization, or death) was approximately 2 per 100 person-years103, but clearly studies based on administrative databases miss less catastrophic hypoglycemia.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [103] Shorr RI Ray WA Daugherty JR Griffin MR Incidence and risk factors for serious hypoglycemia in older persons using insulin or sulfonylureas Arch Intern Med 1997 157 1681 1686 9250229 source

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  • Findingcitation

    A combination of multiple comorbid illnesses and functional impairments was a better predictor of limited life expectancy and diminished benefits of intensive glucose control than age alone.

    “A combination of multiple comorbid illnesses and functional impairments was a better predictor of limited life expectancy and diminished benefits of intensive glucose control than age alone.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [113] Kassirer JP Incorporating patients' preferences into medical decisions N Engl J Med 1994 330 1895 1896 8196734 source

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  • May combine two claims. 61
  • Classified as probably not a substantial claim. 19
  • The quote only partly states this claim. 1

  • May combine two claims.

    Findingcitation

    In the Look AHEAD study, participants aged 65-76 years had lower gains in fitness with the intensive lifestyle intervention than younger patients, but still improved their measures of fitness by a mean of over 15%.

    “In the Look AHEAD study, participants aged 65–76 years had lower gains in fitness with the intensive lifestyle intervention than younger patients, but still improved their measures of fitness by a mean of over 15%92.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [92] Jakicic JM Jaramillo SA Balasubramanyam A Effect of a lifestyle intervention on change in cardiorespiratory fitness in adults with type 2 diabetes: results from the Look AHEAD Study Int J Obes (Lond) 2009 33 305 316 19153582 PMC2656590

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    Findingcitation

    Addition of long-acting insulin was similarly effective in achieving A1C goals for older patients with type 2 diabetes (mean age 69 years) in a series of trials, with no greater rates of hypoglycemia than in younger patients (mean age 53 years).

    “Addition of long-acting insulin was similarly effective in achieving A1C goals for older patients with type 2 diabetes (mean age 69 years) in a series of trials, with no greater rates of hypoglycemia than in younger patients (mean age 53 years)100.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [100] Lee P Chang A Blaum C Vlajnic A Gao L Halter J Comparison of safety and efficacy of insulin glargine and neutral protamine hagedorn insulin in older adults with type 2 diabetes mellitus: results from a pooled analysis J Am Geriatr Soc 2012 60 51 59 22239291 source

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    Findingcitation

    In the same study, half of middle-aged, but only 1/13 older participants, correctly reported that their blood glucose was low during hypoglycemia.

    “Half of middle-aged, but only 1/13 older participants, correctly reported that their blood glucose was low during hypoglycemia102.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [102] Bremer JP Jauch-Chara K Hallschmid M Schmid S Schultes B Hypoglycemia unawareness in older compared with middle-aged patients with type 2 diabetes Diabetes Care 2009 32 1513 1517 19487634 PMC2713637 source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    In the same study, middle-aged participants had a significant increase in autonomic and neuroglycopenic symptoms at the end of the hypoglycemic period, while older participants did not.

    “Hormonal counter-regulatory responses to hypoglycemia did not differ between age groups, but middle-aged participants had a significant increase in autonomic and neuroglycopenic symptoms at the end of the hypoglycemic period, while older participants did not.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [102] Bremer JP Jauch-Chara K Hallschmid M Schmid S Schultes B Hypoglycemia unawareness in older compared with middle-aged patients with type 2 diabetes Diabetes Care 2009 32 1513 1517 19487634 PMC2713637 source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    In a study of patient preferences regarding diabetes complications and treatments, end-stage complications had the greatest perceived burden on quality of life; comprehensive diabetes treatments had significant negative perceived quality of life effects, similar to those of intermediate complications.

    “In a study of patient preferences regarding diabetes complications and treatments, end- stage complications had the greatest perceived burden on quality of life; however, comprehensive diabetes treatments had significant negative perceived quality of life effects, similar to those of intermediate complications117.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [117] Huang ES Brown SE Ewigman BG Foley EC Meltzer DO Patient perceptions of quality of life with diabetes-related complications and treatments Diabetes Care 2007 30 2478 2483 17623824 PMC2288662

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  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingcitation

    Diabetes is common in LTC facilities, with an overall diabetes prevalence of 25% (22% in Caucasian and 36% in Non-caucasian residents).

    “Diabetes is common in LTC facilities, with an overall diabetes prevalence of 25% (22% in Caucasian and 36% in Non-caucasian residents)122.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [122] Resnick HE Heineman J Stone R Shorr RI Diabetes in U.S. nursing homes, 2004 Diabetes Care 2008 31 287 288 17977933

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  • May combine two claims.

    Findingcitation

    In the Medicaid study, independent risk factors for hypoglycemia included hospital discharge within the prior 30 days, advanced age, black race, and use of 5 or more concomitant medications.

    “In the Medicaid study cited above, independent risk factors included hospital discharge within the prior 30 days, advanced age, black race, and use of 5 or more concomitant medications103.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [103] Shorr RI Ray WA Daugherty JR Griffin MR Incidence and risk factors for serious hypoglycemia in older persons using insulin or sulfonylureas Arch Intern Med 1997 157 1681 1686 9250229 source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Preferences for each health state varied widely among patients, and this variation was not related to health status.

    “Preferences for each health state varied widely among patients, and this variation was not related to health status118, implying that the preferences of an individual patient cannot be assumed to be known based on health status.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [118] Brown SE Meltzer DO Chin MH Huang ES Perceptions of quality-of-life effects of treatments for diabetes mellitus in vulnerable and nonvulnerable older patients J Am Geriatr Soc 2008 56 1183 1190 18492034 PMC2614394

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    Findingcitation

    The model suggests that life expectancy averages less than 5 years for patients age 60-64 years with 7 additional index points, age 65-69 years with 6 additional points, age 70-74 years with 5 additional points, and age 75-79 years with 4 additional points.

    “This model suggests that life expectancy averages less than 5 years for: patients age 60–64 years with 7 additional index points (points due to comorbid conditions and functional impairments), age 65–69 years with 6 additional points, age 70– 74 years with 5 additional points, and age 75–79 years with 4 additional points.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [113] Kassirer JP Incorporating patients' preferences into medical decisions N Engl J Med 1994 330 1895 1896 8196734 source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    LTC residents with diabetes have more falls, higher rates of CVD and depression, more functional impairment, and more cognitive decline and dependency than residents without diabetes.

    “LTC residents with diabetes have more falls123, higher rates of CVD and depression, more functional impairment, and more cognitive decline and dependency than residents without diabetes124.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [123] Maurer MSBJ Cheng H Diabetes mellitus is associated with an increased risk of falls in elderly residents of a long-term care facility Journal of Gerontology Series A: Biological Sciences and Medical Sciences 2005 60 1157 1162 16183956

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    • cites [124] Travis SS Buchanan RJ Wang S Kim M Analyses of nursing home residents with diabetes at admission J Am Med Dir Assoc 2004 5 320 327 15357889

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    Premisecitation

    Older adults with diabetes have the highest rates of major lower extremity amputation, myocardial infarction, visual impairment, and end-stage renal disease of any age group.

    “Older adults with diabetes have the highest rates of major lower extremity amputation9, myocardial infarction, visual impairment, and end-stage renal disease of any age group.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [9] Li Y Burrows NR Gregg EW Albright A Geiss LS Declining rates of hospitalization for nontraumatic lower-extremity amputation in the diabetic population aged 40 years or older: U.S., 1988–2008 Diabetes Care 2012 35 273 277 22275440 PMC3263875

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Those over age 75 years have double the rate of emergency department visits for hypoglycemia than the general population with diabetes.

    “Those over age 75 years also have double the rate of emergency department visits for hypoglycemia than the general population with diabetes10.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [10] National Diabetes Surveillance System: Diabetes Prevention Program 2008

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  • May combine two claims.

    Premisecitation

    Age-related declines of pancreatic islet function and of islet proliferative capacity have been described.

    “However, age-related declines of pancreatic islet function4, 14 and of islet proliferative capacity15, 16; have been described.”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [4] Chang AM Halter JB Aging and insulin secretion Am J Physiol Endocrinol Metab 2003 284 E7 E12 12485807 source

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    • cites [14] Reers C Erbel S Esposito I Impaired islet turnover in human donor pancreata with aging Eur J Endocrinol 2009 160 185 191 19004984 source

      Not checked in the free run.

    • cites [15] Maedler K Schumann DM Schulthess F Aging correlates with decreased beta-cell proliferative capacity and enhanced sensitivity to apoptosis: a potential role for Fas and pancreatic duodenal homeobox-1 Diabetes 2006 55 2455 2462 16936193 source

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    • cites [16] Rankin MMaK J A Adaptive βCell Proliferation Is Severely Restricted With Advanced Age Diabetes 2009 58 1365 1372 19265026 PMC2682671 source

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  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Even if diabetes incidence rates level off, CDC projections suggest prevalence of diabetes will double in the next 20 years, in part due to aging of the population.

    “projections by the Centers for Disease Control and Prevention (CDC) suggest that even if diabetes incidence rates level off, the prevalence of diabetes will double in the next 20 years, in part due to aging of the population6.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [6] Boyle JP Thompson TJ Gregg EW Barker LE Williamson DF Projection of the year 2050 burden of diabetes in the US adult population: dynamic modeling of incidence, mortality, and prediabetes prevalence Popul Health Metr 2010 8 29 20969750 PMC2984379 source

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  • May combine two claims.

    Premisecitation

    History of retinopathy is significantly more common in older adults with middle age-onset diabetes than those with older-age onset, but there is no difference in prevalence of cardiovascular disease or peripheral neuropathy by age of onset.

    “Although history of retinopathy is significantly more common in older adults with middle age-onset diabetes than those with older-age onset, there is, interestingly, no difference in prevalence of cardiovascular disease or peripheral neuropathy by age of onset8.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] Selvin E Coresh J Brancati FL The burden and treatment of diabetes in elderly individuals in the u.s. Diabetes Care 2006 29 2415 2419 17065677

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  • May combine two claims.

    Premisecitation

    Older-age-onset diabetes is more common in non-Hispanic whites and is characterized by lower mean A1C and lower likelihood of insulin use than is middle-age onset diabetes.

    “Older-age-onset diabetes is more common in non-Hispanic whites and is characterized by lower mean A1C and lower likelihood of insulin use than is middle-age onset diabetes.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] Selvin E Coresh J Brancati FL The burden and treatment of diabetes in elderly individuals in the u.s. Diabetes Care 2006 29 2415 2419 17065677

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  • May combine two claims.

    Premisenone given

    These trials enrolled patients at significantly higher cardiovascular risk than did the UKPDS, with each having a substantial proportion of participants with a prior CV event, mean age at enrollment in the 60s, and established diabetes (8-11 years).

    “The trials enrolled patients at significantly higher cardiovascular risk than did the UKPDS, with each having a substantial proportion of participants with a prior CV event, mean age at enrollment in the 60’s, and established diabetes (8–11 years).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    The UKPDS provided evidence of the benefits of glycemic control on microvascular complications, enrolled middle-aged patients with newly diagnosed type 2 diabetes, excluding those over the age of 65 years at enrollment.

    “The United Kingdom Prospective Diabetes Study (UKPDS), which provided valuable evidence of the benefits of glycemic control on microvascular complications, enrolled middle-aged patients with newly diagnosed type 2 diabetes, excluding those over the age of 65 years at the time of enrollment24, 25.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [24] Group UKPDS Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group Lancet 1998 352 837 853 9742976 source

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    • cites [25] Group UKPDS Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). UK Prospective Diabetes Study (UKPDS) Group Lancet 1998 352 854 865 9742977 source

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  • May combine two claims.

    Premisecitation

    Microvascular benefits persisted during the post-trial follow-up period, and statistically significant reductions in both mortality and myocardial infarctions emerged, referred to as the 'legacy effect' of early glycemic control.

    “Microvascular benefits persisted during the post-trial follow-up period, and statistically significant reductions in both mortality and myocardial infarctions emerged, referred to as the “legacy effect” of early glycemic control26.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [26] Holman RRPS Bethel MA Matthews DR Neil HA 10-Year follow-up of intensive glucose control in type 2 diabetes N Engl J Med 2008 359 1577 1589 18784090 source

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    Premisecitation

    In the DPP, older participants seemed to have more efficacy from the lifestyle intervention than younger participants, but did not appear to benefit from metformin.

    “These participants seemed to have more efficacy from the lifestyle intervention than younger participants, but did not appear to benefit from metformin13, 18.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [13] Knowler WC Barrett-Connor E Fowler SE Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin N Engl J Med 2002 346 393 403 11832527 PMC1370926 source

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    • cites [18] Crandall J Schade D Ma Y The influence of age on the effects of lifestyle modification and metformin in prevention of diabetes J Gerontol A Biol Sci Med Sci 2006 61 1075 1081 17077202 PMC1783677 source

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  • May combine two claims.

    Premisecitation

    The VADT, over 5 years of follow-up, found no statistically significant effect of intensive glucose control on major cardiovascular events or death, but did find significant reductions in onset and progression of albuminuria.

    “The VADT, over 5 years of follow-up, found no statistically significant effect of intensive glucose control on major cardiovascular events or death, but did find significant reductions in onset and progression of albuminuria30.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [30] Duckworth W Abraira C Moritz T Glucose control and vascular complications in veterans with type 2 diabetes N Engl J Med 2009 360 129 139 19092145

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    Premisecitation

    The DPP lifestyle intervention had additional benefits that might impact older adults: reduction in urinary incontinence, improvement in several quality of life domains, and improvements in cardiovascular risk factors.

    “additional benefits of the lifestyle intervention that might impact older adults: reduction in urinary incontinence20, improvement in several quality of life domains21, and improvements in cardiovascular risk factors22”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [20] Brown JS Wing R Barrett-Connor E Lifestyle intervention is associated with lower prevalence of urinary incontinence: the Diabetes Prevention Program Diabetes Care 2006 29 385 390 16443892 PMC1557353 source

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    • cites [21] Florez H Pan Q Ackermann RT Impact of Lifestyle Intervention and Metformin on Health-Related Quality of Life: the Diabetes Prevention Program Randomized Trial J Gen Intern Med 2012 PMC3509296 22692637 source

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    • cites [22] Crandall JP Knowler WC Kahn SE The prevention of type 2 diabetes Nat Clin Pract Endocrinol Metab 2008 4 382 393 18493227 PMC2573045 source

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Other projections suggest the number of cases of diagnosed diabetes in those over 65 years of age will increase by 4.5-fold between 2005 and 2050.

    “Other projections suggest that the number of cases of diagnosed diabetes in those over 65 years of age will increase by 4.5-fold (compared to 3-fold in the total population) between 2005 and 20507.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [7] Narayan KM Boyle JP Geiss LS Saaddine JB Thompson TJ Impact of recent increase in incidence on future diabetes burden: U.S., 2005–2050 Diabetes Care 2006 29 2114 2116 16936162

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    Premisecitation

    The incidence of diabetes increases with age until about age 65 years, after which both incidence and prevalence seem to level off.

    “The incidence of diabetes increases with age until about age 65 years, after which both incidence and prevalence seem to level off (www.cdc.gov/diabetes/statistics).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites www.cdc.gov/diabetes/statistics

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    Premisecitation

    Preventive strategies that can be efficiently implemented in clinical settings and in the community have been developed and evaluated, but there has been little focus on older adults in these translational studies.

    “Preventive strategies that can be efficiently implemented in clinical settings and in the community have been developed and evaluated23, but as yet there has been little focus on older adults in these translational studies.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [23] Ackermann RT Finch EA Brizendine E Zhou H Marrero DG Translating the Diabetes Prevention Program into the community. The DEPLOY Pilot Study Am J Prev Med 2008 35 357 363 18779029 PMC2610485

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  • May combine two claims.

    Premisecitation

    Older adults are at high risk for both diabetes and prediabetes, with surveillance data suggesting that half of older adults have prediabetes.

    “Older adults are at high risk for both diabetes and prediabetes, with surveillance data suggesting that half of older adults have the latter1.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [1] Centers for Disease Control and Prevention National Diabetes Fact Sheet: general information and national estimates on diabetes in the United States, 2011 2011 Atlanta, Georgia U.S.Department of Health and Human Services, Centers for Disease Control and Prevention 2011

      Not checked in the free run.

  • May combine two claims.

    Premisenone given

    The DPP did not enroll significant numbers over the age of 70 years, nor those with functional or cognitive impairments.

    “the DPP did not enroll significant numbers over the age of 70 years, nor those with functional or cognitive impairments.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    ADVANCE had no statistically significant cardiovascular benefits, but there was a significant reduction in the incidence of nephropathy.

    “While there were no statistically significant cardiovascular benefits, there was a significant reduction in the incidence of nephropathy.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [29] Patel A MacMahon S Chalmers J Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes N Engl J Med 2008 358 2560 2572 18539916 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Post-prandial hyperglycemia is a prominent characteristic of type 2 diabetes in older adults, contributing to observed differences in prevalence depending on which diagnostic test is used.

    “Post-prandial hyperglycemia is a prominent characteristic of type 2 diabetes in older adults3, 4, contributing to observed differences in prevalence depending on which diagnostic test is used5.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [3] Szoke E Shrayyef MZ Messing S Effect of aging on glucose homeostasis: accelerated deterioration of beta-cell function in individuals with impaired glucose tolerance Diabetes Care 2008 31 539 543 18083793

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    • cites [4] Chang AM Halter JB Aging and insulin secretion Am J Physiol Endocrinol Metab 2003 284 E7 E12 12485807

      Not checked in the free run.

    • cites [5] Cowie CC Rust KF Ford ES Full accounting of diabetes and pre-diabetes in the U.S. population in 1988–1994 and 2005–2006 Diabetes Care 2009 32 287 294 19017771 PMC2628695

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    A post-hoc analysis of the VADT trial showed that those whose SBP was ≥140 mm Hg had increased mortality, while those at <105 mm Hg, 105-129 mm Hg, and 130-139 mm Hg had equally low mortality rates; for diastolic BP, achieved values <70 mm Hg were associated with higher mortality, while those of 70-79 mm Hg or >80 mm Hg were equally low.

    “A post-hoc analysis of the VADT trial (in which the goal BP was < 130/80 mm Hg) showed, similarly, that those whose SBP was ≥ 140 mm Hg had increased mortality, while those at < 105 mm Hg, 105–129 mm Hg, and 130–139 mm Hg had equally low mortality rates. For diastolic BP, achieved values < 70 mm Hg were associated with higher mortality, while those of 70–79 mm Hg or > 80 mm Hg were equally low48.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [48] Anderson RJ Bahn GD Moritz TE Kaufman D Abraira C Duckworth W Blood pressure and cardiovascular disease risk in the Veterans Affairs Diabetes Trial Diabetes Care 2011 34 34 38 21059830 PMC3005453 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The greater risk of major gastrointestinal or intracerebral bleeding in older adults who use aspirin was suggested by an observational analysis, but diabetes per se was not associated with increased bleeding with aspirin.

    “More recently, the greater risk of major gastrointestinal or intracerebral bleeding in older adults who use aspirin was suggested by an observational analysis, but diabetes per se was not associated with increased bleeding with aspirin52.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [52] De Berardis G Lucisano G D'Ettorre A Association of aspirin use with major bleeding in patients with and without diabetes JAMA 2012 307 2286 2294 22706834

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The screening and interventions for chronic diabetes complications recommended by the American Diabetes Association have a strong evidence base and are cost-effective.

    “The screening and interventions for chronic diabetes complications recommended by the American Diabetes Association have a strong evidence base and are cost-effective54.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [54] Li R Zhang P Barker LE Chowdhury FM Zhang X Cost-effectiveness of interventions to prevent and control diabetes mellitus: a systematic review Diabetes Care 2010 33 1872 1894 20668156 PMC2909081 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The ACCORD-BP trial showed no benefit on the primary outcome (major adverse CV events) of SBP targets <120 mm Hg compared to <140 mm Hg, but found a significant reduction in stroke, a secondary outcome.

    “The ACCORD-BP trial showed no benefit on the primary outcome (major adverse CV events) of SBP targets < 120 mm Hg compared to < 140 mm Hg, but found a significant reduction in stroke, a secondary outcome46.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [46] Cushman WC Evans GW Byington RP Effects of intensive blood-pressure control in type 2 diabetes mellitus N Engl J Med 2010 362 1575 1585 20228401 PMC4123215 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The California Healthcare Foundation/American Geriatrics Society guideline suggested that the timeline of benefits was estimated to be at least 8 years for glycemic control and 2-3 years for blood pressure and lipid control.

    “The guideline also suggested that the timeline of benefits was estimated to be at least 8 years for glycemic control and 2–3 years for blood pressure and lipid control2.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [2] Brown AF Mangione CM Saliba D Sarkisian CA Guidelines for improving the care of the older person with diabetes mellitus J Am Geriatr Soc 2003 51 S265 S280 12694461

      Not checked in the free run.

  • May combine two claims. The quote only partly states this claim.

    Premisecitation

    A retrospective cohort study of 71,092 patients with type 2 diabetes ≥60 years of age found that mortality had a U-shaped relationship with A1C; compared to risk with A1C <6.0%, mortality risk was lower for A1C between 6.0%-9.0% and higher at A1C ≥11.0%; risk of any endpoint became significantly higher at A1C ≥8.0%; patterns were generally consistent across age groups (60-69, 70-79, and 80+ years

    “A retrospective cohort study of 71,092 patients with type 2 diabetes, ≥60 years of age evaluated the relationships between baseline A1C and subsequent outcomes (acute non-fatal metabolic, microvascular, and cardiovascular events and mortality). As in the prior study, mortality had a U-shaped relationship with A1C. Compared to risk with A1C <6.0%, mortality risk was lower for A1C between 6.0%–9.0%”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [35] Huang ES Liu JY Moffet HH John PM Karter AJ Glycemic control, complications, and death in older diabetic patients: the diabetes and aging study Diabetes Care 2011 34 1329 1336 21505211 PMC3114320

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationreasoning

    Extensive review of the guidelines is beyond the scope of this report, but there are similar themes, which suggest pursuing an individualized approach with a focus on clinical and functional heterogeneity and comorbidities, and weighing the expected timeframe of benefit of interventions against life expectancy.

    “Extensive review of the guidelines is beyond the scope of this report, but there are similar themes, which suggest pursuing an individualized approach with a focus on clinical and functional heterogeneity and comorbidities, and weighing the expected timeframe of benefit of interventions against life expectancy.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The American Diabetes Association goals for glycemic control do not specifically mention age.

    “The American Diabetes Association goals for glycemic control do not specifically mention age.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [17] American Diabetes Assoication Standards of medical care in diabetes--2012 Diabetes Care 2012 35 Suppl 1 S11 S63 22187469 PMC3632172 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The incidence of gastrointestinal bleeding with use of aspirin has not been directly compared in older versus middle-aged adults, but in separate studies rates were higher (1-10 per 1,000 annually) for older adults than those for middle-aged adults (3 per 10,000 annually).

    “The incidence of gastrointestinal bleeding with use of aspirin has not been directly compared in older versus middle-aged adults, but in separate studies rates were higher (1–10 per 1,000 annually) for older adults51 than those for middle-aged adults (3 per 10,000 annually49.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [51] Hernandez-Diaz S Garcia Rodriguez LA Cardioprotective aspirin users and their excess risk of upper gastrointestinal complications BMC Med 2006 4 22 16987411 PMC1590044

      Not checked in the free run.

    • cites [49] Baigent C Blackwell L Collins R Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials Lancet 373 1849 1860 19482214 PMC2715005

      Not checked in the free run.

  • May combine two claims.

    Premisereasoning

    The benefits of aspirin for primary prevention of CVD events have not been thoroughly elucidated in older adults with diabetes, and must be balanced against risk of adverse events such as bleeding.

    “However, the benefits of aspirin for primary prevention of CVD events have not been thoroughly elucidated in older adults with diabetes, and must be balanced against risk of adverse events such as bleeding.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisenone given

    Several organizations have developed diabetes guidelines specific to, or including, older adults.

    “Several organizations have developed diabetes guidelines specific to, or including, older adults.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    A randomized study of Japanese individuals with diabetes but no CVD history demonstrated no significant benefit for aspirin on the composite primary outcome, but subgroup analysis of subjects over 65 years of age demonstrated a significantly lower risk of the primary endpoint with aspirin.

    “A randomized study of Japanese individuals with diabetes but no CVD history demonstrated no significant benefit for aspirin on the composite primary outcome, but subgroup analysis of subjects over 65 years of age demonstrated a significantly lower risk of the primary endpoint with aspirin50.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [50] Ogawa H Nakayama M Morimoto T Low-dose aspirin for primary prevention of atherosclerotic events in patients with type 2 diabetes: a randomized controlled trial JAMA 2008 300 2134 2141 18997198

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Geriatric syndromes occur at higher frequency in older adults with diabetes, and may affect self-care abilities and health outcomes including quality of life.

    “a group of conditions termed geriatric syndromes, described below, also occur at higher frequency in older adults with diabetes, and may affect self-care abilities and health outcomes including quality of life58.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [58] Laiteerapong N Karter AJ Liu JY Correlates of quality of life in older adults with diabetes: the diabetes & aging study Diabetes Care 2011 34 1749 1753 21636795 PMC3142040 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Diabetes is associated with increased risk of multiple co-existing medical conditions in older adults, ranging from cardiovascular disease to cancer, potentially impacting treatment decisions.

    “Diabetes is associated with increased risk of multiple co-existing medical conditions in older adults, ranging from cardiovascular disease to cancer, potentially impacting treatment decisions, such as whether stringent glycemic control would be of net benefit36, 37.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [36] Piette JD Kerr EA The impact of comorbid chronic conditions on diabetes care Diabetes Care 2006 29 725 731 16505540

      Not checked in the free run.

    • cites [37] Laiteerapong N Huang ES Chin MH Prioritization of care in adults with diabetes and comorbidity Ann N Y Acad Sci 2011 1243 69 87 22211894 PMC3292541

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Observational analyses of other trial cohorts suggest no benefit to SBP targets more aggressive than <140 mm Hg, and that low diastolic BP may be a risk factor for mortality in older adults.

    “Observational analyses of other trial cohorts suggest no benefit to SBP targets more aggressive than < 140 mm Hg, and that low diastolic BP may be a risk factor for mortality in older adults.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisenone given

    The Department of Veterans Affairs and Department of Defense (VA/DOD) diabetes guideline was updated in 2010.

    “The Department of Veterans Affairs and Department of Defense (VA/DOD) diabetes guideline was updated in 2010.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisereasoning

    The VA/DOD guidelines highlight the frequency of comorbid conditions in patients with diabetes, and stratify glycemic goals based on comorbidity and life expectancy.

    “They highlight the frequency of comorbid conditions in patients with diabetes, and stratify glycemic goals based on comorbidity and life expectancy.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The American Diabetes Association section on older adults discusses the heterogeneity of persons over the age of 65 years and the lack of high-level evidence.

    “The section discusses the heterogeneity of persons over the age of 65 years and the lack of high-level evidence.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [17] American Diabetes Assoication Standards of medical care in diabetes--2012 Diabetes Care 2012 35 Suppl 1 S11 S63 22187469 PMC3632172 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The American Diabetes Association includes a section on older adults in its annual Standards of Medical Care in Diabetes.

    “The American Diabetes Association includes a section on older adults in its annual Standards of Medical Care in Diabetes17.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [17] American Diabetes Assoication Standards of medical care in diabetes--2012 Diabetes Care 2012 35 Suppl 1 S11 S63 22187469 PMC3632172 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisenone given

    The European Diabetes Working Party for Older People recently published guidelines for treating people with diabetes over aged 70 years.

    “The European Diabetes Working Party for Older People recently published guidelines for treating people with diabetes over aged 70 years.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Post-hoc analyses suggested that mortality in the intensive vs. standard glycemic control arm was inversely related to duration of diabetes at the time of study enrollment; those with diabetes duration less than 15 years had a mortality benefit in the intensive arm, while those with duration of 20 years or more had higher mortality in the intensive arm.

    “Post-hoc analyses suggested that mortality in the intensive vs. standard glycemic control arm was inversely related to duration of diabetes at the time of study enrollment. Those with diabetes duration less than 15 years had a mortality benefit in the intensive arm, while those with duration of 20 years or more had higher mortality in the intensive arm31.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [31] Duckworth WC Abraira C Moritz TE The duration of diabetes affects the response to intensive glucose control in type 2 subjects: the VA Diabetes Trial J Diabetes Complications 2011 25 355 361 22055259 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In a 5-year longitudinal observational study of Italian patients with type 2 diabetes, having an A1C of <6.5% or <7% at baseline was associated with lower 5-year incidence of cardiovascular events in the low-to-moderate comorbidity subgroup, but not in the high comorbidity subgroup, suggesting that patients with high levels of comorbidity may not receive cardiovascular benefit from intensive blood

    “Having an A1C of < 6.5% or < 7% at baseline was associated with lower 5-year incidence of cardiovascular events in the low-to-moderate comorbidity subgroup, but not in the high comorbidity subgroup, suggesting that patients with high levels of comorbidity may not receive cardiovascular benefit from intensive blood glucose control38.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [38] Greenfield S Billimek J Pellegrini F Comorbidity affects the relationship between glycemic control and cardiovascular outcomes in diabetes: a cohort study Ann Intern Med 2009 151 854 860 20008761

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In the ACCORD trial, neither intensive glycemic control nor blood pressure control to a target systolic <120 mmHg was shown to prevent decline in brain function.

    “In this trial, neither intensive glycemic control nor blood pressure control to a target systolic < 120 mmHg was shown to prevent decline in brain function61.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [61] Launer LJ Miller ME Williamson JD Effects of intensive glucose lowering on brain structure and function in people with type 2 diabetes (ACCORD MIND): a randomised open-label substudy Lancet Neurol 2011 10 969 977 21958949 PMC3333485 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Nearly 1 in 5 older U.S. adults with diabetes report visual impairment.

    “Nearly 1 in 5 older U.S. adults with diabetes report visual impairment81.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [81] Prevention CfDCa Centers for Disease Control and Prevention Diabetes Data & Trends 2012 Volume 2012

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Hypoglycemia is linked to cognitive dysfunction in a bidirectional fashion: cognitive impairment increases subsequent risk of hypoglycemia, and a history of severe hypoglycemia is linked to incidence of dementia.

    “Hypoglycemia is linked to cognitive dysfunction in a bidirectional fashion: cognitive impairment increases subsequent risk of hypoglycemia60, and a history of severe hypoglycemia is linked to incidence of dementia63.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [60] Punthakee Z Miller ME Launer LJ Poor cognitive function and risk of severe hypoglycemia in type 2 diabetes: post hoc epidemiologic analysis of the ACCORD trial Diabetes Care 2012 35 787 793 22374637 PMC3308284

      Not checked in the free run.

    • cites [63] Whitmer RA Karter AJ Yaffe K Quesenberry CP Jr Selby JV Hypoglycemic episodes and risk of dementia in older patients with type 2 diabetes mellitus JAMA 2009 301 1565 1572 19366776 PMC2782622

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Obesity exacerbates decline in physical function due to aging and increases the risk of frailty.

    “Obesity exacerbates decline in physical function due to aging and increases the risk of frailty86.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [86] Villareal DT Banks M Sinacore DR Siener C Klein S Effect of weight loss and exercise on frailty in obese older adults Arch Intern Med 2006 166 860 866 16636211 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Normal aging and diabetes, and conditions that impair functionality, are associated with higher risk of falls and fractures.

    “Normal aging and diabetes, and the conditions described above that impair functionality, are associated with higher risk of falls and fractures70, 71.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [70] Volpato S Leveille SG Blaum C Fried LP Guralnik JM Risk factors for falls in older disabled women with diabetes: the women's health and aging study J Gerontol A Biol Sci Med Sci 2005 60 1539 1545 16424285 PMC2366043

      Not checked in the free run.

    • cites [71] Schwartz AV Hillier TA Sellmeyer DE Older women with diabetes have a higher risk of falls: a prospective study Diabetes Care 2002 25 1749 1754 12351472

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    After controlling for age, people with diabetes are less physically active and have more functional impairment than those without diabetes.

    “After controlling for age, people with diabetes are less physically active and have more functional impairment than those without diabetes64, 65.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [64] Gregg EW Mangione CM Cauley JA Diabetes and incidence of functional disability in older women Diabetes Care 2002 25 61 67 11772902

      Not checked in the free run.

    • cites [65] Gregg EW Sorlie P Paulose-Ram R Prevalence of lower-extremity disease in the US adult population >=40 years of age with and without diabetes: 1999–2000 national health and nutrition examination survey Diabetes Care 2004 27 1591 1597 15220233

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Age-related changes may translate into increased risk for hypoglycemia, potential need for reduced doses of certain medications, and attention to renal function to minimize side effects.

    “These changes may translate into increased risk for hypoglycemia, potential need for reduced doses of certain medications, and attention to renal function to minimize side effects94, 95.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [94] Lipska KJ Bailey CJ Inzucchi SE Use of metformin in the setting of mild-to-moderate renal insufficiency Diabetes Care 2011 34 1431 1437 21617112 PMC3114336 source

      Not checked in the free run.

    • cites [95] Shorr RI Ray WA Daugherty JR Griffin MR Individual sulfonylureas and serious hypoglycemia in older people J Am Geriatr Soc 1996 44 751 755 8675920 source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Understanding the advantages and disadvantages of each hyperglycemic drug class helps clinicians individualize therapy for patients with type 2 diabetes.

    “Understanding the advantages and disadvantages of each hyperglycemic drug class helps clinicians individualize therapy for patients with type 2 diabetes96.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [96] Inzucchi SE Bergenstal RM Buse JB Management of Hyperglycemia in Type 2 Diabetes: A Patient-Centered Approach: Position Statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) Diabetes Care 2012 35 1364 1379 22517736 PMC3357214

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    People with diabetes of longer duration, and those with higher A1C, have lower muscle strength per unit of muscle mass than BMI- and age-matched people without diabetes, and than those whose disease is of shorter duration or under better glycemic control.

    “People with diabetes of longer duration, and those with higher A1C, have lower muscle strength per unit of muscle mass than BMI- and age-matched people without diabetes, and than those whose disease is of shorter duration or under better glycemic control90.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [90] Park SW Goodpaster BH Strotmeyer ES Decreased muscle strength and quality in older adults with type 2 diabetes: the health, aging, and body composition study Diabetes 2006 55 1813 1818 16731847 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Untreated depression can lead to difficulty with self-care and with implementing healthier lifestyle choices.

    “Untreated depression can lead to difficulty with self-care and with implementing healthier lifestyle choices77 and is associated with higher risk of mortality and dementia in patients with diabetes78, 79.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [77] Lin EH Katon W Von Korff M Relationship of depression and diabetes self-care, medication adherence, and preventive care Diabetes Care 2004 27 2154 2160 15333477

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    There is often inadequate oversight of glycemic control related to infrequent review of glycemic trends, complex and difficult-to-read glucose logs, and lack of specific diabetes treatment algorithms including glycemic parameters for provider notification.

    “There is often inadequate oversight of glycemic control related to infrequent review of glycemic trends, complex and difficult-to-read glucose logs, and lack of specific diabetes treatment algorithms including glycemic parameters for provider notification128.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [128] Feldman SM Rosen R DeStasio J Status of diabetes management in the nursing home setting in 2008: a retrospective chart review and epidemiology study of diabetic nursing home residents and nursing home initiatives in diabetes management J Am Med Dir Assoc 2009 10 354 360 19497549 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    National Vital Statistics Life Table estimates of average life expectancy for adults of specific ages, genders, and races may not apply to older adults with diabetes, who have shorter life expectancies than the average older adult.

    “National Vital Statistics Life Table estimates of average life expectancy for adults of specific ages, genders, and races106, may not apply to older adults with diabetes, who have shorter life expectancies than the average older adult.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [106] Arias E United States life tables, 2007 Natl Vital Stat Rep 2011 59 1 60 22070012

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Key components of the shared decision-making approach are establishing an ongoing partnership between patient and provider, information exchange, deliberation on choices, and deciding and acting on decisions.

    “Key components of the shared decision-making approach are 1) establishing an ongoing partnership between patient and provider, 2) information exchange, 3) deliberation on choices, and 4) deciding and acting on decisions115.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [115] Montori VM Gafni A Charles C A shared treatment decision-making approach between patients with chronic conditions and their clinicians: the case of diabetes Health Expect 2006 9 25 36 16436159 PMC5060323

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Serving meals that take into account the patient's culture, preferences, personal goals and abilities may increase quality of life, satisfaction with meals, and nutrition status.

    “Serving meals that take into account the patient’s culture, preferences, personal goals and abilities may increase quality of life, satisfaction with meals, and nutrition status125.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [125] Dorner B Friedrich EK Posthauer ME Position of the American Dietetic Association: individualized nutrition approaches for older adults in health care communities J Am Diet Assoc 2010 110 1549 1553 20882714

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Among older adults, African Americans and Hispanics have higher incidence and prevalence of type 2 diabetes than non-Hispanic whites, and those with diagnosed diabetes have worse glycemic control and higher rates of comorbid conditions and complications.

    “Among older adults, African Americans and Hispanics have higher incidence and prevalence of type 2 diabetes than non-Hispanic whites, and those with diagnosed diabetes have worse glycemic control and higher rates of comorbid conditions and complications120.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [120] Traylor AH Subramanian U Uratsu CS Mangione CM Selby JV Schmittdiel JA Patient race/ethnicity and patient-physician race/ethnicity concordance in the management of cardiovascular disease risk factors for patients with diabetes Diabetes Care 2010 33 520 525 20009094 PMC2827501

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationcitation

    Studies of glycemic control targets in critically ill patients did include older adults, and therefore the recommendations for insulin infusions and glycemic goals of the American Diabetes Association are reasonable for older adults in intensive care units.

    “Studies of glycemic control targets in critically ill patients did include older adults, and therefore the recommendations for insulin infusions and glycemic goals of the American Diabetes Association17 are reasonable for older adults in intensive care units.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [17] American Diabetes Assoication Standards of medical care in diabetes--2012 Diabetes Care 2012 35 Suppl 1 S11 S63 22187469 PMC3632172 source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Shared decision-making has been advocated as an approach to improving the quality of preference-sensitive medical decisions.

    “Shared decision-making has been advocated as an approach to improving the quality of these so-called preference-sensitive medical decisions113, 114.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [113] Kassirer JP Incorporating patients' preferences into medical decisions N Engl J Med 1994 330 1895 1896 8196734 source

      Not checked in the free run.

    • cites [114] Barry MJ Edgman-Levitan S Shared decision making--pinnacle of patient-centered care N Engl J Med 2012 366 780 781 22375967 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Precipitating situations for volume depletion and hyperglycemic crises include illness, institutional settings (LTC or hospital), aversion to drinking water, dysphasia requiring thickened liquids, and some medications.

    “Precipitating situations include: illness, institutional settings (LTC or hospital), aversion to drinking water, dysphasia requiring thickened liquids, and some medications126.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [126] Thomas DR Cote TR Lawhorne L Understanding clinical dehydration and its treatment J Am Med Dir Assoc 2008 9 292 301 18519109

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Current guidelines recommend preprandial glycemic targets of 100-140 mg/dl with maximal random values of 180 mg/dl in the majority of non-critically ill hospitalized patients, provided these targets can be safely achieved with low risk for hypoglycemia.

    “Current guidelines recommend preprandial glycemic targets of 100–140 mg/dl with maximal random values of 180 mg/dl in the majority of non-critically ill hospitalized patients, provided these targets can be safely achieved with low risk for hypoglycemia.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [130] Moghissi ES Korytkowski MT DiNardo M American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control Diabetes Care 2009 32 1119 1131 19429873 PMC2681039

      Not checked in the free run.

    • cites [131] Umpierrez GE Hellman R Korytkowski MT Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline J Clin Endocrinol Metab 2012 97 16 38 22223765

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    In general, glucose levels should be maintained at values below 200 mg/dl to minimize symptomatic hyperglycemia with associated fluid and electrolyte abnormalities, renal complications, and risk for infection.

    “However, in general, glucose levels should be maintained at values below 200 mg/dl to minimize symptomatic hyperglycemia with associated fluid and electrolyte abnormalities, renal complications, and risk for infection131, 132.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [131] Umpierrez GE Hellman R Korytkowski MT Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline J Clin Endocrinol Metab 2012 97 16 38 22223765

      Not checked in the free run.

    • cites [132] Moghissi ES Korytkowski MT DiNardo MM American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycemic Control Diabetes Care 2009 32 1119 1131 19429873 PMC2681039

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The Institute of Medicine found that although health-care access and demographic variables account for some racial and ethnic disparities, there are persistent, residual gaps in outcomes attributed to differences in the quality of care received.

    “The Institute of Medicine found that although health-care access and demographic variables account for some racial and ethnic disparities, there are persistent, residual gaps in outcomes attributed to differences in the quality of care received121.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [121] Committee on Understanding Eliminating Racial Ethnic Disparities in Health Care. Unequal Treatment:Confronting Racial and Ethnic Disparities in Health Care (with CD) The National Academies Press 2003 25032386

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Mortality prediction models specific to diabetes exist but were not designed to inform treatment decisions.

    “Mortality prediction models specific to diabetes exist but were not designed to inform treatment decisions110, 111.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [110] Wells BJ Jain A Arrigain S Yu C Rosenkrans WA Jr Kattan MW Predicting 6-year mortality risk in patients with type 2 diabetes Diabetes Care 2008 31 2301 2306 18809629 PMC2584185

      Not checked in the free run.

    • cites [111] McEwen LN Kim C Karter AJ Risk factors for mortality among patients with diabetes: the Translating Research Into Action for Diabetes (TRIAD) Study Diabetes Care 2007 30 1736 1741 17468353

      Not checked in the free run.

73 of 73

  • The paper relies on this without support.

    High rates of unidentified cognitive deficits exist in older adults.

    “High rates of unidentified cognitive deficits in older adults suggest that it is important to screen for cognitive dysfunction periodically.”

  • The paper relies on this without support.

    Cognitive dysfunction makes it difficult for patients to perform complex self-care tasks such as glucose monitoring, changing insulin doses, or maintaining timing and content of diet appropriately.

    “Such dysfunction makes it difficult for patients to perform complex self-care tasks such as glucose monitoring, changing insulin doses, or maintaining timing and content of diet appropriately.”

  • The paper relies on this without support.

    Avoidance of severe hyperglycemia and hypoglycemia can decrease the risk of falls.

    “Avoidance of severe hyperglycemia and hypoglycemia can decrease the risk of falls.”

  • The paper relies on this without support.

    Older adults with diabetes are at high risk of polypharmacy, increasing the risk of drug side effects and drug-to-drug interactions.

    “Older adults with diabetes are at high risk of polypharmacy, increasing the risk of drug side effects and drug-to-drug interactions.”

  • The paper relies on this without support.

    In older adults, depression may remain undiagnosed if screening is not performed.

    “In older adults, depression may remain undiagnosed if screening is not performed.”

  • The paper relies on this without support.

    Urinary incontinence is common in older patients, especially women, with diabetes.

    “Urinary incontinence is common in older patients, especially women, with diabetes.”

  • The paper relies on this without support.

    Uncontrolled hyperglycemia can increase the amount and frequency of urination.

    “In addition to standard assessments and treatments for incontinence, clinicians should remember that uncontrolled hyperglyemia can increase the amount and frequency of urination.”

  • The paper relies on this without support.

    Though energy needs decline with age, macronutrient needs are similar throughout adulthood.

    “Though energy needs decline with age, macronutrient needs are similar throughout adulthood.”

  • The paper relies on this without support.

    Meeting micronutrient needs with lower caloric intake is challenging; therefore older adults with diabetes are at higher risk for deficiencies.

    “Meeting micronutrient needs with lower caloric intake is challenging; therefore older adults with diabetes are at higher risk for deficiencies.”

  • The paper relies on this without support.

    Older adults may be at risk for undernutrition due to anorexia, altered taste and smell, swallowing difficulties, oral/dental issues, and functional impairments leading to difficulties in preparing or consuming food.

    “Older adults may be at risk for undernutrition due to anorexia, altered taste and smell, swallowing difficulties, oral/dental issues, and functional impairments leading to difficulties in preparing or consuming food.”

  • The paper relies on this without support.

    Overly restrictive eating patterns, either self-imposed or provider-directed, may contribute additional risk for older adults with diabetes.

    “Overly restrictive eating patterns, either self-imposed or provider-directed, may contribute additional risk for older adults with diabetes.”

  • The paper relies on this without support.

    Overweight and obesity are prevalent among older adults.

    “Overweight and obesity are prevalent among older adults.”

  • The paper relies on this without support.

    Sarcopenia may occur in both over- and underweight older adults.

    “Sarcopenia may occur in both over- and underweight older adults.”

  • The paper relies on this without support.

    Many patients may have low health literacy and numeracy skills, or may be overwhelmed by the presence of multiple comorbidities.

    “Even in the absence of cognitive impairment, educators should consider that many patients may have low health literacy and numeracy skills, or may be overwhelmed by the presence of multiple comorbidities.”

  • The paper relies on this without support.

    Muscle mass and strength decline with age, and these decrements may be exacerbated by diabetes complications, comorbidities, and periods of hospitalization in older adults with diabetes.

    “Muscle mass and strength decline with age, and these decrements may be exacerbated by diabetes complications, comorbidities, and periods of hospitalization in older adults with diabetes.”

  • The paper relies on this without support.

    Even patients with poorer health status benefit from modest increases in physical activity.

    “Even patients with poorer health status benefit from modest increases in physical activity.”

  • The paper relies on this without support.

    Older patients are at increased risk for adverse drug events from most medications due to age-related changes in pharmacokinetics and pharmacodynamics affecting drug disposition.

    “Older patients are at increased risk for adverse drug events from most medications due to age-related changes in pharmacokinetics (in particular reduced renal elimination) and pharmacodynamics (increased sensitivity to certain medications) affecting drug disposition.”

  • The paper relies on this without support.

    The risk for medication-related problems is compounded by the use of complex regimens, high-cost therapies, and polypharmacy or medication burden.

    “The risk for medication-related problems is compounded by the use of complex regimens, high-cost therapies, and polypharmacy or medication burden.”

  • The paper relies on this without support.

    Comparative effectiveness studies of medications to treat diabetes in older adult populations are lacking.

    “Comparative effectiveness studies of medications to treat diabetes in older adult populations are lacking.”

  • The paper relies on this without support.

    Type 2 diabetes with onset later in life is characterized by prominent defects in beta cell function.

    “Type 2 diabetes with onset later in life is characterized by prominent defects in beta cell function, suggesting therapeutic attention to beta cell function and sufficiency of insulin release, as well as the traditional focus on hepatic glucose overproduction and insulin resistance.”

  • The paper relies on this without support.

    Metformin has low risk for hypoglycemia.

    “Metformin, often considered first-line therapy in type 2 diabetes. Its low risk for hypoglycemia may be beneficial in older adults, but gastrointestinal intolerance and weight loss from the drug may be detrimental in frail patients.”

  • The paper relies on this without support.

    Gastrointestinal intolerance and weight loss from metformin may be detrimental in frail patients.

    “Metformin, often considered first-line therapy in type 2 diabetes. Its low risk for hypoglycemia may be beneficial in older adults, but gastrointestinal intolerance and weight loss from the drug may be detrimental in frail patients.”

  • The paper relies on this without support.

    Metformin’s low cost may be a benefit in those on multiple medications or who are subject to the Medicare Part D “doughnut hole.”

    “Metformin’s low cost may be a benefit in those on multiple medications or who are subject to the Medicare Part D “doughnut hole.””

  • The paper relies on this without support.

    Sulfonylureas are a low-cost class of medications, but the risk of hypoglycemia with these agents may be problematic for older patients.

    “Sulfonylureas are also a low-cost class of medications, but the risk of hypoglycemia with these agents may be problematic for older patients.”

  • The paper relies on this without support.

    Glinides are dosed prior to meals and their short half-life may be useful for post-prandial hyperglycemia and impart lower risk for hypoglycemia than sulfonylureas, especially in patients who eat irregularly.

    “Glinides are dosed prior to meals and their short half-life may be useful for post-prandial hyperglycemia and impart lower risk for hypoglycemia than sulfonylureas, especially in patients who eat irregularly.”

  • The paper relies on this without support.

    Glinides' dosing frequency and high cost may be barriers.

    “Their dosing frequency and high cost may be barriers.”

  • The paper relies on this without support.

    Alpha-glucosidase inhibitors specifically target post-prandial hyperglycemia and have low hypoglycemia risk.

    “Alpha-glucosidase inhibitors specifically target post-prandial hyperglycemia and have low hypoglycemia risk, making them theoretically attractive for older patients.”

  • The paper relies on this without support.

    Alpha-glucosidase inhibitors' gastrointestinal intolerance may be limiting, frequent dosing adds to regimen complexity, and this class of medications is costly.

    “However, gastrointestinal intolerance may be limiting, frequent dosing adds to regimen complexity, and this class of medications is costly.”

  • The paper relies on this without support.

    Thiazolidinediones have associated risks of weight gain, edema, heart failure, bone fractures, and possibly bladder cancer.

    “Thiazolidinediones have associated risks of weight gain, edema, heart failure, bone fractures, and possibly bladder cancer, which may argue against their use in older adults.”

  • The paper relies on this without support.

    The use of rosiglitazone is now highly restricted.

    “The use of rosiglitazone use is now highly restricted.”

  • The paper relies on this without support.

    The thiazolidinedione class has traditionally been expensive, although the approval of generic pioglitazone may reduce its cost.

    “The class has traditionally been expensive, although the approval of generic pioglitazone may reduce its cost.”

  • The paper relies on this without support.

    DPP-4 inhibitors are useful for post-prandial hyperglycemia, impart little risk for hypoglycemia, and are well tolerated.

    “DPP-4 inhibitors are useful for post-prandial hyperglycemia, impart little risk for hypoglycemia, and are well tolerated, suggesting potential benefit for older patients.”

  • The paper relies on this without support.

    DPP-4 inhibitors' high cost may be limiting.

    “However, their high cost may be limiting.”

  • The paper relies on this without support.

    GLP-1 agonists target post-prandial hyperglycemia and impart low risk of hypoglycemia, but their associated nausea and weight loss may be problematic in frail older patients.

    “GLP-1 agonists also target post-prandial hyperglycemia and impart low risk of hypoglycemia, but their associated nausea and weight loss may be problematic in frail older patients.”

  • The paper relies on this without support.

    Injection therapy may add to regimen complexity, and GLP-1 agonists' very high cost may be problematic.

    “Injection therapy may add to regimen complexity, and their very high cost may be problematic.”

  • The paper relies on this without support.

    For some agents, dose reduction is required for renal dysfunction.

    “For some agents, dose reduction is required for renal dysfunction.”

  • The paper relies on this without support.

    Problems with vision or manual dexterity may be barriers to insulin therapy for some older adults.

    “Problems with vision or manual dexterity may be barriers to insulin therapy for some older adults.”

  • The paper relies on this without support.

    Pen devices improve ease of use but are more costly than use of vials and syringes.

    “Pen devices improve ease of use but are more costly than use of vials and syringes.”

  • The paper relies on this without support.

    Hypoglycemia risk (especially nocturnal) is somewhat lower with analog compared to human insulins, but the former are more expensive.

    “Hypoglycemia risk (especially nocturnal) is somewhat lower with analog compared to human insulins, but the former are more expensive.”

  • The paper relies on this without support.

    Insulin-induced weight gain is a concern for some patients, and the need for more blood glucose monitoring may increase treatment burden.

    “Insulin-induced weight gain is a concern for some patients, and the need for more blood glucose monitoring may increase treatment burden.”

  • The paper relies on this without support.

    Other approved therapies for which there is little evidence in older patients include colesevelam, bromocriptine, and pramlintide.

    “Other approved therapies for which there is little evidence in older patients include colesevelam, bromocriptine, and pramlintide.”

  • The paper relies on this without support.

    Studies in older individuals with diabetes are limited.

    “Studies in older individuals with diabetes are limited.”

  • The paper relies on this without support.

    The prevalence of any hypoglycemia or severe hypoglycemia in older populations is not known.

    “The prevalence of any hypoglycemia (measured blood glucose below 70 mg/dl) or severe hypoglycemia (requiring third party assistance) in older populations is not known.”

  • The paper relies on this without support.

    Un- or undertreated hyperglycemia also has risks, even in patients with life expectancy too short to be impacted by the development of chronic complications.

    “Although attention has rightly been paid to the risks of overtreatment of hyperglycemia in older adults (hypoglycemia, treatment burden, possibly increased mortality), un- or undertreated hyperglycemia also has risks, even in patients with life expectancy too short to be impacted by the development of chronic complications.”

  • The paper relies on this without support.

    Blood glucose levels consistently over the renal threshold for glycosuria (~180–200 mg/dl, but can vary) increase risk for dehydration, electrolyte abnormalities, urinary incontinence, dizziness, and falls.

    “Blood glucose levels consistently over the renal threshold for glycosuria (~180–200 mg/dl, but can vary) increase risk for dehydration, electrolyte abnormalities, urinary incontinence, dizziness, and falls.”

  • The paper relies on this without support.

    Hyperglycemic hyperosmolar syndrome (HHS) is a particularly severe complication of unrecognized or undertreated hyperglycemia in older adults.

    “Hyperglycemic hyperosmolar syndrome (HHS) is a particularly severe complication of unrecognized or undertreated hyperglycemia in older adults.”

  • The paper relies on this without support.

    A limitation of existing mortality models is that they can help us to rank patients by probability of death, but these probabilities must still be transformed into a life expectancy for a particular older diabetes patient.

    “A limitation of existing mortality models is that they can help us to rank patients by probability of death, but these probabilities must still be transformed into a life expectancy for a particular older diabetes patient.”

  • The paper relies on this without support.

    Simulation models can help transform mortality prediction into a useable life expectancy.

    “Simulation models can help transform mortality prediction into a useable life expectancy.”

  • The paper relies on this without support.

    In light of the paucity of data for diabetes care in older adults, treatment decisions are frequently made with considerable uncertainty.

    “In light of the paucity of data for diabetes care in older adults, treatment decisions are frequently made with considerable uncertainty.”

  • The paper relies on this without support.

    A key component of improving communication in the clinical setting may be finding congruence between patient goals and the biomedical goals on which clinicians tend to focus.

    “A key component of improving communication in the clinical setting may be finding congruence between patient goals and the biomedical goals on which clinicians tend to focus.”

  • The paper relies on this without support.

    Discussions eliciting and incorporating patients’ preferences regarding treatments and treatment targets may be difficult when patients do not understand the significance of risk factors or the value of risk reduction.

    “Discussions eliciting and incorporating patients’ preferences regarding treatments and treatment targets may be difficult when patients do not understand the significance of risk factors or the value of risk reduction.”

  • The paper relies on this without support.

    Many older adults rely on family members or friends to help them with their treatment decisions, or to implement day-to-day treatments.

    “Many older adults rely on family members or friends to help them with their treatment decisions, or to implement day-to-day treatments.”

  • The paper relies on this without support.

    In the case of the older person with cognitive deficits, the family member or friend may in fact be serving as a surrogate decision maker.

    “In the case of the older person with cognitive deficits, the family member or friend may in fact be serving as a surrogate decision maker.”

  • The paper relies on this without support.

    The LTC facility resident may have irregular and unpredictable meal consumption, undernutrition, anorexia, and impaired swallowing.

    “The LTC facility resident may have irregular and unpredictable meal consumption, undernutrition, anorexia, and impaired swallowing.”

  • The paper relies on this without support.

    Therapeutic diets may inadvertently lead to decreased food intake and contribute to unintentional weight loss and undernutrition.

    “Therapeutic diets may inadvertently lead to decreased food intake and contribute to unintentional weight loss and undernutrition.”

  • The paper relies on this without support.

    Vulnerable older adults, particularly those with cognitive dysfunction, may have impaired thirst sensation, contributing to risk of volume depletion and hyperglycemic crises.

    “Vulnerable older adults, particularly those with cognitive dysfunction, may have impaired thirst sensation, contributing to risk of volume depletion and hyperglycemic crises.”

  • The paper relies on this without support.

    Excessive reliance on sliding scale insulin (SSI) has been documented.

    “Excessive reliance on sliding scale insulin (SSI) has been documented.”

  • The paper relies on this without support.

    Evidence-based policies for glycemic control, use of insulin, and treatment of hypoglycemia have the potential to improve the care of residents with diabetes, alleviate some of the burden caused by frequent staff turnover, and even lead to more staff satisfaction.

    “Evidence-based policies for glycemic control, use of insulin, and treatment of hypoglycemia have the potential to improve the care of residents with diabetes, alleviate some of the burden caused by frequent staff turnover, and even lead to more staff satisfaction.”

  • The paper relies on this without support.

    Older adults are more apt to require hospitalization than younger adults, and those with diabetes are at very high risk of requiring hospitalization.

    “Older adults are more apt to require hospitalization than younger adults, and those with diabetes are at very high risk of requiring hospitalization.”

  • The paper relies on this without support.

    There is a dearth of studies addressing older adults with diabetes, particularly more frail older adults, in the hospital.

    “There is a dearth of studies addressing older adults with diabetes, particularly more frail older adults, in the hospital.”

  • The paper relies on this without support.

    Less stringent glycemic targets may be appropriate for patients with multiple co-morbidities and reduced life expectancy, criteria that could be applicable to many hospitalized older adults.

    “Less stringent glycemic targets may be appropriate for patients with multiple co-morbidities and reduced life expectancy, criteria that could be applicable to many hospitalized older adults.”

  • The paper relies on this without support.

    Transitions from hospital to home or to short- or long-term care facilities are times of risk for patients with diabetes, and probably more so for older patients.

    “Transitions from hospital to home or to short- or long-term care facilities are times of risk for patients with diabetes, and probably more so for older patients.”

  • The paper relies on this without support.

    Delirium is a common complication seen in older adults during and after hospitalization.

    “Delirium (acute decline in cognitive function) is a common complication seen in older adults during and after hospitalization and may require more supervision to avoid errors in dosing.”

  • The paper relies on this without support.

    The exclusion of older, and especially frail older, participants from most traditional randomized controlled trials of diabetes interventions has left large gaps in knowledge of how best to address diabetes in the age group with the highest prevalence rates.

    “The exclusion of older, and especially frail older, participants from most traditional randomized controlled trials of diabetes interventions has left us with large gaps in our knowledge of how best to address diabetes in the age group with the highest prevalence rates.”
64 of 64

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Epidemiological data suggests that individuals with various chronic diseases such as cancer, diabetes, and HIV/AIDS are more likely to develop co-morbidities later in life.

    “Epidemiological data does suggest that individuals with various chronic diseases such as cancer, diabetes, and HIV/AIDS are more likely to develop co-morbidities later in life,72,73,74”

    From Asynchronous, contagious and digital aging (2021) · cites this paper as [73]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Life-expectancy model cites the wrong reference

    Minor

    The life-expectancy simulation model is cited as reference 113, but reference 113 is about patients' preferences in medical decisions. Reference 112 is the listed decision analysis on the expected benefits of intensive glucose control in older patients.

1 of 1

Cites

1 retracted

Flagged first, then by citations

1 of the 145 references couldn’t be matched to a known paper.

Research works printed but not linked: 3

  1. Centers for Disease Control and Prevention. National Diabetes Fact Sheet: General Information and National Estimates on Diabetes in the United States, 2011, Atlanta, 2011
  2. American Geriatrics Society, 2012, Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults, J Am Geriatr Soc, 2012, 616
  3. 2003 National Academies Press Washington DC Committee on Understanding Eliminating Racial Ethnic Disparities in Health Care Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (with CD)

Cited by

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Related

Authors
Sue Kirkman, M., Briscoe, V. J., Clark, N., Florez, H., Haas, L. B., Halter, J. B., Huang, E. S., Korytkowski, M. T., Munshi, M. N., Odegard, P. S., Pratley, R. E., & Swift, C. S.
Affiliations
  • Medical Affairs and Community Information American Diabetes Association Alexandria Virginia
  • Vanderbilt University (US)
  • Diabetes Center of Cape Cod Emerald Physicians Hyannis Massachusetts
  • University of Miami (US)
  • VA Puget Sound Health Care System (US)
  • University of Michigan (US)
  • University of Chicago (US)
  • University of Pittsburgh (US)
  • Joslin Diabetes Center (US)
  • University of Washington (US)
  • AdventHealth (US)
  • Kadlec Regional Medical Center (US)
ORCID
Venue
Journal of the American Geriatrics Society
Publisher
Wiley
Published
2012-10-25
Volume
60
Issue
12
Pages
2342-2356
ISSN
  • 0002-8614 (ISSN-L)
  • 1532-5415
DOI
10.1111/jgs.12035
PMC
PMC4525769
OpenAlex
W2110840270
Semantic Scholar
4de9559e53371b7c701c9e8e36d3ed616eb57a84
Cited by
548
References
145
Citations by year
2026: 20 · 2025: 19 · 2024: 29 · 2023: 20 · 2022: 31 · 2021: 35 · 2020: 42 · 2019: 48 · 2018: 54 · 2017: 54 · 2016: 48 · 2015: 61 · 2014: 66 · 2013: 19 · 2012: 1
FWCI
37.73
Type
journal article
Language
en
Open access
Licence
onlinelibrary.wiley.com/termsAndConditions#vor (vor)
Locations
  • Journal of the American Geriatrics Society (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
  • Deep Blue (University of Michigan) (submittedVersion)
Funders
  • U.S. Department of Veterans Affairs
  • John A. Hartford Foundation
  • Hartford Foundation for Public Giving
  • Eli Lilly and Company
  • Sanofi
  • Regeneron Pharmaceuticals
  • Novo Nordisk
  • National Institutes of Health (P60 DK20595, AG-024824)
  • National Institute on Aging (AG‐024824, P30AG024824)
  • National Institute of Diabetes and Digestive and Kidney Diseases (P60DK20595, DK092949, R01DK081796, P60DK020595, P30DK092949, P30DK020572)
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
  • Health Sciences › Medicine › Geriatrics and Gerontology › Pharmaceutical Practices and Patient Outcomes
Keywords
diabetes mellitus, older adults, geriatric diabetes management, consensus recommendations
MeSH terms
Aged, Diabetes Mellitus, Humans, Hypoglycemic Agents, Diabetes Complications

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Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-10.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-10.

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