http://nevadawellness.org/wp-content/uploads/2015/06/Diabetes-self-management-education-for-adults-with-type-2-diabetes-mellitus-A-systematic-review-of-the-effect-on-glycemic-control.pdf

Diabetes self-management education for adults with type 2 diabetes mellitus: A systematic review of the effect on glycemic control.

Supplementary Table S1 Continuous Glucose Monitoring (CGM) has been demonstrated to be clinically valuable, reducing risks of hypoglycemia and hyperglycemia, glycemic variability (GV), and improving patient quality of life for a wide range of patient populations and clinical indications. Use of CGM can help reduce HbA1c and mean glucose. One CGM device, with accuracy (%MARD) of approximately 10%, has recently been approved for self-adjustment of insulin dosages (nonadjuvant use) and approved for reimbursement for therapeutic use in the United States. CGM had previously been used off-label for that purpose. CGM has been demonstrated to be clinically useful in both type 1 and type 2 diabetes for patients receiving a wide variety of treatment regimens. CGM is beneficial for people using either multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII). CGM is used both in retrospective (professional, masked) and real-time (personal, unmasked) modes: both approaches can be ben...

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Continuous Glucose Monitoring: A Review of Recent Studies Demonstrating Improved Glycemic Outcomes

Objective: The objective is to formulate clinical practice guidelines for the treatment of diabetes in older adults. Conclusions: Diabetes, particularly type 2, is becoming more prevalent in the general population, especially in individuals over the age of 65 years. The underlying pathophysiology of the disease in these patients is exacerbated by the direct effects of aging on metabolic regulation. Similarly, aging effects interact with diabetes to accelerate the progression of many common diabetes complications. Each section in this guideline covers all aspects of the etiology and available evidence, primarily from controlled trials, on therapeutic options and outcomes in this population. The goal is to give guidance to practicing health care providers that will benefit patients with diabetes (both type 1 and type 2), paying particular attention to avoiding unnecessary and/or harmful adverse effects.

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Treatment of Diabetes in Older Adults: An Endocrine Society Clinical Practice Guideline

BACKGROUND: Telemedicine, the use of telecommunications to deliver health services, expertise and information, is a promising but unproven tool for improving the quality of diabetes care We summarized the effectiveness of different methods of telemedicine for the management of diabetes compared with usual care METHODS: We searched MEDLINE, Embase and the Cochrane Central Register of Controlled Trials databases (to November 2015) and reference lists of existing systematic reviews for randomized controlled trials (RCTs) comparing telemedicine with usual care for adults with diabetes Two independent reviewers selected the studies and assessed risk of bias in the studies The primary outcome was glycated hemoglobin (HbA 1C ) reported at 3 time points (≤ 3 mo, 4–12 mo and > 12 mo) Other outcomes were quality of life, mortality and episodes of hypoglycemia Trials were pooled using randomeffects meta-analysis, and heterogeneity was quantified using the I 2 statistic RESULTS: From 3688 citations, we identified 111 eligible RCTs ( n = 23 648) Telemedicine achieved significant but modest reductions in HbA 1C in all 3 follow-up periods (difference in mean at ≤ 3 mo: −057%, 95% confidence interval [CI] −074% to −040% [39 trials]; at 4–12 mo: −028%, 95% CI −037% to −020% [87 trials]; and at > 12 mo: −026%, 95% CI −046% to −006% [5 trials]) Quantified heterogeneity ( I 2 statistic) was 75%, 69% and 58%, respectively In meta-regression analyses, the effect of telemedicine on HbA 1C appeared greatest in trials with higher HbA 1C concentrations at baseline, in trials where providers used Web portals or text messaging to communicate with patients and in trials where telemedicine facilitated medication adjustment Telemedicine had no convincing effect on quality of life, mortality or hypoglycemia INTERPRETATION: Compared with usual care, the addition of telemedicine, especially systems that allowed medication adjustments with or without text messaging or a Web portal, improved HbA 1C but not other clinically relevant outcomes among patients with diabetes

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Effect of telemedicine on glycated hemoglobin in diabetes: a systematic review and meta-analysis of randomized trials.

Objective: To formulate clinical practice guidelines for the use of continuous glucose monitoring and continuous subcutaneous insulin infusion in adults with diabetes. Participants: The participants include an Endocrine Society-appointed Task Force of seven experts, a methodologist, and a medical writer. The American Association for Clinical Chemistry, the American Association of Diabetes Educators, and the European Society of Endocrinology co-sponsored this guideline. Evidence: The Task Force developed this evidence-based guideline using the Grading of Recommendations, Assessment, Development, and Evaluation system to describe the strength of recommendations and the quality of evidence. The Task Force commissioned one systematic review and used the best available evidence from other published systematic reviews and individual studies. Consensus Process: One group meeting, several conference calls, and e-mail communications enabled consensus. Committees and members of the Endocrine Society, the American A...

Diabetes Technology—Continuous Subcutaneous Insulin Infusion Therapy and Continuous Glucose Monitoring in Adults: An Endocrine Society Clinical Practice Guideline

Background Episodes of hypoglycemia are particularly dangerous in the older population. To reduce the risk of hypoglycemia, relaxation of the standard hemoglobin A 1c (HbA 1c ) goals has been proposed for frail elderly patients. However, the risk of hypoglycemia in this population with higher HbA 1c levels is unknown. Methods Patients 69 years or older with HbA 1C values of 8% or greater were evaluated with blinded continuous glucose monitoring for 3 days. Results Forty adults (mean [SD] age, 75 [5] years; HbA 1C value, 9.3% [1.3%]; diabetes duration, 22 [14] years; 28 patients [70%] with type 2 diabetes mellitus; and 37 [93%] using insulin) were evaluated. Twenty-six patients (65%) experienced 1 or more episodes of hypoglycemia (glucose level Conclusions Hypoglycemic episodes are common in older adults with poor glycemic control. Raising HbA 1C goals may not be adequate to prevent hypoglycemia in this population.

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Frequent hypoglycemia among elderly patients with poor glycemic control.

OBJECTIVE To evaluate whether assessment of barriers to self-care and strategies to cope with these barriers in older adults with diabetes is superior to usual care with attention control. The American Diabetes Association guidelines recommend the assessment of age-specific barriers. However, the effect of such strategy on outcomes is unknown. RESEARCH DESIGN AND METHODS We randomized 100 subjects aged ≥69 years with poorly controlled diabetes (A1C >8%) in two groups. A geriatric diabetes team assessed barriers and developed strategies to help patients cope with barriers for an intervention group. The control group received equal amounts of attention time. The active intervention was performed for the first 6 months, followed by a “no-contact” period. Outcome measures included A1C, Tinetti test, 6-min walk test (6MWT), self-care frequency, and diabetes-related distress. RESULTS We assessed 100 patients (age 75 ± 5 years, duration 21 ± 13 years, 68% type 2 diabetes, 89% on insulin) over 12 months. After the active period, A1C decreased by −0.45% in the intervention group vs. −0.31% in the control group. At 12 months, A1C decreased further in the intervention group by −0.21% vs. 0% in control group (linear mixed-model, P CONCLUSIONS Only attention between clinic visits lowers diabetes-related distress in older adults. However, communication with an educator cognizant of patients’ barriers improves glycemic control and self-care frequency, maintains functionality, and lowers distress in this population.

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Elizabeth Staum

Papers

Frequent hypoglycemia among elderly patients with poor glycemic control.

Assessment of barriers to improve diabetes management in older adults: a randomized controlled study.