1. Introduction and Historical Background
Carol M. Mangione MD, MSPH
Professor of Medicine and Health Policy and Management
University of California Los Angeles

2. Background
In 2003, AGS in partnership with the California Health Care Foundation published a guideline called “Care of the Older Adult with Diabetes”
During the intervening decade, a number of clinical trials have been completed that provide stronger evidence for care recommendations, especially in the domains of management of cardiovascular risk factors
Today, we will present the 2013 AGS Care Recommendations and will compare and contrast them to 2013 ADA Consensus Report Diabetes in Older Adults

3. Background
During 2012, both the ADA and AGS implemented work to update care recommendations for older adults with diabetes
The ADA group convened a Consensus Development Conference on Diabetes and Older Adults (> 65 years)
The AGS group reviewed the new clinical trial and observational data that had been published, formally graded the evidence, and revised the 2003 recommendations

4. ADA Consensus Development Conference
Following a series of scientific presentations, the writing group developed a report addressing:
Epidemiology and pathogenesis of diabetes in older adults
Evidence for preventing and treating diabetes and its common comorbidities?
Review of current guidelines for treating diabetes in older adults
Individualizing treatment
Consensus recommendations for treating older adults with or at risk for diabetes
How the gaps in the evidence can be filled
Topic

5. ADA Consensus Panel Framework
Panel considered three profiles of older adults with diabetes:
Those relatively good health
Those with complex medical histories that might make self-care difficult
Those with significant comorbid illness and functional impairment
Recognized patient care must be individualized
Made distinct recommendations for the screening and treatment for each group
PURPOSE OF THE CONSENSUS REPORT
To develop consensus recommendations for clinical care, the panel looked at three types of older diabetics:
those in relatively good health;
those with complex medical histories that might make self-care difficult;
those with significant comorbid illness and functional impairment
The Panel made different screening and treatment recommendations for each group.
The Panel recognized recommendations cannot simply be based on age because older people are a very heterogeneous population.
For Example: One 75-year-old may have newly diagnosed diabetes but otherwise be quite healthy and lead a very active life, while another may have multiple diseases, dementia, and longstanding diabetes with complications.
It’s critical to consider overall physical and cognitive function, quality of life, and patient preferences when developing a treatment plan with an older patient,
It also recommended that further research be done that takes into account the complexity of issues facing older adults and that studies include patients with multiple comorbidities, dependent living situations and geriatric syndromes to get the most complete picture of the needs and challenges of frail or complex patients.
Kirkman S, et al. Diabetes in older adults: A consensus report. J Am Ger Soc. 2012; 60(12): ; Diabetes Care. 2012; 35:

6. Consensus Recommendations for Care of Older Adults with Diabetes
Clinical recommendations and recommendations for a research agenda in this report are solely the opinion of the authors, and do not represent the official position of the American Diabetes Association.
Kirkman S, et al. J Am Ger Soc. 2012; 60(12): ; Diabetes Care. 2012; 35:

7. Current Guidelines for Elderly Adults
American Diabetes Association
(2013)
California Healthcare Foundation
American Geriatrics Society
US Dept. of Veterans Affairs
US Dept. of Defense
(2010)
European Diabetes Working Party for Older People
(2011)
CURRENT GUIDELINES FOR ELDERLY ADULTS
Several organizations have developed diabetes guidelines specific to, or including, older adults, including:
American Diabetes Association in 2012
California HealthCare Foundation and American Geriatrics Society in 2003
U.S. Department of Veterans Affairs and the U.S. Department of Defense (VA/DOD) in 2010
European Diabetes Working Party for Older People in 2011
The common thread of these guidelines, are recommendations that encourage pursuing an individualized approach with a focus on clinical and functional heterogeneity and comorbidities, and weighing the expected time frame of benefit of interventions against life expectancy.
American Diabetes Association. Standards of medical care in diabetes Diabetes Care 2012; 35(Suppl. 1):S11–S63
Brown AF, Mangione CM, Saliba D, Sarkisian CA; California Healthcare Foundation/American Geriatrics Society Panel on Improving Care for Elders with Diabetes. Guidelines for improving the care of the older person with diabetes mellitus. J Am Geriatr Soc 2003;51(Suppl. Guidelines):S265–S280
U.S. Department of Veterans Affairs. VA/DOD Clinical Practice Guidelines: Management of Diabetes Mellitus in Primary Care (2010). Available from www .healthquality.va.gov/Diabetes_Mellitus.asp.
Sinclair AJ, et al. European Diabetes Working Party for Older People. European Diabetes Working Party for Older People 2011 clinical guidelines for type 2 diabetes mellitus. Executive summary. Diabetes Metab 2011;37(Suppl. 3):S27–S38

8. AGS Guideline Development Process
Synthesis and evaluation of results from randomized controlled trials and observational studies
Review of existing guidelines
Rating the evidence and guidelines with validated consensus panel methods
Modification of existing guidelines and development of new guidelines specific to older persons with diabetes
Peer review and further revision of guidelines
These guidelines were developed as part of a 12 month evidence review and guideline modification project
The phases of the project included:
Synthesis and evaluation of results from randomized controlled trials and observational studies
Review of existing guidelines
Rating the evidence and guidelines with validated consensus panel methods
Modification of existing guidelines and development of new guidelines specific to older persons with diabetes
Peer review and further revision of guidelines
The slides that follow go into these steps in greater detail
Topic

9. AGS Review / Evaluate the Evidence from Randomized Controlled Trials
Evaluate the clinical evidence on care management for older healthy persons with diabetes
Today, there is considerably more research directed at older adults >65 years with diabetes
When is it appropriate to extrapolate findings from:
Older adults in the general population?
Younger persons with diabetes?
We began by evaluating the clinical evidence on care management for older persons with diabetes
It became clear early in the process that there was very little research directed at older adults with diabetes
As a result, a key issue that we grappled with in many of the care recommendations was when it is appropriate to extrapolate findings from:
Older adults in the general population?
Younger persons with diabetes?
Evidence tables were developed that distilled the major points from papers that addressed care of older persons and/or persons with diabetes. These tables are available on the AGS website.
Topic

10. Review of Existing Guidelines
Review of existing guidelines and quality indicators
National Guidelines Clearinghouse ( )
Organizations and government agencies
e.g. NCEP, NHLBI, AGS, ADA
Major journals
e.g. Diabetes Care, Annals, JAGS
AGS: initial review by 2 independent researchers to exclude items that clearly could not be implemented
Because many organizations have put a lot of resources into developing diabetes guidelines, rather than reinvent the wheel, we reviewed over 40 guidelines and quality indicators that addressed care of persons with diabetes and older adults to identify existing care recommendations appropriate for older persons with diabetes
We started with
National Guidelines Clearinghouse ( )
Organizations and government agencies
e.g. NCEP, NHLBI, AGS, ADA
Major journals
e.g. Diabetes Care, Annals, JAGS
The contents of these guidelines were reviewed by 2 independent researchers to exclude items that clearly could not be implemented
Topic

11. AGS Public and Peer Review and Revision
Public comment and review
Guidelines reviewed by representatives of the following organizations:
American Academy of Family Physicians
American College of Clinical Pharmacy
American College of Physicians
American Diabetes Association
American Association of Clinical Endocrinologists
American Society of Consultant Pharmacists
Society of General Internal Medicine
American Society of Nurse Practitioners
American Academy of Nutrition and Dietetics
American Association of Diabetes Educators
American Medical Directors Association
The completed guidelines were reviewed by the peer-reviewers from each of the organizations listed on this slide.
American Academy of Family Physicians
American College of Clinical Pharmacy
American College of Physicians
American Diabetes Association
American Association of Clinical Endocrinologists
American Society of Consultant Pharmacists
Society of General Internal Medicine
It is important to note that we did not obtain formal endorsement of the guidelines by any of these organizations.
However, after peer review was completed, the guidelines were revised based on the reviewer comments.
Topic

12. AGS Guideline Development Reference
Evidence tables and a full description of the guideline development process are available at:
JAGS supplement in May 2013
The evidence tables and a full description of the guideline development process are available at the American Geriatrics Association website:
Topic

13. Common Themes and Elements Across Both Summaries
Care needs to be individualized and needs to take into consideration patient preferences, comorbidity, functional status, and life expectancy
Lifestyle interventions can be very effective
If a medication is going to be used to control blood sugar, metformin should be used first line unless contraindicated
Blood pressure and lipid control is of paramount importance for reducing the risk of macro and microvascular complications
Screen and treat the geriatric syndromes

14. the Care for Older Persons with Diabetes ADA/AGS Expert Panel for
AGS Panel on Improving
the Care for Older Persons
with Diabetes
Carol Mangione MD, MS
Gerardo Moreno MD, MS
Caroline Blaum, MD, MS
Samuel C. Durso, MD
Sei Lee, MD, MAS
Martha Funnell, MS, RN, CDE
Audrey Chun, MD
Sunny Linnebur, PharmD
Edward Gregg, PhD
Debra Saliba, MD, MPH
AGS
Elvy Ickowicz, MPH
Aimee Cegelka
ADA/AGS Expert Panel for
Consensus Report
for Diabetes in Older Adults
Sue Kirkman, MD
Vanessa Jones Briscoe, PhD, NP
Nathaniel Clark, MD, MS, RD
Hermes Florez, MD, MPH, PhD
Linda B. Hass, RN, CDE
Jeffrey B. Halter, MD
Elbert S. Huang, MD, MPH
Mary T. Korytkowski, MD
Peggy Soule Odegard, PharmD
Richard E. Pratley, MD
Carrie S. Swift, MS, RD, CDE