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China continues to move forward rapidly on healthcare reform, initiating a number of exciting healthcare reforms: 1 In addition to the collaborative and referral relationships between Level 3A hospitals and their local community hospitals that Li and colleagues describe, 1 the NHC has recently ordered that Level 3A hospitals focus on complex or rare diseases and biomedical research while community hospitals provide care for common and chronic conditions.
For example, in Jiading District, in Shanghai, family doctor health services contracts have been completed for , residents, This contract rate is In this special zone, physicians with a valid medical license in other specified countries can practice medicine without having a Chinese medical license. Drugs and medical devices that have been approved in other specified countries can be used without approval from Chinese government authorities.
Academic geriatric medicine itself has also experienced several exciting developments in This is accomplished in collaboration with Wiley, which is also the publisher of the Journal of the American Geriatrics Society. In summary, although Li and colleagues provided an excellent overview based on the information collected at the time their article was developed, China's population statistics, government policy, and reform of geriatrics health care and academic geriatric medicine are moving forward at an unprecedented speed in the complex and evolving healthcare system.
Yiyin Chen, MD. Author Contributions: Yiyin Chen drafted the manuscript. Lin Kang and Xiaohong Liu collected updated information on geriatrics. Youshuo Liu designed and revised the manuscript.
Healthy ageing: Evidence that improvement is possible at every age - ScienceDirect
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In contrast, a well-designed and more intensive lifestyle intervention has been shown to be an effective weight loss strategy and improve glucose homeostasis [ ]. Data from the recent multicenter Look AHEAD Action for Health in Diabetes trial found that intensive lifestyle intervention initial weekly meetings to discuss reduced-calorie kcal diet, use of meal replacements, decreased fat intake to ].
Geriatric Medicine: Volume II: Fundamentals of Geriatric Care: 002
Despite the above findings, there is evidence that older patients can respond positively to lifestyle interventions, and age should not in itself be a deterrent to improving one's lifestyle. In an RCT tailoring nutrition to the individual's medical, lifestyle, and personal factors called Medical Nutrition Therapy MNT , the intervention group had greater improvements in fasting glucose and HgBA1c levels [ ]. The effect of differing dietary macronutrient composition on metabolism and glycemic control in younger versus older individuals is largely unknown.
Despite these recommendations, beneficial effects in both diabetic and non-diabetic subjects, including improved glycemic control and greater weight loss, have been observed by increasing dietary protein and lowering carbohydrate intake [ - ].
Data from several studies conducted in patients with T2DM have found specific benefits of low-calorie diets that contain increased protein and decreased carbohydrate than low-calorie diets with higher carbohydrate content, including a protein-mediated increase in insulin secretion [ ] and greater decreases in body weight, HgbA1c and use of diabetes medications [ ]. These studies, however, were all conducted in young to middle-aged adults.
Short-term studies - ] but longer-term studies are needed and current guidelines do not distinguish by patient age. Older adults with T2D, in particular, are at risk for greater loss of muscle strength compared to younger patients and may benefit from increased protein intake, but studies are limited. The metabolic effects of altering dietary composition in an elderly population and their role in preserving lean mass, especially muscle mass, is thus relatively unknown and requires further investigation. The effect of differing exercise regimens and diet on cognitive function in older individuals and their relationship to metabolic improvements remains controversial.
There is clear evidence that physical activity can contribute to healthy aging and reduce morbidity and mortality [ , ]. Yet there are only a limited number of studies, with small population sizes, addressing the effect of exercise in tertiary prevention of cognitive decline in those with existing dementia [ , ]. Research on the effect of dietary modification to prevent cognitive decline is also in its infancy and the benefits of changing macronutrient content is oftentimes difficult to separate from their effects on associated comorbidities such as obesity, diabetes, and CVD [ ].
One of the major limitations in our current knowledge is the lack of established guidelines and evidence-based studies for exercise and diet in older patients with T2D.
These same guidelines advise older adults to increase their activity to minutes of moderate-intensity or minutes of vigorous-intensity exercise per week combined with muscle training activities [ ]. However, recommendations specific for an older type 2 diabetic patient are lacking. The ADA, for instance, endorses a similar amount of exercise in diabetics as the CDC does for the general population aged 18 to 64, but provides no specific exercise recommendations in those over the age of 65 [ ].
In addition, the ADA has very generalized guidelines for dietary caloric content and macronutrient composition in Type 2 Diabetics, does not set an ideal percentage of calories from carbohydrates, protein, or fat, and does not dictate specific recommendations based on patient age [ ]. Drug therapy for T2D in older patients: There is a paucity of data related to specific drug therapy in older patients with T2D [ ].
Hypoglycemia in older individuals is associated with significant morbidities leading to both physical and cognitive dysfunction, and recurrent hospital admissions due to frequent hypoglycemia are associated with further deterioration in patients' general health that can eventually lead to frailty and disability [ ]. Patients with dementia are four times more likely to be admitted for hypoglycemia episodes compared to those with normal cognition [ ].
Severe hypoglycemia can result in acute vascular complications including stroke, heart failure and arrhythmia [ ]. In addition, the brain is dependent on glucose and is exquisitely vulnerable to the effect of hypoglycemia. After a single hypoglycemia event, cognitive changes occur, and recurrent hypoglycemia leads to a graded increased risk of dementia with each subsequent hypoglycemic episode [ ]. Given that the risk of hypoglycemia is also increased by folds in obesity, the inter-relationship between T2D, obesity, cognitive dysfunction and hypoglycemia during aging must be given consideration in determining a safe treatment regimen.
Listed medications are limited to those commercially available in the U. View Table 2. According to the most recent ADA guidelines, metformin a biguanide is considered first-line therapy in T2D [ ]. Given its low hypoglycemic risk profile and low cost, metformin may also be beneficial in older adults. However, limitations to its use include side effects predominantly gastrointestinal , weight loss which may preclude its use in frail patients, and a small risk of lactic acidosis in patients with renal dysfunction.
Sulfonylureas are also cost-effective, but are limited by hypoglycemia that may be problematic for older patients, especially those with reduced glomerular filtration capacity or poor appetites. The shorter duration glipizide and the glinides repaglinide and nateglinide may be preferable in this scenario; but overall the risk of prolonged hypoglycemia with all sulfonylureas and glinides makes their use largely inadvisable in the elderly population.
Alpha-glucosidase inhibitors such as acarbose specifically target post-prandial hyperglycemia and have low hypoglycemia risk; however, gastrointestinal side effects, frequent dosing, and relatively low efficacy may limit their applicability in some older patients. However, they have been associated with weight gain, edema, heart failure, bone fractures, and bladder cancer, precluding their use in certain older adults.
Dipeptidyl peptidase-IV DPP-4 inhibitors sitagliptin, linagliptin, saxagliptin, and alogliptin preferentially target post-prandial hyperglycemia, carry limited hypoglycemic potential, and are generally well tolerated. This suggests that they may be useful for older patients; but applicable prospective studies are limited.
A recent retrospective observational study focused on the safety and tolerability of the DPP-4 inhibitors in type 2 diabetics aged 65 years and older.
Among patients receiving DPP-4 inhibitors identified in this study, most patients were taking sitagliptin In addition, no significant differences were noted in the HgBA1c-lowering effects of these agents between elderly and younger patients. Glucagon-like peptide-1 GLP-1 receptor agonists twice daily exenatide, once daily liraglutide, once weekly exenatide XR, dulaglutide, and albiglutide are also useful in preventing post-prandial hyperglycemia and impart low hypoglycemic risk. They can promote weight loss, and at higher doses, liraglutide is approved for weight reduction independent of diabetes status.
However, they can cause nausea, promote weight loss, and are injectable therapies and thus may not be ideal for frail patients or those with vision, sensory or hearing impairment. Both the DPP-4 and GLP-1 receptor agonists also require dose reductions with kidney dysfunction and are largely unstudied with coexistent hepatic impairment. Sodium-glucose co-transporter-2 SGLT2 inhibitors canagliflozin, empagliflozin, and dapagliflozin are newer oral diabetes medications, but there experience in older adults is unknown. Their use may also be limited by side effects dehydration, increased thirst, polyuria , increased risk of genital and urinary tract infections and reduced effectiveness in patients with preexisting kidney disease.
Insulin therapy can be used successfully in select older adults with T2D, and generally have similar efficacy and hypoglycemia risk compared to younger patients. The biggest limitation is the potential for hypoglycemia and this risk must carefully be assessed in an individual older patient.
A separate study demonstrated that long-acting insulin in older patients mean age 69 years old with T2D did not increase the risk of hypoglycemia compared to younger patients [ ].
Related Geriatric Medicine: Volume II: Fundamentals of Geriatric Care: 002
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