HypoglycemiaRecommendations
2021 vs 2022：
在 6 個月內，與標準血糖監測相比，使用 CGM 導致低血糖所花費的時間雖然較少，但達統計差異。（調整後的治療差異 -1.9% [-27 分鐘/天]； 95% CI -2.8% 至 -1.1% [-40 至 -16 分鐘/天]；P < 0.001) (40,41)。 在次要結果中，CGM 降低了血糖變異性，這反映在 70 至 180 mg/dL 範圍內花費的時間增加了 8% (95% CI 6.0–11.5)。
Over 6 months, use of CGM resulted in a small but statistically significant reduction in time spent with hypoglycemia (glucose level <70 mg/dL) compared with standard blood glucose monitoring (adjusted treatment difference −1.9% [−27 min/day]; 95% CI −2.8% to −1.1% [−40 to −16 min/day]; P < 0.001) (40,41). Among secondary outcomes, glycemic variability was reduced with CGM, as reflected by an 8% (95% CI 6.0–11.5) increase in time spent in range between 70 and 180 mg/dL. (2022 新增)
2021：
雖然目前老年人的證據基礎主要是 1 型糖尿病，但對於使用每日多次注射胰島素的老年 2 型糖尿病患者，CGM 可能是一種選擇。
While the current evidence base for older adults is primarily in type 1 diabetes, CGM may be an option for older patients with type 2 diabetes using multiple daily injections of insulin.
2022 修正：
雖然目前老年人的證據基礎主要是 1 型糖尿病，但證明 CGM 對使用胰島素的 2 型糖尿病患者的臨床益處的證據正在增加 (42)。CGM 也可能發揮越來越大作用的另一個人群是身體或認知受限的老年人，他們需要通過代理人監測血糖。
While the current evidence base for older adults is primarily in type 1 diabetes, the evidence demonstrating the clinical benefits of CGM for patients with type 2 diabetes using insulin is growing (42). Another population for which CGM may also play an increasing role is older adults with physical or cognitive limitations who require monitoring of blood glucose by a surrogate.
Treatment GoalsRecommendations
2021 vs 2022:
13.6 其他方面健康、幾乎沒有共存慢性疾病且認知功能和功能狀態完整的老年人應該有較低的血糖目標（例如 A1C 低於 7.0-7.5% ），而那些同時患有多種慢性疾病的老年人 疾病、認知障礙或功能依賴的血糖目標應該不那麼嚴格（例如 A1C <8.0–8.5% 低於 8.0% ）。 C
13.6 Older adults who are otherwise healthy with few coexisting chronic illnesses and intact cognitive function and functional status should have lower glycemic goals (such as A1C less than 7.0–7.5% [53–58 mmol/mol]), while those with multiple coexisting chronic illnesses, cognitive impairment, or functional dependence should have less stringent glycemic goals (such as A1C <8.0–8.5% less than 8.0% [64 mmol/mol]). C
2022 新增：
預期壽命變化很大，但通常比臨床醫生意識到的要長。 有多種用於老年人預期壽命的預測工具 (46)，包括專門為患有糖尿病的老年人設計的工具 (47) 老年患者對血糖控制強度和模式的偏好也各不相同（48）
Life expectancies are highly variable but are often longer than clinicians realize. Multiple prognostic tools for life expectancy for older adults are available (46), including tools specifically designed for older adults with diabetes (47) Older patients also vary in their preferences for the intensity and mode of glucose control (48).
Patients With Complications and Reduced Functionality
2021：
這些患者不太可能從降低微血管並發症的風險中受益，更有可能遭受低血糖的嚴重不良反應。
These patients are less likely to benefit from reducing the risk of microvascular complications and more likely to suffer serious adverse effects from hypoglycemia.
2022 修正：
基於競爭死亡率和受益時間的概念，這些患者不太可能從降低微血管並發症的風險中受益（50）。 此外，這些患者更有可能遭受治療的嚴重不良反應，例如低血糖症 (51)。
Based on concepts of competing mortality and time to benefit, these patients are less likely to benefit from reducing the risk of microvascular complications (50). In addition, these patients are more likely to suffer serious adverse effects of therapeutics, such as hypoglycemia (51).
2022 新增：
雖然表 13.1 為識別複雜和非常複雜的患者提供了總體指導，但在老年患者分類方面尚未達成全球共識。 正在進行的根據合併症對老年糖尿病患者進行分類的經驗研究反復發現了三大類患者：健康類、老年人和心血管類 (9,52)。 老年人群的肥胖、高血壓、關節炎和失禁的患病率最高，心血管類的心肌梗塞、心力衰竭和中風的患病率最高。 與健康階層相比，心血管階層的虛弱和隨後死亡的風險最高。 需要進一步的研究來開發可重複的分類方案，以區分疾病的自然史以及對血糖控制和特定降糖藥物的不同反應 (53)。
While Table 13.1 provides overall guidance for identifying complex and very complex patients, there is not yet global consensus on geriatric patient classification. Ongoing empiric research on the classification of older adults with diabetes based on comorbid illness has repeatedly found three major classes of patients: a healthy, a geriatric, and a cardiovascular class (9,52). The geriatric class has the highest prevalence of obesity, hypertension, arthritis, and incontinence, and the cardiovascular class has the highest prevalence of myocardial infarctions, heart failure, and stroke. Compared with the healthy class, the cardiovascular class has the highest risk of frailty and subsequent mortality. Additional research is needed to develop a reproducible classification scheme to distinguish the natural history of disease as well as differential response to glucose control and specific glucose-lowering agents (53).
Pharmacologic TherapyRecommendations
2021：
患有多種疾病的老年人嚴格控制血糖被認為是過度治療，並與低血糖風險增加有關； 不幸的是，過度治療在臨床實踐中很常見 (50,70–73)。
Tight glycemic control in older adults with multiple medical conditions is considered over treatment and is associated with an increased risk of hypoglycemia; overtreatment is unfortunately common in clinical practice (50,70–73).
2022 修正:
在患有復雜或非常複雜的醫療狀況的老年人中使用包括胰島素和磺脲類藥物在內的方案進行強化血糖控制已被確定為過度治療，並且發現在臨床實踐中非常普遍（79–83）。 最終，確定患者是否被視為過度治療需要了解患者對當前藥物負擔和治療偏好的看法。
Intensive glycemic control with regimens including insulin and sulfonylureas in older adults with complex or very complex medical conditions has been identified as overtreatment and found to be very common in clinical practice (79–83). Ultimately, the determination of whether or not a patient is considered overtreated requires an elicitation of the patient’s perceptions of the current medication burden and preferences for treatments.
2021 vs 2022：
現在有多項研究評估了糖尿病和高血壓的去強化方案，證明去強化是安全的，並且可能對老年人有益（88）。
There are now multiple studies evaluating deintensification protocols in diabetes as well as hypertension, demonstrating that deintensification is safe and possibly beneficial for older adults (88).
- Metformin
2022 新增：
對於長期服用 metformin 的人，應考慮監測維生素 B12 缺乏症 (90)。
For those taking metformin long-term, monitoring for vitamin B12 deficiency should be considered (90).
- TZD
2022 新增：
如果使用Thiazolidinediones,藥物，應非常謹慎地用於那些接受胰島素治療的患者以及那些患有或有心力衰竭、骨質疏鬆症、跌倒或骨折和/或黃斑水腫風險的患者 (91,92) 聯合治療中較低劑量的 thiazolidinedione 可以減輕這些副作用。
Thiazolidinediones, if used at all, should be used very cautiously in those patients on insulin therapy as well as those patients with or at risk for heart failure, osteoporosis, falls or fractures, and/or macular edema (91,92)Lower doses of a thiazolidinedione in combination therapy may mitigate these side effects.
- GLP-1
2021:
對該類藥物的幾項試驗的分層分析表明與年齡存在復雜的相互作用。 在LEADER 試驗中，基線時患有 CVD 的年齡 ≥ 50 歲的患者主要結局降低（n = 7,598；[HR] 0.83），而 年齡≥60 歲且未確診 CVD 的患者有顯著不良結局（n = 1,742；HR 1.20，P = 0.04），但年齡≥75 歲的一小部分人群除外 (89,90)。 在使用 albiglutide的 Harmony Outcomes 試驗中也看到了類似的趨勢，該試驗將年齡 <65 歲的參與者與 65-75 歲的參與者和年齡≥75 歲的較小組進行了比較 (91)。
The stratified analyses of several of the trials of this drug class indicate a complex interaction with age. In the Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results (LEADER) trial with liraglutide, those aged ≥50 years with CVD at baseline had a reduction in primary outcome (n = 7,598; hazard ratio [HR] 0.83), whereas those aged ≥60 years with no established CVD had a significantly adverse outcome (n = 1,742; HR 1.20, P = 0.04), except in a small subgroup of those aged ≥75 years (89,90). A similar trend was seen in the Harmony Outcomes trial with albiglutide, comparing participants aged <65 years to those aged 65–75 years and a smaller group aged ≥75 years (91).
2022 修正：
在對 GP-1 -RA 試驗的系統評價和薈萃分析中，發現這些藥物可以將 65 歲以上和以下患者的主要不良心血管事件、心血管死亡、中風和心肌梗塞降低到相同程度。 98)。
In a systematic review and meta-analysis of GLP-1 receptor agonist trials, these agents have been found to reduce major adverse cardiovascular events, cardiovascular deaths, stroke, and myocardial infarction to the same degree for patients above and below 65 years of age (98).
- Insulin Therapy
2022 新增：
在選擇基礎胰島素時，已發現長效胰島素類似物與 NPH 胰島素相比低血糖風險較低。
When choosing a basal insulin, long-acting insulin analogs have been found to be associated with a lower risk of hypoglycemia compared with NPH insulin in the Medicare population.
- Other Factors to Consider
2022 新增：
當需要過渡到急性護理和長期護理 (LTC) 時，對老年人持續支持的需求變得更大。 不幸的是，這些轉變可能導致護理目標的不連續性、劑量錯誤以及飲食和活動的變化 (104)。
The need for ongoing support of older adults becomes even greater when transitions to acute care and long-term care (LTC) become necessary. Unfortunately, these transitions can lead to discontinuity in goals of care, errors in dosing, and changes in diet and activity (104).
- Management of diabetes in the LTC setting is unique.
2022 新增：
隨著人口壽命的延長，糖尿病患者及其在 LTC 中的並發症的護理是一個值得更多研究的領域。
With the increased longevity of populations, the care of people with diabetes and its complications in LTC is an area that warrants greater study.
2022 修正：
The following alert strategy could be considered: Call as soon as possible when
- glucose values are 70–100 mg/dL (regimen may need to be adjusted),
- glucose values are consistently>250 mg/dL within a 24–h period,
- glucose values are consistently>300 mg/dL over 2 consecutive days,
- any reading is too high for the glucometer, or
- the patient is sick, with vomiting, symptomatic hyperglycemia, or poor oral intake.
End-Of-Life CareRecommendations
2021 vs 2022：
Strict glucose and blood pressure control may are not necessary E, and reduction of therapy may be appropriate. simplification of regimens can be considered.
2021 vs 2022:
在姑息治療環境中，提供者應就糖尿病治療的目標和強度展開對話； 嚴格的血糖和血壓控制可能與實現舒適和生活質量不一致。 避免嚴重高血壓和高血糖符合姑息治療的目標。
In the setting of palliative care, providers should initiate conversations regarding the goals and intensity of diabetes care; strict glucose and blood pressure control may not be consistent with achieving comfort and quality of life. Avoidance of severe hypertension and hyperglycemia aligns with the goals of palliative care. (2022 新增）
2021 vs 2022：
在一項多中心試驗中，發現姑息治療患者停用 Statin 類藥物可以改善生活質量 (116-118)。但目前尚無關於血糖和血壓控制的類似證據 (108-110)。 老年人去強化方案的安全性和有效性的證據在控制血糖和血壓方面正在增加 (88,119)，並且顯然與姑息治療相關。
In a multicenter trial, withdrawal of statins among patients in palliative care was found to improve quality of life (116–118). while similar evidence for glucose and blood pressure control are not yet available (108–110). The evidence for the safety and efficacy of deintensification protocols in older adults is growing for both glucose and blood pressure control (88,119) and is clearly relevant for palliative care. (2022 新增）
Different patient categories have been proposed for diabetes management in those with advanced disease
2021 vs 2022:
穩定的患者：繼續患者之前的治療方案，重點是 1) 預防低血糖和 2) 使用血糖檢測管理高血糖，將血糖水平保持在腎葡萄糖閾值以下，以及高血糖導致的脫水 (2022增)。 A1C 監測和降低的作用很小。A1C 監測沒有任何作用。
A stable patient: Continue with the patient’s previous regimen, with a focus on 1) the prevention of hypoglycemia and 2) the management of hyperglycemia using blood glucose testing, keeping levels below the renal threshold of glucose, and hyperglycemia-mediated dehydration. There is very little role for A1C monitoring and lowering. There is no role for A1C monitoring.