Hsu-Ko Kuo, MD, MPH, Department of Geriatrics and Gerontology, National Taiwan University; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
Yau-Hua Yu, DDS, DMSc, Department of Medical Research, Veterans General Hospital, Taipei, Taiwan.
Shin-Yu Lien, BS, School of Nursing, Chang Gung University, Taoyuan, Taiwan.
Yi-Der Jiang, MD, PhD, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.

There has been a substantial increase in total cases of diabetes mellitus in industrialized countries among older adults. Diabetes mellitus has been increasingly recognized as a risk factor for cognitive impairment and dementia. This article discusses the epidemiological evidence for diabetes to predict Alzheimer’s disease, vascular dementia, and decline in various domains of cognition. We also address the features of diabetes-related executive dysfunction and its importance in the clinical care of diabetic older adults.
Key words: diabetes mellitus, cognition, Alzheimer’s disease, vascular dementia, frontal executive dysfunction.

Our focus this month is on diabetes and related endocrine disorders such as the metabolic syndrome. It does not take much in the way of insight to recognize that North American society is getting fatter, decade by decade. The rise in obesity and the aging of the population has resulted in a staggering increase in the prevalence of Type II Diabetes Mellitus (DMII). What surprised me this year, however, was seeing evidence of this phenomenon during my trip to China. In the prosperous urban areas of the country there are many people who are overweight. To my eye there was a clear gradient among those using different modes of transportation. Bicycle riders were more slender than drivers of electric scooters, and drivers of cars seemed to be the heaviest. In the less prosperous rural areas, everybody seemed to be quite slim. In the coming decades the absolute numbers of people with DMII in the developing world will be enormous. This epidemic will not remain a North American/Western European phenomenon.

There is an article by Dr. Jeremy Gilbert in this month’s journal entitled “Pharmacological Treatments for Diabetes Among Older Adults: An Update.” With the proliferation of new treatments for DMII this is indeed a timely topic to address, and our CME course is based on this very practical topic. However, treatment is never as desirable as prevention, and the article “Preventing Diabetes and Cardiovascular Disease in Older Adults: Controlling the Metabolic Syndrome Through Lifestyle Interventions” by Dr. Muhammad Firdaus and Dr. Timothy J. Lyons is particularly important. “Preventing Amputations in Older Adults with Diabetes” by Dr. Naven Duggal completes the trio of topics on this month’s focus.

We also have our usual collection of articles on important geriatric topics. Our cardiovascular disease column this month is “Blood Pressure and Survival in the Very Old” by Drs. Kati Juva, Sari Rastas, and Tuula Pirttilä. Our dementia topic this month is “Use of Atypical Antipsychotic Medications in Later Life” by Drs. Tarek Rajji, Benoit H. Mulsant, Hiroyuki Uchida, and David Mamo. In the past few years, real scientific evidence has started to accumulate on how to use these medications in older adults. To round off this issue, we have an informative case study by David Wan and Dr. Shabbir M.H. Alibhai entitled “A Case of Methotrexate-Induced Pancytopenia.”

Enjoy this month’s issue,

Barry Goldlist

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme.htm

Diabetes mellitus (DM) is a very common condition in the older population. The disease may interact with other medical conditions that increase the degree of frailty in aging adults. Nonpharmacological and pharmacological interventions are the usual steps in managing of DM. In this article, a stepwise treatment strategy will be suggested after a review of the pertinent literature.

Key words: diabetes mellitus, older adult, diet, exercise, pharmacotherapy.

Daniel Tessier MD, MSc, Head of Geriatric Services, Sherbrooke Geriatric University Institute, Sherbrooke, QC.

Raymond Fung, MD, BSc, Fellow, Division of Endocrinology, University of Toronto, Toronto, ON.

Lorraine L. Lipscombe, MD, FRCPC, Clinical Associate, Research Fellow, Division of Endocrinology, Sunnybrook and Women’s College Health Sciences Centre, University of Toronto, Toronto, ON.

The prevalence of diabetes has been increasing significantly in the last several years, especially in the older population. Cardiovascular disease (CVD) represents the most important complication of diabetes in this age group, as up to 80% of persons with diabetes die from CVD. The treatment of dyslipidemia and hypertension are both key in ameliorating CVD risk. Recent randomized controlled trials have included older persons with diabetes and have demonstrated that both statin therapy for dyslipidemia and antihypertensive agents are highly effective and safe in preventing CVD in this population. This review will examine the evidence for treatment in both areas, outlining the special considerations in the aged.

Key words: diabetes mellitus, cardiovascular disease, statins, hypertension, cholesterol.

When I started medical school, the era of syphilis as a major scourge of medicine had already ended. Because of its protean manifestations, it was once said that the doctor who knew syphilis, knew medicine. While I doubt if thoroughly knowing any single disease could ever qualify a person as "knowing medicine," diabetes mellitus might be the disease that comes closest. From head (eye complications) to toe (foot ulcers), it seems that virtually every major body system and anatomical area can be affected by diabetes mellitus. As well, Type II diabetes mellitus gives us an excellent example of how "nature and nurture" interact in chronic disease. Even with the appropriate genotype for the disease, a person who remains fit and lean can often avoid the clinical manifestations of the illness.
In this month's journal, we focus on diabetes management. Over the past few years, new forms of insulin, new oral agents, and a new understanding of the use of oral agents in association with insulin have transformed the glycemic management of diabetes mellitus. Dr. Daniel Tessier, an expert in diabetes mellitus in the older adult, summarizes current practice in his article "Stepwise Approach to the Treatment of Diabetes in the Older Adult." Dr. Shobha Rao reviews the "Diagnosis and Management of Impaired Glucose Tolerance and Impaired Fasting Glucose." Current management of diabetes mellitus might start with glucose control, but it is doomed to failure if other cardiac risk factors are not addressed concurrently. Drs. Raymond Fung and Lorraine Lipscombe contribute the article "Treating Dyslipidemia and Hypertension in the Older Person with Diabetes: An Evidence-Based Review." We have two articles on the complex and challenging task of managing diabetic foot ulcers. Drs. Madhuri Reddy (geriatrician and Associate Editor of Geriatrics & Aging) and Gary Sibbald (dermatologist) have contributed an article entitled "Management of Diabetic Foot Ulcers," while Oksana Davidovich (chiropodist) provides a complementary article on "Promoting Healing in Diabetic Foot Ulcers."
As well, we have our usual assortment of articles pertaining to the care of older adults. Dr. David Fitchett provides the article "ABCs of Prescribing Antianginal Therapy in Chronic Stable Angina." Drs. Alan Bell and Douglas Conway have written the article "Management of the At-Risk Patient with Osteoarthritis." This is particularly relevant given the recent controversies concerning COX-2 inhibitors. Marcia Zalev and Penny Pashby, two social workers with extensive experience in managing patients with dementia, have written the article "Using the C.A.R.E Approach: Supporting Family Caregivers of Dementia Patients." It also serves as an important reminder that management of patients with dementia requires much more than just the provision of effective medications. We continue the publication of evidence-based material with the article "Translating Evidence into Clinical Practice: A Falls Prevention Program for Community Dwelling Seniors" by Susan Maddock, Susan Gal, MaryJane McIntyre, Rory Fisher, and Barbara Liu. Those who read this journal regularly know how excited I am about the topic of falls prevention, and how important I feel widespread community programs are for this issue, so I thank our editorial staff for
publishing this article! Dr. D'Arcy Little, Medical Director for CME, provides conference coverage with an article entitled "Psychogeriatric Update 2004: Late-Life Mood Disorders." Finally, Dr. Mark Clarfield provides a diversion in his article, "Medical Meanings."

Enjoy this issue,
Barry Goldlist

Daniel Tessier, MD, FRCPC, Professor, Head of Geriatric Service, Sherbrooke Geriatric University Institute, Sherbrooke University, Sherbrooke, QC.

The concept of insulin resistance is a major field of interest in the medical literature. The basic science research has significantly increased our knowledge of this phenomenon, which has become a silent killer in our society. The main factors involved in insulin resistance are obesity (mainly abdominal), lack of physical activity, loss of muscle mass and secondary diminution in insulin action followed by diabetes mellitus. The changes in lifestyle and diet observed in many older subjects increases the risk of insulin resistance and diabetes. This paper will underline the main elements for primary and secondary prevention of insulin resistance in older adults.
Key words: insulin resistance, older adults, diabetes mellitus, obesity, free fatty acid, pharmacotherapy.

Amish Parikh, MD and I. George Fantus, MD, FRCPC, Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, ON.

Microvascular complications of both Type 1 and Type 2 diabetes mellitus (DM) can be classified into three major categories: retinopathy, nephropathy and neuropathy. Numerous studies have consistently shown that the development of complications in both Type 1 and Type 2 diabetes is related to several factors. The most important ones, however, include glycemic control (as measured by hemoglobin A1c) and the duration of diabetes. This article reviews the details of screening and management of diabetic microvascular complications in older adults. It incorporates guidelines from both the Canadian and American Diabetes Associations, as well as reviews of recently published literature.
Key words: diabetes mellitus, retinopathy, nephropathy, neuropathy, screening, management.