Madhuri Reddy, MD, MSc, FRCPC, Assistant Professor, Department of Medicine,
University of Toronto, Associate Editor, Geriatrics & Aging, Toronto, ON.

R. Gary Sibbald, BSc, MD, FRCPC (Med), FRCPC (Derm), MACP, DABD, Associate Professor and Director of Continuing Education, Department of Medicine, University of Toronto, Toronto, ON.

Prevention of diabetic foot wounds is of crucial importance. Diabetic foot wounds are basically pressure ulcers due to improper footwear, and therefore the most critical aspect of prevention is wearing proper shoes, checked regularly by a reputable orthotist. Once foot wounds have occurred in a person with diabetes, proper footwear continues to be
crucial. Also of importance are adequate vascular supply, treatment of infection, and surgical debridement, if necessary. All diabetic foot wounds should be probed in order to evaluate depth. If the wound probes to bone, osteomyelitis should be presumed unless proven otherwise.

Key words: diabetes, wounds, ulcers, vascular, infection.

Isabelle J. Dionne, PhD, Faculty of Physical Activity and Sports, University of Sherbrooke; Research Centre on Aging, Geriatric Institute of Sherbrooke University, Sherbrooke, QC.
Martin Brochu, PhD, Faculty of Physical Activity and Sports, University of Sherbrooke; Research Centre on Aging, Geriatric Institute of Sherbrooke University, Sherbrooke, QC.

There is a high prevalence of obesity in older adults up to the age of 80. While women generally gain body weight during the menopausal transition, men tend to accumulate an excess of fat mass earlier in life for as yet unknown reasons. Consequently, an increasing proportion of older adults are now obese. Obesity’s association with metabolic diseases such as metabolic syndrome, type II diabetes, and cardiovascular disease is widely recognized. However, recent evidence shows that, in older adults, obesity is also related to functional impairment and decreased quality of life. This review addresses the actual prevalence and definition of obesity in older adults, the energy-balance equation, and the known consequences of obesity. Finally, the heterogeneity of obesity in older adults regarding its association with metabolic diseases and functional capacity will be discussed, as well as how obesity treatment should be conducted in this population.

Key words: obesity, metabolic syndrome, diabetes, weight loss, impaired functional capacity.

David Fitchett, MD FRCP(C), St Michael’s Hospital, University of Toronto, Toronto, ON.

As a response to recent clinical trials of low-density lipoprotein (LDL) lowering, the Adult Treatment Panel III (ATP III) has proposed new thresholds and targets for treatment. In addition, the population that is considered to benefit from LDL lowering has been extended to include the diabetic and the older patient. This article reviews the clinical trial evidence, and the new recommendations, and provides commentary with special reference to management of the older person.

Key words: cardiovascular disease, LDL cholesterol, statin therapy, older patients, diabetes.

Madhuri Reddy, MD, MSc, FRCPC, Assistant Professor, University of Toronto, Sunnybrook and Women's College Hospital, Toronto, ON.

Chronic wound pain adversely affects quality of life and causes functional impairment in the older adult. As the population ages and the prevalence of chronic illness increases, an explosion in the number of chronic wounds is expected in both long-term care and community care. Chronic wounds have a myriad of causes and complications, and care can be complex. The most common types of chronic wounds include venous stasis ulcers, diabetic ulcers and pressure ulcers. There is a paucity of clinical trials of chronic wound pain management in the older patient. In the absence of an adequate evidence base, we present a comprehensive clinical approach to chronic wound pain management.
Key words: chronic wounds, pain, venous stasis, diabetes, pressure.

Ellie Chuang, MD and Mark E. Molitch, MD, Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.

The worldwide prevalence of diabetes is expected to double to 300 million people by 2025, and nearly 40% of those currently diabetic are older than 65 years. In those who are at high risk for diabetes, including older adults, intervention with diet and exercise has been shown to markedly reduce the development of diabetes. Medications such as metformin, acarbose, troglitazone, pravastatin, ramipril, losartan and estrogen/progestin also have been shown to be effective, although benefits in older patients have not always been demonstrated. Implementation of lifestyle changes in people of all ages could dramatically reduce the size of the developing diabetes epidemic.
Key words: diabetes, primary prevention, impaired glucose tolerance, impaired fasting glucose, older adults.

Ernane D. Reis, MD, Assistant Professor, Department of Surgery, Mount Sinai School of Medicine, New York, NY.
Nicholas Morrissey, MD, Assistant Professor, Department of Surgery, Mount Sinai School of Medicine, New York, NY.

Prevalence of peripheral arterial disease (PAD) increases with age. PAD is not only associated with disability (e.g., claudication, limb loss), but also with increased mortality from cardiac and cerebrovascular events. A thorough assessment of symptoms, risk factors and physical signs--including ankle-brachial indices--can be sufficient to determine whether PAD is present. Further testing--such as Duplex examination, magnetic resonance imaging and conventional arteriography--is often required to determine progression and accurate localization of lesions, as well as to direct therapeutic intervention. Early detection of PAD can help prevent functional impairment and death in the elderly.
Key words: atherosclerosis, peripheral arterial disease, ankle-brachial index, diabetes, claudication.

Women with coronary heart disease (CHD) who were randomly assigned to postmenopausal hormone therapy had a 35% lower risk for developing diabetes mellitus than those assigned to placebo, according to an analysis of data from the Heart and Estrogen/progestin Replacement Study (HERS).

Observational studies in the past have found that postmenopausal women taking hormone therapy have lower fasting glucose or hemoglobin A1c levels than women not taking hormones, while only a few of these studies have found a corresponding reduction in incidence of diabetes. To date, there has been no prospective, controlled trial evaluating the effect of postmenopausal hormone therapy on the development of diabetes. To address these unresolved issues, investigators analysed data from HERS, a randomized, double-blind, placebo-controlled trial of 0.625mg conjugated estrogen plus 2.5mg medroxyprogesterone acetate for the prevention of coronary events in postmenopausal women with established CHD.

In the 2,763 women enrolled, fasting serum glucose was measured at baseline, at one year and at the end of trial visit; participants were followed for an average of 4.1 years. Self-report of diabetes or disease complication, initiation of therapy with diabetes medication, or a fasting glucose level of 6.9mmol/L or greater was taken as an indication of diabetes, whereas women with fasting glucose levels between 6.0 and 6.9mmol/L were classified as having impaired fasting glucose.

Analyses found that women with and without diabetes at baseline who were assigned to placebo had significantly worse fasting glucose values compared with women in the hormone therapy group, who experienced no significant change in glucose measurements. A similar pattern was seen among women with impaired fasting glucose. Furthermore, the cumulative incidence of diabetes was 6.2% for women in the hormone therapy group compared with 9.5% for those assigned to placebo (p=0.006). This 35% lower risk for diabetes was primarily attributed to the fact that women in the hormone group maintained lower fasting glucose levels than women in the placebo group. Other characteristics commonly associated with diabetes, such as body mass index, hypertension, dyslipidemia and smoking, were not found to be responsible for the treatment effect.

In the present study, for every 30 women treated for about four years, hormone therapy was found to prevent one case of diabetes. However, all must now be well aware of the increased risks for venous thromboembolic events, stroke and breast cancer with long-term hormone therapy use. Therefore, although hormone therapy is not a viable approach to diabetes prevention in women with heart disease, these data allude to the important metabolic benefits of hormone therapy which warrant further investigation.

Source

1. Kanaya AM, Herrington D, Vittinghoff E, et al. Glycemic effects of postmenopausal hormone therapy: The Heart and Estrogen/progestin Replacement Study. Ann Intern Med 2003;138:1-9.

David H. Fitchett MD, FRCP(C), St Michael's Hospital, University of Toronto, Toronto, ON.

For the diabetic patient, hypertension more than doubles the risk of myocardial infarction, stroke and cardiovascular death, and is central in the development of diabetic nephropathy. Control of hypertension is an important vascular protective measure. However, the thresholds and goals of antihypertensive treatment have fallen as trials have shown improved outcomes with blood pressures reduced to 120/80mmHg or less. Although reducing blood pressure to the lower target levels must be the primary goal of treatment, the use of diuretics and angiotensin-converting enzyme inhibitors should be considered as first-line therapy in the diabetic patient. Both agents have been demonstrated to improve a wide range of cardiovascular outcomes compared to other antihypertensive medications.
Key words: diabetes, hypertension, nephropathy, blood pressure control.

• Office-based risk factor evaluation is mandatory in people with diabetes, and aggressive risk factor modification should be based on those results.
• The metabolic syndrome commonly precedes the onset of diabetes by several years. Insulin resistance apparently predates the risk factors associated with metabolic syndrome, thus detection of insulin resistance relatively early in life offers the opportunity to identify, at an early stage, those people likely to develop blood fat abnormalities, high blood pressure (HBP) and, ultimately, diabetes.
• A person with diabetes who smokes is at double the risk for cardiovascular disease (CVD). Therefore, every effort must be made to convince the patient to stop smoking.
• HBP increases a diabetic patient's risk of coronary heart disease (CHD), stroke, kidney failure and heart failure. Treatment of HBP in people with diabetes should be intensive enough to reach blood pressure goals.
• The common drugs to treat high blood pressure--diuretics, beta-blockers, angiotensin converting enzyme (ACE) inhibitors and calcium channel blockers--are generally effective in treating patients with diabetes.
• Assiduous treatment of high blood pressure in people with diabetes can delay the progression of diabetic nephropathy and retinopathy, as well as CVD.

Tess Montada-Atin, RN, CDE
Care Leader

Marilyn Mori, RD
Lina Medeiros, MSW
Diabetes Education Centre,
Toronto Western Hospital
University Health Network
Toronto, ON

Diabetes is a chronic illness with significant short and long term complications.¹ The Diabetes Education Centre (DEC) at the Toronto Western Hospital, University Health Network, supports people with diabetes, their family and friends to better understand and manage diabetes. The 1998 Clinical Practice Guidelines (CPG) for the management of diabetes in Canada, recommends initial and ongoing education for the person with diabetes as part of diabetes care and not just as an adjunct to treatment. Diabetes Education should be recognized as a life long commitment.² Comprehensive management of diabetes should be planned around an interdisciplinary diabetes health care team,^1-3 which can be through a DEC. To learn and use the varied complex skills required, people with diabetes need the support of such a team of expert professionals.¹ Interdisciplinary interventions have been shown to improve glycemic control in the elderly. Studies have suggested that a team approach toward older people with diabetes improves blood glucose control, quality of life and adherence to therapy.³

Factors that affect glycemic control are diet, diabetes medications and exercise.