The 2022 edition of "China's Clinical Guidelines for the Prevention and Treatment of Type 2 Diabetes in the Elderly" was released!

Edited by Yimaitong, please do not reprint without authorization
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According to the Bulletin of the Seventh National Census of the National Bureau of Statistics, in 2020, the population of the elderly aged 60 and above in China will reach 260.
4 million, of which about 30% are diabetic patients (more than 95% are type 2 diabetes).
—2030) one of the key actions
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Recently, the "Chinese Clinical Guidelines for the Prevention and Treatment of Type 2 Diabetes in the Elderly (2022 Edition)" was released in the "Chinese Journal of Internal Medicine".
, The implementation of clinical measures for diagnosis and treatment, and continuously improve the overall management level of elderly diabetes
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This article shares the content of "comprehensive management of diabetes in the elderly" and "complication prevention"
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Watch elderly diabetic "integrated management" screening and tertiary prevention of type 2 diabetes in elderly elderly 1.
The health check 2h blood glucose (2hPG) screening (C, Ⅱa) after addition to FPG, the recommended increase glucose load
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Fasting or random blood glucose should be measured in elderly patients in emergency department for various reasons (C, IIa)
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The determination of HbA1c is helpful for the diagnosis and treatment selection of diabetic patients (B, Ⅰ)
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Prediabetes and new-onset diabetes are key populations for diabetes management in the elderly (A, I)
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Early prevention, early diagnosis, early life>
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Regular screening of diabetic complications and evaluation of organ function, comprehensive treatment (B, I)
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2.
Optimization of treatment strategies for elderly type 2 diabetes.
Comprehensive assessment of blood glucose and pancreatic islet function levels, complications and comorbidities, organ function and personal living ability in elderly patients with type 2 diabetes is to formulate an individualized treatment plan.
The basis of (A, I)
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Early prevention, early diagnosis, early treatment, and early compliance are the basic principles for optimizing the outcome of treatment for type 2 diabetes in the elderly (B, I)
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To develop individualized glycemic control goals to maximize benefits and minimize risks in elderly patients with type 2 diabetes (A, I)
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The blood glucose control target defined by HbA1c is less than 7.
0%, corresponding to fasting blood glucose of 4.
4-7.
0 mmol/L and 2 h PG<10.
0 mmol/L, which is suitable for most people with long life expectancy, no risk of hypoglycemia, and no serious heart, brain and kidney disease.
of elderly patients with type 2 diabetes (A, I)
.

HbA1c≤8.
5%, corresponding FPG≤8.
5 mmol/L and 2 h PG<13.
9 mmol/L are acceptable blood glucose control standards for elderly diabetic patients
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It is suitable for elderly diabetic patients with long course of disease, difficulty in blood sugar control, and high risk of hypoglycemia, and it is necessary to avoid the occurrence of acute complications of diabetes (B, I)
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3.
Diabetes education and patient self-management Diabetes education can significantly improve patients' HbA1c level and overall control of diabetes (B, I)
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Provide teaching materials and implementation methods of basic diabetes management (diet, exercise, blood sugar monitoring, healthy behaviors) with the characteristics of the elderly, individualized and various forms, and encourage and promote patients and their families to actively participate in blood sugar management (B, I)
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Strengthening the introductory education and early positioning management (responsible doctor) of diabetic patients can help to improve the prognosis (B, I)
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A hospital-community joint diabetes grading management system is a necessary measure to improve the overall management of diabetes (B, I)
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4.
Dietary management of elderly diabetes mellitus Individualized diet prescription is configured according to the patient's age, height, weight, metabolic index, and organ function, to ensure the needs of physiological activities and not increase the metabolic burden (C, I)
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The energy-supplying nutrients should be mainly carbohydrates (50%-55%).
It is advisable to choose foods with high energy density, rich dietary fiber and low glycemic index, and increase vegetables and an appropriate proportion of low-sugar fruits (B, I)
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The recommended protein intake is 1.
0-1.
5 g·kg-1·d-1, mainly high-quality protein, which can improve insulin resistance and reduce age-related muscle loss (A, I)
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Regular diabetes education and dietary guidance can significantly reduce HbA1c (B, I)
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Changing eating habits, first soup and then staple food, is beneficial to reduce postprandial blood sugar fluctuations (B, Ⅰ)
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5.
Exercise treatment of diabetes in the elderly The goal of exercise therapy for diabetes is to maintain good physical fitness and help blood sugar control (B, Ⅰ)
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Elderly diabetic patients can choose individualized, easy-to-perform and adhere to, and muscle-building body and limb exercise patterns and exercise time (30–45 min/d) (C, IIa)
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For elderly diabetic patients without walking difficulties, it is recommended to do appropriate short-distance activities after three meals a day, which is beneficial to relieve postprandial hyperglycemia (B, I)
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Do preparatory activities before exercising, and pay attention to preventing falls and fractures during exercise (A, I)
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6.
Self-monitoring of blood sugar in elderly diabetic patients Self-monitoring of blood sugar (SMBG) helps patients understand their condition and provides evidence for hypoglycemic therapy (A, Ⅰ)
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According to the condition and planned blood glucose monitoring, it is helpful for patients to manage themselves, assist in the adjustment of hypoglycemic program, and promote the ideal control of blood sugar (B, I)
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Multi-point or continuous blood glucose monitoring is beneficial to provide information for better adjustment of hypoglycemic therapy when the condition changes (A, I)
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7.
In the drug treatment of hyperglycemia, the islet function should be evaluated before treatment, and the treatment plan should be formulated according to the blood sugar level of the patient during treatment and the HbA1c detection value as a reference (B, I)
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When choosing hypoglycemic drugs, attention should be paid to cardiovascular and cerebrovascular diseases, renal function, hypoglycemia risk, impact on body weight, cost, risk of side effects, and the patient’s medical insurance affordability, and to formulate more beneficial individualized hypoglycemic treatment plans (A, I)
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Choosing a simplified, easy-to-operate, and low-risk medication mode can improve compliance (B, I)
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Metformin is the drug of choice (no age limit) and can be used for a long time (except for severe renal insufficiency) (A, I)
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On the basis of life>
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When combined with atherosclerotic cardiovascular disease (ASCVD) or high risk factors, renal disease or heart failure, SGLT-2i or GLP-1RA is preferred according to individual patient conditions (A, I)
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On the basis of combined treatment with life>
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It is recommended to use multiple insulin injections (intensive therapy) or continuous subcutaneous insulin infusion in special circumstances such as concomitant hyperglycemia (HbA1c>9.
5%, FPG>12 mmol/L), co-infection or acute complications, surgery or stress state.
Note (CSII) method (A, I)
.

8.
Comprehensive prevention and treatment of cardiovascular risk factors In general, the blood pressure control target for elderly diabetic patients with hypertension is <140/85 mmHg (1 mmHg=0.
133 kPa).
The control standard should be adjusted to <130/80 mmHg, but the blood pressure should not be lower than 110/60 mmHg.
The blood pressure of elderly patients with cerebral infarction and long-term poor blood pressure control can be <150/80 mmHg (A, I)
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Angiotensin II receptor blocker (ARB) or angiotensin-converting enzyme inhibitor (ACEI) antihypertensive drugs are the first choice and basic antihypertensive drugs for elderly diabetic patients (A, I)
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Dyslipidemia in elderly diabetic patients should focus on low-density lipoprotein cholesterol (LDL-C), and statin lipid-lowering drugs should be used to control it within the required range according to cardiovascular risk stratification (A, I)
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Controlling hyperuricemia is one of the important management goals in elderly patients with diabetes
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Simple diabetes complicated with hyperuricemia, blood uric acid should be controlled at normal (<420 μmol/L), if combined with cardiovascular and renal diseases, blood uric acid should be reduced to <360 μmol/L (for patients with gout attack, blood uric acid should be reduced to <360 μmol/L.
Uric acid <300 μmol/L) (A, I)
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To control cardiovascular risk factors, attention should also be paid to weight management, correction of hyperhomocysteinemia, and safe application of antiplatelet aggregation drugs (A, I)
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Elderly diabetic patients face multi-disease drug treatment, and need to pay attention to drug-drug interactions to reduce the risk of polypharmacy (A, I)
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Management of "acute and chronic complications" of elderly diabetes 1.
Acute complications of diabetes Elderly diabetic patients need to control their blood sugar within an acceptable range as much as possible to avoid the occurrence of diabetic ketoacidosis (DKA) and diabetic hyperglycemia and hyperosmolar state (HHS).
)(A,I)
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Rehydration is the primary treatment for DKA and HHS, and 0.
9% sodium chloride injection is recommended
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In principle, it should be fast first and then slow, and the subsequent rehydration rate should be adjusted according to the degree of dehydration, electrolyte level, urine output, and cardiac and renal function of the patient (A, I)
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In DKA and HHS patients, insulin therapy is started at the same time as fluid replacement, and continuous intravenous infusion of 0.
1 U kg-1 d-1 is recommended; the amount of insulin infusion will be adjusted according to the hourly blood glucose changes (A, I).
Treatment of elderly diabetic patients The first dose of intravenous insulin is not recommended (C, IIb)
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In DKA patients, intravenous potassium supplementation should be started when serum potassium <5.
2 mmol/L and adequate urine output (>40 ml/h) (B, IIa)
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DKA patients with severe acidosis (pH<7.
0) need appropriate intravenous sodium bicarbonate injection (B, IIa)
.

0.
9% Sodium Chloride Injection is the first choice for intravenous fluids in HHS patients.
If conditions permit, warm boiled water can be added orally.
When blood sugar drops to 16.
7 mmol/L, intravenous supplementation of 5% sugar-containing injection is started (B, IIa)
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Severe hypoglycemia and hypokalemia should be avoided during DKA and HHS treatment (B, I)
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2.
Chronic complications of diabetes 1.
Diabetic macrovascular disease (1) Comprehensive management of elderly diabetes mellitus complicated with cardiovascular disease (CVD): those with hypertension and high LDL-C can aggravate the occurrence and development of CVD (A, I)
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Risk factors for CVD should be assessed annually (B, I)
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Multi-factor comprehensive high-quality management (control of "four highs" and anti-platelet aggregation therapy) can significantly improve the risk of CVD and death (A, I)
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Patients with multiple coronary artery (coronary artery) lesions may experience serious cardiovascular events such as silent myocardial infarction, atypical heart failure, and sudden cardiac death (B, I)
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Combined with ASCCVD, or if there is no contraindication, the combination of GLP-1RA and SGLT-2i hypoglycemic agents is preferred (A, I)
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(2) Comprehensive prevention and treatment of senile diabetes complicated with cerebrovascular disease: risk factors for cerebrovascular disease should be evaluated in all elderly patients diagnosed with diabetes (A, I)
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Primary prevention of cerebral infarction includes life>
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For secondary prevention of cerebral infarction, LDL-C should be controlled at <1.
8 mmol/L
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Blood pressure should not be controlled too strictly, <150/85 mmHg is also an acceptable standard, and the blood pressure should be gradually adjusted to <140/80 mmHg after the condition is stable (A, I)
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On the basis of dietary management, elderly patients treated with single drug or in combination with two or more non-insulin secretagogues should strive for HbA1c<7.
0%.
Patients who need insulin or insulin secretagogue therapy are at risk of hypoglycemia, and blood sugar control standards need to be Relaxed as appropriate, HbA1c<8.
5% is an acceptable standard, and postprandial or random blood glucose should be <13.
9 mmol/L
.

In particular, HHS should be avoided, aggravating or inducing another cerebral infarction (A, I)
.

2.
Diabetic microangiopathy DKD and CKD: It is recommended that all patients have at least an annual assessment of urinary albumin/creatinine ratio (UACR) and eGFR to guide the diagnosis and treatment of DKD (B, I)
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Effective hypoglycemic therapy and blood pressure control can delay the occurrence and progression of DKD (A, I)
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In elderly patients with DKD, renin-angiotensin system (RAS) blockers, SGLT-2i or GLP-1RA should be preferentially selected according to the principle of individualized treatment to improve the renal outcomes of patients (A, I)
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DKD patients need to pay attention to life>
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Diabetic retinopathy (DR) and blindness: Comprehensive eye examination should be performed every year to detect lesions in time and start treatment early (B, I)
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Good control of blood sugar, blood pressure and blood lipids can prevent or delay the progression of DR (A, I)
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Patients with nonproliferative DR of moderate or higher macular edema should be further managed by an ophthalmologist with relevant knowledge and experience (A, I)
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Diabetic peripheral neuropathy (DPN): Screening for DPN should be performed at the time of diagnosis of diabetes and annually thereafter (A, I)
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Screening and early management of distal peripheral neuropathy and autonomic neuropathy are prognostic for patients (B, I)
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Acute painful neuropathy and chronic distal neuropathy with abnormal pain tingling have different prognosis, and need to be differentiated and treated symptomatically (B, IIa)
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Complicated cranial nerve and spinal radiculopathy should be actively treated to relieve symptoms (B, IIa)
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Good control of blood sugar and various metabolic abnormalities can delay the progression of DPN (B, I)
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3.
Diabetic foot disease patients with diabetic foot warning have a high risk of death and disability (A, Ⅰ)
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Comprehensive control of risk factors, early screening and early treatment of diabetic peripheral vascular and neuropathy are important steps to prevent the occurrence of diabetic foot disease (A, Ⅰ)
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Elderly diabetic patients should pay attention to daily foot care, and deal with damage to the foot skin in time to reduce the infection rate (A, Ⅰ)
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Once the foot infection develops into ulcer and gangrene, it needs to be treated according to the specific classification, and comprehensive treatment to improve the nutritional status of the whole body, control blood sugar, effectively fight infection, and improve blood circulation (revascularization) (A, I)
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4.
Prevention and treatment of concomitant diseases and problems that need to be taken into account 1.
Elderly osteoporosis Elderly diabetic patients with increased bone fragility have a higher fracture risk than non-diabetic patients (A, Ⅰ)
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Risk assessment tools such as bone mineral density T-score measured by dual-energy X-ray absorptiometry (DXA) and fracture risk assessment (FRAX) often underestimate the fracture risk in diabetic patients, and osteoporosis treatment in elderly diabetic patients should be as early as possible (A, I)
.

Good control of blood glucose is beneficial to reduce the progression of osteoporotic lesions (B, IIa)
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When possible and not contraindicated, hypoglycemic drugs such as metformin, GLP-1RA and DPP-4i, which have less effect on bone metabolism and fracture risk, should be used preferentially (B, I)
.

Bisphosphonates remain the drug of choice for the treatment of osteoporosis in diabetic patients, but teriparatide or denosumab may be considered as alternatives in diabetic patients with older age and/or decreased renal function (B, IIa )
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2.
Assessment and management of geriatric syndrome The components of geriatric syndrome often associated with elderly diabetic patients include frailty, increased risk of falls, polypharmacy, and cognitive impairment
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The assessment and treatment of sarcopenia and cognitive impairment need to be focused on (A, I)
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The treatment of sarcopenia is mainly nutritional support and exercise rehabilitation
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The diet of the elderly needs to ensure adequate protein, vitamin D, antioxidants and long-chain unsaturated fatty acids
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Non-elderly elderly patients can perform moderate-to-high-intensity exercise such as brisk walking, swimming or jogging for 30-40 minutes per week, and resistance exercise for 20-30 minutes per week for ≥3 days (C, IIa)
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Early identification of cognitive dysfunction through corresponding neuropsychological and daily living ability scales, and behavioral and drug interventions can delay the progression to dementia (A, I)
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The prevention and treatment of cognitive impairment is first to identify and control risk factors.
Once cognitive impairment is diagnosed, a “supervisor” needs to be established, and a beneficial treatment plan should be formulated under the guidance of a doctor, including daily life, diet, functional training, etc.
(B, IIa )
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The original text of the guideline: http://rs.
yiigle.
com/CN112138202201/1347049.
htm The above content is excerpted from: China Clinical Guidelines for the Prevention and Treatment of Type 2 Diabetes in the Elderly and Metabolism Branch, et al.
Clinical Guidelines for the Prevention and Treatment of Type 2 Diabetes in the Elderly in China (2022 Edition) [J].
Chinese Journal of Internal Medicine, 2022, 61(1):12-50.