Foreword

The cognoscenti, the small cadre of experts on diabetes in older people, will skip this foreword and dive right into the individual chapters. There they will find many treasures related to clinical science and clinical care, as well as historical vignettes and current controversies related to diabetes in aging patients.

You, by reading this foreword in a book on diabetes in old age, are marking yourselves as non-expert but you are clearly ahead of your medical colleagues. You are recognizing that the excellent textbooks on diabetes and excellent textbooks on geriatric medicine, though they cover medical care of the older patient, typically fall short in dealing with the older patient with diabetes.

These textbooks mirror the state of affairs in medical care today. When I was a young physician, I was impressed that excellent internists provided excellent care for their patients, including very good diabetes management. My impression now is that very good internists continue to provide very good care, except for diabetes where the care often is only mediocre. Many endocrinologists, formerly excellent in diabetes, are also falling further and further back from the cutting edge of diabetes care. This is especially sad because we now know more than ever the importance of good management and have better tools with which to approach the desired goals. The gap between "excellent" and "actual" widens as the patient's age increases.

In this essay, I plan to inspire you, to help guide you into a highly satisfying professional path, a path that will please you, as well as enhance your value to your patients and to your medical community. The rest of this book is filled with instructional material that you will find very useful. My goal is to provide an overarching view from the top of the mountain.

Nourishing the soul

Champions seek new challenges, set new goals. For mountain climbers and cellists, surgeons and swimmers, dancers and authors, striving for excellence channels energies and rejuvenates the self. The physician who adopts the mindset of a champion helps his or her patients, helps other health care professionals with their patients and nourishes his or her own soul. At this time in medicine, when physician burnout is epidemic, nourishment for the soul can be life-saving. In the USA, where the pension systems are in disarray and large debts have been piled up to pay for schooling, physicians will be working many years past the hallowed 65. The best preparation for the long journey is passion in one's professional pursuit. As an internist, or endocrinologist, or geriatrician, join me in exploring the attractions of becoming skilled in the care of diabetes of the old.

When I entered the profession fifty years ago, antibiotics were routing many infectious diseases. The ancient aphorism "If you know syphilis, you know all of medicine" was being re-modelled; syphilis was replaced by diabetes.

I propose a new model: "If you know diabetes in old age, you know all of medicine".

The challenge for the profession

Increasingly, medicine in general is benefiting from the introduction of protocols and algorithms. While improving care, these also shrink the intellectual distance between the physician, the physician's assistant and the nurse. I am guessing that a 37-year-old professor of computer science with type 1 diabetes can probably manage well with a little help from a diabetes educator and an occasional visit to a physician. Recall the World War II pharmacist's mate who in the pre-antibiotic area successfully removed an inflamed appendix from a crew member of his submarine submerged beneath the waters of the Pacific.

Advancing age brings growing complexity. Elderly patients with diabetes need continuous input from skilled physicians. For these physicians, protocols and algorithms are the starting point but the real plan needs multiple modifications, surveillance, balancing of competing priorities, and skilled navigation of poorly charted waters. It demands professional skills at their best.

Interpreting data

Multi-centre trials, the foundation of therapeutics today, are typically performed on younger patients. With the basic and clinical science in the background, the data from widely heralded multi-centre trials (with patients who are typically younger and less complicated) provide a basis but not a recipe for care of the elderly patient. Advanced age and other exclusionary criteria, including medications, make extrapolations to older people more tenuous. The loud "microphones" supported by pharmaceutical company coffers often fill the air with information that is misleading for older patients.

Laboratory standards are based on younger populations. Data in the elderly are much sparser. Even when the mean and median for a lab test remain unchanged, the splay typically increases so that higher and lower values that are "normal" for an older patient are easily labelled as pathological.

New medications are largely tested on younger, less complicated patients. Data among older patients are sparse. Many side effects of drugs emerge gradually in the years after their introduction. The catalogue of side effects among older complex patients emerge more slowly. The sparseness of data dictates that new drugs should be avoided in older patients, except on the very rare occasion when the new drug is a very substantial advance and other drugs cannot meet the need.

Adverse drug interactions between two drugs are identified slowly. Many remain undetected. Typical elderly patients take many medications, exponentially increasing the likelihood of adverse drug interactions and, equally, making their detection most difficult.

Depression

Advancing age as well as medications and multiple medical conditions are associated with depression. The link between diabetes and depression has received a lot of attention recently. Growing evidence that depression impacts negatively on physical health mandates that depression, so common in older people, be detected and treated energetically.

In dealing with depression, especially in the older patient, recall:

1. Depression without sadness is easy to miss.
2. Screening instruments are helpful.
3. Personalized rationalizations of the healthcare professional ("If I were 82 and living alone, I would also feel that way .") can obscure the correct diagnosis and management.
4. Drugs as well as endocrine diseases and other disorders are common aetiologies of depression that is reversible.
5. When medication and psychotherapy fail, ECT (electroconvulsive therapy), is an excellent therapeutic choice to consider.
6. With ageing, suicide rates rise sharply, especially among white males. Living alone and having firearms in the home each add to the risk.

Demographics and disease

The population is being enriched progressively with patients who are over 65. They are living longer. The so-called old-old are a rapidly growing group. Objective data to guide the physician require ever longer lines of extrapolation, demanding more of the physician's judgment. The incidence and prevalence of diabetes increase with age. Ageing brings out diabetes; diabetes accelerates biological ageing and onset of other pathology. These processes corrode cognition.

Ageing in our Society: The universal reverence, or at least respect, for the elderly that held sway worldwide since the beginning of human memory, has been replaced in the industrialized world of today with a wide range of negative attitudes, mostly undeserved. In their care for the elderly, physicians and their teammates in care will be energized by recalling the widely appreciated positive features of a majority of the elderly:

1. Every older patient can be improved in some way by an encounter with a professional.
2. Typically, older people are appreciative of the care and express their appreciation.
3. Their expectations for improvement are realistically tempered.
4. They are individually "more unique".

"More unique" is a phrase that will galvanize to action legions of amateur grammarians all over the English-speaking world. They will reflexly remind me that unique indicates one-of-a-kind and therefore no comparator is permitted. Biology and I will prove them wrong. Let's start with a fertilized egg that is just dividing to generate a pair of monozygotic twins. They are not identical and progressively diverge, distancing one biological self from the other. All humans do the same. The extremely similar looking zygotes, and highly similar looking newborns progressively diverge, biologically, sociologically and medically, to the delight and amazement of the skilled physician and other health care providers. Like snowflakes, Rembrandt paintings, precious gemstones, and leaves from a single tree, blessedly, there are no sames among older patients with diabetes.

Valediction

With a little luck, it is likely that you, in your lifetime, will never lack for food for your body. Much more at risk, and therefore more to be guarded, is the supply of nourishment for your professional soul.

Jesse Roth MD, D.H.C., FACP
Investigator & Head, Laboratory of Diabetes and Diabetes-Related...