From the ACP Diabetes Care Guide

Depression is approximately twice as common in patients with diabetes (ranging from 15% to 30%) than in the general population. The odds of major depression is increased in patients with diabetes who also have two or more coexisting chronic conditions, such as hypertension, coronary artery disease, or arthritis. Diabetes and depression increase the risk of death from all causes of mortality.

The effect that treatment of depression has on glycemic control is not well defined in these patients. However, the presence of depression may play an important role by affecting a patient's ability to adapt and manage his or her disease (e.g., take medications, exercise, and make dietary modifications).

NOTE: You may order free copies of the complete ACP Diabetes Care Guide (book and CD-ROM).

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From the ACP Diabetes Care Guide

Persons with diabetes are at increased risk for macrovascular disease; microvascular disease, including retinopathy and nephropathy; peripheral and autonomic neuropathies; and lower extremity disease.

• Diabetic retinopathy is the leading cause of noncongenital blindness among adults.
• Diabetes is the most common cause of endstage kidney disease in the United States, especially among Native American, Hispanic, and African American persons. One quarter to one third of patients with type 1 or type 2 diabetes develop some degree of nephropathy.
• Diabetes doubles the risk for cardiovascular disease in men and triples it in women (data from the Multiple Risk Factor Intervention Trial [MRFIT]).
• Patients with diabetes are several-fold more likely to have peripheral arterial disease than patients without diabetes.
• Peripheral arterial disease and foot ulcers in patients with diabetes account for two thirds of all nontraumatic amputations performed in the United States.

Screening for and prevention of these complications are fundamental to the care of patients with diabetes and are important components of quality of care initiatives for diabetes.

NOTE: You may order free copies of the complete ACP Diabetes Care Guide (book and CD-ROM).

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From the ACP Diabetes Care Guide

As the population lives longer, the number of older adults with diabetes will continue to increase significantly. In addition to macro- and microvascular complications of diabetes, elderly patients with diabetes are also at increased risk of the adverse effects of polypharmacy, functional disabilities, cognitive dysfunction, depression, urinary incontinence, falls, and persistent pain.

Elderly patients with diabetes represent a heterogeneous population ranging from those who are highly functional and reside independently in the community, to those who live in assisted-care facilities, to functionally dependent persons who live in nursing homes. Although the overall goals of diabetes management in the elderly are similar to those in younger adults, several concerns are unique and need individualized consideration.

Topics in this chapter include:

• Glycemic Goals and Control of Other Risk Factors
• Medical Management
• Diet and Exercise
• Special Considerations (Hypoglycemia, Nonketotic Hyperosmolar Syndrome, Cognitive Impairment and Depression, Polypharmacy, and Falls)
• Management of Elderly Patients in the Chronic Care Setting

NOTE: You may order free copies of the complete ACP Diabetes Care Guide (book and CD-ROM).

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From the ACP Diabetes Care Guide

Several ethnic groups, including Hispanic Americans, African Americans, Asian Americans, Native Americans, and Pacific Islanders, have a higher prevalence of type 2 diabetes, impaired glucose intolerance, and gestational diabetes than white Americans have. Diabetes-related morbidity and mortality is also higher in these groups. Several theories have been proposed to explain these differences ("thrifty genotype", environmental changes and western lifestyle, and socioeconomic factors).

NOTE: You may order free copies of the complete ACP Diabetes Care Guide (book and CD-ROM).

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From the ACP Diabetes Care Guide

Persons with diabetes have a 2- to 4-fold higher hospitalization rate than do those without diabetes. Diabetes predisposes to a number of conditions that may lead to hospitalization, including coronary artery disease, cerebrovascular disease, peripheral vascular disease, nephropathy, and infection. Poorly controlled diabetes has been associated with increased infectious complications, delayed wound healing, increased medical costs, increased length of stay, and increased mortality.

The general goals for patients with diabetes in the acute care setting are:

• Avoiding hypoglycemia or hyperglycemia
• Avoiding metabolic abnormalities, such as volume depletion or electrolyte abnormalities
• Meeting nutritional needs
• Assessing educational needs

NOTE: You may order free copies of the complete ACP Diabetes Care Guide (book and CD-ROM).

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Increasingly adults are living to advanced age. Older adults with diabetes mellitus within any age cohort exhibit striking functional and medical heterogeneity. Some are physically and cognitively robust, while others are frail and have reduced functional and cognitive ability, or suffer from multiple comorbid illnesses. Those with diabetes mellitus may experience

As expected, the functional and medical heterogeneity that is prevalent in older adults with diabetes mellitus produces widely variable average life expectancy. This, and varied personal preferences for health care, provides important context when considering the likelihood of benefit for preventive and therapeutic interventions for diabetes mellitus and co-existing

Most current guidelines for the managment of diabetes mellitus focus on glycemic control. The Califoria Health Care Foundation/American Geriatrics Society Guidelines for Improving the Care of Older Persons with Diabetes Mellitus addresses the complexity of health care status and provides guidance to physicians by prioritizing therapies and goals for older

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This session answers the following questions:

• What is the role of glycemic control in diabetic patients with acute infections?
• What are important treatment or monitoring issues in managing the immunocompromised patient with a severe infection (role of GCSF, modify immunosupressives, IV vs. oral therapy, double coverage)?
• Management of severe necrotizing skin infections-role of surgical management. Are any antibiotics preferable?
• Management of severe limb infection in the diabetic patient.

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Chronic hyperglycemia impairs wound healing and alters immune function. Patients with diabetes are at increased risk for infections and complications related to surgical and nonsurgical wounds. Hospital length of stay is increased in such patients.

There is also evidence to suggest that patients with diabetes are additionally predisposed to obstructive sleep apnea (related to obesity), venous thrombosis, osteoporosis, dementia, and depression, and several cancers, including colorectal carcinoma and endometrial carcinoma in women.

The link between the metabolic abnormalities and the neoplasia are not well understood, although the mitogenic effects of insulin in hyperinsulinemic patients have been suspected.

Note: Subscription to MKSAP 14 is required to view this material. For more information, visit www.acponline.org.

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Hearing impairment is common in adults with diabetes, and diabetes seems to be an independent risk factor for the condition, according to a new analysis of the National Health and Nutrition Examination Survey.

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Patients with depression may be more likely to develop diabetes, and patients who have been diagnosed with type 2 diabetes are more likely to have depressive symptoms, a new study found.

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Question
In outpatients with diabetes mellitus and depression, what is the incremental cost-effectiveness of systematic depression treatment?

Conclusion
In patients who had diabetes mellitus and depression, a collaborative-care program increased time free of depression and saved money.

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Question
In patients with type 1 diabetes mellitus receiving intensive treatment with injections of regular insulin before meals, is the administration of regular insulin with the evening meal and neutral protamine Hagedorn (NPH) insulin at bedtime (split regimen) more effective than administering both with the evening meal (mixed regimen) for reducing nocturnal hypoglycemia?

Conclusion
In patients with type 1 diabetes mellitus receiving intensive treatment, administration of regular insulin before each meal and neutral protamine Hagedorn (NPH) insulin at bedtime reduced nocturnal hypoglycemia and improved control of blood glucose levels more than mixing the evening dose of regular insulin with NPH and administering this mix with the evening meal.

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Question
What are the effects of candesartan or lisinopril, or both, on blood pressure and the urinary albumin excretion rate in patients with hypertension, microalbuminuria, and type 2 diabetes mellitus?

Conclusions
Candesartan and lisinopril were effective monotherapies for reducing blood pressure and microalbuminuria; however, their combined use was well tolerated and more effective for reducing blood pressure in patients with type 2 diabetes, hypertension, and microalbuminuria.

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Question
In patients with hypertension and diabetes mellitus, what is the effectiveness of various antihypertensive treatments?

Conclusion
Intensive blood-pressure control reduces cardiovascular morbidity and mortality in patients with hypertension and diabetes mellitus regardless of which of 4 classes of antihypertensive drugs (low-dose diuretics, β-blockers, ACE inhibitors, and calcium antagonists) is used as first-line therapy.

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