第十六章 糖尿病管理相关技术
一、血糖监测
血糖监测技术包括自我血糖监测、CCM、糖化白蛋白和HbA1c等。
HbA1c是临床上用以评价长期血糖控制状况的金标准,是调整治疗方案的重要依据。对于HbA.未达标的患者,建议每3个月检测一次。一旦达标后,可每6~12个月检测一次。但 HbA,也存在一定的局限性,如难以反映血糖波动,无法捕捉低血糖事件等。建议胰岛素治疗的老年糖尿病患者进行自我血糖监测,基本监测点为空腹和三餐前,以了解患者的血糖基线水平,如患者存在夜间低血糖风险,建议根据情况加测睡前和夜间血糖,对于口服降糖药治疗且血糖控制平稳的患者无需频繁监测血糖。
在老年糖尿病患者中，佩戴 CGM 能进一步改善HbA1c，同时降低血糖变异性，而不增加低血糖风险［321‑322］ 。T1DM 患者胰岛功能差、血糖波动大，更可能从CGM中获益。建议临床医师结合患者的血糖情况、认知水平、行动能力、经济情况等进行综合评估后提出是否佩戴CGM的建议。在使用基础胰岛素的老年T2DM患者中，使用CGM的患者较传统指血检测的患者 TIR 增加，其获益与年轻患者一致［323］ 。
TIR 是指 24 h 内葡萄糖在目标范围的时长或所占的百分比，成人糖尿病患者中TIR的血糖范围一般界定为3.9~10.0 mmol/L，但尚缺乏针对老年糖尿病患者的研究。近年来国际共识推荐 TIR 可作为成人 T1DM 和 T2DM 血糖控制情况的评价指标，同时 TBR和 TAR也可以作为评价治疗方案的有效参数。我国的研究表明，在 T2DM 中 TIR 独立于HbA1c与糖尿病微血管并发症相关（患者平均年龄60.4岁）［324］ ，与心血管死亡、全因死亡相关（患者平均年龄 61.7 岁）［325］ 。在老年糖尿病的管理中，TIR也可以作为评价血糖控制水平的补充指标，但尚需针对老年糖尿病患者的研究证实。TIR 目标的确定需考虑老年糖尿病患者的个体化差异和低血糖风险，并有待进一步的循证医学证据明确。研究显示，在 T1DM 中 TIR 与 TAR 相关性强，但与 TBR 相关性弱，对于使用自动胰岛素给药系统的老年患者，应优先考虑降低 TBR 以减少低血糖风险［326］ 。除了影响血糖控制外，CGM 对老年糖尿病还具有其他获益，例如患者可以与家人或其他照护者持续分享血糖结果；减少指血血糖检测次数，尤其是对于有身体残疾、认知障碍或视力障碍的患者；对于低血糖觉察能力降低或受损的患者，CGM 可以帮助患者觉察低血糖［327］ 。
二、注射技术
正确的皮下胰岛素注射技术包括每次注射后更换针头、选择合适的部位注射、轮换注射的部位、适当护理注射部位以及避免肌肉注射。推荐注射部位包括腹部、大腿、臀部和上臂。长期在同一部位进行 注射可能导致局部脂肪肥大或脂肪萎缩［328］，需定期并轮替变换注射部位 。 中国 ITIMPROVE 研究对中国糖尿病患者、医师和护士的问卷调查显示，34.7% 患者出现注射部位脂肪增生，针头重复使用以及注射部位轮换不当可分别使脂肪增生风险增加 3.15 倍和 1.27 倍，同时也增加HbA1c达标的风险［329］ 。
老年糖尿病患者如果存在痴呆、视力丧失、神经病变、活动能力差、手指灵活性差等情况，在进行胰岛素注射时出现遗漏注射、错误注射的风险增加，医师也无法准确了解患者胰岛素的实际注射情况。随着胰岛素注射笔的不断改良，更多的功能已被开发并应用。记忆功能可记录上次胰岛素注射的剂量和注射时间，帮助提高胰岛素治疗的依从性［330］ 。依托具有可连接功能、支持近距离无线通信的手机等智能设备进行连接，可以将胰岛素注射记录传输到智能手机等设备并通过应用程序生成可视化注册日志并分享。一项前瞻性临床研究提示，可连接胰岛素笔能显著减少43%的胰岛素注射遗漏，提高TIR，降低TAR和TBR［331］ 。
无针注射技术是《中国糖尿病药物注射技术指南》推荐的注射方法之一，能缓解患者对传统有针注射笔的恐针心理，降低注射痛感，从而提高患者依从性，改善血糖控制［332］ 。此外，无针注射可减少有针注射相关的不良反应，如皮下硬结、脂肪增生或萎缩，并减少了胰岛素的用量。有条件时可用于健康状态为良好（Group 1）和中等（Group 2）的老年糖尿病患者。但无针注射的操作相较于胰岛素笔注射复杂，需经专业人员指导，熟练掌握操作方法后方可自行注射。对于无法自行完成注射操作的患者，需教育患者家属积极协助或选用其他的注射方式。
三、胰岛素泵
胰岛素泵是采用人工智能控制的胰岛素输送装置，可以连续进行皮下胰岛素注射，最大程度模拟胰岛素的生理分泌，以帮助管理血糖。对于老年糖尿病患者，尤其是 T1DM，如采用多针胰岛素皮下注射治疗血糖波动大、低血糖风险高，建议试用胰岛素泵。采用多针胰岛素皮下注射难以精确调整胰岛素用量的患者也可考虑应用胰岛素泵。在老年 T2DM 患者中，有研究提示，相较于多针胰岛素皮下注射，使用胰岛素泵可以有效控制血糖，安全性和患者满意度良好［333］ 。有研究证实在平均年龄大于 60 岁的 T2DM 患者中应用自动胰岛素输注系统的安全性和有效性［334］ 。认知能力下降、视力下降、手指灵活性下降、无他人协助、缺乏胰岛素泵的知识等均可能是老年糖尿病患者使用胰岛素泵的限制因素［335］ 。临床医师需结合患者的个体情况决定是否采用胰岛素泵治疗，并对患者及家属进行胰岛素泵知识的充分教育，包括胰岛素泵的设置、报警的处理、潜在的并发症等。应建立良好的协助模式，在患者的胰岛素泵需要调整时能被快速有效地处理，以免出现胰岛素泵相关的急性不良事件。
第十七章 老年糖尿病与中医药学
糖尿病属中医“消渴病”范畴，我国传统医学治疗历史由来已久。中医认为，糖尿病的基本病机为阴虚燥热，因具有口干多饮、多食易饥、小便频数的临床特点，分别涉及肺、胃、肾等病位，其治疗相应可分上、中、下三消论治。中医药在糖尿病及其并发症的治疗中有一定效果。由于老年患者常伴器官功能衰退，多种并发症和合并症并存，中西药物使用情况复杂等多重因素，因此，需要在专业中医指导下接受中医、中西医结合治疗，并且在治疗过程中注意用药的安全性。
执笔者：
潘 琦（北京医院内分泌科 国家老年医学中心）
邓明群（北京医院内分泌科 国家老年医学中心）
虞睿琪（中国医学科学院北京协和医院内分泌科）
专家委员会名单（按照姓氏拼音排序）：
陈 宏（南方医科大学珠江医院内分泌科）
陈 丽（山东大学齐鲁医院内分泌科）
陈莉明（天津医科大学朱宪彝纪念医院内分泌科）
陈有信（中国医学科学院北京协和医院眼科）
窦京涛（解放军总医院第一医学中心内分泌科）
杜建玲（大连医科大学附属第一医院内分泌科）
段滨红（黑龙江省医院内分泌科）
郭立新（北京医院内分泌科 国家老年医学中心）
洪天配（北京大学第三医院内分泌科）
侯新国（山东大学齐鲁医院内分泌科）
胡 吉（苏州大学附属第二医院内分泌科）
姬秋和（空军军医大学西京医院内分泌科）
纪立农（北京大学人民医院内分泌科）
姜 昕（深圳市人民医院老年病科）
蒋 升（新疆医科大学第一附属医院内分泌科）
康 琳（中国医学科学院北京协和医院老年医学科）
匡洪宇（哈尔滨医科大学附属第一医院内分泌科）
邝 建（广东省人民医院内分泌科）
雷闽湘（中南大学湘雅医院内分泌科）
李春霖（解放军总医院第二医学中心内分泌科）
李全民（火箭军特色医学中心内分泌科）
李 兴（山西医科大学第二医院内分泌科）
李延峰（中国医学科学院北京协和医院神经内科）
李益明（复旦大学附属华山医院内分泌科）
李 勇（复旦大学附属华山医院心血管内科）
梁瑜祯（广西医科大学第二附属医院内分泌科）
林夏鸿（中山大学附属第七医院内分泌科）
刘 静（甘肃省人民医院内分泌科）
刘幼硕（中南大学湘雅二医院老年医学科）
鹿 斌（复旦大学附属华东医院内分泌科）
陆颖理（上海交通大学医学院附属第九人民医院内分泌科）
吕文山（青岛大学附属医院内分泌科）
母义明（解放军总医院第一医学中心内分泌科）
潘 琦（北京医院内分泌科 国家老年医学中心）
秦贵军（郑州大学第一附属医院内分泌科）
沈云峰（南昌大学第二附属医院内分泌科）
施 红（北京医院老年医学科 国家老年医学中心）
宋光耀（河北省人民医院内分泌科）
童南伟（四川大学华西医院内分泌科）
王建业（北京医院泌尿外科 国家老年医学中心 中国医学科学院老
年医学研究院）
王世东（北京中医药大学东直门医院内分泌科）
王颜刚（青岛大学附属医院内分泌科）
王正珍（北京体育大学运动医学与康复学院）
吴 静（中南大学湘雅医院内分泌科）
吴天凤（浙江医院内分泌科）
武晓泓（浙江省人民医院内分泌科）
肖建中（清华大学附属北京清华长庚医院内分泌科）
肖新华（中国医学科学院北京协和医院内分泌科）
谢晓敏（银川市第一人民医院内分泌科）
徐 静（西安交通大学第二附属医院内分泌科）
徐向进（解放军联勤保障部队第九〇〇医院内分泌科）
徐焱成（武汉大学中南医院内分泌科）
徐 勇（西南医科大学附属医院内分泌科）
徐玉善（昆明医科大学第一附属医院内分泌科）
许樟荣（解放军战略支援部队特色医学中心内分泌科）
薛耀明（南方医科大学第一临床医学院南方医院内分泌科）
杨 川（中山大学孙逸仙纪念医院内分泌科）
杨 静（山西医科大学第一医院内分泌科）
杨 涛（南京医科大学第一附属医院内分泌科）
杨 莹（云南大学附属医院内分泌科）
余学锋（华中科技大学同济医学院附属同济医院内分泌科）
袁慧娟（河南省人民医院内分泌科）
张 波（中日友好医院内分泌科）
张存泰（华中科技大学同济医学院附属同济医院老年医学科）
张俊清（北京大学第一医院内分泌科）
章 秋（安徽医科大学第一附属医院内分泌科）
赵家军（山东第一医科大学附属省立医院内分泌科）
利益冲突 所有作者声明无利益冲突
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