The IDF global guideline for managing older people with type 2 diabetes: Implications for nurses

The global prevalence of diabetes in older people is 11% (International Diabetes Federation [IDF], 2013a) and older people make up 25% of the adult population (IDF, 2013b). A significant proportion of older people have undiagnosed diabetes but the diagnosis is often missed or delayed because symptoms are atypical and non-specific, and often attributed to age (Chiasson et al, 2002; IDF, 2013a). Diabetes is a major cause of complications, falls, reduced quality of life and changed physical and mental functioning in older people (Kirkman, 2012; Zhang et al, 2012), depression (Cahoon, 2012) and is a leading cause of death from cardiovascular and other complications (Zhang et al, 2012).

Changes in glucose homeostasis, counter-regulatory and other hormones, and end-organ function, such as renal and liver disease, and cardiovascular function affect medicine safety and choices and functional status (Ginsberg et al, 2005; Meneilly et al, 2011). The progressive decline in beta cell function and first phase insulin response means many older people eventually require insulin. Care is often suboptimal and does not take account of these physiological changes or functional status (Sinclair and Morley 2013a; Wellard et al, 2013).

Although several guidelines developed for adults with diabetes contain small sections about managing older people with diabetes, they do not take account of the changed pathophysiology in older people, the effects on functional status, disability and frailty, polypharmacy and the implications for safety and quality of life (Cheung et al, 2009; Scottish Intercollegiate Guidelines Network [SIGN] 2010; NICE, 2011). Interestingly, the Royal Australian College of General Practitioners’ publication (2006), Medical Care of Older Persons in Residential Aged Care Facilities, known locally in Australia as the “Silver Book”, does not include diabetes. In 2012, Sinclair and colleagues released a position statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), The European Diabetes Working Party for Older People (EDWOP) and the International Taskforce of Experts in Diabetes, which paved the way for the IDF guideline.

The IDF guideline for older people with type 2 diabetes
Guidelines are designed to be used to guide clinical decisions after a comprehensive assessment of the individual and their situation has been completed. In addition, guideline recommendations need to be operationalised to suit specific groups of people and care settings.  The best guidelines are developed following agreed guideline development processes, as was the case with all IDF guidelines.

The purpose of the IDF guideline is to outline an international approach to caring for older people with diabetes, provide guidance about the philosophy behind the principles of care of older people with diabetes and foster a collaborate approach within the interdisciplinary care team.

The development process generally consists of forming an expert writing group, undertaking a systematic literature review, determining the quality of the evidence, and synthesising the information into relevant guidelines, public consultation about the draft guidelines and incorporating relevant comments into the final guideline document.

There is little randomised control trial evidence directly applicable to older people with diabetes because they are usually excluded from such trials (Bugeja et al, 1997; Bayer and Tadd, 2000). Even when well-designed studies are available, the information cannot always be generalised to individual older people, or extrapolated to older cohorts (University of Michigan, 2011).

Thus, a set of guiding principles was developed to serve as the philosophical framework for the IDF guideline. This strategy has been used to develop other guidelines when there was very little evidence and has been found to add value to the evidence base and clinical applicability of the resultant guidelines (Dunning et al, 2012;  2014).

Core principles of the guideline
The core principles of the guideline are:

• “One size does not fit all”.
• Older people with diabetes are highly individual; they are not a homogenous group.  Therefore, care must be designed alongside the older person and/or their family or carers to suit their functional status, social situation and life expectancy. The care plan must be holistic and personalised.
• Care should be guided by the findings of regular comprehensive assessments and regular medicine reviews.
• Care should be safe for the individual considering the risk/benefit ratio and life expectancy.
• Prevention has a key place in care and should consist of identifying relevant individual risks and planning care to manage those risks. Significant risks include cardiovascular disease, falls, medicine-related adverse events, pain and functional decline leading to disability and frailty.
• Careful use of medicines and pharmacovigilance are essential to minimise polypharmacy and the associated risks of medicine errors and adverse events.
• The needs of family and/or carers must be considered, particularly as some family member or carers will also be old and have their own health problems.

Outline of the guideline contents
One of the initial challenges faced by the  guideline development group was defining “older people”. A range of ages has been used to categorise older people in the literature but there is no consensus definition. Furthermore, chronological age does not indicate how an older person manages their life, or indicate the best treatment outcomes (Sinclair et al, 2012; Dunning et al, 2014) Thus, for the purpose of the guidelines, older people refers to people aged 70 and older, and the care focus is on functional status rather than on age.

The guideline consists of 14 individual guidelines, or chapters, that address key care issues, such as screening and diagnosis, education, depression, risks such as cardiovascular risk, frailty, delirium and falls, management in care homes and end-of-life care. It also includes a chapter on sexual health and other special considerations. Care is described in each individual guideline according to three main functional categories:

• Category 1: Functionally independent.
• Category 2: Functionally dependent, which has two subcategories:
  – Frail: Frail older people are less able to tolerate the stress of illness, which is likely to increase the risk of falls and admission to hospital. However, frail older people can undertake some self-care with support.
  – Dementia.
• Category 3: End-of-life, which refers to the last stages of life, defined as stable or unstable, deteriorating and terminal (Palliative Care Outcomes Collaborative, 2008); this generally refers to the last 12 months of life. People with diabetes can have long periods of stable/unstable diabetes before they enter the deteriorating and terminal phases of care. Significantly, palliative approaches can be combined with active treatment in frail older people and those with end-stage renal disease, and liver and cardiovascular disease to manage pain, improve comfort and quality of life.

Box 2 suggests some key issues that need to be considered when planning care for older people with diabetes.

Challenges of caring for older people
Planning care for older people with diabetes is very challenging because of diabetes complications, such as sensory, mental health, cognitive and physical changes, which can all impact on learning capability, functional status, self-care capacity, safety and independence.  These factors increase the risk of falling, developing pressure ulcers, including foot ulcers, depression and pain. Pain is often not recognised and frequently treated inadequately (Royal College of Physicians, British Geriatrics Society and British Pain Society, 2007). These issues are outlined in Box 1.

Frailty is highly prevalent with increasing age and confers a high risk of adverse outcomes, such as admission to hospital and/or care homes, falls and death (Freid et al, 2001; Sinclair and Morley, 2013b). Significantly, frailty is not synonymous with comorbidity or disability but comorbidity is a risk factor for frailty, and disability is consequently an outcome of frailty. It is important to identify older people at risk of frailty. Diabetes complications, frailty and dementia also make it difficult for the person to exercise and undertake diabetes and other self-care activities.

Hyperglycaemia is often regarded as relatively unimportant in older people because we are not trying to stop complications, but it is not a benign condition and should be managed to promote comfort and quality of life, and reduce the cognitive effects of hyperglycaemia (Crane et al, 2013; Seaquist et al, 2013). In addition, hyperglycaemia may be a risk factor for dementia (Crane et al, 2013). Managing hyperglycaemia is an important aspect of reducing cardiovascular risk along with controlling blood pressure, lipids and not smoking.

Hypoglycaemia is a significant risk for all older people treated with most glucose-lowering medicines because of the associated decline in renal (Yun et al, 2012) and liver function, circulatory changes, nutrition deficits and declining production of key counter-regulatory hormones, such as glucagon, which result in changed symptomology and predominance of neuroglycopenic symptoms (Meneilly et al, 2011; Seaquist et al, 2013). In the short term, hypoglycaemia affects delayed and working memory (Feinkohl et al, 2013) and can precipitate myocardial infarction (Chopra and Kewal, 2012). In the longer term, hypoglycaemia is associated with dementia (Greco et al, 2010).

Older people are at high risk of medicine-related adverse events and errors, and admission to hospital or a care home for older people (Gurwitz et al, 2003; Budnitz et al, 2011). Thus, pharmacovigilance is essential.  There is strong evidence that many medicines commonly prescribed for older people should not be used or should be used with caution; for example, antipsychotic medicines are not the safest choice to manage dementia-related behavioural problems and sliding insulin scales are not an appropriate way of managing episodes of hyperglycaemia (American Geriatrics Society, 2012).

Regular comprehensive medicine reviews are needed, especially when several doctors prescribe medicines for the same older person.  Medicines reviews undertaken at home can provide important information about the individual’s social circumstances and the medicine behaviours they might not disclose to health professionals during consultations.  Many medicines prescribed to manage diabetes and its complications are classed as high-risk medicines because of their side effects and the way they are used and metabolised in the body (Department of Health, Australia, 2014).

Summary
Box 3 outlines some strategies DSNs and practice nurses can use to implement the guidelines in clinical practice. Planning care for older people should focus on safety, maintaining independence, functional status and quality of life, managing symptoms, and reducing the impact of diabetes complications and other diseases on health and well being. Individualising management targets is essential (Sinclair et al, 2012, Dunning et al, 2014), as is involving the older person and their family/carers in management decision. Education for health professionals, older people with diabetes and their carers is also vitally important.

The IDF guideline provides recommendations to help DSNs and practice nurses develop relevant policies and procedures, and holistic, personalised care plans for older people with diabetes.