By Charlotte Lindsay
GPs should prioritise the assessment of frailty in older patients with type 2 diabetes and tailor their care plans accordingly, new guidelines urge.
It is proposed that GPs ask patients aged 60 or older to complete 4-m gait speed and ‘get up and go’ tests and use an appropriate index tool to assess frailty. An initial management plan should then be discussed and clear treatment goals identified. If appropriate, the patient can be referred to a diabetes specialist or geriatrician for a comprehensive assessment.
Less aggressive HbA1c targets than those recommended by NICE and the American Diabetes Association should be set for frail older people, according to the collaborative group of diabetes, geriatric and primary care experts, who were led by the University of Exeter Medical School. An HbA1c treatment target of 64 mmol/mol (8%) is given for older adults with moderate to severe frailty and 70 mmol/mol (8.5%) for those with very severe frailty. In fit older adults, the HbA1c target is 58 mmol/mol (7.5%). The group also points out that intensive glucose monitoring in this patient group offers limited benefits and can be harmful.
A strategy is put forward to address issues associated with inappropriate polypharmacy, which is associated with an increased risk of falls, functional impairment, non-adherence and adverse drug events. Healthcare professionals are advised to avoid initiating new agents that may cause hypoglycaemia or exaggerate weight loss in any older person with diabetes. Medicines affecting quality of life should be evaluated and withdrawn or avoided at a threshold of HbA1c 58 mmol/mol (7.5%) in the presence of moderate or severe frailty and 64 mmol/mol (8%) in cases of very severe frailty. The threshold given for the evaluation of medications affecting quality of life in fit older adults is 53 mmol/mol (7%).
Frailty is a growing problem, as the number of older people with diabetes is increasing rapidly. Roger Gadsby, Honorary Associate Clinical Professor at Warwick Medical School, is supportive of the proposal, saying: “I think this initiative is very helpful in giving clinicians practical guidance to help them care for frail older people with diabetes.”
The guidelines, which were published in Diabetic Medicine, have been developed in partnership with NHS England. “The focus for diabetes healthcare professionals, in collaboration with older adults with diabetes, should be on preventing diabetes-disabling states in older people,” the authors conclude. “Our proposal to promote the introduction of a frailty assessment scheme as part of routine diabetes management should allow more appropriate and safer treatment strategies to be employed.”