Older and frail people
Clare Hambling and Su Down
GP, Norfolk and Chair, PCDS; Diabetes Nurse Consultant, Somerset
Frailty is a medical syndrome with multiple causes and contributors, characterised by diminished strength, endurance and physiologic function that increases an individual’s vulnerability for developing increased dependency and/or death (Morley et al, 2013).
- Diabetes is associated with accelerated ageing and frailty.
- Frailty is a better predictor of COVID-19 outcomes COVID-19 than age (Hewitt et al, 2020).
- To assess frailty, watch people get up and walk from the waiting room; use tools such as the Rockwood Clinical Frailty Scale to formally evaluate individuals. Encourage accompanying family members to input. The easy-to-use Clinical Frailty App is available from www.acutefrailtynetwork.org.uk.
- eFrailty index score can be used across the practice population, but is dependent on accurate coding.
- Agree frailty-appropriate HbA1c goals (e.g. 58 mmol/mol fit elderly; 64 moderate-to-severe frailty; 70 severe frailty).
- Review regularly and de-escalate proactively at 53, 58 and 64 mmol/mol for fit, moderate-to-severe frailty and severely frail, respectively.
- Choose therapies wisely. Anticipate and avoid risk of hypoglycaemia or weight loss (see Strain et al, 2021).
Resources
- Diabetes and frailty: An expert consensus statement on the management of older adults with type 2 diabetes: bit.ly/3HUSZdv
- How to manage diabetes in later life: bit.ly/2VBzXUj
Connecting the dots in the obesity pathway
Jennifer Logue
Professor of Metabolic Medicine, University of Lancaster
What can we do in primary care?
- Reduce obesity bias. Use person-first language and encourage uptake of preventive healthcare amongst those with obesity.
- Measure and record BMI.
- Classify correctly. Normal BMI, 18.5–24.9 kg/m2; overweight, 15–29.9; obese class I, 30–34.9; obese class II, 35–39.9; obese class III ≥ 40; ethnic cut-offs in non-Caucasian people.
- Identify if other, higher priorities right now. If so, make a note to return to weight discussion later; if priority, Ask, Assess, Assist.
- Ask if OK to discuss weight. Explain losing weight could help with their condition(s); NHS programmes can aid weight loss.
- Assess using importance and confidence ruler tools.
- Assist. If ready to change, refer to weight management services (know what is available, how to refer). If not ready, ensure understanding of weight loss benefits and services available; agree review. In England, there is a four-tier obesity management system (Hazlehurst et al, 2020).
- Consider contribution of medications and amend, if possible.
Diabetes and sexual health
Nicola Milne and Naresh Kanumilli
Community Diabetes Specialist Nurse, Manchester; GP and Community Consultant in Diabetes, Manchester
Male erectile dysfunction (ED)
- Affects > 50% of men with diabetes, 3.5 times higher than in men without.
- May be presenting symptom for a new diabetes diagnosis.
- Tendency to more severe and refractory ED in those with diabetes.
- Pathophysiology of ED in diabetes is often multifactorial, including vascular and neurological impairments, and possible androgen deficiency. Screen for low testosterone.
- Medical therapies for ED less successful in people with diabetes.
- Surgical intervention may be associated with increased general health risk.
- Try to differentiate psychogenic ED (sudden onset; situational; normal waking/nocturnal and masturbation erections) from organic ED (gradual onset; all situations; reduced/absent waking, nocturnal and masturbation erections; penile pain).
- When diagnosing ED, assess for CVD risk, type 2 diabetes and testosterone deficiency; refer to appropriate clinic.
Female sexual dysfunction (FSD)
- Studies have shown a 20–78% decreased level of sexual desire in women with diabetes more common in women with type 2 diabetes.
- The prevalence of sexual dysfunction is higher in women with type 1 diabetes (50.3%) compared with those without diabetes (35.0%), and sexual dysfunction is associated with both diabetes distress and depression, but no clear associations with chronic diabetes complications.
- Up to 76% of women with diabetes are affected in the arousal phase of sexual activity by lack of lubrication.
- Structural changes in female genital tissue, and impairment of nerve and blood supply, might impact arousal and orgasmic response.
- For guidance on contraception and diabetes, consult UK Medical Eligibility for Contraceptive Use.
Medications associated with ED/FSD
- Diuretics
- Anticholinergics
- CVD medications/anti-hypertensives
- Tranquillisers
- Antidepressants
- H2 antagonists
- Hormone treatment
- Cytotoxic agents/chemotherapy
- Androgen deprivation therapy
Resources
- How to diagnose and manage testosterone deficiency in adult men: bit.ly/34EJUYc
- How to diagnose and manage erectile dysfunction in men with diabetes: bit.ly/3gQq8LD
- Diabetes before, during and after pregnancy: bit.ly/3LDKEgJ
- Sexual Advice Association factsheets: bit.ly/3oTocGE
