Conference over coffee: Frailty, obesity and sex

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 HbA_1c 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