Looking after the older generation

As the general population grows older and the number of treatment options for diabetes continues to increase, caring for the older person with diabetes becomes more complex.

Unfortunately, as many of us may have experienced, older people with diabetes can often be overlooked and over-medicated. It is important that we treat all people with diabetes as individuals, ensuring that the target HbA_1c reflects their specific needs and considers the potential risks of glycaemic control. As with all people with diabetes, HbA_1c targets for older, more frail people with diabetes should ensure that there is low risk of both hypoglycaemia and hyperglycaemia but, most importantly, safety should be the main consideration.

Often this patient group will have multiple comorbidities, including dementia, cardiovascular disease and chronic obstructive pulmonary disease. These comorbidities significantly increase the complexity of the care plan.

International guidance
A leading expert in the care of older people, Professor Alan Sinclair, has claimed that older people with diabetes are being “let down” and “overlooked” by the system. This has prompted the development of a new international position statement on diabetes management in frail, older people, An International Position Statement on the Management of Frailty in Diabetes Mellitus (Sinclair et al, 2017). The position statement, which was published in October, 2017, outlines a ground-breaking model for how to manage older people with diabetes who also have physical weakness and fatigue, which are common problems in this age group.

The document was compiled by Professor Sinclair, who is the Director of the Foundation for Diabetes Research in Older People and Diabetes Frail and Professor Bruno Vellas, Chief of the Department of Internal Medicine and Geriatrics at the Toulouse University Hospital, France, and former President of the International Association of Gerontology and Geriatrics. The guidance was developed in collaboration with the Hong Kong Geriatrics Society and an international group of experts in diabetes and geriatrics.

The document makes a series of recommendations to help doctors and nurses treat people over 70 years who have diabetes and potentially other conditions linked to physical weakness.

The position statement was compiled because the prevalence of diabetes is increasing among people between the ages of 60 to 79 years, and frailty may be present in up to 1 in 4 people in this age range. In older people with the condition, frailty, and loss of muscle mass and strength, known as sarcopenia, have become serious complications and are often overlooked or not diagnosed by healthcare professionals.

Definition of frailty
For the purposes of the position statement, Professor Sinclair and colleagues have classified frailty as:

• A vulnerability state that leads to a range of measurable adverse outcomes, such as falls or a decline in physical performance.
• A decline in physiological reserve and the inability to resist physical or psychological stressors.
• A pre-disability condition.

This is the first time an international consensus document has been published on this subject and the experts involved have called for a “clear focus on patient safety” and early recognition of the deterioration of a person’s health. Professor Sinclair said:

“Frailty is now recognised as a new complication of diabetes in ageing populations and needs to be a priority for action. This is because frailty leads to excess disability in diabetes, leading to earlier institutionalisation, decreased quality of life, and premature death. Yet early prevention and management should lead to longer, healthier lives.”

The document lays out a specific model for all healthcare professionals working in primary, secondary and community care to help them understand how to prevent frailty and ensure the early management of the condition. It also provides a platform for a model of care to be coordinated across local regions to help those older people with diabetes who are developing frailty, have developed frailty, and those progressing to disability.

Key principles
The document outlines a number of key principles that incorporate the important elements of managing older adults with frailty and diabetes. These are:

• Individualised goals of care with functional status and complexity of illness, including comorbidity profiles and life expectancy.
• Where possible, all therapeutic decisions should be based on comprehensive geriatric assessment and risk stratification, including the identification and subsequent assessment of key risks in frail older adults with diabetes. The key risks include hypoglycaemia, inability to carry out “activities of daily living” (walking, bathing, dressing etc) and “instrumental activities of daily living” (cooking, driving, managing medication etc), falls, and adverse events from treatment.
• A management strategy that is clearly defined and agreed with all parties that aims to avoid disability both from vascular complications and deterioration in functional status.
• A clear focus on patient safety, avoiding hospital/emergency department admissions and institutionalisation by recognising the deterioration early and maintaining independence and quality of life, and ensuring a dignified death.
• A management plan that incorporates educational support for families and caregivers, as well as health and social care professionals.
• A recognition that older people from minority ethnic populations are likely to have specific education and care needs.
• An emphasis to promote locally relevant interdisciplinary diabetes care teams to develop specific pathways for frail older people with diabetes.
• An encouragement to promote high quality clinical research and audit in the area of frailty management in diabetes.

Logistics for implementation
The document is an interesting read and highlights an important gap in the care of older people with diabetes, but I’m left thinking where will the funding come from to underpin this strategy? I’m not aware of any other funding available for diabetes care in my local area at the moment. Any funding awarded to the North Central London Boroughs under the “sustainability and transformation plans” process (King’s Fund and The Nuffield Trust, 2017) is being channelled into improving targets, diabetes education and inpatient care.

It is crucial that this funding need is addressed, as it is this group of patients who are requiring more frequent admissions and longer hospital stays. Surely it would be cheaper in the long term to prevent these hospital admissions by improving care of older people with diabetes and ensuring that they can have the best possible care, with an individualised and multidisciplinary approach. It makes sense to me; what do you think?

Please do let us know what your are doing in your local area. Do you have any locally driven initiatives around improving the care of older people. You can get in touch via: [email protected]