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In this summary

 

Impact of diabetes in an ageing population

  • Both ageing and diabetes are recognised as important risk factors for the development of functional decline and disability, which are often compounded with impaired quality of life

Box 1: What’s new?

  • The population of older adults with diabetes is rapidly growing
  • Older adults have a different natural history of disease, attributable, in part, to shorter life expectancy, greater comorbidity and increased risk of complications from interventions
  • An updated approach to the assessment of frailty in older adults with diabetes
  • Guidance for establishing individualised targets and treatment algorithms for both onward prescribing and de-prescribing therapies or older adults in order to improve the quality of life for these older adults with diabetes

Detecting frailty in the community

  • The recommended steps for detecting frailty in older adults with diabetes are outlined below, including additional roles for specialist review

Frailty assessment pathway in diabetes

Frailty assessment pathway in diabetes. Download a PDF of this pathway. 

Priorities for improving high-quality diabetes care

  • Management of older people with diabetes is often inadequate and inappropriate because it fails to take account of three important elements of care: complex illness management; the need for an individualised approach to care; and an appreciation of age-related physiology and pharmacology which increase the risk of iatrogenic adverse drug reactions
  • The key features of a modern diabetes services sensitive to the special needs of older people is summarised in box 2
    • it includes recommendations for de-prescribing, that is the process of withdrawing inappropriate medications with the clear goals of enhancing clinical outcomes and improving patient safety, in a manner that may be undertaken without harm, while supporting those practitioners who wish to optimise care for the people with diabetes with whom they work

Box 2: Key features

  • Inter-professional activity leading to an agreed diabetes and frailty care plan
  • A medication risk minimisation to decrease unwanted drug events, hospitalisation, and hypoglycaemia
  • An active de-prescribing policy that avoids over-prescribing of glucose-lowering and other medications without compromising patient safety
  • A review of diabetes and frailty status at the time of care home residency
  • An easy access to pathway to Palliative Care Services when End of Life issues arise
  • Use of additional outcomes of clinical care that can form the basis of multi-professional audit (and national audits of care) and be more aligned with the needs of the older adult with diabetes, e.g. quality of life, change in functional status, falls rate, admissions to hospital for hypoglycaemia

Establishing targets for older adults

  • ‘Biologically young’ older adults may be regarded as having similar needs to adults aged <65 years. For these individuals, a glycaemic target of 59 mmol/mol (7.5%) remains the standard:
    • be mindful of the risk of hypoglycaemia in these individuals when adding in therapies, as the consequences of hypoglycaemia may be just as significant in the fit as the frail older adult with diabetes. Therefore, caution is required against the introduction of insulin secretagogues (sulfonylureas or glinides) or short-acting insulins for these adults. An individual who has good glycaemic control would not necessarily require de-escalation of their medical regimen unless there is evidence of overtreatment
  • Very few people with diabetes aged >70 years would be anticipated to benefit from intensive intervention targets below 53 mmol/mol (7%):
    • interventions associated with hypoglycaemia, weight loss or that otherwise limit the quality of life may be reasonably discontinued. Please see table 1 (below) for recommendations on therapeutic targets and de-escalation thresholds
Recommended therapeutic targets and treatment de-escalation thresholds
 De-escalation thresholdTreatment target
 

Threshold

 

Suggested interventions

 

Targets

 

Interventions

 

The fit older adult with diabetes

 

53 mmol/mol (7.0%)

 

Evaluate long-acting sulfonylurea and insulin therapy that may cause hypoglycaemia. Consider appropriate dosage in setting of renal function

58 mmol/mol (7.5%)

Avoid initiating new agents that may cause hypoglycaemia or exaggerate weight loss

 

Moderate—severe frailty

 

58 mmol/mol (7.5%)

 

Discontinue any sulfonylurea if HbA1c below threshold. Avoid TZDs because of risk of heart failure.

Cautious use of insulin and metformin mindful of renal function

64 mmol/mol (8.0%)

 

DPP-4 inhibitors and longer-acting insulins have demonstrated safety. TZDs may increase risk of heart failure. SGLT2 inhibitors may provide additional benefit in people with heart failure but also exacerbates symptoms of diabetes

Very severe frailty

 

64 mmol/mol (8.0%)

 

Withdraw sulfonylureas and short-acting insulins because of risk of hypoglycaemia.

Review timings and suitability of NPH insulin with regard to risk of hypoglycaemia. Therapies that promote

weight loss may exacerbate sarcopenia.

70 mmol/mol (8.5%)

 

DPP-4 inhibitors renally at appropriate dose for those close to target. Consider once-daily morning NPH insulin or analogue alternatives if symptomatic nocturnal hyperglycaemia. Educate carers and relatives regarding risk of hypoglycaemia

NPH=neutral protamine hagedorn; DPP-4=dipeptidyl peptidase-4; SGLT2=sodium-glucose co-transporter-2; TZD=thiazolidinediones.

Treatment of the mild to moderately frail

  • The mild to moderately frail population represents the majority of older adults who have additional comorbidities
  • A level of ≤64 mmol/mol (8%) is suggested as a usual target for older adults with mild to moderate frailty
  • There are no proven short-term benefits of achieving glycaemic control below 59 mmol/mol (7.5%)
  • Careful consideration ofPrimum non nocere is required as all interventions come with a potential negative impact on quality of life, often in measures not routinely evaluated. For example:
    • peroxisome proliferator-activated receptor gamma (PPAR-γ) antagonists (thiazolidinediones) precipitate osteoporosis, but, often more pertinently in older adults cause peripheral oedema reducing mobility
    • the polyuria and candidiasis risk of sodium-glucose co-transporter-2 (SGLT2) inhibitors may be regarded as similar to the underlying symptoms they originally presented with
    • the weight loss of incretin therapies may exacerbate frailty and sarcopenia
    • the risk of hypoglycaemia with sulfonylureas and shorter-acting insulin can have devastating consequences
  • Evaluate the symptoms of our older adults with diabetes, with a very low threshold for withdrawal of drugs in anyone with a HbA1c  <59 mmol/mol (7.5%)

Management of the very frail

  • Frailty itself is the most important prognostic indicator
  • Many of the diagnostic elements of frailty, however, may themselves represent side-effects of interventions for diabetes. These include iatrogenic weight loss, hypoglycaemia-induced cognitive impairment or depression associated with polypharmacy of diabetes
  • A rational approach must be employed to ensure that while symptoms remain controlled, over­-aggressive pharmacotherapy is not attenuating functional ability
  • Review and deprescribe any treatment that does not serve to improve the quality of life of the older adult with diabetes
  • Discontinue oral therapy for any severely frail person with an HbA1c <64 mmol/mol (8%)
  • Short-acting insulins should also be discontinued because of their significant risk of hypoglycaemic, unless there are apparent symptoms of postprandial hyperglycaemia. If administration of fast-acting insulin analogues is required it should be administered after meals on an ’as required basis’ based on postprandial monitoring, in order to account for the variable and unpredictable calorific intake when frailty ensues
  • Chronic hyperglycaemia itself has negative physiological consequences impairing the quality of life of the person with diabetes; with osmotic diuresis leading to dehydration, impaired vision and decreased cognition. HbA1c targets of <70 mmol/mol (8.5%) are recommended for even the very frail older adults
  • The choice of agents to achieve these targets are limited:
    • metformin is the logical choice given its low frequency of hypoglycaemia and good cardiovascular profile, up to 50% of very frail older people will have a contraindication to use, predominantly because of a reduced estimated glomerular filtration rate. In addition to the risk of hypoglycaemia with sulfonylureas, their utility in the frail older adult developing b-cell failure is limited
    • DPP-4 inhibitors have proven safety even in the very frail, and have similar efficacy in the older population to that in younger adults, and hence may be a suitable option for those who are within 11 mmol/mol (1%) of their goal
    • the use of glucagon-like peptide-1 receptor agonists, SGLT2 inhibitors and thiazolidinediones is limited for the reasons described above
  • The use of insulin becomes the logical intensification step in order to treat the osmotic symptoms which lead to weight loss or lethargy or other uncomfortable non-specific symptoms:
    • choice may range from combination of basal insulin and oral hypoglycaemic agents, through to mixed insulin or, very rarely, a basal-bolus regimen. For the majority of frail adults, a simple approach of once-daily isophane insulin in the morning, would provide a modest peak in insulin availability after ~4 hours, coinciding with the main meal of the day
    • should nocturnal insulin be required, a once-daily regimen of long-acting analogue insulin may be associated with a lower risk of hypoglycaemia than twice-daily isophane insulin
    • where self-injection is not possible, community nursing support may be required to administer insulin. In these cases, the protracted duration of insulin degludec that has been demonstrated in younger adults may facilitate more flexibility in scheduling for community staff should the extended duration of activity be verified in this population

Conclusion

  • Support for people living with frailty is both a key challenge and opportunity for the NHS
  • The focus for diabetes healthcare professionals, in collaboration with older adults with diabetes, should be on preventing diabetes-disabling states in older people which lead to dependency and institutionalisation and rising health and social care costs
  • The 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 for this continuing relatively neglected older population

full guideline available from… 

onlinelibrary.wiley.com/doi/full/10.1111/dme.13644 

Strain WD, Hope SV, Green A, Kar P, Valabhji J and Sinclair AJ. Type 2 diabetes mellitus in older people: a brief statement of key principles of modern day management including the assessment of frailty. A national collaborative stakeholder initiative. Diabetic Medicine 2018; 35 (7): 838–845. 

First included: March 2019.