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Meeting the challenges of diabetes in older people

Older people do not accept illness without question and expect equity of access to treatment and services as do younger people. The medical and nursing profession must honour their own commitment to strive for excellence in care and diabetes poses one of the greatest challenges in this arena. Several important and key skills are required in managing patients with this common and chronic metabolic illness: thoroughness and vigilance in the areas of assessment and treatment; positive attitudes to illness in old age (avoiding agism and a reductionist approach); and acquiring unique knowledge of the special characteristics of diabetes in the elderly.  

Irrespective of the condition, to bring about substantial change in the way we manage older people in any clinical environment we require the following:

  • A need to stimulate the interest of clinical and laboratory researchers to provide us with the evidence to justify particular therapeutic interventions.
  • To promote specific patterns of care characterised by three themes:
    • A major emphasis on quality of life and wellbeing for each patient.
    • Early and effective interventions.
    • A commitment to improve or maintain functional status.1

Principles of diabetes care
There are generic principles in diabetes care which I assume we all subscribe to and aims that are particularly applicable to the elderly. These are represented in Table 1.

[[Tab 1_diab]]

These form a template for diabetes care.2 However, there are a series of other factors which influence management in individual cases, as shown in Table 2.

It should be remembered that these issues are inseparable if you wish to deliver integrated diabetes care at a high level. This approach will have its rewards although you must realise that in managing older people "small gains" are the norm. However, despite being small they often have a considerable impact on wellbeing.

Functional impairment in diabetes
Diabetes is associated with both functional impairment and disability. The wide spectrum of vascular complications, acute metabolic decompensation, adverse effects of medication, and the effects of the condition on nutrition and lifestyle behaviour, may all create varying levels of impairment and/or disability. These changes may have adverse rebound effects on vulnerability to other comorbidities, independence and quality of life. Advancing age itself, even in the absence of specific diagnosed conditions, is associated with disability suggesting that disease prevention or amelioration would only be partially effective.

Each disability has the potential to disadvantage individuals considerably (handicap), such as failure to enjoy outside entertainment and leisure activities, and inability to go shopping. Handicap is not an inevitable occurrence since many factors such as the reversibility of the intrinsic impairment, presence of other medical comorbidities, mood, and even social support and financial status can have dramatic effects on the level of impact of the disability.  

In a similar manner to educational programmes, encouraging subjects to take an active part in rehabilitation can foster autonomy, improve self-esteem and coping skills, and reduce anxiety and depression.

Falls and fall-related fractures are a source of enormous morbidity and resultant disability, and there is increasing evidence of important links with diabetes. In people with diabetes, the increased risk of falling is nearly threefold and diabetic subjects have a twofold increase in having a fall which is injurious, with falls-related fractures being more common in women. Factors contributing to falls include problems with gait and balance as well as neurological and musculoskeletal disabilities. In addition, in people with diabetes, the high rate of cardiovascular disability, visual deficit, cognitive impairment and treatment-related issues are likely to be contributory, as is treatment with insulin which may be a marker of diabetes severity and/or an increased rate of hypoglycaemia. Clinicians involved in managing older people with diabetes must directly question patients about falls occurrence and provide an estimate of risk.

It is also important to identify those patients where a label of "frailty" is appropriate since their aims of care are modified. Frailty, in this context, represents a vulnerability to a wide range of adverse outcomes secondary to the effects of aging, long-term vascular complications of diabetes, physical and cognitive decline, and the presence of other medical comorbidities. In the "Frailty Model of Diabetes",3 a framework is developed that provides further assistance with clinical decisions. This allows health professionals to define a series of factors such as recurrent hypoglycaemia, cardiac disease, and reduced recovery from metabolic decompensation, which have three characteristics in common:

  • These may represent a precursor state to disability.
  • They are often a direct threat to independence.
  • They may have preventable or reversible components.

Identifying those who require more detailed functional evaluation
Table 3 identifies those older subjects who require more detailed evaluation of their physical and mental performance.

[[Tab 2-3_diab]]

The annual review process should now include an assessment of basic measures of activities of daily living (ADL) function such as a Barthel test, of cognitive function such as the mini-mental state examination (MMSE) or Clock Test, a screen for depression such as the "Geriatric Depression Score" (GDS), and an assessment of gait and balance which can be simply estimated by the timed "Get Up and Go" test. This involves asking the patient to stand from a chair which has armrests, walk 3 m, turn, walk back to the chair, and sit down. If this takes longer than 30 seconds, there is evidence of impaired mobility.
Patients with major mobility disorder require referral to a local therapy centre where physiotherapy and occupational therapy are available or to a geriatrician, preferably to one who has an interest in diabetes! Patients with falls disorder require direct referral to a specialist falls assessment service.

Diabetes and cognitive performance
Impaired cognitive function has been demonstrated in older subjects with type 2 diabetes. Women with diabetes for longer than 15 years had a threefold increase of having cognitive impairment at baseline and a doubling of the risk of decline.4 Impaired cognitive function may result in poorer adherence to treatment, worsen glycaemic control due to erratic taking of diet and medication, and increase the risk of hypoglycaemia if the patient forgets that he or she has taken the hypoglycaemic medication and repeats the dose.

There may be several benefits associated with the early recognition of cognitive impairment in older people with diabetes, which emphasises the importance of tests of cognition being part of the functional assessment of all older patients. Depending on its severity, cognitive dysfunction in older diabetic subjects may have considerable implications, including increased hospitalisation, less ability for self-care, less likelihood of specialist follow-up and increased risk of institutionalisation.5

Clinicians must be prepared to refer patients for specialist assessment if memory loss or behaviour change becomes an issue. The worst thing you can do is to forget to look for these deficits!

Depression and diabetes
Patients with diabetes and depression have poorer glycaemic control, more diabetes symptoms and greater all-cause mortality. Diabetes appears to double the odds of developing depression and failure to recognise depression can be serious since it is a long-term, life-threatening, disabling illness and have a significant impact on quality of life.6

As a consequence of these findings it is imperative that an enquiry about mood and symptoms of depression is undertaken by the clinician and specialist support may be required.

Effective diabetes care for older people - importance of goal setting
Modern diabetes care for older people requires integrated care between primary and community diabetes care professionals, hospital specialists (diabetologists and geriatricians) and other members of the healthcare team. This should have a multidimensional approach with an emphasis on prevention of diabetes and its complications, early intervention for vascular disease, assessment of disability due to limb problems, eye disease and stroke, and overall to promote wellbeing and normal life expectancy. An initial plan of management is presented in Table 4.7

[[Tab 4_diab]]

Conclusion
Diabetes mellitus, in view of its high prevalence, long duration of impact, wide spectrum of complications, and emotional and psychological sequelae, is accurately described as "complex" and clinicians involved in managing "complex" disease require a comprehensive skill set.

Nurses and other key health professionals can enhance their clinical effectiveness by taking on some of the above approaches to diabetes care and the rationale should be about reduced acute hospitalisation, lower outpatient costs, and less long-term disability.

References
1. Sinclair AJ, Finucane P. Diabetes in old age. 2nd ed. Chichester: John Wiley & Sons; 2001.
2. Sinclair AJ, Meneilly GS. Type 2 diabetes mellitus in senior citizens. In: Pathy MSJ, Sinclair AJ, Morley JE, editors. Principles and practice of geriatric medicine. 4th ed. Chichester: John Wiley & Sons; 2006.
3. Sinclair AJ. Diabetes in old age - changing concepts in the secondary care arena. J Roy Coll Phys (Lond) 2000;34:240-4.
4. Gregg EW, Beckles GL, Williamson DF, Leveille SG, Langlois JA, Engelgau MM, Narayan KM. Diabetes and physical disability among older US adults. Diabetes Care 2000;23:1272-7.
5. Sinclair AJ, Girling AJ, Bayer AJ. Cognitive dysfunction in older subjects with diabetes mellitus: impact on diabetes self-management and use of care services. All Wales Research into Elderly (AWARE) Study. Diabetes Res Clin Pract 2000;
50:203-12.
6. Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care 2001;24:1069-78.
7. European Diabetes Working Party for Older People 2001-4. Clinical guidelines for type 2 diabetes mellitus. Available from: http://www.eugms.org