Su Down, Nurse Consultant, Diabetes, provides her perspective on the critical role primary care healthcare professionals play in managing type 2 diabetes in elderly and frail patients.
Intended for UK and Ireland healthcare professionals only. This article has been commissioned and funded by Boehringer Ingelheim. Su Down, Nurse Consultant, Diabetes received an honorarium for developing and writing the content. Boehringer Ingelheim reviewed the content for medical accuracy and compliance with the ABPI Code of Practice.
Has COVID-19 impacted the care needs for elderly and frail people with type 2 diabetes?
As the UK government is reaching its target of vaccinating health and care workers and the most vulnerable people, including the elderly and frail, against COVID-19, there is now an opportunity for healthcare teams to re-focus on areas which affect these groups, particularly type 2 diabetes in the elderly and frail.
It was a particularly challenging year for HCPs in 2020. Even before the pandemic, the NHS was already facing challenges around tackling type 2 diabetes and there was a need for special consideration on how to deliver care to the elderly and frail. While the NHS has expanded its support to people with type 2 diabetes during this time, a recent survey of GPs and practice nurses from Boehringer Ingelheim uncovered that these challenges have only been exacerbated by the COVID-19 crisis, and there is a clear need to continue to provide further support to healthcare teams to manage these patients.
What are some of the key challenges to primary care healthcare professionals when encountering frailty and type 2 diabetes?
Managing older people with type 2 diabetes is often seen as complicated. The complexity is apparent in the relationship between frailty and type 2 diabetes – not only are elderly and frail people overall at an increased risk of type 2 diabetes, the risks are often associated with an accelerated aging process that promotes frailty. This means that type 2 diabetes and frailty need to be considered as co-dependent factors when managing the condition.
Assessing frailty in the context of type 2 diabetes
Care settings are under immense pressure due to COVID-19, making it even more important that healthcare professionals get more support to address any concerns in care and confidence in the care delivery to elderly people with type 2 diabetes.
Detecting frailty is crucial in being able to identify targeted interventions but it can sometimes go unnoticed or undermanaged in type 2 diabetes, often due to a lack of confidence around identifying frailty.
Managing frailty in the context of type 2 diabetes
Effective management of type 2 diabetes in older adults requires healthcare professionals to appreciate the increasing complexity of the illness and that care may need to operate over four decades (60–90 years and older) and respond to the changing circumstances of an individual’s health status.9
Managing type 2 diabetes in high-functioning older people with an anticipated long-life expectancy is often similar to those for younger people. However, these approaches are inappropriate and potentially unsafe if applied to functionally impaired or frail individuals.
Glycaemic targets and type 2 diabetes in elderly and frail people
Measurement of HbA1c plays a central role in diagnosing diabetes, as well as monitoring and managing treatment. However, there is discussion around whether this is in fact the most appropriate diagnostic method for an older, potentially frail person. Some studies show that there are increased levels of HbA1c in non-diabetic elderly people, which could ultimately make it even harder for the healthcare professional to have confidence in their diagnosis and subsequent care or treatment decisions.
Once a diagnosis is made healthcare professionals need to factor in the increased risk of hypoglycaemia with treatment of these people. The link between recurrent hypoglycaemia and a resulting increase in frailty is well documented and many hypoglycaemic events being missed or caught too late, leading to falls.7,11
Despite there being some guidelines that allude to the importance of relaxing HbA1c targets for the older or frail person, they lack specification. Guidelines from organisations such as the American Diabetes Association (ADA), European Association for Study of Diabetes (EASD), National Institute for Health and Care Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN) acknowledge the need for individualised care and the careful consideration of patient factors and preferences should inform targets. The ADA has suggested some specific targets for older patients which could help to inform healthcare professionals for any de-escalation therapy, if needed.
The GMS contract QOF set for GP surgeries in the UK now recognises frailty as an important consideration in routine care of older people with diabetes and acknowledges that higher glycaemic targets may be appropriate for older adults living with frailty (HbA1c 75 mmol/mol or less). In addition, a recent expert consensus suggests it is reasonable to set less intensive glycaemic goals in more frail individuals with diabetes and provides more detailed advice on what is needed for healthcare professionals to provide care and support for elderly people with type 2 diabetes.
The consequences of hypoglycaemia
The risk of falls to this group of people can be devastating – they can often lead to lengthy hospital stays and a further decline in frailty – and the risk of hypoglycaemic events needs to be better understood and managed in this group.
Managing lifestyle interventions in elderly people living with type 2 diabetes and de-escalation of medicines
Type 2 diabetes often occurs in younger adults in the context of obesity and associated insulin resistance with consultations often centring around lifestyle modifications such as weight loss and diet to support in achieving glycaemic control. However, aging is associated with a marked decrease in bodyweight and food intake, so conversations need to be adapted to suit key considerations such as age-related sarcopenia, as losing weight is often detrimental for this group.
Hypoglycaemic medication review or even de-escalation may be suitable in this group of people.6
What do you think needs to be done to help better equip healthcare professionals in their diagnosis and management of type 2 diabetes in the elderly?
- Further training and awareness regarding which assessment methods to use for clinicians.
- Suitable insights on how to plan their initial and ongoing management, especially as frailty can both improve and decline over time.
- Better integration between specialisms in providing care; including GPs, community nurses and care home staff.
- Encourage use of appropriate tools (e.g. STOPP/START) that can support GPs with conducting regular medication reviews to check that glycaemic control (and other risk factor management) is appropriate for each frailty category and reduce polypharmacy where possible.
Diabetes and elderly care is an exciting field which will evolve. It is clear that this is more complex than initially thought and frailty is fast becoming a critical complication for healthcare professionals to consider when managing older people and their type 2 diabetes, providing that it has actually been identified for an individual patient. Now more than ever there needs to be clear guidance and support for healthcare professionals in managing this group, especially as the numbers will continue to grow as the population ages.
- NHS (2021) ‘The most vulnerable and health and care workers offered COVID-19 jab as government hits target to protect those most at risk. Available at: https://www.gov.uk/government/news/the-most-vulnerable-and-health-and-care-workers-offered-covid-19-jab-as-government-hits-target-to-protect-those-most-at-risk [Accessed April 2021].
- NHS (2017) ‘Tackling Diabetes is One of the Biggest Healthcare Challenges of our Time’. Available: https://www.england.nhs.uk/blog/tackling-diabetes-is-one-of-the-biggest-healthcare-challenges-of-our-time/ [Accessed April 2021]
- Diabetes UK (2019) ‘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’. Available at: https://www.guidelines.co.uk/diabetes/type-2-diabetes-frailty-in-older-people/454600.article [Accessed April 2021]
- NHS (2020) ‘NHS expands offer of help to people with diabetes during coronavirus outbreak’. Available at: https://www.england.nhs.uk/2020/05/nhs-expands-offer-of-help-to-people-with-diabetes-during-coronavirus-outbreak/ [Accessed April 2021]
- Boehringer Ingelheim (2020). Survey Data on file: LIN 20-04
- Abdelhafiz, AH., Koay, L., & Sinclair, AJ. (2016). The effect of frailty should be considered in the management plan of older people with Type 2 diabetes. Future science OA, 2(1), FSO102. https://doi.org/10.4155/fsoa-2015-0016 [Accessed April 2021]
- Down, S. (2020). ‘New advice on frailty and type 2 diabetes management: A great start to the year!’ Available at: https://www.diabetesonthenet.com/resources/details/new-advice-frailty-and-type-2-diabetes-management-great-start-year [Accessed April 2021]
- NHS. Electronic Frailty Index. Available at: https://www.england.nhs.uk/ourwork/clinical-policy/older-people/frailty/efi/ [Accessed April 2021]
- Strain, WD. et al (2018) 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. Jul;35(7):838-845.doi: 10.1111/dme.13644. Epub 2018 May 6. Available at: https://pubmed.ncbi.nlm.nih.gov/29633351/ [Accessed April 2021]
- Masuch, A., Friedrich, N., Roth, J. et al. (2019) Preventing misdiagnosis of diabetes in the elderly: age-dependent HbA1c reference intervals derived from two population-based study cohorts. BMC Endocr Disord 19, 20. https://doi.org/10.1186/s12902-019-0338-7 [Accessed April 2021]
- Abdelhafiz, A., Rodríguez-Mañas, L., Morley, J., Sinclair, A., (2015) Hypoglycemia in Older People – A Less Well Recognized Risk Factor for Frailty. Aging and Disease 6(2):156-57. https://doi.org/10.14336/AD.2014.0330 [Accessed April 2021]
- National Institute for Health and Care Excellence (2015). Type 2 diabetes in adults: management. Available at: https://www.nice.org.uk/guidance/ng28/resources/type-2-diabetes-in-adults-management-pdf-1837338615493 [Accessed April 2021].
- Davies, MH et.al., (2018). Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care Dec; 41(12): 2669-2704. Available at: https://care.diabetesjournals.org/content/41/12/2669 [Accessed April 2021]
- Scottish Intercollegiate Guidelines Network (SIGN) (2017). Pharmacological management of glycaemic control in people with type 2 diabetes. Available at: https://www.sign.ac.uk/media/1090/sign154.pdf [Accessed April 2021]
- American Diabetes Association (2021). Diabetes Care. Jan;44(supplement 1): S168-S179. Available at: https://care.diabetesjournals.org/content/44/Supplement_1/S168 [Accessed April 2021]
- NHS England. 2019/20 General Medical Services (GMS) contract quality and outcomes framework (QOF). Guidance for GMS contract 2019/20 in England. 2019. https://www.england.nhs.uk/wp-content/uploads/2019/05/gms-contract-qof-guidance-april-2019.pdf [Accessed April 2021]
- Strain, WD, Down, S, Brown P et al (2021) Diabetes and Frailty: An Expert Consensus Statement on the Management of Older Adults with Type 2 Diabetes. Diabetes Therapy doi: 10.1007/s13300-021-01035-9. Available at: https://doi.org/10.1007/s13300-021-01035-9 [Accessed April 2021]