diabetes research and clinical practice 103 (2014) 538–540
Contents available at ScienceDirect
Diabetes Research and Clinical Practice jou rnal hom ep ag e: w ww.e l s e v i er . c om/ loca te / d i ab r es
International Diabetes Federation
New IDF Guideline for managing type 2 diabetes in older people§ Trisha Dunning, Alan Sinclair, Stephen Colagiuri
Just over 8.3% of the global population has diabetes [1]. Increasing age is a significant risk factor for type 2 diabetes but the diagnosis is often missed or delayed because the clinical presentation is different from that in younger people. Diabetes is a major cause of complications, reduced quality of life and changed physical and mental functioning in older people [2–4]. It is also a leading cause of death in older people from cardiovascular and other related medical co-morbidities. In addition, many older people have additional risk factors for diabetes and may have undiagnosed complications. Diabetes is a leading cause of death in older people. The International Diabetes Federation launched a Global Guideline for Managing Older People with Type 2 Diabetes in a Satellite Symposium about diabetes in older people held in association with the World Diabetes Congress in Melbourne in December 2013. The essential messages in the IDF Guideline are described in this paper. It is important to recognise that older people with diabetes are highly individual and that the data from published studies, even when these are well designed, cannot always be generalised or extrapolated to older cohorts. It is important to consider the individual’s health status, social situation and available support from family and/or the community.
1. Planning care with older people with diabetes The goal of involving the older person in care decisions is to reach a shared understanding of their specific situation and life. Chronological age does not indicate how an older person manages their life and does not predict treatment outcomes. It is better to plan care according to the person’s functional status, degree of medical co-morbidities present, the impact of any §
diabetes-related vascular complications, and whether frailty or dementia is present. When frailty is present, many older people are less able to tolerate the stress of illness and this is likely to increase the risk of falls and admission to hospital. Planning care for older people with diabetes can be very challenging because of the effects of diabetes complications, e.g. sensory changes with reduced sight and hearing; mental challenges including confusion, depression, delirium and dementia; and physical changes such as arthritis and other disorders in joints and tissues which are often present. These factors increase the person’s risk of falling and developing pressure ulcers including foot ulcers and pain, which are often not recognised or treated appropriately. When these factors operate at the same time, the risk of medicine-related adverse events and admission to hospital or a care home for the aged increases significantly. In addition, diabetes complications, frailty and dementia make it difficult for the person to exercise and undertake diabetes and other self-care activities. Frailty and dementia make it difficult to exercise and undertake diabetes and other self-care activities.
2.
Medicine
There is strong evidence that many medicines commonly prescribed for older people should not be used or, alternatively, should be used with caution. Such medicines include antipsychotic medicines to manage behavioural problems associated with dementia, and some sulfonylureas, used to lower blood glucose, especially if they are long acting. There is also concern about using sliding insulin scales [5] to manage hyperglycaemia. Thus, regular comprehensive medicine checks are needed, especially when several doctors prescribe medicines for the same person. Medicine reviews can be
This article first appeared in the International Diabetes Federation’s magazine Diabetes Voice. http://dx.doi.org/10.1016/j.diabres.2014.03.005 0168-8227/# 2014 Published by Elsevier Ireland Ltd.
diabetes research and clinical practice 103 (2014) 538–540
undertaken at home. Many medicines prescribed to manage diabetes and its complications are classed as high-risk because of their side effects and the way they are used and metabolised in the body.
3.
Key issues to consider when planning care
Care plans need to be developed with the individual and their family caregivers to suit the individual’s health status and life expectancy and keep the individual living safely and independently as long as possible [8]. Care plans could encompass: Screening older people for undiagnosed diabetes. Proactively undertaking comprehensive risk assessments to identify and manage: diabetes complications including renal and liver disease which affect medicine choices; inadequate nutrition, which also affects medicine choices; low vitamin D and B 12 are common; pain; falls risk; delirium; increasing frailty; unsafe driving; hypoglycaemia and hyperglycaemia risk; geriatric syndromes, see Box. Setting blood glucose, HbA1c, blood pressure (BP) and other care targets to suit individual requirements; for example, a high functionally independent rating should target HbA1c 7.0–7.5% (53–59 mmol/mL) and BP < 140/90 mmHg; functionally dependent: HbA1c 7.0–8.0 (53–64 mmol/mL), BP < 140/90 mmHg; and frail and dementia: HbA1c up to 8.5% (70 mmol/mL) BP < 150/90 mmHg. Preventing or managing cardiovascular disease. If cardiovascular disease is present, it needs to be treated early and effectively using a healthy diet and physical activity approach; and lipid lowering medicines, aspirin and antihypertensive medicines when indicated and safe. Controlling hyperglycaemia to promote comfort, reduce cardiovascular risks and microvascular disease, enhance self-care, reduce falls risk, manage hyperglycaemia-related symptoms such as tiredness, thirst and frequent urination, and dehydration and the associated risk of ketoacidosis, hyperosmolar states, delirium, cognitive impairment and depression. However, ‘tight’ blood glucose control is not usually warranted and may place the person at significant risk of hypoglycaemia. Conducting regular comprehensive medicine reviews including asking about herbal medicines and vitamin and mineral supplements and other complementary therapies use as well as self-prescribed conventional medicines. Safe medicine use (pharmacovigilence) can be achieved using a quality use of medicines (QUM) approach [6]. QUM is a decision-making framework that applies to the entire medication pathway, but clinically it means: selecting medicines wisely based on a comprehensive health assessment; using non-medicine options where possible but choosing a suitable medicine if indicated;
539
using medicines safely and effectively for the individual older person and monitoring the outcomes, which encompasses regular clinical assessment and medicine reviews. Many medicines should be used with caution or are contraindicated in older people [5]. Assessing physical status (functional status), kidney and liver function, mental health, cognitive functioning and selfcare regularly; at least annually and whenever health or the management regimen changes. General health assessments such as mammograms, prostate checks, bowel checks, thyroid function, immunization status and sexual health and well-being should be assessed regularly in addition to regular diabetes-related assessments. Such assessments may be needed more frequently than annually. Developing a plan indicating when to stop driving. Developing a plan for end of life care. Implementing medical alert and call systems to enhance safety, especially for community dwelling older people, when indicated. Supporting carers.
Patient safety in a complex illness such as diabetes must be a priority. Safe use of medicines is a key component of care planning.
4.
Summary
Management focuses on safety, maintaining independence and functional status and quality of life, managing symptoms, reducing the impact of diabetes complications and other diseases. Individualising management targets is essential [7]. Involving the older person and their family or other carers in management decisions is essential.
Common geriatric syndromes:
The term ‘geriatric syndrome’ refers to a group of conditions that often occur together and affect the person’s health and self-care capacity and include:
falls; pain; urinary tract infection; cognitive impairment which can be assessed using Mini-Mental State Examination, Mini-Cog, or the Clock drawing test; depression, which can be assessed using the Geriatric Depression Scale, or Patient Health Questionnaire (PHQ2); hypoglycaemia; delirium; polypharmacy, which usually means using more than five medicines.
540
diabetes research and clinical practice 103 (2014) 538–540
references
[1] International Diabetes Federation. IDF Diabetes Atlas. 6th ed. Brussels: IDF; 2013. [2] Sinclair AJ, Barnett AH. Special needs of elderly geriatric patients. BMJ 1993;306:1142–3. [3] Gu K, Cowie C, Harris M. Mortality differences between adults with and without diabetes in a national sample 1973– 1993. Diabetes 1997;46:26A. [4] Zhang Y, Hu G, Yuan Z. Glycosylated haemoglobin in relationship to cardiovascular outcomes and death in patients with type 2 diabetes; a systematic review and metaanalysis. PLoS ONE 2012;7:e42551. [5] American Geriatrics Society. American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc 2012;60:616–31. [6] Department of Health and Aging. National Strategy for Quality Use of Medicines. Australia; 2002, www.health.gov.au/internet/main/publishing.nsf/Content/ nmp-pdf-natstrateng-cnt.htm.
[7] Sinclair A, Morley JE, Rodriguez-Manas L, et al. Diabetes mellitus in older people: position statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People (EDWPOP) and the International Task Force of Experts in Diabetes. J Am Med Dir Assoc 2012;13:497–502. [8] Dunning T, Savage S, Duggan N. McKellar Guidelines for Managing Diabetes in Residential Aged Care Facilities. Geelong: Centre for Nursing and Allied Health Research; 2014. Trisha Dunning is Chair in Nursing for the School of Nursing and Midwifery at Deakin University and Director for the Centre for Nursing and Allied Health Research in Geelong, Australia. Alan Sinclair is Dean at the Bedfordshire and Hertfordshire Postgraduate Medical School, and Director of the Institute of Diabetes for Older People (IDOP) in Luton, Bedfordshire, UK. Stephen Colagiuri is the Professor of Metabolic Health at the University of Sydney at the Boden Institute, University of Sydney Camperdown, New South Wales, Australia.
Contents available at ScienceDirect
Diabetes Research and Clinical Practice jou rnal hom ep ag e: w ww.e l s e v i er . c om/ loca te / d i ab r es
International Diabetes Federation
New IDF Guideline for managing type 2 diabetes in older people§ Trisha Dunning, Alan Sinclair, Stephen Colagiuri
Just over 8.3% of the global population has diabetes [1]. Increasing age is a significant risk factor for type 2 diabetes but the diagnosis is often missed or delayed because the clinical presentation is different from that in younger people. Diabetes is a major cause of complications, reduced quality of life and changed physical and mental functioning in older people [2–4]. It is also a leading cause of death in older people from cardiovascular and other related medical co-morbidities. In addition, many older people have additional risk factors for diabetes and may have undiagnosed complications. Diabetes is a leading cause of death in older people. The International Diabetes Federation launched a Global Guideline for Managing Older People with Type 2 Diabetes in a Satellite Symposium about diabetes in older people held in association with the World Diabetes Congress in Melbourne in December 2013. The essential messages in the IDF Guideline are described in this paper. It is important to recognise that older people with diabetes are highly individual and that the data from published studies, even when these are well designed, cannot always be generalised or extrapolated to older cohorts. It is important to consider the individual’s health status, social situation and available support from family and/or the community.
1. Planning care with older people with diabetes The goal of involving the older person in care decisions is to reach a shared understanding of their specific situation and life. Chronological age does not indicate how an older person manages their life and does not predict treatment outcomes. It is better to plan care according to the person’s functional status, degree of medical co-morbidities present, the impact of any §
diabetes-related vascular complications, and whether frailty or dementia is present. When frailty is present, many older people are less able to tolerate the stress of illness and this is likely to increase the risk of falls and admission to hospital. Planning care for older people with diabetes can be very challenging because of the effects of diabetes complications, e.g. sensory changes with reduced sight and hearing; mental challenges including confusion, depression, delirium and dementia; and physical changes such as arthritis and other disorders in joints and tissues which are often present. These factors increase the person’s risk of falling and developing pressure ulcers including foot ulcers and pain, which are often not recognised or treated appropriately. When these factors operate at the same time, the risk of medicine-related adverse events and admission to hospital or a care home for the aged increases significantly. In addition, diabetes complications, frailty and dementia make it difficult for the person to exercise and undertake diabetes and other self-care activities. Frailty and dementia make it difficult to exercise and undertake diabetes and other self-care activities.
2.
Medicine
There is strong evidence that many medicines commonly prescribed for older people should not be used or, alternatively, should be used with caution. Such medicines include antipsychotic medicines to manage behavioural problems associated with dementia, and some sulfonylureas, used to lower blood glucose, especially if they are long acting. There is also concern about using sliding insulin scales [5] to manage hyperglycaemia. Thus, regular comprehensive medicine checks are needed, especially when several doctors prescribe medicines for the same person. Medicine reviews can be
This article first appeared in the International Diabetes Federation’s magazine Diabetes Voice. http://dx.doi.org/10.1016/j.diabres.2014.03.005 0168-8227/# 2014 Published by Elsevier Ireland Ltd.
diabetes research and clinical practice 103 (2014) 538–540
undertaken at home. Many medicines prescribed to manage diabetes and its complications are classed as high-risk because of their side effects and the way they are used and metabolised in the body.
3.
Key issues to consider when planning care
Care plans need to be developed with the individual and their family caregivers to suit the individual’s health status and life expectancy and keep the individual living safely and independently as long as possible [8]. Care plans could encompass: Screening older people for undiagnosed diabetes. Proactively undertaking comprehensive risk assessments to identify and manage: diabetes complications including renal and liver disease which affect medicine choices; inadequate nutrition, which also affects medicine choices; low vitamin D and B 12 are common; pain; falls risk; delirium; increasing frailty; unsafe driving; hypoglycaemia and hyperglycaemia risk; geriatric syndromes, see Box. Setting blood glucose, HbA1c, blood pressure (BP) and other care targets to suit individual requirements; for example, a high functionally independent rating should target HbA1c 7.0–7.5% (53–59 mmol/mL) and BP < 140/90 mmHg; functionally dependent: HbA1c 7.0–8.0 (53–64 mmol/mL), BP < 140/90 mmHg; and frail and dementia: HbA1c up to 8.5% (70 mmol/mL) BP < 150/90 mmHg. Preventing or managing cardiovascular disease. If cardiovascular disease is present, it needs to be treated early and effectively using a healthy diet and physical activity approach; and lipid lowering medicines, aspirin and antihypertensive medicines when indicated and safe. Controlling hyperglycaemia to promote comfort, reduce cardiovascular risks and microvascular disease, enhance self-care, reduce falls risk, manage hyperglycaemia-related symptoms such as tiredness, thirst and frequent urination, and dehydration and the associated risk of ketoacidosis, hyperosmolar states, delirium, cognitive impairment and depression. However, ‘tight’ blood glucose control is not usually warranted and may place the person at significant risk of hypoglycaemia. Conducting regular comprehensive medicine reviews including asking about herbal medicines and vitamin and mineral supplements and other complementary therapies use as well as self-prescribed conventional medicines. Safe medicine use (pharmacovigilence) can be achieved using a quality use of medicines (QUM) approach [6]. QUM is a decision-making framework that applies to the entire medication pathway, but clinically it means: selecting medicines wisely based on a comprehensive health assessment; using non-medicine options where possible but choosing a suitable medicine if indicated;
539
using medicines safely and effectively for the individual older person and monitoring the outcomes, which encompasses regular clinical assessment and medicine reviews. Many medicines should be used with caution or are contraindicated in older people [5]. Assessing physical status (functional status), kidney and liver function, mental health, cognitive functioning and selfcare regularly; at least annually and whenever health or the management regimen changes. General health assessments such as mammograms, prostate checks, bowel checks, thyroid function, immunization status and sexual health and well-being should be assessed regularly in addition to regular diabetes-related assessments. Such assessments may be needed more frequently than annually. Developing a plan indicating when to stop driving. Developing a plan for end of life care. Implementing medical alert and call systems to enhance safety, especially for community dwelling older people, when indicated. Supporting carers.
Patient safety in a complex illness such as diabetes must be a priority. Safe use of medicines is a key component of care planning.
4.
Summary
Management focuses on safety, maintaining independence and functional status and quality of life, managing symptoms, reducing the impact of diabetes complications and other diseases. Individualising management targets is essential [7]. Involving the older person and their family or other carers in management decisions is essential.
Common geriatric syndromes:
The term ‘geriatric syndrome’ refers to a group of conditions that often occur together and affect the person’s health and self-care capacity and include:
falls; pain; urinary tract infection; cognitive impairment which can be assessed using Mini-Mental State Examination, Mini-Cog, or the Clock drawing test; depression, which can be assessed using the Geriatric Depression Scale, or Patient Health Questionnaire (PHQ2); hypoglycaemia; delirium; polypharmacy, which usually means using more than five medicines.
540
diabetes research and clinical practice 103 (2014) 538–540
references
[1] International Diabetes Federation. IDF Diabetes Atlas. 6th ed. Brussels: IDF; 2013. [2] Sinclair AJ, Barnett AH. Special needs of elderly geriatric patients. BMJ 1993;306:1142–3. [3] Gu K, Cowie C, Harris M. Mortality differences between adults with and without diabetes in a national sample 1973– 1993. Diabetes 1997;46:26A. [4] Zhang Y, Hu G, Yuan Z. Glycosylated haemoglobin in relationship to cardiovascular outcomes and death in patients with type 2 diabetes; a systematic review and metaanalysis. PLoS ONE 2012;7:e42551. [5] American Geriatrics Society. American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc 2012;60:616–31. [6] Department of Health and Aging. National Strategy for Quality Use of Medicines. Australia; 2002, www.health.gov.au/internet/main/publishing.nsf/Content/ nmp-pdf-natstrateng-cnt.htm.
[7] Sinclair A, Morley JE, Rodriguez-Manas L, et al. Diabetes mellitus in older people: position statement on behalf of the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People (EDWPOP) and the International Task Force of Experts in Diabetes. J Am Med Dir Assoc 2012;13:497–502. [8] Dunning T, Savage S, Duggan N. McKellar Guidelines for Managing Diabetes in Residential Aged Care Facilities. Geelong: Centre for Nursing and Allied Health Research; 2014. Trisha Dunning is Chair in Nursing for the School of Nursing and Midwifery at Deakin University and Director for the Centre for Nursing and Allied Health Research in Geelong, Australia. Alan Sinclair is Dean at the Bedfordshire and Hertfordshire Postgraduate Medical School, and Director of the Institute of Diabetes for Older People (IDOP) in Luton, Bedfordshire, UK. Stephen Colagiuri is the Professor of Metabolic Health at the University of Sydney at the Boden Institute, University of Sydney Camperdown, New South Wales, Australia.
