Is current guidance relevant, or even detrimental in the management of the Frail/Elderly person with diabetes in a care home setting in Wales
By Nicola Hewer
Community Diabetes Specialist Nurse Education Practitioner
Cardiff and Vale UHB
RGN, BN Wales, PGCE, Community Practitioner Nurse Prescribing, BSc Community Health Studies, DIPHE in Professional Practice Diabetes in Primary Care
The International Diabetes Federation (IDF) (1), currently estimates that there are 463 million people living in the world with diabetes, these figures, however, do not include people over the age of 80 years. In the UK, of the 4.9 million people registered with diabetes, approximately 13% are over the age of 80, which equates to one in five people over the age of 80 have type 2 diabetes (2).
With increasing ageing of the population, the epidemiology of diabetes is shifting towards old age especially among individuals between the ages of 60 and 79 years (3). The high prevalence of type 2 diabetes among the elderly has also been confirmed in a prospective population-based study in The Netherlands, showing that the elderly aged 70 years and over, account for 50% of the population who have type 2 diabetes (4).
Effectiveness and quality of care
Guidelines have been developed to cover a range of aspects in diabetes care from inpatients to medications managed in the UK and elsewhere. It has been stated that guidelines have a range of purposes, to improve effectiveness and quality of care, to decrease variations in clinical practice and to decrease costly and preventable mistakes and adverse events.
Extensive research has been undertaken over the last thirty years on the methods underpinning clinical practice guidelines (CPG’s), including their development, updating, reporting, tailoring for specific purposes, implementation and evaluation. However, it also needs to be taken into account that the most important limitation of guidelines, is that the recommendations may be wrong (or at least wrong for individual patients), and that scientific evidence about what is recommended is often lacking, misleading or misinterpreted (5).
Although people with diabetes are widely represented in clinical practice, focus on diabetes care in this age group is still relatively scarce, a recent analysis showed that only 0.6% of interventional trials in diabetes specifically targeted elderly people, 30.8% excluded people older than 65 years and the majority excluded those aged over 75 years altogether (6).
The IDF supports this, stating that it accepts that an important limiting factor for producing specific evidence-based clinical guidelines for older people with diabetes is the need to extrapolate evidence from clinical studies in younger adults and that the lack of well-designed studies on cost effective diabetes care for older people prevents specific recommendations in this aspect of service development (7).
The working group of The National Institute of Health and Care (NICE), in a more recent report, has also recognised that a number of clinical areas in diabetes receive little or no attention in many published clinical guidelines. They also found that there is a lack of data from published studies where individuals included were over 70 years of age, where the risk of complex comorbidity, frailty and dependency is so often seen (8).
It is suggested that effective management of diabetes in older adults requires the appreciation by both clinicians and policy makers that care has to take into account the increasing complexity of the illness, that such care may need to operate over four decades (60-90 years and older) and respond to the changing circumstances of an individuals health status. The same piece of work found that these individuals are, however, routinely excluded from clinical trials, with only 1.4% of clinical trials explicitly recruiting older adults and a smaller percentage still, specifically recruiting frail older adults.
Frailty and sarcopenia (age-related muscle loss associated with reduced power) are emerging as newly recognised complications of diabetes in older people. Frailty has been described as an adverse health state represented by an increased vulnerability to physical or psychological stressors as a result of decreased physiological reserve, affecting multiple organ systems that create a limited capacity to maintain homeostasis (9). It has been acknowledged that frailty is a common finding and may be present in 32-48% of adults aged 65 years and over with diabetes, and is associated with adverse outcomes and reduced survival (6).
Diabetes management strategies for high functioning older people with an anticipated long-life expectancy are similar to those for younger people. Such strategies applied to functionally impaired or frail individuals, however, maybe inappropriate and potentially unsafe if interventions with more immediate adverse effects are used. Furthermore, generic metabolic targets, whether they be glycaemic, lipid or even blood pressure, ignore the importance of holistic personalised care in the presence of multi-morbidity or moderate to severe frailty (10).
Hypoglycaemia is a physical stressor that frail adults may have difficulty responding to, and it has been discussed in the literature that elderly and frail individuals with diabetes are at marked increase in risk of adverse effects of treatment for diabetes including hypoglycaemia. Hypoglycaemia in the elderly is associated with serious morbidity, including cardiovascular events, stroke, arrythmias, falls, and frequently resulting fractures (6). The Accord study in 2008, showed that intensive blood glucose control had no significant effect on macrovascular events, however, more patients undergoing intensive control were hospitalised due to severe hypoglycaemia. Other trials people have shown that there is a strong association between severe hypoglycaemia and cardiovascular mortality, especially in the elderly population (11).
The physiological differences of frail/elderly are substantial, due to their failing renal function, hepatic function, autonomic nervous system, incretin system which includes both production and sensitivity to the incretin hormones, and cognitive decline. Older people and those with dementia, are also at an increased risk of hypoglycaemia because appetites are often poorer, resulting in weight loss (12). Although hypoglycaemia in older people (greater than 75 years) with diabetes is common, its recognition can sometimes be difficult, making a diagnosis uncertain in this age group.
It has been explained that due to the predominance of neurological rather than autonomic symptoms, hypoglycaemia may present with symptoms such as dizziness or visual disturbance resulting in another diagnosis. Another diagnostic challenge, is the similarities in the clinical presentation of hypoglycaemia with that of dementia, where individuals present with agitation, increased confusion or behavioural changes (13).
Frailty has a significant impact in terms of increased adverse outcomes and reduced survival
There is also evidence that HbA1c may be artificially higher in older adults owing to red cell fragility, as a result, this client group, if treated to a specific target HbA1c, will be at further risk of hypoglycaemia. Drivers of over treatment of the elderly was due in part to the introduction of the General Medical Services (GMS) contract in 2004 for GPs in the UK incentivised glycaemic monitoring as part of the quality outcome framework. It has been explained that this “payment by results” approach, led to an overall improvement in the blood pressure and glycaemic and lipid management in people with diabetes in the UK. However, the contract did not differentiate based on age, limited life expectancy or frailty. As a result, a significant proportion of older adults were commenced on agents that could cause hypoglycaemia years ago to improve glycaemic control, but despite significant changes in the client’s overall wellbeing and physical status, these medicines have not been reviewed (14).
Since the IDF produced their guidelines in 2013 (15), there has been increasing evidence that, older age and frailty has a significant impact in terms of increased adverse outcomes and reduced survival, and that frailty is now emerging as a recognised and diagnosable condition (16).
The objective of this essay is to review the clinical guidance currently used in practice, and to discuss how the more recent guidelines (17,9), may influence the management of the frail/older person with diabetes.
The National Institute of Health and Care (NICE), describes itself as a public body that provides national guidance and advice to improve health and social care in England and wales. They use information from scientific research, testimonials from practitioners and from people using these services on which to base their recommendations. To date, NICE have produced over 340 guidelines, two specific guidelines in regard to adult diabetes care which are applicable to the older person with diabetes are the diagnosis and management of Type 1 diabetes (18), and the management of type 2 diabetes in adults (19).
In 2015, NICE updated both of these guidelines, suggesting considering relaxing target HbA1c for people who were older or frail, however, no specific targets were recommended. Both of these guidelines were updated again in 2019, reasons given for this update was that there was availability of new evidence and several key developments which had prompted an update, specifically in relation to managing blood glucose levels, anti-platelet therapy and erectile dysfunction. However, again no mention was made of recommendations specifically in regards to the frail elderly.
The NICE Guidelines on Cardiovascular risk (20), and Hypertension (21), (both updated in 2020) do suggest that clinical judgement is needed for people with frailty, multimorbidity and polypharmacy. These guidelines also agreed with current thoughts, discussing the lack of evidence for targets in people over 80 years, and suggested that further research in this area would be helpful, explaining that current healthcare professionals should refer to NICE guidelines on multimorbidity for further advice.
The NICE guideline on multimorbidity (22), last published in 2016 and updated in 2020, explains that the Health Care Professional (HCP) needs to be aware that the evidence for recommendations in NICE guidance on single health conditions, is regularly drawn from people without multimorbidity and taking fewer prescribed regular medicine. The guideline also states that an approach to care that takes account of multimorbidity if the person has frailty or falls should be considered. However, as per previous NICE guidelines, there are no recommended targets for HbA1c, lipids or blood pressure for the frail/elderly with diabetes. This concern was also identified in another review which found that there are no clinical guidelines that gave clear advise as to when to deintensify hypoglycaemic medications if appropriate (23).
Frailty, as well as emerging as a recognisable and diagnosable condition, has also been described as a third category of complications in addition to those of the traditional micro and macrovascular disease processes (24). A report into the rates of complications and mortality in older people with diabetes actually found that the 4-year incidence of cardiovascular complications and hypoglycaemia traded positions, among most frequent non-fatal complications of diabetes, while microvascular complications and acute hyperglycaemic events occurred at much lower rates (25).
It has been identified that frail elderly people are more prone to develop complications from hypoglycaemia such as confusion and dementia (26). In one large observational cohort study of 16,667 older adults with diabetes, a single hypoglycaemic episode was associated with a 26% increased risk of cognitive impairment, and an individual experiencing three or more hypos had almost twice the risk of future dementia (27). Hypos have also been found to be associated with a 45-70% increased risk of fall-related fracture in people over 65 years, as well as with an increased risk of cardiovascular events and cardiovascular mortality (14).
Current guidelines in many instances, fail to take account important elements of care, specific to the frail/elderly which are complex illness management, necessitating an individual approach to care, and appreciation of age-related physiology and pharmacology which increases the risk of iatrogenic adverse drug reactions. Key features of a modern diabetes service sensitive to the specific needs of older people have been identified as needing an active de-prescribing policy, and a review of diabetes and frailty status (9).
Frailty has a significant impact in terms of increased adverse outcomes and reduced survival. Recent publications of international clinical guidelines have provided a modern but still general, overview of management approach for older people with diabetes (17). The IDF Global guidance (7), was one such document which did for the first time, give recommendations for those with dependency including frailty. However, the Association of British Clinical Diabetologists (ABCD) felt that there were many areas where specific advice was still needed within local NHS settings which would help the clinician in decision making (17).
This was further supported in a research paper written in 2017, which stated that there were no clinical guidelines that clearly advised when to deintensify hypoglycaemic medications or de-scribe. The paper suggested that clinical practice should view prescribing and deprescribing, as two sides of the same coin and that care for older people with diabetes should weigh up the risks and benefits of treatment, that is dynamic, and shifts with deteriorating function including weight loss and frailty.
Severe vascular disease
The following year, a further review was published which had two main objectives, the first objective was to look at how the care home population was characterised, what interventions had been undertaken to improve care, and what guidelines were available to enhance quality indicators. The second objective was to define what was needed to be done urgently to address the needs of this vulnerable sector of the population with diabetes, and how the information gathered could provide a new framework for implementing diabetes care within care homes.
The study found, that as previously reported, individuals in care homes were likely to have severe vascular disease, to be physically and cognitively impaired and have high levels of dependency. There were also other factors identified such as physiological dysregulation and disturbed homeostasis which would result in frailty and disability. It was suggested that these various factors caused the individual with diabetes to enter into a downward decline eventually resulting in sarcopenia and frailty.
The report suggested eleven priority areas that needed to be addressed, these were the need for screening of diabetes at admission, lack of assessment and monitoring, lack of specialist input, poor communication channels between primary and secondary care professionals, patchy staff education and training and a call for tighter regulation to improve care (28). The call for tighter regulation has been partially met by a relatively recent Care Quality Guidance (CQC) issued to inspectors of Care Homes in England that highlight important features that a care home should have in place (29). In its introduction the guidance explains that diabetes is the most common metabolic problem in our ageing society, affecting up to one in four residents of care homes who are often frail, and have high rates of admission to hospital when their health deteriorates, however, in Wales there does not appear to be any evidence of this happening.
Even though it is recognised that the incidence of those individuals in care homes who have diabetes is high, research has shown that diabetes is often still poorly understood and managed in care homes. Key findings of an audit carried out England wide in 2013/14, showed that two thirds of care homes have no policy on screening for diabetes, nearly two thirds of homes did not have a designated member of staff with responsibility for diabetes management, more than one in three did not have a written policy for managing hypoglycaemia and one third admitted that they do not have access to local diabetes educational and training courses (30).An admission avoidance and diabetes guidance for clinical commissioning groups and clinical teams (31), in 2013 recommended that a diabetes service should support diabetes education, footcare and management in residential and nursing homes, with recurrent staff training in identifying highest risk residents which may reduce admissions by more than 50% in this population.
If a person with diabetes is admitted to hospital, then this should be seen as an opportunity to revisit previous targets and to individualise goals appropriate to the persons degree of frailty. However, any changes made in the treatment regimens and goals need to be communicated clearly to the nursing home staff, with the rationale for changes explained clearly (16). To achieve this, it has been concluded that clinicians will need to adopt a new set of outcome measures in the management of frailty and diabetes both in hospital settings and in community and primary care. This process will also require a culture change by the diabetes healthcare team and a phase of upskilling in assessment procedures.
The document further explains that it is common for people with severe acute hypoglycaemia to be seen by ambulance crews after an emergency call, most patients are treated at home, but many are taken to the emergency department some of these individuals are then admitted. Available data at that time, suggested 70-100,000 emergency calls outs per year in the UK at significant cost to the NHS, as well as the resulting anxiety and distress to those needing treatment. It has been estimated that the cost of one hypoglycaemic episode needing admission could be as much as £2152 (2015). The use of a Local Impact Hypoglycaemia Tool could be used to estimate the cost of hypoglycaemia for the frail/elderly person with diabetes, this would provide the opportunity to explore how reducing hypoglycaemia rates could result is substantial savings to the NHS (32).
Clinical guidelines can help patients by influencing public policy. They call attention to under recognised health problems, clinical services, preventative interventions and to neglected patient populations and high-risk groups. They offer explicit recommendations for clinicians who are uncertain about how to proceed, overturn the beliefs of doctors accustomed to outdated practices, improve the consistency of care, and provide authoritative recommendations that reassure practitioners about the appropriateness of their treatment policies (5).
The most recent guideline published by the Association of British Clinical Diabetologist ABCD (17), represents a timely initiative to address the important issues of frailty and its association with diabetes. The new Guidance has been structured into three main section headings, which deal with definition of, and the clinical importance of frailty, a summary of areas of management including glucose regulation, role of exercise interventions and hypoglycaemia. Unlike previous guidelines, the recommendations provide specific advice to aid clinicians when making therapeutic decisions for the older person. Not only that, but stress that clinicians should also be made aware of the need for a reverse algorithm to de-intensify complex insulin regimes in frail older adults. The guideline also recommends that HCP caring for older people with diabetes should evaluate their risk of hypoglycaemia and develop individualised HbA1c and blood glucose goals to reduce the risk of hypoglycaemia.
It is clear that up to date clinical guidelines provide specific advice to aid clinicians in making safer therapeutic decisions for older frail people with diabetes. However, guidance alone does not appear to solve the problems of sub-optimal care which has been identified in the literature. For example, the IDP-ABCD audit (31), found that one in three care homes admitted they do not have a written policy for managing hypoglycaemia even though there are numerous clinical guidelines available. The consequences of hypoglycaemia as already discussed can be serious, with physical injury including fractures, head injury, cardiovascular events, psychological harm affecting quality of life (32) and in some cases death.
This essay recommends that a whole system approach is also needed to introduce the new guidance specific to the needs of those frail/elderly with diabetes in a care home setting. This approach should include primary and secondary care, ambulance, trusts, local clinical networks or clusters and specialist HCP’s who are based or work mainly in the community such as Community Diabetes Specialist Nurses, Podiatrist, Dieticians, Dementia Intervention Teams all needing to be familiar with the recent recommendations. Highlighted areas include introduction of an assessment tool for frailty on admission to the home, and re-assessment as indicated, the need for regular audit of diabetes care against established standards should be prioritised.
At the same time the review on “Failing to meet the needs of generations of care home residents with diabetes: a call for action” (28), has concluded that sustainable effective diabetes care within care homes requires additional resources, including trained staff, equipment, modification of facilities to allow for implementing new audit programmes. A call of action is proposed to address these requirements which include a greater prominence to be given by health professionals to older people with diabetes living in a care home environment, all residents with diabetes should be named on a local diabetes register to increase their opportunity to be involved in clinical audits. Health professionals, researchers and research funding bodies should do more to overcome the barriers to effective diabetes audit and research in care homes. As the article states, such a call to action can only succeed if new initiatives are disseminated to influence policy, clinical behaviour and the wellbeing of this neglected population with diabetes.
While researching for this piece of work it became apparent that there is a distinct lack of information in regards to all aspects of care being delivered not only to those frail/elderly individuals but also in regard to any person who has type 1 or type 2 diabetes needing nursing care in Wales.
The ongoing Covid-19 pandemic, has however, raised awareness of the vulnerability of the frail/elderly with diabetes and the need to maintain safety and quality of life to those living in care homes. Guidance was issued to care homes in a response to Covid-19 (33), following on from this, it was identified that such homes often have an ill prepared care workforce to manage acutely ill residents with diabetes, that there is a lack of joined up thinking and collaboration between care homes and local health and social services, and that there is an absence of tried and tested communication channels.
In Wales, a government initiative was implemented during this pandemic to offer health care services in a safe and secure way to see individuals via a video link. It also allowed relatives to be able to communicate with their families, technology in the form of i-pads, was provided to each nursing home along with IT support and education. Looking forward, this initiative could be the first of many, to develop virtual aids for communication with residents, but also, as a means of providing education to care home staff, and for consultations from other HCP’s involved in the persons diabetes care. However, a robust auditing strategy will need to be implemented at the same time, to ensure the momentum for change, which Covid-19 has provided, continues.
A National Advisory Panel is soon to be set up to focus on diabetes in care homes, led by Professor Alan Sinclair. The aim of the advisory panel will be to produce a Strategic Document of Diabetes Care which will help ensure that the highest standard of care possible will be delivered.
This essay concludes then, that guidelines currently in use could potentially cause harm, for example, by setting HbA1c targets too low, which could result in hypoglycaemia, when caring for those frail/elderly individuals with diabetes. However, the implementation of new guidelines will provide specific advice to aid clinicians in making safer therapeutic decisions for older frail people with diabetes. New initiatives how-ever, will need to be disseminated if they are to influence policy, clinical behaviour, and the well-being of this neglected population with diabetes.
This highlights the essential role of the Community Diabetes Specialist Nursing Team, in providing education, advice and support, to both the residents and staff of care homes across Wales.
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