Professor Alan Sinclair, National Clinical Lead for Diabetes in Older People

Professor Alan Sinclair is our National Clinical Lead for Diabetes in Older People and he has just started a new blog. In his monthly postings, Alan will offer helpful suggestions about improving diabetes care for older people which you will be able to take back to your teams. 

July 2012: Applying the correct principles of care for older people with diabetes 

April 2012: Diabetes in older people – a focus on end of life care and care homes 

February 2012: Diabetes in older people – what is key to improving care?

July 2012: Applying the correct principles of care for older people with diabetes

Diabetes care for older people takes place in multiple clinical settings such as hospital inpatient wards, outpatient clinics, general practice surgeries, community-based provider units, residential and nursing homes, sheltered housing and of course in the patient’s own home or that of their family. A set of generic diabetes care principles apply to each of these settings and can be summarised as:

1. A clinician mindset that aims to find a diagnosis for illness-related symptoms and not easily settle for non-specific presentation
2. A major emphasis on quality of life and well-being for each patient
3. The early and effective use of interventions that can be applied in community settings to avoid hospital admissions
4. A commitment by a healthcare or social care team to improving or maintaining functional status
5. Avoid ageism and a reductionist approach to care

The Older People Diabetes Network (OPDN), by the activities of its regional roles, seeks to embody these principles universally in our communities, but recognises that many non-clinical factors currently interplay to create barriers to effective delivery of care. These might include social isolation, other socio-economic factors and varying family dynamics.  The OPDN recognises that more networking, collaboration with existing key stakeholders such as Diabetes UK, Age UK, the Royal Colleges and ABCD, enhanced engagement with primary care and finding better opportunities to listen to and work with patients and carers, are important initiatives and priorities to take forward.

There are many good examples of recent progress within the network in enhancing diabetes care for older people – in the North of England, for example, Julia Hobbs and Dr Ahmed Hafiz and other members of our regional OPDN Network are meeting with the Lancashire County Council Health Scrutiny Committee steering group to discuss residential care home provision.  The purpose of the Health Scrutiny Committee is to review and scrutinise issues around public health and health inequalities, including the work and performance of any relevant part of the County Council and its partners. OPDN are highlighting the care standards required to meet the needs of older people with diabetes. Our goal is to ensure that the council's preferred providers attain and maintain high quality diabetes care services for their residents. This is clearly exciting work!

In our OPDN London region, Lisa Phillimore and Professor Angus Forbes are doing some marvellous work in the area of reviewing best clinical practices in diabetes care for older people and examining the roles of hospice care in meeting the needs of older patients with diabetes in the end of life scenario. They have also started to identify ways of ensuring older people with both diabetes and visual loss gain access to early detection of disease and effective treatment.

We believe that our campaign to highlight the special and often unique features of older people with diabetes is working and beginning to influence attitudes and behaviour, but this will need demonstrating. We are working to develop a number of key audits in this arena. The OPDN is also carrying out its own review of how far we have travelled in meeting some of the key needs of our clinicians as well as those of patients, families and carers for quality diabetes care. An exciting and worthwhile journey!

April 2012: Diabetes in older people – a focus on end of life care and care homes

Up to one in five older people have diabetes and a similar proportion may have undiagnosed diabetes. We know diabetes is associated with increasing age, family history, ethnicity, obesity and sedentary lifestyle. It causes premature morbidity, mortality and is a substantial health burden on individuals, health systems and society. Thus it is not a trivial disease and poses many significant challenges to the delivery of effective and safe care. Based on this evidence, developing a network dedicated to enhancing the diabetes care for older people is extremely well justified.

Recognising diverse health and social care needs

Within the Older People Diabetes Network (OPDN), we have recognised that older people are not a homogeneous group of individuals, but have varying levels of cognitive and functional ability and an often complex set of health and social care needs. Although an older person with diabetes has a high likelihood of being well and enjoying a good quality of life, many are functionally dependent or have other co-morbidities which can influence goals of care and alter management strategies.

We have previously recognised that the effective management of the older patient with diabetes requires an emphasis on safety, prevention and early treatment for vascular disease, and functional assessment of disability due to limb problems, or eye disease and stroke. Additionally, in older age, prevention and management of other diabetes-related complications and associated conditions – such as cognitive dysfunction, severe mood disturbance, falls and erectile dysfunction – become a priority.

Patient safety is an a priority issue for managing older people with diabetes, but is often compromised by inappropriate treatment choice, suboptimal specialist follow up and patient-centred issues such as the development of social isolation or mental illness. This theme will be a thread throughout the work of the OPDN.

Emerging Issues requiring attention

It has been estimated that up to nine per cent of all deaths in the UK are in people with diabetes and that end of life diabetes care (EOLDC) does not have sufficient quality standards to ensure a consistent high-quality approach. Part of the explanation lies in the lack of knowledge and skills in the workforce in this area. Clinical guidelines for diabetes generally fail to include EOLDC and research on best clinical practice in this area is scarce. That’s why as the chair of the OPDN, I am involved in looking at this area in a collaborative approach led by Diabetes UK and involving IDOP and ABCD (Association of British Clinical Diabetologists), where national guidance and recommendations for quality are being developed. This work has identified a set of key principles of which the following three provide the platform for enhanced EOLDC:

• Provision of a painless and symptom-free death
• Avoid frequent and unnecessary hypoglycaemia
• Provision of an appropriate level of intervention according to stage of illness, symptom profile, and respect for dignity

We must wait to see how the new commissioning phase for health in the NHS will invest in EOLDC, but the OPDN will attempt to implement new initiatives in this area which focuses on care pathway design, training and education of the healthcare workforce, and defining quality standards of care for the purposes of assessment by regulatory bodies and clinical audit.

Care home diabetes

Diabetes management in care homes continues to pose significant challenges to health and social care professionals in the provision of high quality, safe and effective care. Work undertaken in 2010 by a task and finish group of Diabetes UK, led by me, has producednational guidance on diabetes care for residents of care homes. This has been well received and is also available as a publication in the form of an executive summary in the medical journal, Diabetic Medicine, in July 2011. A task of the OPDN is to encourage the implementation of this national guidance.

More recently, IDOP and NHS Diabetes carried out the Beds & Herts Care Home Diabetes Audit Pilot, which showed variations between the homes in the quality of diabetes care and a lack of access to structured diabetes education for care home staff. However, this audit also shows that there does appear to be enthusiasm within care homes to enhance the quality of care and to be more engaged in promoting training and education of staff.

This has prompted the need to ascertain what the national picture is in relation to care home diabetes care. As a result, I am pleased to announce that IDOP and the Association of British Clinical Diabetologists (ABCD) in a collaborative venture with NHS Diabetes and other stakeholders will be undertaking a national care homes diabetes audit beginning early summer 2012. Watch this space!

Moving forward

The OPDN goes from strength to strength with well-attended regional conferences, local media interest, the skilled work of our four coordinators and the important contributions of our four clinical champions. Julian Backhouse and I have a superb group of colleagues to share our ideas with and seek their own perspectives on the fascinating and challenging area of diabetes in older people.

February 2012: Diabetes in older people – what is key to improving care?

Introduction

One of the greatest challenges the medical profession faces in the 21^st century is the epidemic relating to obesity and the marked rise in type 2 diabetes. All must honour their own commitment to strive for excellence in medical care, and diabetes in ageing people poses one of the more distinct of these challenges.

Thoroughness and vigilance are prime qualities that are needed in managing older people with diabetes, especially in the areas of assessment and treatment. This may be particularly important in older people with diabetes who may have considerable (but often undetected) impaired lower extremity function. 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 co-morbidities, independence and quality of life.

Each disability has the potential to disadvantage individuals considerably (handicap) such as failure to enjoy outside entertainment, leisure activities and an 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 co-morbidities, mood, and even social support and financial status, can have dramatic effects on the level of impact of the disability.

Clinicians managing older people do require detailed knowledge of their assessment and the available therapies via the multidisciplinary environment. They also need the ability to set goals, a realistic time frame for rehabilitation and whatever aides and appliances are available. In a similar manner to educational programmes, encouraging people to take an active part in their rehabilitation can foster autonomy, improve self-esteem and coping skills, and reduce anxiety and depression in my experience.

This is a complex area but several research groups have undertaken studies, which take us forward to understanding the nature of the disabling process and are paving the way for reablement. Whilst the ‘multifactorial’ nature of this process may prevent straightforward interventions from being effective, we do need a greater understanding of the role of glycaemic control and larger scale randomised controlled trials are needed to assist us in this exploration.

In addition, we need to stimulate the interest of clinical and laboratory researchers to provide us with the evidence to justify particular therapeutic interventions and to promote specific patterns of care characterised by three themes:

• a major emphasis on quality of life and well being for each patient
• early and effective interventions
• a commitment to improve or maintain functional status.

Acquiring unique knowledge and skills in the Textbook of Diabetes for older people enhances diabetes care for the vulnerable directly and often indirectly by influencing attitudes (avoiding ageism and a reductionist approach) to care: this textbook has been devoted to this goal.

The nature of the problem – diabetes in older people

Older adults with diabetes have a two-to-four fold increase in the risk of hospitalisation and factors such as a high likelihood of significant pre-admission medical co-morbidities and disability, often results in poor clinical outcomes and prolonged length of stay. Major vascular episodes such as a stroke or myocardial infarction are common causes of admission in older patients with diabetes. Diagnosis of diabetes is often made for the first time at admission into hospital since 40 per cent of older adults presenting with hyperglycaemia have no previous history of diabetes. It is imperative that the treatment of diabetes is not delayed as mortality can be significant within the first two days of admission. Older adults also pose several additional problems of diabetes care relating to the time of admission, their inpatient stay and the pre-discharge and discharge phases. Up to now these issues have not been addressed.

What is the solution?

Preventative strategies in the community to reduce hospitalisation include:

• prompt treatment of urinary and chest and skin infections
• opportunistic screening for diabetes in housebound elderly and care home residents where early treatment will reduce metabolic decompensation
• early recognition of depressive illness.
  

We should examine the possibility that a minimum data set of key variables (elements of information) might enhance the opportunity for improvement in diabetes care for older people. This approach would ensure that the essential data is collected to allow a more informed interpretation of outcome data. It is reasonable to conclude that this approach may be valid in different disease areas where a more uniformed approach to research is required.

In the field of type 2 diabetes of older people, a minimum data set might serve four primary purposes:

1. Provide a standardised method of assessment and outcome measures for conducting large-scale intervention studies with a randomised controlled design
2. Enable valid comparisons of research findings in different populations of patients
3. Allow a more detailed analysis of the validity, reliability and sensitivity of existing measures and promote the development of new measures suitable for studies in older people
4. By conducting a systematic review of procedures and meta-analyses of studies using a recognised minimum data set, there will be an increased likelihood of demonstrating both clinical and cost-effectiveness of a range of interventions.

How to influence commissioners and clinicians?

As other initiatives will demonstrate, this is the important challenge! The Clinical Commissioning Groups (CCGs) are just beginning to take up the reins. Diabetes and older people may be relatively low on their priority given all the challenges they face. To propel diabetes in older people up the agenda we will need to have a strong and united voice. This is where the work of the Older Peoples Diabetes Network will be vital. We are more likely to be listened to if we do the work for them by providing well worked solutions which are affordable and fulfil all available clinical guidelines.

Conclusions

In order for progress to be made in the overall standard of diabetes care for older people in the United Kingdom, we require cooperation to record key data (a specified minimum dataset), an agreement on major clinical pathways and great encouragement to set up future clinical trials. This requires cooperation between all the key organisations involved in diabetes care and those involved in specialist care of older people.

Diabetes in the elderly is in an exciting phase because the special issues involved in effective management and the realisation of important gaps in care provision has been increasingly recognised. An increasing number of major clinical trials now involve older people and with this comes data to support specific interventions even in the aged.