Obesity in the ageing patient 

Dr David H Haslam, GP and a physician specialising in obesity medicine at the Centre for Obesity research at Luton & Dunstable Hospital

Over the past decade, the prevalence of obesity in Western and Westernising countries has more than doubled.1 BMI data has been evaluated as part of an analysis of the Global Burden of Disease. Prevalence rates for overweight and obese people are very different in each region with the Middle East, Central and Eastern Europe and North America having higher prevalence rates. Obesity is usually now associated with poverty even in developing countries. Data suggests that abdominal obesity in adults, with its associated enhanced morbidity, occurs particularly in those who had lower birth weights and early childhood stunting.1

A study that evaluated the contributions of socioeconomic, lifestyle and body weight factors to predicted risk of coronary heart disease found that overweight and obesity now dominate the standard risk factors of coronary heart disease in men and should be the focus of national policies for prevention.2

In the Look AHEAD study overweight volunteers with type 2 diabetes were studied and the long-term effects of an intensive lifestyle intervention programme was reviewed. This programme was designed to achieve and maintain weight loss by decreased caloric intake and increased physical activity. The magnitude of weight loss at one year was strongly (p< 0.0001) associated with improvements in glycemia, blood pressure, tryiglycerides and HDL cholesterol but not with LDL cholesterol.3

At year four, participants who maintained the loss, compared with those who did not, attended more treatment sessions and reported more favorable physical activity and food intake. These results provide critical evidence that a comprehensive lifestyle intervention can induce clinically significant weight loss in overweight/obese participants with type 2 diabetes and maintain this loss in more than 45% of patients at four years.4

Management of obesity is mostly by lifestyle measures such as diet and exercise programmes. However, studies have shown that orlistat produces greater weight loss than diet alone.5 During four years of treatment, orlistat plus lifestyle intervention significantly decreased the progression to type 2 diabetes compared with placebo plus lifestyle intervention. Cumulative incidence of diabetes was 6.2% with orlistat and 9% with placebo, corresponding to a 37.3% decrease in the relative risk of developing diabetes with orlistat.

Sarcopenia, the age-associated loss of skeletal muscle mass, is a major concern in ageing populations and has been associated with metabolic impairment, CVD risk factors, physical disability and mortality. Sarcopenia often coexists with obesity. To fully understand the effect of obesity on mortality in the elderly it is important to take muscle mass into account. The evidence suggests that sarcopenia with obesity may be associated with higher levels of metabolic disorders and an increased risk of mortality than obesity or sarcopenia alone. Efforts to promote healthy ageing should focus on preventing obesity and maintaining or increasing muscle mass.6

Other conditions associated with obesity include coronary artery disease, sleep apnoea, congestive cardiac failure, rheumatoid arthritis, osteoarthritis and hypertension.

1. James PT, et al. Obes Res 2001; 9 Suppl 4: 228S–233S
2. Nanchahal K, et al. Int J Obes 2005; 29(3): 317–23
3. https://www.lookaheadtrial.org/public/home.cfm
4. http://onlinelibrary.wiley.com/doi/10.1038/oby.2011.230/full
5. Sjöström L, et al. Lancet 1998; 352: 167–72
6. Wannamethee SG, et al. Proc Nutr Soc 2015; 27: 1–8

Supportive and Palliative Care in Primary Care

Dr Ken O’Neill, General Practitioner, Midlock Medical Centre, Glasgow

The publication Living and Dying Well: a national action plan for palliative and end of life care in Scotland was the outcome of an extensive process of collaboration across Scotland. It was published in 2008 and had two key principles: 

  • A person-centred approach to care and care planning 
  • Importance of communication, collaboration and continuity of care.

The report also aimed to ensure early identification of palliative care needs, holistic assessment with the patient and carer, as well as co-ordination and delivery of care.1 It stated that diagnosing dying is seldom easy, but increasing clinical expertise is available in this area and there is increasing awareness that recognition and agreement by the healthcare team that a patient is entering the dying phase allows the planning and implementation of appropriate care.

The report recommended the use of recognised tools to facilitate the assessment and review of those with palliative and end of life care needs. This included the use of an integrated care pathway such as the Liverpool Care Pathway (LCP) for the Dying Patient in the last days of life.2

Developed from a model of care successfully used in hospices, the LCP is a generic approach to dying. It was intended to ensure that uniformly good care was given to everyone thought to be dying within hours or within two-three days whether in hospital, a nursing home or in their own home. Because of substantial criticism of the LCP in the media and elsewhere, Norman Lamb MP, Minister of State for Care Support, asked Baroness Julia Neuberger to chair a panel to review the use and experience of the LCP in England, to be kept independent of Government and the NHS. The review made 44 recommendations, including the phasing out of the LCP to be replaced by individual care plans for the dying.2

There is still a lot of work to be done to improve end of life care in the UK. The recent report Dying Without Dignity from the Parliamentary and Health Service Ombudsman said that there is potential to improve the experience of care in the last year and months of life for approximately 355,000 people.3

It also stated that there is a need for the NHS to get better at recognising that people are dying, making sure that symptoms are properly controlled, communicating with people, their families and each other, providing out of hours services and making sure that service delivery and organisation help people to have a good death.3  

New national guidelines on palliative care were published last year for the NHS in Scotland, which included a ‘key’ focus for healthcare professionals to consider the concerns and expectations of the patient, their family and informal carers. Open communication between the patient, family and health professionals in the days and weeks prior to someone dying, sharing feelings and fears, and building on trust and mutual confidence are of ‘paramount importance’, the document states.4

One way to achieve this could be through anticipatory care planning (ACP) as this can improve the quality of care and reduce the risk of medication harm. ACP encourages people to adopt a ‘thinking ahead’ approach and to have greater control and choice by planning for what their preferred support and care intervention would be in the event of a future flare-up or deterioration in their condition or a carer crisis.

1. http://www.gov.scot/resource/doc/239823/0066155.pdf

2. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/212450/Liverpool_Care_Pathway.pdf

3. http://www.ombudsman.org.uk/__data/assets/pdf_file/0019/32167/Dying_without_dignity_report.pdf

4.     http://www.palliativecareguidelines.scot.nhs.uk/ 


Dementia: where are we up to? 

Professor John O’Brien, Professor of Old Age Psychiatry, University of Cambridge

Dementia is defined as global cognitive decline leading to functional impairment. There are many causes, most commonly Alzheimer’s disease, vascular dementia, Lewy body dementia and fronto-temporal dementia.

It represents a huge economic burden to the NHS (>£20 million per year), and each dementia case costs five times more than each cancer case in terms of NHS and social care costs. There are currently estimated to be over 820,000 cases in the UK alone with numbers set to double in the next 30 years.

First described by Alois Alzheimer in 1907, Alzheimer’s disease is the most common cause of dementia. It is a degenerative disease with gradual onset. Usually memory is affected first followed by loss of other cognitive functions and variable behavioural and psychiatric features (depression, loss of interest, delusions and agitation). At post-mortem it is associated with profound brain shrinkage and focal deposits of amyloid and tau protein (plaques and tangles).

The NINCDS/ADRDA Criteria for Alzheimer’s disease required dementia (two or more cognitive deficits including memory impairment), impairment in social/occupational functioning, progressive deterioration, no disturbances of consciousness, onset between age of 40–90 years and is not accounted for by another brain disorder.

These criteria were developed over 30 years ago and require the presence of dementia and significant impairment in social or occupational functioning, so do not allow very early diagnosis. 

It is important to diagnose early to exclude remedial causes, provide certainty, allow understanding and provide information about the illness and prognosis and to give appropriate disease specific management. It also allows planning for future, early access to services/benefits, medico-legal issues as well as wider benefits such as community resources, planning and access to disease modifying drugs.

Criteria proposed for diagnosis of very early Alzheimer’s disease suggest requirements for  progressive change in memory function reported by patients or an informant over more than six months, objective evidence of significantly impaired episodic memory and at least one of the following biomarkers to be present:

  • Medial temporal lobe atrophy on MRI
  • Bilateral temporal/parietal hypometabolism on PET/SPECT
  • Amyloid positive PET imaging
  • Abnormal CSF biomarkers (reduced A beta 42, raised tau/p-tau).

Trials have been conducted to see whether  cholinesterase inhibitors (ChEIs) currently approved for symptomatic treatment of mild to moderate Alzheimer’s disease, can prevent progression from mild cognitive impairment to Alzheimer’s disease. Unfortunately these studies have uniformally been negative.1

Another study found benefit of continuing ChEIs in patients with moderate or severe Alzheimer’s disease. Continued treatment with donepezil, as opposed to switching to placebo, was associated with cognitive benefits that exceeded the minimum clinically important difference and with significant functional benefits over the course of 12 months.2

Prevention though is clearly better than cure, but it is likely you need to start in mid life. Studies looking at prevention of dementia have found that the following may possibly be helpful, though more evidence is needed: physical exercise, mental stimulation, red wine, curry, a Mediterranean diet and modifying vascular risk.

1. Raschetti R et al. PLoS Med 2007; 4: e338

2.     Howard R, et al. N Engl J Med 2012; 366: 893–903 

 

Managing diabetes in the elderly patient 

Professor Sarah Wild, Professor of Epidemiology and Honorary Consultant in Public Health, NHS Lothian

Older people with diabetes represent a heterogeneous group of people with recent onset and a longer-term history of diabetes. Current guidelines do not distinguish between sub-groups, partly because of limited availability of evidence from randomised controlled trials.  

In the Scottish Diabetes Survey 2014, there were 27 new cases of type 1 diabetes in people over the age of 69 years of age and this was 3.1% of the 883 new cases in total. This was in contrast to 4,217 cases of type 2 diabetes in people aged over 69 years (26% of the 16,379 new cases in total). There was also a greater prevalence of type 2 diabetes in men compared to women.1

A systematic review found that type 2 diabetes diagnosed at 60–69 years of age was associated with 40% higher mortality compared to an age matched population without diabetes. However, the increased mortality was 13% higher among men and 19% higher among women and was no longer statistically significant among people whose diabetes was diagnosed after 69 years of age.2

In addition to vascular disease, diabetes is associated with substantially increased risks of premature death from several cancers, infectious diseases, external causes, intentional self-harm and degenerative disorders and is independent of several major risk factors.3

Similar treatment of hyperglycaemia and other cardiovascular risk factors may be warranted for some older people with diabetes as for younger populations. The aim of treatment is to manage symptoms and reduce risk of complications while avoiding hypoglycaemia and hypotension. Drug interactions due to polypharmacy are even more important in the frail elderly age group. As there is limited trial data in older age groups, treatment and targets should be individualised, using similar treatments to younger populations.4

The appropriate HbA1c target in fit older patients who have a life expectancy of over 10 years should be similar to those developed for younger adults (<7.0%).4 A target HbA1c of 7.0–7.9 % (median of 7.5%) may be safer than a lower target for patients with long-standing type 2 diabetes who are at high risk for cardiovascular disease. The goal should be somewhat higher (≤8.0%) in frail older adults with medical and functional comorbidities and in those whose life expectancy is less than 10 years.

For cardiovascular risk management, smoking cessation should be promoted along with physical activity. Treatment for dyslipidaemia and hypertension should be initiated as there is evidence of benefit for people over 80 years of age. Aspirin should also be prescribed for secondary prevention. Goals for risk factor management (hypertension, hyperlipidemia) should be adjusted based upon older patients’ life expectancy, comorbidities, cognitive status and personal preferences.4

A study looked at diabetes self-management programmes for older adults and found that they demonstrate a small reduction in HbA1c , lipids and blood pressure. These findings may be of greater clinical relevance when offered in conjunction with other therapies.5 More research is necessary to determine the mechanics through which diabetes self-management programmes improve clinical outcomes, either through education, patient engagement, goal-setting or treatment/medication adherence.

To conclude, the prevalence of diabetes is increasing. This is because of increasing survival. Diabetes is still associated with increased risk of cardiovascular disease and cancer as well as physical and mental comorbidity. Glycaemic control is required to avoid effects on cognition. Data on treatment and targets is limited so treatment should be individualised.

1. http://diabetesinscotland.org.uk/Publications/SDS2014.pdf

2. Barnett KN, et al. Age Ageing 2006; 35(5): 463–68

3. http://www.nejm.org/doi/full/10.1056/NEJMoa1008862

4. www.uptodate.com/contents/treatment-of-type-2-diabetes-mellitus-in-the-older-patient

5.     Sherifali D, et al. Diabet Med 2015 doi: 10.1111/dme.12780