Type 2 diabetes in the older, frailer patient

In a symposium sponsored by Boehringer Ingelheim, Dr Sarah Jarvis and Dr Amrit Lamba discussed the challenges, consequences and management of type 2 diabetes in the older patient.

Although type 2 diabetes is beginning to increasingly affect people of a younger age, there is no question that type 2 diabetes is more common in older adults. Dr Jarvis explains that older and frailer patients are at a higher risk of getting diabetes and suffering from complications of the condition.

There are various challenges facing the ageing population with type 2 diabetes, including:

  • A limited choice of medication
  • Presence of comorbidities
  • Increased risk of falls
  • Polypharmacy
  • Risk of hypoglycaemia
  • Propensity for adverse events due to comorbities

Hypoglycaemia carries particular risks for those who are frail, particularly in the elderly as well as those with long duration diabetes, irregular eating habits, prior hypoglycaemia and hypoglycaemia unawareness.

Despite these risks, hypoglycaemia can be difficult to recognise in the old and frail population. This is often because symptoms are non-specific or a-typical (unsteadiness, light-headedness), or misdiagnosed or misinterpreted (stroke, vertigo, dementia). This is further complicated if the patient is unaware of the symptoms associated with hypoglycaemia or has dementia and is unable to communicate their feelings and symptoms.

There are also various side effects associated with drug treatment for type 2 diabetes, which can be problematic for the older patient. In fact, over 35% of the elderly population are prescribed SU or insulin, which can both cause significant risk of hypoglycaemia.

Dr Jarvis highlights this tendency to over-treat patients with drugs, and stresses that healthcare professionals should always assess the frailty of their older patients with type 2 diabetes, and be aware of the potential need to adjust glycaemic targets.

Dr Lamba affirms this idea and emphasises the importance of adopting an individualised approach to diabetes care, which is tailored to personal circumstances and preferences.

This is particularly important for Hba1c targets, as he explains older, fitter adults should have different targets than those who have severe health problems or frailty due to life expectancy and other risks.

Dr Lamba recommends the use of DPP-4 inhibitors as a second and third-line treatment option. He particularly recommends Linagliptin (Trajenta), after a clinical trial found that more patients aged 75 and over taking the medication achieved their Hba1c target without hypoglycaemia and weight gain. He also recommends the drug as a means of simplifying treatment, as a 5mg once daily should always be given irrespective of age, disease duration, ethnicities, background therapy, hepatic function and renal function.

 

Could a high fibre diet help to prevent/manage type 2 diabetes?

A high fibre diet is known to have many health benefits, including maintaining bowel health, lowering cholesterol levels and controlling blood sugar levels. And now, clinical research is increasingly showing how a high fibre diet can help to prevent or manage type 2 diabetes.

In a highly anticipated lecture, Dr Denise Robertson, a Reader in Nutritional Physiology from the University of Surrey, spoke about the ways in which fibre can improve factors that are important in managing diabetes and avoiding its complications, like Hba1c and blood fats.

Throughout the discussion, Dr Robertson highlights the importance of dietary fibre for a healthy gut microbiome. She explains how the bacteria in our gut play a very important role in breaking down fibre and producing short chain fatty acids. Short chain fatty acids can improve insulin sensitivity and reduce internal fat build up.

A high fibre diet can therefore help to maintain a healthy weight while also lowering your risk of cardiovascular disease. For these reasons, high-fibre diets have been linked to lower mortality rates in people with all types of diabetes.

However, if our gut bacteria don’t have enough fibre, it will break down protein instead. By-products of this process can cause a ‘leaky gut’ which in turn can lead to insulin resistance and type 2 diabetes.

It is therefore extremely important for everyone, but particularly those with type 2 diabetes, to get enough fibre. But this can be hard to do, with the recommended fibre intake for adults sitting at 30-35g of fibre per day. Dr Robertson discusses how resistant starch could be utilised by people with type 2 diabetes in a bid to reduce blood sugar levels.

Resistant starch is a form of starch that acts like fibre. It isn’t broken down in the gut, so the glucose it’s made up of won’t be absorbed into the blood, which means it shouldn’t raise blood glucose levels. It is found naturally in foods like wholegrains and green bananas and can be altered so that it has higher levels of this type of starch.

With funding from Diabetes UK, Dr Robertson is now researching whether swapping normal starch with resistant starch could help people with type 2 diabetes to manage their condition. The project is currently still underway, but you can read more about it here.

In the meantime, Dr Robertson says the main challenge is to work out simple ways to encourage the general population to eat more fibre, making sure it is affordable and accessible to everyone.

 

New programme to help people with eating disorders and type 1 diabetes

Research suggests that having diabetes doubles your risk of having an eating disorder, with 30% of women and 7% of men with type 1 diabetes reporting they have experimented with manipulating and restricting insulin in order to control their weight.

 However, a recent systematic review demonstrated that at present, we do not have an effective intervention method for type 1 diabetes and eating disorders that also addresses glycaemic control. 

In a lecture examining this issue, Marietta Stadler discusses a new intervention, called STEADY (safe management of people with type 1 diabetes and eating disorders study). The programme aims to support people to reduce dangerous eating behaviours, including skipping or reducing insulin and the distress associated with living with an eating disorder. 

The programme works collaboratively with doctors, nurses, psychologists and dieticians, as well as people with type 1 diabetes themselves, in order to put people with lived experience at the very centre of development.

A toolkit, designed to be tailored to the individual’s needs, was designed over six workshops and draws on cognitive behavioural therapy (CBT) and diabetes education.

STEADY will now be tested within a small group of people with type 1 diabetes and an eating disorder, in order to compare how efficacy of the toolkit compared to regular care. STEADY will then be developed and refined dependent on the feedback provided from the participants in the trial.

If successful, STEADY will be tested in a larger study, with the hope of offering the intervention on the NHS in the future.

 

New evidence of link between type 2 diabetes and dementia

During a session on insights from real world data, Dr Eszter Vamos of Imperial College London presented new findings that could help explain how type 2 diabetes and dementia are linked.

It is well known that having type 2 diabetes can increase a person’s risk of developing dementia, however, why this is has not been proven. With funding from Diabetes UK, Dr Vamos set out to discover whether factors affecting heart health in people with type 2 diabetes could influence their risk of developing dementia.

Certain cardiometabolic factors, such as high blood sugar levels, blood pressure and cholesterol, are known to damage blood vessels and lead to serious cardiovascular problems, such as heart attacks and strokes. Some experts think that these factors can also affect brain health, which could play a role in developing dementia in people with type 2 diabetes.

In order to test this hypothesis, Dr Vamos and her team analysed data from 227,580 people with type 2 diabetes and found around 10% went on to develop dementia over a 20-year period. The team then looked at whether the participants experienced any changes in cardiometabolic factors and body weight in the 20-year period prior to their dementia diagnosis, and compared these to those who didn’t develop the condition.

The team discovered that changes in blood pressure differed between those who did develop dementia and those who didn’t. Among those who developed the condition, the team found higher blood pressure readings from 11-19 years before their diagnosis. This declined at a much quicker rate closer to their diagnosis, compared to those who didn’t develop dementia.

Furthermore, blood sugar and cholesterol levels were generally higher across the 20-year period among those who went on to develop dementia. A decline in bodyweight was also found in people who developed the condition, starting from 11 years before the diagnosis. Again, this decline was much steeper in those who developed dementia compared to those who didn’t.

Dr Vamos stresses that this information can be used to help lower the risk of developing dementia in those with type 2 diabetes. She highlights the importance of supporting people with type 2 diabetes to manage their blood pressure, cholesterol and glucose levels as soon as they are diagnosed in order to reduce this risk as much as possible.

Dr Elizabeth Robertson, Director of Research at Diabetes UK said: “These crucial findings have uncovered how type 2 diabetes may contribute to dementia onset. Changes in the body that lead to dementia occur years before symptoms arise, and for the first time, researchers have uncovered a pattern of changes in people with type 2 diabetes that are associated with dementia.

“Knowing which factors contribute to the development of dementia, and when they have the biggest impact, is vital in giving people with type 2 diabetes the best possible care to prevent or delay dementia onset.”

The researchers will go on to investigate whether diabetes-related complications such as eye and kidney problems could be linked to dementia risk. They will also examine whether risk factors for type 2 diabetes that we can’t control (such as age and ethnicity) could work alongside cardiometabolic factors to determine dementia risk.

 

Care homes, Covid-19 and diabetes care

During a lecture on the topic of delivering diabetes essential care needs during Covid-19, Samuel Seidu discusses the issues surrounding caring for those in care homes with type 2 diabetes, and how caring for these patients has been further complicated by the pandemic.

Dr Seidu begins by explaining that we are seeing an increasing number of people with diabetes as our population is living longer than ever before. The increasing age of the population means we are seeing many people with type 2 diabetes who have other co-morbidities, and are being over-treated with medication.

Dr Seidu states that in his experience, the older patient is more concerned with their quality of life rather than its longevity. And so, care workers should adopt an individualised approach when managing diabetes care.

He suggests that normal care is appropriate for those who are functionally independent. However, for those who are functionally dependent, particularly those who are in care homes, care should focus on improving quality of life. Dr Seidu suggests a focus on patient safety, reducing hospitalisation and the relaxation of glycaemic goals, while encouraging the patient to avoid hypoglycaemia and hyperglycaemia.

If a patient is at the end of their life, targets should become less important and the patient should simply be encouraged to avoid hypo and hyperglycaemia. The focus should be on providing the best quality of life possible, by keeping the patient hydrated and comfortable, and avoiding the use of HbA1C targets.

Across the UK, there has been a spike in hospitalisations with patients with hyperglycaemia which has been especially difficult to handle during the pandemic. Dr Seidu therefore summaries support advice for care home managers who may need help with this issue. He suggests:

  • Equip your care home with sufficient capillary blood glucose (sugar) strips (with a metre), and strips for ketones if possible
  • Have available a hypoglycaemia treatment kit plus intramuscular (IM) glucagon, and replenishing this every time it has been used
  • Maintain a written record of resident’s blood glucose, medications, temperature, food chart and body weight
  • Have a daily foot care surveillance plan in place for all residents with diabetes to ensure good foot health
  • Ensure good communication with your local diabetes specialist nurses, the community nursing service and with your primary care team who will provide you and your staff with support and guidance wherever possible.

Dr Seidu emphasises the importance of alerting healthcare professionals to the fact Covid-19 has heightened the risk of hospitalisation, developing severe disease, and death for people with diabetes. This is particularly acute for those who have co-morbidities (especially cardiovascular and respiratory disease) diabetes complications, are frail, are being treated with steroids and who have a life expectancy of less than 6 months.

For this reason, Dr Seidu states the main objective for diabetes care in care homes is to minimise morbidity and mortality, and his team have developed guidelines in order to aid practitioners in order to achieve this goal.

The Eden Cares e-programme aims to improve knowledge and confidence for those caring for service users living with diabetes, helping to improve standards of care and reduce hospital admissions from hypos, illness and foot problems.

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