Undiagnosed diabetes in older people: prevalence, risks and solutions

Advanced nurse practitioner and Queen’s Nurse, Yemi Osho is passionate about the prevention and management of diabetes. The founder and CEO of non-for-profit organisation Diabetes Action CIC, Ms Osho has a family history of diabetes, while her work as advanced nurse practitioner in the community and primary care means that over the years she has seen “the impact of diabetes, in its different shapes and forms, on people’s lives”.

“Diabetes is a condition that affects every organ of the body,” she says. As people age they become more at risk of type 2 diabetes, which is why “it is so important that practitioners working with older people make them aware of the risk factors and educate them about taking preventative measures,” she says.

With cases of diabetes on the rise, it is even more vital for practitioners to champion its prevention, early diagnosis, and management.Recent analysis from the charity Diabetes UK shows that almost 4.1 million people are now living with a diagnosis of any type of diabetes, and that there are an additional 850,000 living with type 2 diabetes, who are yet to be diagnosed.¹

Cases of diabetes in the UK have almost doubled in the past 15 years,¹ and the charity predicts that about 5.3 million people are expected to be living with the condition by 2025.²

Risk factors for type 2 diabetes include age, ethnicity and a family history of the condition. Risk increases over the age of 40 if you’re white, and over the age of 25 if you’re African-Caribbean, Black African, or South Asian.

Diabetes and risk factors

Anyone supporting older people’s care should be aware that this population is particularly at risk of developing the condition. A decrease in insulin production, and a lack of physical exercise linked to obesity, are just some of the factors that lead to type 2 diabetes as we grow older.

According to the British Geriatrics Society (BGS), diabetes is the most common metabolic long-term condition in older people and is characterised by a high rate of vascular complications and subsequent disability, frequent hospital admissions, and increased institutionalisation.³

Half of all people with diabetes in the UK are aged over 65 years and a quarter are over 75, meaning 10% of people aged over 75 years and 14% of those aged over 85 years have diabetes.⁴

Up to 27%of residents in older people’s care homes are likely to have diabetes.⁵ “With a growing number of older people and an increased risk of type 2 diabetes with age, the need is ever more pressing to ensure a good standard of diabetes care for a group of people who are vulnerable, with complex needs,” says Dan Howarth, head of care at Diabetes UK. If not managed properly, diabetes can lead to serious health complications like heart disease, stroke, sight loss, and kidney damage.

Diabetes care: challenges for older people

Diabetes care for older people is particularly challenging for a number of reasons: patient frailty, especially in the very old, influences their tolerance of standard therapies, says the BGS.³

“Often they have impaired ability to self-care and self-medicate and the requirement of education and support for carers is often omitted from routine service provision.

“As with other branches of geriatric medicine, management of multiple comorbidities including cognitive and mood dysfunction are particularly challenging in patients with diabetes, which is associated with particularly high rates of such impairments,” the BGS says.

Prediabetes, diet and exercise

Older patients who are identified as being at high risk of type 2 diabetes or ‘prediabetes’ can be advised that, many people can prevent or delay its development, through getting support to follow a healthy diet and be active. “Where deemed appropriate, if you are overweight or living with obesity, losing just five per cent of your body weight can significantly reduce your risk of developing the condition,” says Mr Howarth.

Older people, including those with frailty, have been shown to benefit from light resistance and balance training. “Exercise to build limb strength and flexibility for those who are housebound and confined to a bed or chair can be taught by a physiotherapist and supported by carers,” says Mr Howarth.

This January, Ms Osho set up a 12 month project supported by the Queen’s Nursing Institute (QNI), aimed at reducing the development of diabetes in those with prediabetes and/or the reversal of confirmed diagnoses of diabetes using a digital platform to effect behavioural change. “The project looks at how to use lifestyle modifications to prevent and reverse type 2 diabetes,” says Ms Osho.

Interim findings reveal that through a programme of diet, mindfulness, physical exercise and general education about diabetes (delivered weekly virtually via Zoom), more than 50% of the 35 study participants have lost 5-7% of their baseline weight. Furthermore, 90% of participants have indicated that they have improved their diet and made changes to their lifestyle.

This has been achieved through simple interventions, such as healthy meal demonstrations, advice about cutting down on carbohydrates, a low-fat diet, an increase in vegetables and fruit consumption, and increasing daily physical exercise up to 30 minutes a day. Gardening is also recommended. Ms Osho adds that she would like the programme to be “rolled out across the country”.

Signs, symptoms and missed diagnosis

Symptoms of diabetes include frequent urination especially at night, being very thirsty, tired and losing weight without trying to. Skin infections, thrush, incontinence, blurred vision, and wounds that are slow to heal are other signs of this condition.

While the symptoms of type 1 diabetes can come on very quickly, symptoms of type 2 diabetes often develop much more slowly, and can sometimes go undetected. Not everyone has obvious symptoms of type 2 diabetes, meaning a person can live with the condition for up to 10 years before diagnosis, Mr Howarth says.

A lack of diabetes diagnosis is also due to “an absence of symptoms in insidious onset, a lack of awareness, and attribution to other causes”, says Patrick English, a consultant in diabetes, endocrinology, acute and general internal medicine, at Derriford Hospital, Plymouth. Older people may think their symptoms are simply due to ‘old age’ for example. During the pandemic, some people may have been reluctant to seek medical help, thinking that their symptoms were not ‘serious’ enough, says Mr Howarth. Recent research found that up to 60,000 type 2 diabetes diagnoses may have been missed or delayed during the pandemic.⁶

Dr English points out that in undiagnosed diabetes “people may not have any symptoms or specific signs, so it will only be picked up if they are screened because they were high risk due to their other risk factors”. He advises that anyone with vascular disease, heart attack, stroke or peripheral arterial disease should be screened for diabetes.

Screening to address undiagnosed diabetes

Dr James Boorer, a GP partner and clinical network director at Pathfields Medical Group, Plymouth, says that to help address the issue of undiagnosed diabetes his practice has developed “a targeted, opportunistic and proactive diabetes screening programme based purely on readily available biometrics, age and BMI. He says the programme is “easy to use, and time efficient”.

Data was pulled for 18,000 patients at the practice, focusing on those aged over 20 who had type 2 diabetes, pre diabetes or have had screening for diabetes with HbA1C during the preceding two or five years. Data was stratified by age and BMI to help plan a targeted screening programme, which revealed that peak missed diagnoses was in the 50-60 age bracket with patients of a BMI between 25-30.

Dr Boorer believes practitioners should proactively case find diabetes and pre-diabetes through offering an HbA1C to any adult over 50 every few years. “Early identification of impaired glycaemic control gives patients the option of making lifestyle changes, and early detection of diabetes helps reduce pancreatic damage, making a person’s blood sugars easier to control in the medium to long term. This has benefits for both the patient and the practice who will be assessed against the glycaemic control target for QOF,” he says.

Getting tested, diagnosed and being given the right treatment as soon as possible is vital, and can reduce the chances of developing serious complications of diabetes, says Mr Howarth. Practitioners can provide information about diabetes sensitively to their patients, signposting them to educational resources on the Diabetes UK website.

Educating about risks

They can also educate older people about the risks of developing type 2 diabetes, signposting them to Diabetes UK materials. Social prescribers in general practices can also help to “reach out” to older patients to raise awareness about diabetes symptoms and prevention, says Ms Osho.

The role of the practitioner is “critical in the prevention of diabetes, irrespective of whether you’re a specialist in this area. We should all be encouraging older people to be cognisant of the risk factors, working with them to help prevent this condition, and supporting them to lead healthy lives.”

The Queen’s Nursing Institute (QNI) has opened two more funding opportunities for project leaders next year.

References

1. Diabetes UK. (2021) Diabetes diagnoses double in the last 15 years https://www.diabetes.org.uk/about_us/news/diabetes-diagnoses-doubled-prevalence-2021. Accessed 11/10/21
2. Diabetes UK. (2020) Number of people with diabetes reaches 4.8 million. https://www.diabetes.org.uk/about_us/news/diabetes-prevalence-2019. Accessed 11/10/21
3. British Geriatrics Society (2009) Diabetes Good Practice Guide. https://www.bgs.org.uk/resources/diabetes#:~:text=Recommendations-,Introduction,years per cent20have per cent20diabetes per cent20(1) Accessed 11/10/21
4. Croxson SC et al. The prevalence of diabetes in elderly people. Diabet Med 1991; 8 (1): 28-31
5. Sinclair AJ, Gadsby R, Penfold S et al (2001) Prevalence of diabetes in care home residents. Diabetes care 2001; 24(6) 1066-68
6. Carr MJ. Impact of COVID-19 on diagnoses, monitoring, and mortality in people with type 2 diabetes in the UK. Lancet 2021; 9(7): 413€“15
7. https://www.thelancet.com/journals/landia/article/PIIS2213-8587(21)00116-9/fulltext