Diabetes

INTRODUCTION:

We now face an increasing challenge of managing type 1 diabetes (T1DM) in older people. 3% of patients with T1DM are over 80 years old - a number that is set to rise over the coming decades. Diabetes is a risk factor for frailty, and advanced age comes with a higher incidence and severity of comorbidities affecting patients’ ability to manage their treatments, such as arthritis or dementia. A recent systematic search in England highlighted the scarcity of data surrounding this, finding no articles specifically researching frailty in older adults with T1DM.

CASE STUDY:

●90-year-old lady with T1DM

●Living alone with mild frailty

●Mild cognitive impairment

Despite living alone and being independent with many of her activities of daily living, her mild cognitive impairment made her unable to manage her insulin safely. Consequently, she had recurrent hospital admissions due to labile blood sugars. Local services (even in central Manchester) offer a maximum of two visits each day, which is not a safe insulin regime for most patients living with T1DM. As family were not available to support, she had prolonged inpatient hospital stays and ultimately had to explore 24-hour nursing care, despite being otherwise independent.

The case provides a poignant illustration of an issue which is only going to become more frequent as the early users of insulin now reach older age.

Introduction

One in four Care Home (CH) residents have diabetes, making diet crucial for controlling glucose levels (GLs). Continuous blood glucose monitoring (CGM) now offers deeper insights into GL fluctuations. Diabetes in severe frailty is often overtreated, particularly with insulin, posing risks such as hypoglycemia, avoidable hospital admissions, and labour-intensive clinical supervision. While protein and vegetables can slow glucose absorption, dietary advice for CH residents typically emphasizes carbohydrates and may not be tailored to their frailty. This study investigates the impact of modifying protein intake in insulin-using diabetics to improve glycaemic control.

Method

A small pilot study assessed if protein-rich foods (e.g. eggs, peanut butter) given for breakfast stabilise GLs throughout the day. Eight diabetic CH residents using insulin were randomly selected over four months. A diabetic frailty pharmacist monitored GLs with the CGM device (Freestyle Libre) and analysed GLs after a protein-rich breakfast. Descriptive analysis and t-tests were conducted using R before and after the food intervention, and ANOVA was used to analyse significant differences in GLs.

Results

Six out of eight patients showed statistically significant reductions in GL spikes, sustained throughout the day. For the remaining two patients, the food intervention helped maintain target GLs. This led to the discontinuation of insulin in one patient, and in the second, problematic frequent hypoglycemia was mitigated by the food intervention. Clinical decisions on patient safety influenced outcomes for these two patients but were not excluded from analysis.

Conclusion

Six of the eight residents given additional protein at breakfast showed significant GL reductions, leading to decreased insulin dosing and simpler regimes. Carers reported improvements in mood, sleep, and energy levels anecdotally. A holistic dietary approach in managing diabetes in CH residents, emphasizing increased morning protein intake, should be considered to enhance GL control and allow deprescribing. A larger study is planned.

Introduction

16% of adults over the age of 75 years old have a diabetes diagnosis¹ and 1 in 6 hospital beds in the UK is occupied by someone with diabetes². Keeping diabetic patients safe during hospital stays is a priority, and in 2023 the Joint British Diabetes Societies (JBDS-IP) published guidance on managing Diabetes in Frail inpatients³. An audit at our hospital later that year found that 70% of Capillary Blood Glucose (CBG) testing was non-compliant with guidelines resulting in unnecessary patient intervention, use of staff time and consumption of non-recyclable resources. The main aim of our project was to improve compliance with these guidelines and establish potential time and cost saving resulting from this.

Method

Focus on medical education with teaching sessions, information cards for lanyards and prompt posters around the inpatient ward areas. Worked with electronic prescribing team to establish use of an order-set for CBG testing to allow medical team to accurately communicate with nursing colleagues.  In addition, engaged nursing staff via ward bulletins and observed CBG testing on ward.  

Results

There was a reduction in CBG frequency for all diabetic patients of 27.9%. We identified that those patients with diet-controlled diabetes were commonly over tested, and in this sub-group the number of CBG tests performed was reduced by 51.9%. Average time for CBG testing was 147 seconds with anticipated cost savings from staff time and equipment use.

Conclusions

The use of default four times a day CBG testing results in unnecessary intervention in our frail inpatients. Through education and use of electronic systems we can reduce these interventions based on national guidelines, but more work needs to be done. Reducing CBG testing reduces use of healthcare assistant time, costly non-recyclable materials and overall reduces unnecessary patient intervention.

References

1. NHS England (2023) Health Survey for England, 2021 Part 2 < https://digital.nhs.uk/data-and-information/publications/statistical/health-survey-for-england/2021-part-2/adult-health-diabetes#:~:text=Prevalence%20of%20doctor%2Ddiagnosed%20diabetes%2C%20by%20age%20and%20sex&text=Prevalence%20increased%20with%20age%2C%20from,adults%20aged%2075%20and%20over.> Accessed 8/11/24
2. Watts.E, Rayman. G (2018) Diabetes UK: Making Hospitals safe for people with diabetes. Available at < https://www.diabetes.org.uk/resources-s3/2018-12/Making%20Hospitals%20safe%20for%20people%20with%20diabetes_FINAL%20%28002%29.pd> Accessed 24/07/2024
3. JPDS-IP 2023: Inpatient care of the Frail Older Adult with Diabetes. Available at <JBDS_15_Inpatient_Care_of_the Frail_Older_Adult_with_Diabetes_with_QR_code_February_2023.pdf (abcd.care)>

Introduction

There is a high prevalence of diabetes in patient populations undergoing Vascular Surgery. Appropriate and responsive management of diabetes in the perioperative setting is critical for reducing morbidity and perioperative complications e.g. diabetic emergencies, poor wound healing, delirium. The aim of this project was to review current practice for perioperative management of older people with diabetes against guidance outlined by the Centre for Perioperative Care (CPOC) on a regional vascular surgery ward.

Methods

A retrospective observational evaluation design was conducted from May-June 2024. Data were collected for patients all aged >60years with a pre-admission diagnosis of diabetes admitted to the ward in this period. Standards of care were derived from CPOC guidance. Data were collated and analysed using descriptive statistics.

Results

28 patients were included (20 male, 8 female). The mean age was 72 years. 86% (n=24) had Type 2 Diabetes and the remainder had Type 1. 82% (n=23) were emergency admissions and 93% (n=26) had surgery at some point in their admission. Only 38% (n=10) were prioritised as first patient on operating lists. There was mixed concordance with guidance on administration of oral diabetes medication perioperatively. However, all patients on SGLT2 inhibitors had these withheld appropriately. There was inconsistency in the frequency of capillary blood glucose (CBG) monitoring with variable responses to episodes of hypo and hyper-glycaemia and variable rate insulin prescriptions were not consistently utilised when indicated.

Discussion

This study has highlighted several areas for improvement of the perioperative management of diabetes in older vascular patients. The next stage of this work will involve a multi-component quality improvement initiative to provide education and support for all healthcare professionals involved in caring for this patient group.

Background: Care home residents form a large number of admissions to Emergency Departments (ED) across the UK. Over an 8-month period we reviewed care home admissions to ED to provide further insight on these admission types and identify ways to improve care.

Method: All patients with a frailty score of 6 or more admitted from care homes to Chelsea and Westminster Hospital ED between 1^st June 2022 and to 31^st January 2023 were included. Data was collected from the hospital computer system and London Ambulance Service (LAS) attendance sheets. Information collected included; care home the patient resided at, LAS attendance times at scene, if discussion with a Health Care Professional (HCP) prior to attendance had occurred, Presenting Complaint (PC) and Length Of Stay (LOS). We then sub-categorised data accordingly.

Results: There were 180 patient admissions from 34 care homes. 34% (N=61) of LAS attendances occurred during normal working hours (9am-5pm Monday- Friday) with only 43% (N=26) of patients being discussed with an HCP prior to admission. Of these, 30% (N=18) were discharged <24hrs and subjectively 39% (N=7) did not require ED admission. Out of hours (OOH) attendances formed 66% of admissions, with most common PC being fall (33%, N=59) followed by respiratory issues (22%, N=38). Overall admissions accounted for 454 bed stay days.

Conclusion: Discussing patient’s with an HCP prior to contacting LAS would reduce ED admissions alongside accessing rapid response team more frequently. Expanding an HCP accessible service OOH would be necessary to facilitate this and implementing a frailty telephone service from Chelsea and Westminster may be one solution. Focusing on individual care homes and working with community teams form the next steps in this review.  

Older people with diabetes are often admitted with falls, dizziness or confusion that may stem from undiagnosed episodes of hypoglycaemia. We examined the use of a 10-day period of round the clock glucose monitoring (CGM), to detect hypoglycaemia in older people with diabetes with symptoms potentially related to hypoglycaemia. 

Methods 

Population: Age 75 years and older, on sulfonylureas and/or insulin, presenting to hospital with a fall and/or symptoms suggestive of unrecognised hypoglycaemia. 

Design: Single-centre, observational study (no change to standard diabetes care). Intervention: 10 days of CGM with Dexcom G6 sensor and Android app on smartphone to continuously transmit data. 

Primary outcomes: Proportion of participants with captured hypoglycaemia; within that group, time spent in the hypoglycaemic range (Battelino T, Danne T, Biester T, et al. Diabetes Care. 2019;42(8):1593-603.). 

Secondary outcomes: Overall time in range; emergency department re-attendances and/or hospital re-admissions for falls, fractures, heart attacks, ischaemic strokes and death within 30 days. REC IRAS project ID: 301286. 

Results 

26 eligible participants of which 13 consented to participate. At the time of writing, nine participants (mean age 81 years) completed the study.

There were no reports of pain or skin reactions from the participants.

Hypoglycaemic events were captured in 3 of 9 participants, with two participants suffering >1 hour below 3.9mmol/L. Only 3 participants achieved >50% time in range target (3.9-10.0mmol/L). 

Discussion 

We have detected significant hypoglycaemic episodes in our participants. CGM should be used more widely in older patients with diabetes who present with falls, dizziness or confusion. 

Limitations include issues around data capture due to participants struggling to navigate the mobile phone app. Despite this, all participants felt that CGM was better than finger-prick glucose testing. Future work is needed to explore how CGM can be deployed after acute admissions in this patient group.

Background:

Type II Diabetes Mellitus (T2DM) is a common condition managed by geriatricians. Drugs and treatment goals for T2DM are individualized to patient profile and physician preference. Some diabetic medications are also known to affect appetite and subsequently, nutrition. The authors examined whether there is a correlation between glycemic control and malnutrition in older adults.

Methods:

This cross-sectional study enrolled patients > 70 with T2DM in a teaching hospital in Singapore. Data was collected on age, sex, ethnicity, body-mass index (BMI), function (iADL-impairment), Barthel’s score and cognitive scores (Abbreviated Mental Test), as well as the last glycated hemoglobin (HbA1c) reading. Nutritional assessment was performed using Mini Nutritional Assessment (MNA) screen. Univariate analysis and logistic regression analysis were performed to determine predictors of malnutrition.

Results:

Overall, 135 patients were recruited (57.1% male, mean age 85.6 [6.1] years). 75 patients (56.7%) were classified to have moderate or severe disability by Barthel’s and 19 (14.1%) had a BMI classified as underweight. 76 (56.7%) patients were considered to have good glycemic control (HbA1c < 7%) and 58 (43.3%) were not on any medications. Prevalence of patients with or at risk of malnutrition was high with 105 (77.8%) scoring MNA < 12. On univariate analysis, factors such as age, BMI, Barthel’s score, iADL-impairment and AMT scores were significantly associated with malnutrition. Multivariate logistic regression analysis showed that there was no association between good glycemic control and malnutrition (aOR 0.95, [0.14, 2.47], p=0.467)

Conclusion:

Good glycemic control was not significantly associated with malnutrition after adjusting for confounders. Older adults at baseline have increased risk of malnutrition and more education delivered towards a proper diet.