Diabetes

Introduction: The representation of frailty in type 2 diabetes trials is unclear. This study used individual patient data (IPD) from trials of newer glucose-lowering therapies to quantify frailty and assess the association between frailty and treatment efficacy and adverse events. 

Methods: We analysed IPD from 34 trials of sodium glucose cotransporter 2 inhibitors, glucagon-like peptide-1 receptor analogues and dipeptidyl peptidase-4 inhibitors. Frailty was quantified using a cumulative deficit frailty index (FI). For each trial we assessed the distribution of the FI; interactions between frailty and treatment efficacy (HbA1c and major adverse cardiovascular events [MACE]); and associations between FI and non-completion, adverse events, and hypoglycaemic episodes before pooling results using random-effects network meta-analysis. 

Findings: Trial participants numbered 25,208. Mean age 53.8-74.2 years. Median frailty prevalence (FI>0.24) was 1.9% (IQR 0.8% to 6.1%). There was no heterogeneity in treatment efficacy by FI for MACE or HbA1c in the primary analysis (high uncertainty for MACE). A 0.1-point increase in the FI was associated with adverse events (incidence rate ratio, IRR 1.43, 95% confidence interval 1.34-1.53), treatment-related adverse events (1.35, 1.22-1.50), serious adverse events (2.04, 1.80-2.30), hypoglycaemia (1.18, 1.04-1.34), MACE (hazard ratio 3.02, 2.49-3.68) and early withdrawal (odds ratio 1.45, 1.30-1.62). 

Conclusions: Frailty is associated with similar efficacy of treatment but with greater incidence of both adverse events and MACE. Frailty was rare in most trials. While these findings support calls to relax HbA1c-based targets in people living with frailty, they also highlight the need for inclusion of people living with frailty in trials.
 

Background: Newer glucose-lowering agents for type 2 diabetes (sodium glucose cotransporter 2 inhibitors (SGLT2i), glucagon-like peptide-1 receptor analogues (GLP1ra) and dipeptidyl peptidase-4 inhibitors (DPP4i)) improve hyperglycaemia and SGLT2i and GLP1ra reduce the risk of major adverse cardiovascular events (MACE). It is not clear whether the efficacy of these agents varies by age.

Methods: We searched Medline and Embase, plus clinical trial registries, for randomised controlled trials of SGLT2i, GLP1ra and DPP4i, versus placebo or active comparator, in adults with type 2 diabetes.

Outcomes: HbA1c and MACE. Where IPD were available, we modelled age-treatment interactions for each trial. Otherwise, we assessed age distributions along with results from aggregate trial data. IPD and aggregate findings were combined in a Bayesian network meta-analysis to assess whether the efficacy differed by age.

Results: We identified 616 eligible trials (604 reporting HbA1c, 23 reporting MACE) and obtained IPD for 75 trials (6 reporting MACE). Mean age was 59.0 (10.7) years and 64.0 (8.6) in HbA1c and MACE trials, respectively. SGLT2i reduced HbA1c by 0.5-1.0% overall compared to placebo. This reduction versus placebo was attenuated in older participants (change in HbA1c 0.25 percentage-points less for 75-year-olds compared to 45-year-olds). SGLT2i showed greater relative efficacy in MACE risk reduction among older than younger people. This finding was sensitive to the exclusion of one of the IPD MACE trials, however, in all sensitivity analyses, SGLT2i were either as efficacious or more efficacious in older participants. There was no consistent difference in efficacy by age for GLP1ra or DPP4i for HbA1c or MACE.

Conclusion: Newer glucose-lowering drugs are efficacious across age and sex groups. SGLT2i are more cardioprotective in older than younger people despite smaller HbA1c reductions. Age alone should not be a barrier to treatments with proven cardiovascular benefit providing they are well tolerated align with patient priorities.

Background

Perioperative management of diabetes is a strong predictor of post-operative outcomes for patients undergoing major elective surgery. The national confidential enquiry into patient outcome and death (NCEPOD) has specific recommendations for diabetes care in the perioperative phase. We aimed to audit current practice in East Sussex Healthcare Trust (ESHT) against these recommendations prior to the introduction of a recognised programme designed to improve the perioperative pathway for patients with diabetes (IP3D).

Methods

A retrospective audit of 30 patients with diabetes who underwent major orthopaedic or colorectal surgery. Data was collected on basic demographics, quality of initial referral, preoperative assessment, intraoperative diabetes management and postoperative recovery.

Results

Mean patient age was 73 (57-91), with the majority having type-2 diabetes (93%, n=28). Initial referral letters mentioned diabetes in 77% (n=23) of cases; 7% (n=2) included the latest HbA1c. 97% (n=29) had a pre-operative HbA1c; mean was 50.9mmol/mol (39-74). 43% (n=13) of patients were scheduled in the first third of the operating list. Blood glucose was measured preoperatively in 93% (n=28), intraoperatively in 40% (n=12) and postoperatively in 77% (n=23). Postoperatively, three patients had hypoglycaemic events and five had hyperglycaemic events. One patient had deficient wound healing due to poorly controlled diabetes.

Conclusions

Perioperative management of patients with diabetes at ESHT does not currently meet the NCEPOD standards. This shortfall will be addressed by the implementation of the IP3D programme and supported by a perioperative diabetes specialist nurse. The programme will focus on educating and supporting patients perioperatively whilst improving diabetes knowledge amongst surgical staff.

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.