A/Prof Varghese
Goals of care in the frail and elderly patient with diabetes should focus on symptom management rather than preventing long-term complications.
Speaking at the Australia Diabetes Educators Association (ADEA) Queensland branch conference on the Gold Coast, Associate Professor Paul Varghese said diabetes care should be stripped back for many elderly people and especially for those entering residential aged care.
Given the majority of people in residential aged care live less than three years, he said there was little point in complicated medication regimens designed to prevent complications in five to ten years.
His advice is consistent with new guidance from the American College of Physicians regarding HbA1c targets in type 2 diabetes.
“Clinicians should treat patients with type 2 diabetes to minimize symptoms related to hyperglycemia and avoid targeting an HbA1c level in patients with a life expectancy less than 10 years due to advanced age (80 years or older), residence in a nursing home, or chronic conditions (such as dementia, cancer, end-stage kidney disease, or severe chronic obstructive pulmonary disease or congestive heart failure) because the harms outweigh the benefits in this population,” the guidance said.
Associate Professor Varghese, a geriatrician from Brisbane’s Princess Alexandra Hospital, told the meeting it was a well-meaning case of a different set of rules for the elderly than the young.
Importantly, there was more risk of doing harm than good when patients did not have capacity to self-manage their diabetes or there were insufficient nursing resources to assist them.
“Guidelines need to be individualised for older patients and the management plan needs to be kept simple,” he said.
However there were a number of barriers to making the changes.
“Deprescribing makes sense but there is little evidence,” he said. “Patient expectations can also be tricky if they are used to a particular drug.”
He added that a lot of people enter aged care facilities from hospital, and GPs were reluctant to stop treatment that had been started in hospital.
“Most endocrinologists who have been in the business for any length of time will have worked out the same thing, in that old people are different and they need individualised care rather than target-based care.”
“In terms of the complex diabetes regimes that people are going into care with, that can be changed but it needs adequate resourcing to do it. These people need a comprehensive geriatric assessment, they need a medication care plan and review by someone who is familiar with dealing with frailty and disability.”
He said goals of care should be relatively simple – to deal with symptoms such as polydipsia and polyuria and avoid episodes of hypoglycaemia and falls.
For functional independence, there should be no insulin and no point of care testing.
“A complex insulin regimen may be the difference between [discharge to] high care and a pensioner unit,” he said.
He said SGLT2 inhibitors could worsen urinary incontinence in the elderly while metformin can cause faecal incontinence.
And polypharmacy was a known risk factor for falls in the elderly.
He added a permissive hyperglycaemia in patients on prolonged bed rest provided a buffer when patients started to mobilise again and blood sugar levels could drop quickly.