Care of Older People with Diabetes

Contributors xxvii Foreword xxxiii Preface xxxv About the Companion Website xxxvii Characteristics and Care Needs xxxix Ahmed H Abdelhafiz, Ann Middleton and Alan J Sinclair Introduction xxxix Characteristics xli Care Needs xliii Physical Function xliii Mental Function xliii Care Delivery xlvi Family Support xlvi Care Organisation xlvii Continuity of Care xlvii Care Homes xlviii Conclusion xlix Clinical Practice Question xlix References xlix 1 Epidemiology and Pathophysiology 1 Sarah L Sy Introduction 1 Epidemiology 2 Pathophysiology of Diabetes in Older Adults 3 Age- related Alterations in Glucose Metabolism 3 Genetics 5 Lifestyle and Environmental Factors 5 Other Factors 6 What Are the Key Issues? 6 Prevention of Diabetes in Older Adults 6 Hypoglycaemia 7 Management 7 Summary 7 Clinical Practice Question 9 References 9 2 Screening and Diagnosis 11 Isabelle Bourdel- Marchasson Introduction 11 Background 12 Key Issues 14 Screening 14 Diagnosis 16 Clinical Practice Questions 17 References 18 3 Lifestyle Interventions 21 Abdiazizi Yusuf and Ahmed H Abdelhafiz Introduction 21 Impact of Lifestyle Changes 22 Lifestyle Intervention 23 Nutrition 24 Exercise 25 Synergy Between Nutrition and Exercise 27 Care Homes 27 Summary 28 Clinical Practice Question 28 References 29 4 Oral Hypoglycaemic Therapy 31 Nahian Kazi and Ahmed H Abdelhafiz Introduction 31 Hypoglycaemic Agents 32 Low Hypoglycaemia- Risk Agents 32 Metformin 32 Dipeptidyl Peptidase- 4 Inhibitors 34 Sodium Glucose Transporter- 2 Inhibitors 34 Glucagon- like Peptide- 1 Receptor Agonists 35 Thiazolidinediones 35 Alpha- glucosidase Inhibitors 36 High Hypoglycaemia Risk Agents 36 Sulfonylureas 36 Meglitinides 37 Therapeutic Approach 37 Summary 38 Future Perspectives 39 Clinical Practice Question 39 References 40 5 Insulin Therapy 41 Giuseppe Maltese Introduction 41 Basal Insulin Analogues 42 Rapid- acting Analogues 44 Treatment Regimens 45 Summary 47 Clinical Practice Question 47 References 47 6 Use of Continuous Glucose Monitoring in Older People with Diabetes 49 Giuseppe Maltese Introduction 50 Continuous Glucose Monitoring 50 Patient Assessment 52 Challenges 54 Clinical Practice Question 54 References 55 7 Education: Key Features for Achieving Success 57 Kirsty Winkley and Angus Forbes Introduction 57 Key Issues 58 Diabetes Complications 59 Other Comorbidities Not Specific to Diabetes 60 Polypharmacy 60 Anti- diabetes Oral and Injectable Agents 60 Hypoglycaemia 62 Risk of Falls and Fractures 63 Cognitive Impairment 63 Nutrition 64 Management 64 Determine Frailty Risk 64 Deprescribing and Optimisation 65 Glucose Monitoring and Insulin Delivery Technologies 66 Physical Exercise 66 Healthy Diet 67 Diabetes Self- management Education for Older People 67 Clinical Practice Question 68 References 68 8 Carers and Care Needs 71 Puja Merwaha and Ahmed H Abdelhafiz Introduction 71 Care Needs 72 Carer Groups 73 Role of Carers 73 Benefit of Care on Outcomes 74 Caring for Carers 74 Carers’ Burden 75 Supporting Carers 75 Summary 76 Clinical Practice Question 78 References 78 9a Macrovascular Complications: Peripheral Arterial Disease 81 Leocadio Rodríguez- Mañas, Rubí E Sandoval- Santoyo and Marta Castro-Rodríguez Epidemiology 81 Risk Factors 81 Prevalence 82 Pathogenesis 82 Consequences of Peripheral Arterial Disease 83 Investigations 83 Anamnesis 83 Physical Examination 84 Non- invasive Tests 84 Invasive Tests 85 Management 85 Risk Factor Modification 85 Exercise Rehabilitation 85 Foot Care 86 Pharmacological Therapy 86 Antiplatelet Therapy 86 Cilostazol 86 Revascularisation 86 Clinical Practice Question 86 References 87 9b Macrovascular Complications: Coronary Arterial Disease 89 Leocadio Rodríguez-Mañas, Rubí E., Sandoval-Santoyo and Marta Castro Rodríguez Epidemiology 89 Pathogenesis 90 Medical Treatment 90 Indications for Revascularisation 91 Management of Cardiovascular Risk Factors According to Baseline Functional and Cognitive Status 92 Effect of Glycaemic Control on Cardiovascular Events 92 Effect of Blood Pressure Control 92 Lipid Monitoring 93 Physical Exercise and Diet 93 Frailty Management 93 Management 93 Summary 95 Clinical Practice Question 95 References 96 9c Macrovascular Complications: Cerebrovascular Disease 97 Abubakhr Subkhan, Arshad Majid and Ali Ali Introduction 97 Epidemiology 98 Risk Factors 98 Aetiology and Pathophysiology 99 Presentation 99 Stroke and Transient Ischaemic Attack 101 Cerebral Small Vessel Disease and Dementia 101 Management of Cerebrovascular Disease 102 Acute Stroke 102 Management of Risk Factors 104 Prognosis 105 Summary 106 Clinical Practice Question 106 References 107 10a Microvascular Complications: Diabetic Eye Disease 109 Archith Kamath and Nachiketa Acharya Introduction 110 Epidemiology 110 Presentation 110 Pathophysiology 111 Management 113 Primary Care 113 Secondary Care 115 Summary 117 Clinical Practice Questions 117 References 118 10b Microvascular Complications: Diabetic Kidney Disease 119 Mohsen El Kossi Introduction 119 Diabetic Kidney Disease 120 Definitions and Diagnoses 120 Management 121 Lifestyle 121 Glycaemic Control 122 Blood Pressure Control 122 Lipid Control 123 Diabetic Kidney Disease- related Complications 124 Anaemia 124 Mineral Bone Disorder 124 Metabolic Acidosis and Fluid Retention 125 Nephrology Referral 125 Summary 126 Clinical Practice Question 127 References 127 10c Microvascular Complications: Peripheral Neuropathy 129 Mitra Tavakoli Introduction 130 Prevalence and Risk Factors 130 Clinical Manifestations and Complications 131 Diagnosis and Assessment 132 Management of Diabetic Neuropathy 135 Diabetes Foot Care in Care Homes 136 Summary 138 Clinical Practice Question 138 References 139 11a Vascular Risk Factors: Hypertension 141 Pann Ei Hnynn Si and Ahmed H Abdelhafiz Introduction 141 Age- related Blood Pressure Changes 142 Definition 142 Diagnosis 144 Types 144 Management 145 Recommended Targets 145 Medications 146 Considerations in Older People 147 Orthostatic Hypotension 147 Falls 148 Systolic Hypertension 148 Frailty 148 Dementia 149 Comorbidity 149 Polypharmacy 149 Summary 149 Clinical Practice Question 151 References 151 11b Vascular Risk Factors: Dyslipidaemia 153 Pann Ei Hnynn, Si and Ahmed H Abdelhafiz Introduction 153 Ageing and Lipid Profile 154 Diabetes and Lipid Profile 154 Diabetes and Risk of Atherosclerotic Cardiovascular Disease 155 Atherosclerotic Cardiovascular Disease Risk Reduction 156 Lipid- lowering Agents 157 Goals of Therapy in Old Age 160 Recommendations from Guidelines 160 Goals in Frailty 162 Summary 162 Clinical Practice Question 162 References 164 12a Metabolic Decompensation: Hyperglycaemic Crisis 165 Puja Merwaha and Ahmed H Abdelhafiz Introduction 165 Epidemiology 166 Precipitating Factors 166 Pathogenesis 168 Clinical Presentation 168 Diagnosis 169 Management 171 Correction of Hypovolaemia 172 Correction of Hyperglycaemia 173 Correction of Acidosis 174 Correction of Electrolytes 175 Complications 175 Prevention 176 Clinical Practice Question 176 References 177 12b Metabolic Decompensation: Hypoglycaemia 178 Srikanth Bellary, Ahmed H Abdelhafiz and Alan J Sinclair Introduction 179 Definition 179 Recognition 179 Epidemiology 180 Pathophysiology 180 Clinical Consequences 181 Impact on Cognition 182 Impact on Frailty 182 Management 183 Summary 185 Clinical Practice Question 185 References 186 13a Management of Diabetes in Hospital 189 Julie Lewis and Chris Cottrell Introduction 189 Fundamentals of Care 190 Key Considerations for Effective Inpatient Care for Older People with Diabetes 192 The Inpatient Setting 192 Pressure Damage and Footcare Assessment 193 Planning Care 193 Key Considerations to Reduce Unscheduled Admission to Hospital 193 Monitoring Requirements 196 Education and Training 196 Summary 197 Clinical Practice Questions 198 References 199 13b Management of Diabetes in Care Homes 201 Lynne Reedman and Alan J Sinclair Introduction 201 Important Considerations for Diabetes Care 203 Importance of Monitoring Glucose Levels 207 Other Management Issues 207 Hypoglycaemia 208 Diabetes Foot Disease 209 Nutritional Deficiency and Weight Loss 209 Frailty 210 Education 210 Communication and Collaboration 211 Use of Audit 211 Measuring Outcomes 212 Summary 212 Clinical Practice Question 213 References 214 14 Nutrition 215 Rihan Said and Grace Zaman Introduction 215 Nutritional Deficiencies 216 Causes of Malnutrition in the Elderly 216 Recommendations 217 Specific Recommendations for Older People with Diabetes 218 Practical Steps for Nutritional Care in the Elderly 218 Screening 218 Assessment 219 Intervention 219 Enteral Nutrition 221 Types of Enteral Tubes 221 Types of Feeds 221 Enteral Feed Delivery Options 221 Management of Blood Glucose 221 Parenteral Nutrition 222 Management of Blood Glucose 223 General Considerations for Patients on Nutritional Support 224 Summary 224 Clinical Practice Questions 225 References 226 15 Sexual Health 229 Pann Ei Hnynn Si and Ahmed H Abdelhafiz Introduction 229 Ageing and Sexual Function 230 Diabetes and Sexual Dysfunction 230 Sexual Dysfunction in Men 231 Aetiology and Pathogenesis 231 Diagnosis 232 Treatment 233 Sexual Dysfunction in Women 236 Aetiology and Pathogenesis 236 Diagnosis 237 Treatment 237 Summary 238 Clinical Practice Questions 238 References 239 16a Special Issues in Old Age: Frailty 241 Alan J Sinclair and Ahmed H Abdelhafiz Introduction 241 Frailty–diabetes Inter- relationship 242 Effect of Diabetes on Frailty 244 Effects of Frailty on Diabetes 245 Outcome Effects 249 Metabolic Effects 249 Sarcopenic Obese Phenotype 254 Anorexic Malnourished Phenotype 254 Prevention and Management 255 Screening 255 Non- pharmacological Therapy 256 Pharmacological Therapy 257 Special Considerations 259 Glycaemic Control 259 Choice of Hypoglycaemic Agent 260 Sarcopenic Obese Phenotype 260 Anorexic Malnourished Phenotype 260 Goals of Therapy 261 Summary 262 Future Perspectives 262 Clinical Practice Question 263 References 264 16b Special Issues in Old Age: Multimorbidity 266 Alan J Sinclair and Ahmed H Abdelhafiz Introduction 266 Multimorbidity 267 Multimorbidity–Frailty Interaction 268 Multimorbidity Effects on Diabetes 268 Clusters of Multimorbidity 269 Clinical Implications 270 Summary 272 Future Perspectives 272 Clinical Practice Question 273 References 273 16c Special Issues in Old Age: Type 1 Diabetes Mellitus 275 Alex M Summerbell and Ahmed H Abdelhafiz Introduction 275 Epidemiology and Diagnosis 276 Management 276 Insulin Therapy 278 Monitoring 279 Reducing Hypoglycaemia 280 Goals of Therapy 282 Summary 282 Clinical Practice Question 282 References 283 16d Special Issues in Old Age: Cognitive Health Agility, Cognitive Dysfunction, Dementia and Diabetes 285 Tali Cukierman- Yaffe Introduction 286 Population Studies Demonstrating the Relationship Between Cognitive Dysfunction, Dementia and Diabetes 286 Implications of the Relationship Between Diabetes and Cognitive Dysfunction 287 The Effect of Cognitive Dysfunction on Self- care Capacity in Older People with Diabetes 288 Assessment of Cognitive Health Agility in Older People with Diabetes 290 Prevention and Treatment of Cognitive Dysfunction in Older People with Diabetes 291 The Effect of Current Diabetes Pharmacological Agents on Cognitive Dysfunction 291 Glucose Control 292 Insulin 293 Dipeptidyl Peptidase- 4 Inhibitors 294 Glucagon- like Peptide- 1 Receptor Analysts 294 The Multidomain Approach 295 Summary, Knowledge Gaps and Future Research 296 Clinical Practice Question 296 References 298 16e Special Issues in Old Age: Depression 299 Sara- Louise Wylie Introduction 299 Depression and Diabetes 300 Presentation 300 Evaluation 302 Screening 302 Diagnosis 303 Assessment 304 Management 307 Lifestyle 307 Pharmacological Therapy 308 Psychotherapy 309 Collaborative Care 310 Summary 310 Clinical Practice Question 310 References 311 16f Special Issues in Old Age: Foot Care 313 Solomon Muzulu Introduction 313 Epidemiology 314 Pathogenesis 314 Ageing and Diabetic Foot Ulcer Disease 315 Assessment of a Diabetic Foot 316 Testing for Peripheral Sensory Neuropathy 316 10- g Monofilament Test 317 128- Hz Tuning Fork 318 Ipswich Touch Test 318 Checking for Peripheral Vascular Disease 318 Management 318 Offloading 320 Debridement 320 Dressings 320 Infection Control 320 Ischaemia Relief 321 Glycaemic Control 322 Prevention 322 Summary 323 Clinical Practice Question 323 References 324 16g Special Issues in Old Age: Skin Care 326 Grace Keegan and Sarah Mahmoud Introduction 326 Age- related Skin Changes 327 Diabetes Mellitus- related Skin Conditions 327 Primary Skin Conditions 328 Acanthosis Nigricans 328 Necrobiosis Lipoidica 328 Diabetic Dermopathy 329 Bullous Eruption of Diabetes Mellitus 329 Diabetes- related Skin Infections 330 Bacterial Infections 330 Fungal Infections 331 Diabetes Medications- related Skin Adverse Effects 334 Insulin 334 Sodium Glucose Transporter- 2 Inhibitors 334 Summary 334 Clinical Practice Question 335 References 335 16h Special Issues in Old Age: Falls and Bone Health 336 Nandkishor V Athavale Introduction 336 Epidemiology 337 Pathophysiology of Fracture Risk in Diabetes 337 Pathophysiology and Risk Factors for Falls in Diabetes 338 Assessment of the Risk of Falls in the Community 339 Assessment of Bone Health in Community 340 Management and Prevention 344 Falls 344 Fractures 345 Summary 345 Clinical Practice Question 345 References 346 16i Special Issues in Old Age: Avoiding Hospitalisation 347 Demelza Emmerton and Ahmed H Abdelhafiz Introduction 347 Risk Factors for Hospitalisation 348 Avoiding Hospitalisation 349 Patient- Related Interventions 349 Physical Function 349 Mental Function 351 Polypharmacy 351 Healthcare System- related Interventions 352 Community Setting 352 Care- home Setting 353 Emergency Setting 353 Summary 355 Clinical Practice Question 355 References 356 16j Special Issues in Old Age: Use of Technology 357 Anna Kahkoska, Aastha Dubal, Josh Weinstein and Ruth S Weinstock Introduction 358 What Is Diabetes Technology? 358 What Is Remote Patient Monitoring? 359 Diabetes Technology and Remote Patient Monitoring in Older Adults 360 Management 362 Continuous Glucose Monitoring 362 What Is Continuous Glucose Monitoring? 362 What Is the Evidence for Continuous Glucose Monitoring as Part of Management for Older Adults with Diabetes? 362 What Are Challenges for Continuous Glucose Monitoring Use in Older Adults? 363 Automated Insulin Delivery Systems 363 What Is Automated Insulin Delivery? 363 Evidence on Automated Insulin Delivery for Older Adults 364 Clinical Guidelines for Automated Insulin Delivery Usage among Older Adults with Type 1 Diabetes 364 What Are Challenges for Automated Insulin Delivery Use in Older Adults? 364 Integration of Diabetes Technologies with Remote Patient Monitoring 365 What Are the Key Issues? 366 Clinical Practice Questions 368 References 369 16k Special Issues in Old Age: Annual Reviews 371 Puja Merwaha and Ahmed H Abdelhafiz Introduction 371 Diabetes Phenotype in Older People 372 Multimorbidity 372 Geriatric Syndromes 373 Frailty 373 Functional Implications 373 Annual Review Contents 374 Demographics 374 History 374 Physical Examination 374 Vascular Complications 376 Sexual Function 376 Cognition and Mood 376 Physical Function and Frailty 377 Foot Care 377 Diet and Nutrition 377 Medication Review 377 Infection Prevention 378 Summary 378 Clinical Practice Question 378 References 380 16l Special Issues in Old Age: Mouth Care 381 Nali Ahmed and Ahmed H Abdelhafiz Introduction 381 Age- related Oral Changes 382 Diabetes- related Oral Changes 382 Common Oral Conditions in Older People with Diabetes 384 Periodontal Disease 384 Dental Caries 384 Dry Mouth 385 Candida 386 Oral Cancer 386 Taste Impairment 387 Mouth Care 387 Education 387 Glycaemic Control 388 Preventative Measures 388 Summary 389 Clinical Practice Question 390 References 390 16m Special Issues in Old Age: Pain Management 392 Pann Ei Hnynn Si and Ahmed H Abdelhafiz Introduction 392 Aetiology 393 Assessment 393 Pain in Care- home Residents 396 Management 397 Non- pharmacological Therapy 397 Pharmacological Therapy 398 Prevention 401 Clinical Practice Question 401 References 402 17 Deintensification of Therapy 405 Antoine Christiaens Introduction 405 Key Issues 407 Management 407 Identifying Patients Who Might Benefit 407 Deintensifying Glucose- lowering Treatment in Older Patients 409 Implementing Deintensification in Daily Clinical Practice 410 Clinical Practice Questions 411 References 412 18 Diabetes in End- of- Life Care 413 June James Introduction 413 Background 414 What is End of Life and How is the Need for End- of- life Care Identified? 414 Management of Diabetes in End- of- Life Care 419 Medicines Management and De- escalation of Therapies 419 Steroids and Cancer 422 Nutrition and Enteral Feeding 424 Advanced Care Planning 424 Treatment Withdrawal 424 Workforce Training and Competencies 424 Summary 425 Clinical Practice Questions 425 References 426 Answers to Clinical Practice Questions 429 Index 445