Ahmed H. Abdelhafiz

Hypoglycemia in Older People - A Less Well Recognized Risk Factor for Frailty

Recurrent hypoglycemia is common in older people with diabetes and is likely to be less recognized and under reported by patients and health care professionals. Hypoglycemia in this age group is associated with significant morbidities leading to both physical and cognitive dysfunction. Repeated hospital admissions due to frequent hypoglycemia are also associated with further deterioration in patients general health. This negative impact of hypoglycemia is likely to eventually lead to frailty, disability and poor outcomes. It appears that the relationship between hypoglycemia and frailty is bidirectional and mediated through a series of influences including under nutrition. Therefore, attention should be paid to the management of under nutrition in the general elderly population by improving energy intake and maintaining muscle mass. Increasing physical activity and having a more conservative approach to glycemic targets in frail older people with diabetes may be worthwhile.

Hypoglycaemia in residential care homes

Hypoglycaemia is the most common metabolic complication occurring in older people with type 2 diabetes. Limited data are available about prevalence of diabetes or its complications in care homes. However, the prevalence of residents with diabetes in care homes seems to be significant. There is high level of disability, dependency, and polypharmacy among residents in these settings. Hypoglycaemia is both an important adverse reaction of treatment and an outcome measure. This study reviews the relevant literature and reports a case of hypoglycaemia to demonstrate the causes of hypoglycaemia, characteristics of these patients, and the complexity of their problems.

Management of Type 2 Diabetes in Older People

The prevalence of diabetes is increasing due to aging of the population and increasing obesity. In the developed world, there is an epidemiologic shift from diabetes being a disease of middle age to being a disease of older people due to increased life expectancy. In old age, diabetes is associated with high comorbidity burden and increased prevalence of geriatric syndromes in addition to the traditional vascular complications. Therefore, comprehensive geriatric assessment should be performed on initial diagnosis of diabetes. Due to the heterogeneous nature of older people with diabetes and variations in their functional status, comorbidities, and life expectancy, therapeutic interventions, and glycemic targets should be individualized taking into consideration patients’ preferences and putting quality of life at the heart of their care plans.

Frailty and sarcopenia - newly emerging and high impact complications of diabetes

Diabetes increases the risk of physical dysfunction and disability. Diabetes-related complications and coexisting morbidities partially explain the deterioration in physical function. The decline in muscle mass, strength and function associated with diabetes leads to sarcopenia, frailty and eventually disability. Frailty acts as a mediator in the pathogenesis of disability in older people with diabetes and its measurement in routine daily practice is recommended. Frailty is a dynamic process which progresses from a robust condition to a pre-frail stage then frailty and eventually disability. Therefore, a multimodal intervention which includes adequate nutrition, exercise training, good glycaemic control and the use of appropriate hypoglycemic medications may help delay or prevent the progression to disability.

Hypoglycemia, frailty and dementia in older people with diabetes: Reciprocal relations and clinical implications

The relationships between hypoglycemia, frailty and dementia appear to be reciprocal and can lead to a vicious circle. Frailty appears to be a crucial factor increasing the risk for both hypoglycemia and dementia, initiating the reciprocal relationships. Weight loss is likely to be the underlying risk factor for frailty. Many frail older people with diabetes seem to have unnecessarily tight glycemic control, being treated with hypoglycemic medications that likely increase the risk of hypoglycemia. As patients get older with significant weight loss their glycemic targets should be reviewed, and reduction or even withdrawal of their hypoglycemic medications should be considered.

Cost of acute stroke care for patients with atrial fibrillation compared with those in sinus rhythm.

BackgroundAtrial fibrillation (AF) is a major risk factor for stroke. Cost-effectiveness studies of anticoagulants for stroke prevention in AF rarely utilise AF-stroke-specific cost data in their analyses, as data are limited. Data that exist do not account for AF found on prolonged cardiac monitoring after stroke, further underestimating the clinical and economic burden of AF-stroke.ObjectiveOur objective was to investigate differences in direct medical costs of acute stroke care among patients with and without AF.MethodsData were prospectively collected from 213 consecutive patients with confirmed stroke (196 ischaemic [IS], 17 intracranial haemorrhage [ICH]), admitted to a UK district general hospital between November 2011 and October 2012. Sociodemographic, clinical and cardiac monitoring characteristics were recorded, and resource use was calculated using a ‘bottom-up’ approach. Univariate and multivariate stepwise regressions were performed to identify predictors of direct cost.ResultsAmong patients with IS, 73 had AF (37xa0%). These patients were older, experienced greater stroke severity, lengths of hospitalisation, inpatient mortality and discharge to institutionalised care than those without AF. Mean acute care costs for the year 2012 were £6,978 (standard deviation [SD] 6,769, range 510–36,952). Mean (SD) costs were significantly higher for patients with AF than for those without (£9,083 [7,381] vs. £5,729 [6,071], pxa0=xa0<0.001). AF independently predicted acute care cost along with history of heart failure and stroke severity. The adjusted independent effect of having AF on costs was an additional £2,173 (95xa0% confidence interval 91–4,254; pxa0=xa00.041). Costs for patients with an ICH did not differ according to cardiac rhythm.ConclusionDirect medical costs of acute stroke care for patients with AF may be 50xa0% greater than for patients without. Economic studies should take this into account to ensure the benefits of anticoagulants are not underestimated.

Low HbA1c and Increased Mortality Risk-is Frailty a Confounding Factor?

Diabetes mellitus is increasingly becoming an older person disease due to the increased survival and aging of the population. Previous studies which showed benefits of tight glycemic control and a linear relationship between HbA1c and mortality have largely included younger patients newly diagnosed with diabetes and with less comorbidities. Recent studies, which included older population with diabetes, have shown a U-shaped relationship of increased mortality associated with low HbA1c. The mechanism of such relationship is unclear. There was no direct causal link between low HbA1c and mortality. It appears that malnutrition, inflammation and functional decline are characteristics shared by the populations that showed increased mortality and low HbA1c. In these studies functional status, disability or frailty was not routinely measured. Therefore, although adjustment for comorbidities was made there may be a residual confounding by unmeasured factors such as frailty. Thus, frailty or decline in functional reserve may be the main confounding factor explaining the relationship between increased mortality risk and low HbA1c.

Diabetes, Nutrition, and Exercise

Aging is associated with body composition changes that lead to glucose intolerance and increased risk of diabetes. The incidence of diabetes increases with aging, and the prevalence has increased because of the increased life expectancy of the population. Lifestyle modifications through nutrition and exercise in combination with medications are the main components of diabetes management. The potential benefits of nutrition and exercise intervention in older people with diabetes are enormous. Nutrition and exercise training are feasible even in frail older people living in care homes and should take into consideration individual circumstances, cultural factors, and ethnic preferences.

The effect of frailty should be considered in the management plan of older people with Type 2 diabetes

The prevalence of diabetes is increasing especially in older age due to increased life expectancy. In old age, diabetes is associated with high comorbidity burden and increased prevalence of geriatric syndromes including frailty in addition to micro- and macro-vascular complications. The emergence of frailty may change the natural history of Type 2 diabetes from a progressive to a regressive course with increased risk of hypoglycemia. This may result in normalization of blood glucose levels and lead to a state of burnt-out diabetes in frail older people with significant weight loss. Although guidelines suggest relaxed glycemic control in frail elderly with diabetes, complete withdrawal of hypoglycemic medications may be necessary in these frail populations to reduce the risk of hypoglycemia.

Prevalence and determinants of anemia in older people with diabetes attending an outpatient clinic: a cross-sectional audit.

IN BRIEF This cross-sectional audit investigates the prevalence and determinants of anemia in older people with diabetes attending an outpatient clinic. Anemia was found to be highly prevalent, affecting 59% of patients. Older age and longer duration of diabetes were the main predictors of anemia, whereas the presence of chronic kidney disease was a mediator rather than a direct cause.