Alan Sinclair

Costs of Malnutrition in Institutionalized and Community-Dwelling Older Adults: A Systematic Review

OBJECTIVES The aim of this study was to assess health economics evidence published to date on malnutrition costs in institutionalized or community-dwelling older adults. DESIGN A systematic search of the literature published until December 2013 was performed using standard literature, international and national electronic databases, including MedLine/PubMed, Cochrane Library, ISI WOK, SCOPUS, MEDES, IBECS, and Google Scholar. Publications identified referred to the economic burden and use of medical resources associated with malnutrition (or risk of malnutrition) in institutionalized or community-dwelling older adults, written in either English or Spanish. Costs were updated to 2014 (€). RESULTS A total of 9 studies of 46 initially retrieved met the preestablished criteria and were submitted to thorough scrutiny. All publications reviewed involved studies conducted in Europe, and the results regarding the contents of all the studies showed that total costs associated with malnutrition in institutionalized and community-dwelling older adults were considerably higher than those of well-nourished ones, mainly due to a higher use of health care resources (GP consultations, hospitalizations, health care monitoring, and treatments). Interventions to reduce the prevalence of malnutrition, such as the use of oral nutritional supplements, showed an important decrease in-hospital admissions and medical visits. CONCLUSION Malnutrition is associated with higher health care costs in institutionalized or community-dwelling older adults. The adoption of nutritional interventions, such as oral nutritional supplements, may have an important impact in reducing annual health care costs per patient.

The Third Transition: The Clinical Evolution Oriented to the Contemporary Older Patient

Ageing of all western populations has been accompanied by dramatic changes in demographic structure, diseases patterns, and healthand social-care needs of individuals. As a result, it is also transforming our key personal aspirations, which now include healthy aging. The first of these dramatic changes was the demographic transition, which has been mostly completed in western societies but may still influence developing societies.1,2 It is characterized by decreasing birth and mortality rates that have led to populations with longer life expectancy, with considerable numbers of people over the age of 65 and, particularly, a rising number and percentage of the “oldest old” (>80 years). This latter group displays different health and social characteristics and needs compared with younger old people who, in many ways, resemble the average adult population. These demographic changes are often accompanied by wider mini-transitions that involve political, economic, and social issues, including the sustainability of the welfare state, the rising age for retirement, or the reorganization of social roles.3,4 The second of these changes that had a significant impact on the development of national healthcare systems was the epidemiologic transition, which started in the first three decades of the 20th century in developed countries.5 It was characterized by a marked shift in disease patterns, in that infectious diseases (pneumonia, tuberculosis, or diarrhea) were replaced by chronic noncommunicable conditions, such as cardiovascular diseases, cancer, diabetes, and chronic lung disease, as the main causes of illness and death. Moreover, in a second phase of this epidemiologic transition, there has been a substantial increase in survival of these latter conditions, which has led to a greater prevalence and associated health and social needs.3,6 This increasing disease burden of the noncommunicable diseases is

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.

Hypoglycaemic symptoms and hypoglycaemia threshold in older people with diabetes-A patient perspective

Objectives: ObjectivesTo investigate patients’ views about their lowest tolerable blood glucose level and explore symptoms they may develop below that level.DesignA semi-structured patient interview.SettingOutpatient clinic for older people (≥75 years) with diabetes.ParticipantsPatients attending an outpatient clinic over a six months period who are monitoring their blood glucose at home and able to participate in interview.ResultsSixty one patients gave answers to the interview questions. Mean (SD) age was 82.3 (3.9) years and 33 (54%) were females. All patients indicated that they were usually aware when hypoglycaemia occurs but the symptoms reported were mostly non specific. The threshold for hypoglycaemia was 5 mmol/L in 13 (21%) patients, 6 mmol/L in 14 (23%) patients, 7 mmol/L in 13 (21%) patients, 8 mmol/L in 17 (28%) patients and 9 mmol/L in 4 (7%) patients. There was no significant difference between patients who were symptomatic at a higher blood glucose level (>6mmo/L) and those who developed symptoms at a lower level (≤6mmol/L).ConclusionOlder people with diabetes who seem to be aware of hypoglycaemia report mostly non specific symptoms. The threshold of experiencing hypoglycaemic symptoms appears to be higher than the usually defined <4mmol/L.

Diabetes and Frailty: Two Converging Conditions?

Diabetes mellitus is a disabling, chronic cardiovascular and medical disease with a tremendous health, social and economic burden in our ageing communities. It has a prevalence of 10% to 30% in people older than 65 years of age, and more than half of all subjects with diabetes in the United States are older than 60 years of age. The main impact of diabetes in older adults stems from its effect on function, both physical and cognitive, that finally impairs their quality of life, although the impact on survival is modest. Frailty has emerged during the past 2 decades as the most powerful predictor of disability and other adverse outcomes, including mortality, disability and institutionalization in older adults. In this article we explore the relationship between diabetes and frailty, and we recognize that they are intimately related chronic medical conditions that result in huge societal and personal health burdens.

Mean HbA1c, HbA1c variability, and mortality in people with diabetes aged 70 years and older: a retrospective cohort study

BACKGROUND Glycaemic targets for older people have been revised in recent years because of concern that more stringent targets are associated with increased mortality. We aimed to investigate the association between glycaemic control (mean HbA1c) and variability (variability of HbA1c over time) and mortality in older people with diabetes. METHODS We did a 5-year retrospective cohort study using The Health Improvement Network database, which includes data from 587 UK primary care practices. We included patients of either sex who were aged 70 years and older with type 1 or type 2 diabetes. The primary outcome was time to all-cause mortality. Our primary exposure variables were mean HbA1c and variability of HbA1c over time. The observation included a 4-year run-in period (from 2003) as a baseline, with a 5-year follow-up (from 2007 to 2012). We assessed mean HbA1c in three models: a baseline mean HbA1c for 2003-06 (model 1), the mean across the whole follow-up period (model 2), and a time-varying yearly updated mean (model 3). A variability score (from 0 [low] to 100 [high]) was calculated on the basis of number of changes in HbA1c of 0·5% (5·5 mmol/mol) or more from 2003 to 2012 or to the point of mortality, based on changes in the annual mean as per each model with a minimum of six readings. FINDINGS The cohort consisted of 54 803 people, of whom 17 680 (8614 [30·7%] of 28 017 women and 9066 [33·8%] of 26 786 men) died during the observation period. The overall mortality rate was 77 per 1000 person-years (73 per 1000 person-years for women and 80 per 1000 person-years for men). The data showed a J-shaped distribution for mortality risk in both sexes, with significant increases with HbA1c values greater than 8% (64 mmol/mol) and less than 6% (42 mmol/mol), although excess mortality risk was non-significant in model 1 for men at HbA1c values of 8% (64 mmol/mol) to less than 8·5% (<69 mmol/mol) and in models 1 and 3 for both sexes assessed individually at HbA1c values less than 6% (42 mmol/mol). Mortality increased substantially with increasing HbA1c variability in all models (overall and for both sexes). For the model 2 HbA1c measure, the adjusted hazard ratios comparing patients with a glycaemic variability score of more than 80 to 100 with those with a score of 0 to 20 were 2·47 (95% CI 2·08-2·93) for women and 2·21 (1·87-2·61) for men. Fitting the mean HbA1c models with the glycaemic variability score altered the risk distribution; this observation was most marked in the model 2 analysis, in which a significant increased risk was only apparent with HbA1c values greater than 9·5% (80 mmol/mol) in women and 9% (75 mmol/mol) in men. INTERPRETATION Both low and high levels of glycaemic control were associated with an increased mortality risk, and the level of variability also seems to be an important factor, suggesting that a stable glycaemic level in the middle range is associated with lower risk. Glycaemic variability, as assessed by variability over time in HbA1c, might be an important factor in understanding mortality risk in older people with diabetes. FUNDING Kings College London and Diabetes Frail.

Managing glycaemia in older people with type 2 diabetes: a retrospective, primary care based cohort study, with economic assessment of patient outcomes.

To describe the relative health and economic outcomes associated with different second‐line therapeutic approaches to manage glycaemia in older type 2 diabetes patients requiring escalation from metformin monotherapy.

What is new in exercise regimes for frail older people — How does the Erasmus Vivifrail Project take us forward?

1 Physical activity as an intervention is one of the most important components in the prevention and treatment of frailty. The benefits of physical exercise in improving the functional capacity of frail, older adults have been the focus of considerable recent research (1-4). Frailty is an age-associated biological syndrome characterized by decreased biological reserves, strongly associated with sarcopaenia, diminished strength, endurance, and reduced physiologic function that increases an individual’s vulnerability for developing adverse outcomes like disability, death and hospitalization (5-8). At the same time, frailty is a good predictor of other adverse health events in the short, medium and long term. Its practical relevance relies not only on its value as the main prognostic factor for many of those outcomes but also on the fact that functional level is one of the best indicators of health status in older adults. Accordingly an important conceptual idea for frailty is that the focus should be on functionality and not on the diagnosis of disease when facing older patients. Physical inactivity is a key factor contributing to the onset of muscle mass and function decline (i.e. sarcopenia), which in turn appears to be a central aspect related to frailty. In view of this, a focus on improvements in function and quality of life may be more beneficial in frail older patients than other targets for intervention (9). Poor health, disability and dependency are not inevitable consequences of ageing. The promotion of a healthy lifestyle, the avoidance of sedentariness, and physical exercise have proven to be effective for frail, older adults, enhance their independency, and probably incur fewer health-related costs. The main interventions that have proven effective to prevent and even reverse the frail state are physical exercise, multidimensional geriatric assessment and intervention on major geriatric syndromes, with emphasis on proper adjustment of medication. Interventions to promote physical activity in the population have been effective in improving mobility and function. Other interventions such as nutritional or pharmacological are inconclusive. The positive effects of exercise intervention on functional capacity, rate of falls, gait ability, balance, cardiorespiratory and strength performance may be observed more often when multiple physical conditioning components (i.e., strength, endurance, or balance) are included in the exercise intervention compared with only one type of exercise (1-4, 10-13). Multicomponent exercise programmes, and particularly those including strength training, are the most effective interventions to delay disability and other adverse events (4). Indeed, it has been recently reported that multicomponent exercise training including explosive resistance training improved neuromuscular function and functional outcomes in frail institutionalized nonagenarians after long-term physical restraint (10), as well as in frail multicomorbid patients (14). Furthermore, physical exercise administration is relatively free of potential unwanted side effects caused by common medications that are prescribed in patients with multiple comorbidities (14). Although studies have focused on the benefits of concurrent training on young populations, a limited number have explored or implemented training adaptations in older subjects. The absence of changes in functional or strength outcomes measured in some previous studies suggests that the exercise prescription may not have been carefully adapted to provide a sufficient stimulus for improving not only maximal strength but also the functional capacity and muscle power output performance of frail subjects. Therefore, it would seem relevant to identify and implement good practice in the methods and procedures among different European partners involved in research in physical exercise as a mechanism to promote careful prescription of physical exercise to prevent and manage frailty and related diseases. With this framework in mind, the European Union has included several initiatives in many of their Programs. This is also the case for the Erasmus initiative, which has been created to support European health systems to handle the challenges of efficient care provision and system reorganisation aimed to meet future needs, related to an ageing society and the search for formulae that improve quality of life. Ageing is one of the greatest social and economic challenges of the 21st century, and according to European Commission data, by 2025 more than 20% of Europeans will be 65 years or over, with a particularly rapid increase in numbers of over-80 years of age. As a consequence, and to obtain European added value, it is worth promoting healthy and dignified ageing by helping countries to make their health systems more efficient to implement pilot programmes that can interact directly with frail older patients, aiming to measure the response to multicomponent sport exercise programmes for tackling very late-life disability. The need for agreed and transferable methods is urgent. Individual institutions have tended to adopt solutions that often address only their specific problems, and even though cultural and WHAT IS NEW IN EXERCISE REGIMES FOR FRAIL OLDER PEOPLE HOW DOES THE ERASMUS VIVIFRAIL PROJECT TAKE US FORWARD?

A pilot project to explore the feasibility and potential of a protocol to support district nurses in the assessment of older frail people with type 2 diabetes

A study was undertaken to explore the potential of district nurses assessing older frail people with type 2 diabetes using an explicit schedule in the form of an annual review. A pilot study following pre- and post-test (six-month interval) design explored both process and outcome variables. Twelve older people (mean age 79 years, range 70-86 years) with a diagnosis of type 2 diabetes took part. No statistically significant differences were observed on any of the main outcome measures at the post-test assessment. These findings were explained by insufficient sample size and attrition; a failure to instigate treatment following the identification of specific diabetes-related problems, especially on the part of the GP; and the fact that the sample was reasonably well controlled at the start of the study. The study showed that district nurses were able to administer the annual review satisfactorily but that they found execution of the protocol time-consuming. A great deal of variation was found among respondents, which pointed to different sub-groups of frailty in the older population of people with diabetes, each sub-group having different needs. It was concluded that if district nurses are going to undertake this work, their activity needs to be targeted at the groups of older people most likely to benefit. The current protocol needs further refinement and should be linked to clearer clinical action pathways with a multidisciplinary focus to ensure that the appropriate remedial therapy is instigated.

Frailty – An emerging high impact complication of diabetes requiring specific management approaches

Ever since the Frailty model for diabetes was first described (1) a different management approach to older adults with diabetes who develop frailty has been suggested. The European Diabetes Working Party for Older People (EDWPOP) identified frailty as a key priority area for action (2) and published a glucose-lowering algorithm for frail patients with type 2 diabetes. More recently, the international Diabetes Federation (IDF) launched global guidance on the management of diabetes in older adults and made specific recommendations on treatment in those adults who are dependent and frail who depend on others for their diabetes care (3). Other organisations recognise the impact of multimorbidity and frailty in the overall management of older citizens with diabetes (4-6). We are pleased to announce that more considered guidance to this complex area of diabetes management is in development and in mid-2017, an international collaboration consisting of EDWPOP, IAGG-Garn, AMDA, ICFRSR, and an International Group of Experts, will publish a Position Statement in this area* (see list of collaborators at end of article). In planning the Position statement, the international Writing Group have acknowledged that frailty is a common finding and may be present in 32-48% of adults aged 65 years and over with diabetes (7) and is associated with adverse outcomes and reduced survival (8). At the same time, the Group have recognised the scarcity of specific studies of glucose-lowering treatments in older patients with frailty and diabetes (9), the lack of an operational definition of frailty, the urgent need for health professionals involved in diabetes care to acquire new skills and competencies in assessment of functional status, and the need for education and practical guidance for clinicians in managing frailty in those with diabetes. The Position Statement will point out the limitations of pharma-directed, short duration studies (10) and emphasise the need for a wider application of the concept of frailty in the clinical arena, a greater use of frailty assessments in clinical diabetes practice (for example, recommending simple, pragmatic tools to identify patients at risk , the development of specific clinical trial methodology for frailty in diabetes, and a renewed emphasis on how we influence commissioners (health boards, primary care organisations) of clinical services to purchase care pathways for frailty in their diabetic populations (11). Recent studies that have attempted to study the benefits of treating glycaemia with DPP4-inhibitors in older adults with multimorbidity or frailty (9, 10) point out the advantages in treatment such as a reduced risk of hypoglycaemia and no appreciable weight gain. These are indeed important aspects of individualised care in this class of glucose-lowering therapy but future studies involving a wider spectrum of agents need to discuss precisely the description of HbA1c targets, and how these should be managed, achieved, and what clinical relevance they have. The use of fasting glucose levels to guide treatment decisions is also questionable in older patients. Attempts to lower HbA1c towards 7·0% (53 mmol/mol) or less in an older cohort of patients with diabetes might seem unnecessary or even dangerous since higher target levels are now recommended (2, 4, 6) and more liberal targets in those who are frail are now recommended (3). Such practical issues in management are important to a clinician and those in primary care and community care settings need to be convinced of their importance, otherwise they will not be acted upon. Relevant outcome measures will also prove to have an important influence in deciding if a specific management strategy is worthwhile in routine clinical care. Apart from glycaemia targets, two other key outcomes that require assessment but usually are not a feature of every day clinical practice are quality of life and functional health status indicators but to introduce these measures will require a culture change by the diabetes healthcare team and a phase of upskilling in assessment procedures. Other outcomes such as rates of admission to hospital, falls rate, changes in cognition and balance, and other functional measures such as walking speed need to become a routine part of the annual review process. Sarcopenia is associated with diabetes (7) and may be an integral phase towards the development of frailty (12). Muscle loss is also accelerated in diabetes (13) and lower limb muscles may be in a profound state of insulin resistance (14). As a consequence, the clinician must now also consider the use of insulin sensitisers combined with weight loss and resistance exercise to improve muscle function in frailty (7). Clinical trial evidence of the benefits or not of resistance training in older people with diabetes and frailty will be available in Mid-2017 EDITORIAL