Professor Alan Sinclair explains how care should be personalised and targets adapted for older people with diabetes, including an assessment of frailty

SINCLAIR_Alan

Professor Alan Sinclair

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Read this article to learn more about:

  • how to recognise the key features of frailty
  • methods that are currently advocated for the assessment of frailty
  • how to plan key aspects of managing frailty in diabetes.

Implementation actions for STPs and ICSs

Implementation actions for clinical pharmacists in general practice

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Frailty and sarcopenia (age-related muscle loss associated with reduced power) are emerging as newly recognised complications of diabetes in older people. In view of their capacity to cause considerable disability, frailty and sarcopenia should become a major cause for concern and have increased importance in future public health policy decisions.1 Type 2 diabetes is a risk factor for the development of both frailty and sarcopenia.2 Thus a key strategy will be how to implement preventive action to reduce the risk of these complications developing in people with diabetes. Since regular exercise and optimal nutrition can lessen the risk of both diabetes and frailty, a national initiative aimed at improving activity levels and nutrition in older people may have significant advantages in delaying or preventing these adverse health conditions.3

What is frailty?

Frailty is an adverse health state represented by an increased vulnerability to physical or psychological stressors as a result of decreased physiological reserve, affecting multiple organ systems that create a limited capacity to maintain homeostasis.4 Two conceptual models form the basis of what most clinicians regard as frailty. The first is the physical phenotypic model of Fried et al,5 which defines frailty in a person who meets at least three of the following criteria:

  • upper and lower extremity weakness
  • poor exercise tolerance
  • exhaustion
  • weight loss.

The second is the accumulative deficit model, which comprises a multimorbidity basis for poor clinical outcomes.6 The prevalence of physical frailty is in the range 14–24% in older people and is associated with poor survival in a dose–response manner.7

The National Collaborative Stakeholder Group on frailty in diabetes

In 2017, an international position statement on the management of frailty in diabetes mellitus was published. This represented the first global attempt to provide a framework for action in managing older people with diabetes and frailty.8 Following this, a national UK collaborative stakeholder group developed a framework document Type 2 diabetes mellitus in older people: a brief statement of key principles of modern day management including the assessment of frailty, published in 2018.9 This laid the groundwork for the assessment and detection of frailty in primary care along with key management aspects. The intention was to introduce consistency in the provision of care in this area, with the hope that a new framework would bring with it improvements in the diabetes care delivered and enhanced clinical outcomes. It is worth noting that this collaborative document may have played a part in influencing the UK Government’s decision to introduce a number of new indicators to the 2018/19 quality and outcomes framework (QOF) for diabetes that take account of frailty (see Table 1).10

Table 1: QOF indicators for ongoing management of diabetes that include mention of frailty11
QOF indicator referenceNICE 2018 menu IDIndicatorPointsAchievement thresholds

DM019

NM159

The percentage of patients with diabetes, on the register, without moderate or severe frailty in whom the last blood pressure reading (measured in the preceding 12 months) is 140/80 mmHg or less

10

38–78%

DM020

NM157

The percentage of patients with diabetes, on the register, without moderate or severe frailty in whom the last IFCC-HbA1c is 58 mmol/mol or less in the preceding 12 months

17

35–75% 

DM021

NM158

The percentage of patients with diabetes, on the register, with moderate or severe frailty in whom the last IFCC-HbA1c is 75 mmol/mol or less in the preceding 12 months

10

52–92%

DM022

NM162

The percentage of patients with diabetes aged 40 years and over, with no history of cardiovascular disease and without moderate or severe frailty, who are currently treated with a statin (excluding patients with type 2 diabetes and a CVD risk score of <10% recorded in the preceding 3 years)

4

50–90%

QOF=quality and outcomes framework; IFCC=International Federation of Clinical Chemistry and Laboratory Medicine; HbA1c =glycated haemoglobin; CVD=cardiovascular disease

British Medical Association, NHS England. 2019/20 General Medical Services (GMS) contract Quality and Outcomes Framework (QOF). BMA, NHSE; 2019. Available at: www.england.nhs.uk/wp-content/uploads/2019/05/gms-contract-qof-guidance-april-2019.pdf

Contains public sector information licensed under the Open Government Licence v3.0.

This article highlights five key take-home messages from the national stakeholder document,9 which aim to address the special concerns and challenges of frailty care in diabetes.

1. Understand that frailty is a serious but avoidable complication of diabetes

Diabetes is a risk factor for the development of frailty and is also associated with hypertension, renal dysfunction, and a dementia subgroup.9,12–14 Diabetes appears to increase the risk of disability measured by mobility disturbances and a restriction of activities of daily living by about 50–80%, and this risk increases with age.15 Frailty is considered to be a pre-disability condition,1 and therefore management strategies should focus on prevention of disability through timely interventions.

2. Be aware of the shortfalls of current international guidance

A number of international clinical guidelines for managing older people with type 2 diabetes have been developed, and while they have been well received, most have been developed for specialist care or general global adoption and have not addressed the important issue of how to stimulate and encourage uptake of recommendations in varied primary care settings.16–18 The collaborative framework document attempts to address this shortfall by providing assessment and detection methods for frailty that can easily be introduced in primary care (see Figure 1).9 The authors have also reviewed the evidence base to provide implementable glycaemic targets that are aligned with specific categories of frailty; these now allow a more meaningful interpretation of the new frailty-related QOF standards.9

Figure describing a frailty assessment pathway for patients with diabetes

Figure 1: Frailty assessment pathway in diabetes8,9

Adapted from Strain W, Hope S, Green A, Kar P, Valabhji J, Sinclair A. Type 2 diabetes mellitus in older people: a brief statement of key principles of modern day management including the assessment of frailty. A national collaborative stakeholder initiative. Diabet Med 2018; 35 (7): 838–845.
© The Authors. Reproduced with permission.

3. Use simple methods to detect frailty and assess functional status

The framework document supports the view that detecting frailty in the community brings about new opportunities for targeted interventions that reduce functional decline and the risk of disability. In the previous GP Contract (2017/18), GPs were encouraged to identify frailty in people aged 65 years and over using the recently introduced electronic Frailty Index (eFI) (see Table 2). This assessment tool, developed following analysis of over 2000 Read codes, enables primary care software systems (EMIS Web and SystmOne) to automatically derive a frailty index score without the need for actual physical assessment. This means that the clinician does not have to carry out any direct assessments or procedures to derive a frailty score.19

Although there is likely to be a need for software improvements to more accurately derive the eFI in primary care, this tool appears to be helpful for highlighting the importance of frailty in these settings. However, clinicians are only likely to appreciate what frailty is, what it looks like in older people, and what can be done to reverse it, by taking a thorough history, using physical assessment methods, and gaining experience from tailoring interventions to manage frailty effectively. To this end, a 4-metre gait speed evaluation and a timed get-up-and-go test, in conjunction with the eFI, are invaluable tools for the assessment of frailty in primary care.

Table 2: Electronic Frailty Index scores for different categories of frailty20,21
eFI scoreCategoryDescription

0–0.12

Fit

People who have no or few long-term conditions that are usually well controlled. This group would mainly be independent in day-to-day living activities

0.13–0.24

Mild frailty

People who are slowing up in older age and may need help with personal activities of daily living such as finances, shopping, transportation

0.25–0.36

Moderate frailty

People who have difficulties with outdoor activities and may have mobility problems or require help with activities such as washing and dressing

>0.36

Severe frailty

People who are often dependent for personal care and have a range of long-term conditions/multimorbidity. Some of this group may be medically stable but others can be unstable and at risk of dying within 6–12 months

eFI=electronic Frailty Index

4. Tailor goals of care with measures of frailty status

The writing group of the stakeholder document acknowledged concerns about the increasing reports of polypharmacy in older adults with diabetes, the personal and public burden (GP and ambulance call outs, hospitalisation) of hypoglycaemia, and the lack of individualised targets being used in routine clinical practice. For frail older adults with diabetes, a consensus view is that very few people aged 70 years and over with diabetes benefit from intensive glucose control targets measured by glycated haemoglobin (HbA1c) of less than 53 mmol/mol (<7.0%) as the available evidence does not support these strict limits.22 A target range of 53–58 mmol/mol (7.0–7.5%) seems appropriate for people who are functioning well, but in people with features of moderate-to-severe frailty, a more appropriate HbA1c target is 64 mmol/mol (8.0%). For people with severe frailty, the HbA1c target is further increased to 70 mmol/mol (8.5%) (see Table 3).9

Table 3: Recommended therapeutic targets and treatment de-escalation thresholds9
 De-escalation threshold Treatment target
 

Threshold

Suggested interventions

Targets

Interventions

The fit older adult with diabetes

53 mmol/mol

(7.0%)

Evaluate long-acting sulfonylurea and insulin therapy that may cause hypoglycaemia. Consider appropriate dosage in setting of renal function.

58 mmol/mol

(7.5%)

Avoid initiating new agents that may cause hypoglycaemia or exaggerate weight loss.

Moderate–severe frailty

58 mmol/mol

(7.5%)

Discontinue any sulfonylurea if HbA1c below threshold. Avoid TZDs because of risk of heart failure. Cautious use of insulin and metformin mindful of renal function.

64 mmol/mol

(8.0%)

DPP-4 inhibitors and longer-acting insulins have demonstrated safety. TZDs may increase risk of heart failure. SGLT-2 inhibitors may provide additional benefit in people with heart failure but also exacerbate symptoms of diabetes.

Very severe frailty

64 mmol/mol

(8.0%)

Withdraw sulfonylureas and short-acting insulins because of risk of hypoglycaemia. Review timings and suitability of NPH insulin with regard to risk of hypoglycaemia. Therapies that promote weight loss may exacerbate sarcopenia.

70 mmol/mol

(8.5%)

DPP-4 inhibitors at renally appropriate dose for those close to target. Consider once-daily morning NPH insulin or analogue alternatives if symptomatic nocturnal hyperglycaemia. Educate carers and relatives regarding risk of hypoglycaemia.

HbA1c =glycated haemoglobin; TZD=thiazolidinediones; DPP-4=dipeptidyl peptidase-4; SGLT-2=sodium-glucose co-transporter-2; NPH=neutral protamine Hagedorn

Strain W, Hope S, Green A, Kar P, Valabhji J, Sinclair A. Type 2 diabetes mellitus in older people: a brief statement of key principles of modern day management including the assessment of frailty. A national collaborative stakeholder initiative. Diabet Med 2018; 35 (7): 838–845.

© The Authors. Reproduced with permission.

5. Take specific actions to improve patient outcomes

There are certain practical and important management actions that underpin improved quality of care for older adults with diabetes and frailty (see Box 1).

Box 1: Management actions to improve care for frail older adults with diabetes9

  • People with diabetes who are aged 65 years and over should be assessed for frailty (including severity of frailty) using the eFI tool and a few simple physical assessments
  • Glycaemic targets should be sensible, safe, and appropriate and should be aimed at keeping patients free from adverse events, and maintaining functional status and quality of life
  • All older adults with diabetes and frailty should have their medications regularly reviewed and be considered for a de-intensification approach where appropriate:23
    • although there are no real restrictions on glucose-lowering agents in frail older people with diabetes, caution must be exercised with longer-acting sulfonylureas, complex insulin regimens, undernutrition, care home residency, and severe frailty, all of which increase the risk of hypoglycaemia
    • the use of agents such as SGLT-2 inhibitors and thiazolidinediones (pioglitazone) should be limited in moderate-to-severe frailty in view of adverse side-effects including weight loss, dehydration, and possible toe amputations (SGLT-2 inhibitors),24 as well as the risk of heart failure, fractures, and bladder cancer.25 GLP-1 receptor agonists can cause weight loss and anorexia, and should only be used with great caution
  • The frailty diabetes pathway should form part of a wider diabetes service for older people that addresses concerns such as frailty, multimorbidity, and cognitive impairment
  • Healthcare professionals who are directly involved in managing diabetes in older people should receive education and training to upskill in the area of frailty and functional evaluation to be able to deliver informed enhanced care.
eFI=electronic frailty index; SGLT-2=sodium-glucose co-transporter-2; GLP-1=glucagon-like polypeptide-1

Conclusion

The UK collaborative stakeholder initiative outlines how management of diabetes should be tailored towards older people with frailty.9 Assessment of functional status and the diagnosis of frailty can be achieved in primary care with minimum training and should be a routine element of care in older people with diabetes.

A large, randomised controlled trial of resistance training and nutritional education in people aged over 70 years with diabetes and frailty demonstrated significant improvements in functional status after just 16 weeks and maintained at 1 year, and was associated with significant healthcare cost savings (mainly hospitalisation costs).26 Studies like this demonstrate that the situation is not irreversible—primary care professionals managing older people with diabetes and frailty should feel inspired, as planned interventions do bring about benefits for patients.

Professor Alan Sinclair

Association of British Clinical Diabetologists; Director, Foundation for Diabetes Research in Older People; co-author of the collaborative stakeholder initiative for the management of type 2 diabetes in older people

Implementation actions for STPs and ICSs

written by Dr David Jenner, GP, Cullompton, Devon

The following implementation actions are designed to support STPs and ICSs with the challenges involved with implementing new guidance at a system level. Our aim is to help you consider how to deliver improvements to healthcare within the available resources.

  • Agree a local approach to identifying and assessing frailty, noting that the electronic Frailty Index (eFI) is already built into general practice systems and forms part of the GP contract and QOF
  • Seek to refine assessments of frailty for people with diabetes identified by eFI as having moderate or severe frailty using the examination techniques highlighted by the national stakeholder document
    • for severe frailty this could be built into the annual review mandated by the GP contract and, for moderate frailty, into the annual diabetes review
  • Personalise treatment targets for HbA1c, blood pressure, and lipids in older frail people with diabetes in accordance with their needs and the risk of side-effects
  • Review medication for patients with diabetes and frailty through pharmacist-led targeted medication reviews to identify potential polypharmacy and drug interactions.

STP=sustainability and transformation partnership; ICS=integrated care system; eFI=electronic Frailty Index; QOF=Quality and Outcomes Framework; HbA1c =glycated haemoglobin

Implementation actions for clinical pharmacists in general practice

written by Anjna Sharma, Director of Pharmacist Services, Soar Beyond Ltd

The following implementation actions are designed to support clinical pharmacists in general practice with implementing the guidance at a practice level. 

With the focus in the PCN DES on structured medication reviews for older people, the GP clinical/PCN pharmacist is now more instrumental in driving better outcomes for older patients. With an average PCN population of 30,000–50,000 patients, stratifying older patients with type 2 diabetes should be an excellent starting point for implementing the 2020 DES.

Furthermore, for the first time, QOF now incentivises practices to individualise and de-intensify medications by aiming to have 52–92% of patients ‘on the register, with moderate or severe frailty in whom the last IFCC-HbA1c is 75 mmol/mol or less in the preceding 12 months’.

Our recommendations for pharmacists at network or at practice level are as follows:

  • Stratify patients who are at highest risk and agree a PCN-wide approach. If you have care homes, for example, consider starting here first
  • Know your eFI codes and the corresponding relaxed glycaemic targets for frail older people—this will help you to identify those at highest risk and relevant treatment goals
  • Run searches to identify and quantify highest risk groups such as:
    • patients aged over 65 years who are on a long-acting sulfonylurea
    • patients with severe frailty (>0.36) with a SNOMED code of type 2 diabetes with a HbA1c target below 70 mmol/mol
    • other groups, such as moderate to severely frail patients on insulin may not be within your scope of competence, but you can and should still identify them and lead a network/practice approach to ensure they are not slipping through the net 
  • Put forward a simple case for why and how you would advise these patients are appropriately de-escalated and what support is needed to do this safely
  • Know your scope of competence—perhaps start with moderately frail patients because they may be less vulnerable to destabilisation. Polypharmacy reviews and de-escalation of treatment will take confidence and competence. Always ensure adequate supervision and ensure carers are informed along the way.
  • Learn how to conduct simple frailty assessments such as the get-up-and-go test. Start to identify patients with type 2 diabetes in your long-term condition clinics who may be at risk of becoming frail or being too intensively treated and take preventative action by proactively treating to relaxed targets.

PCN=Primary Care Network; DES=Directed Enhanced Service; QOF=Quality and Outcomes Framework; IFCC=International Federation of Clinical Chemistry and Laboratory Medicine; HbA1c=glycated haemoglobin; eFI=electronic Frailty Index

References

  1. Sinclair A, Abdelhafiz A, Rodríguez-Mañas L. Frailty and sarcopenia—newly emerging and high impact complications of diabetes. J Diabetes Complications 2017; 31 (9): 1465–1473.
  2. Sinclair A, Morley J. Frailty and diabetes. Lancet 2013; 382 (9902): 1386–1387.
  3. Sinclair A, Dunning T, Rodríguez-Mañas L. Diabetes in older people: new insights and remaining challenges. Lancet Diabetes Endocrinol 2015; 3 (4): 275–285.
  4. Bergman H, Ferrucci L, Guralnik J et al. Frailty: an emerging research and clinical paradigm—issues and controversies. J Gerontol A Biol Sci Med Sci 2007; 62 (7): 731–737.
  5. Fried L, Tangen C, Walston J et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56 (3): M146–M156.
  6. Rockwood K, Mitnitski A. Frailty in relation to the accumulation of deficits. J Gerontol A Biol Sci Med Sci 2007; 62 (7): 722–727.
  7. Shamliyan T, Talley K, Ramakrishnan R, Kane R. Association of frailty with survival: a systematic literature review. Ageing Res Rev 2013; 12 (2): 719–736.
  8. Sinclair A, Abdelhafiz A, Dunning T et al. An International Position Statement on the management of frailty in diabetes mellitus: summary of recommendations 2017. J Frailty Aging 2018; 7 (1): 10–20.
  9. Strain W, Hope S, Green A, Kar P, Valabhji  J, Sinclair A. Type 2 diabetes mellitus in older people: a brief statement of key principles of modern day management including the assessment of frailty. A national collaborative stakeholder initiative. Diabet Med 2018; 35 (7): 838–845.
  10. Diabetes Times. New QOF indicators added to menu by NICE. 2018. diabetestimes.co.uk/new-qof-indicators-added-to-menu-by-nice/ (accessed 1 August 2019).
  11. British Medical Association, NHS England. 2019/20 General Medical Services (GMS) contract Quality and Outcomes Framework (QOF). BMA, NHSE; 2019. Available at: www.england.nhs.uk/wp-content/uploads/2019/05/gms-contract-qof-guidance-april-2019.pdf
  12. Fukazawa R, Hanyu H, Sato T et al. Subgroups of Alzheimer’s disease associated with diabetes mellitus based on brain imaging. Dement Geriatr Cogn Disord 2013; 35 (5–6): 280–290.
  13. Hirose D, Hanyu H, Fukasawa R et al. Frailty in diabetes-related dementia. Geriatr Gerontol Int 2016; 16 (5): 653–655.
  14. Mehta H, Mehta V, Goodwin J. Association of hypoglycaemia with subsequent dementia in older patients with type 2 diabetes. J Gerontol A Biol Sci Med Sci 2017; 72 (8): 1110–1116.
  15. Wong E, Backholer K, Gearon E et al. Diabetes and risk of physical disability in adults: a systematic review and meta-analysis. Lancet Diabetes Endocrinol 2013; 1 (2): 106–114.
  16. Sinclair A, Paolisso G, Castro M et al. European diabetes working party for older people 2011 clinical guidelines for type 2 diabetes mellitus. Executive summary. Diabetes Metab 2011; 37 (Suppl 3): S27–S38.
  17. Kirkman M, Briscoe V, Clark N et al. Diabetes in older adults. Diabetes Care 2012; 35 (12): 2650–2664.
  18. Dunning T, Sinclair A, Colagiuri S. New IDF Guideline for managing type 2 diabetes in older people. Diabetes Res Clin Pract 2014; 103 (3): 538–540.
  19. Millares-Martin P. Large retrospective analysis on frailty assessment in primary care: electronic Frailty Index versus frailty coding. BMJ Health Care Inform 2019; 26. DOI: 10.1136/bmjhci-2019-000024.
  20. Clegg A, Bates C, Young J et al. Development and validation of an electronic frailty index using routine primary care electronic health record data. Age Ageing 2016; 45: 353–360.
  21. De Blase S. The electronic Frailty Index guidance notes. Yorkshire and Humber Academic Health Science Network Improvement Academy. Available at: improvementacademy.org/documents/Projects/healthy_ageing/eFI%20Guidance%20SystmOne%20Notes%20for%20HAC%20Partners.pdf
  22. Hambling C, Khunti K, Cos X et al. Factors influencing safe glucose-lowering in older adults with type 2 diabetes: a PeRsOn-centred ApproaCh To IndiVidualisEd (PROACTIVE) Glycemic Goals for older people: a position statement of Primary Care Diabetes Europe. Prim Care Diabetes 2019; 13 (4): 330–352.
  23. Abdelhafiz A, Sinclair A. Deintensification of hypoglycaemic medications: use of a systematic review approach to highlight safety concerns in older people with type 2 diabetes. J Diabetes Complications 2018; 32 (4): 444–450.
  24. NICE. Type 2 diabetes in adults: management. Evidence reviews for SGLT-2 inhibitors and GLP-1 mimetics. NICE Guideline 28. NICE, 2018. Available at: www.nice.org.uk/guidance/ng28/evidence/march-2018-evidence-reviews-for-sglt2-inhibitors-and-glp1-mimetics-pdf-4783687597
  25. Turner R, Kwok C, Chen-Turner C et al. Thiazolidinediones and associated risk of bladder cancer: a systematic review and meta-analysis. Br J Clin Pharmacol 2014; 78 (2): 258–273.
  26. Rodríguez-Mañas L, Laosa O, Vellas B et al. Effectiveness of a multimodal intervention in functionally impaired older people with type 2 diabetes mellitus. J Cachexia Sarcopenia Muscle 2019; 10 (4): 721–733.