Institute of Diabetes for Older People

Aiming for excellence in diabetes care

Current IDOP research activity

One of the key activities of IDOP relates to clinical research and audits of diabetes care. In this part of the website, we have provided some details of projects that IDOP is currently involved with.

Diabetes in Older People – developing initiatives to enhance diabetes care:

A partnership between IDOP and NHS Diabetes

Phase 1

During 2010-11, IDOP and NHS Diabetes (Department of Health) were engaged in promoting a national initiative to enhance diabetes care for older people.

Background:

Diabetes in older people is often a dynamic and complex interaction between the relentless process of ageing, a major metabolic disturbance, widespread vascular disease, and functional loss. Cognitive dysfunction, depressive illness and falls are also important complications which require novel and innovative strategies to minimise their risk of development.  Older people with complex needs require multidisciplinary care, which is well coordinated across primary, secondary and residential care and social services.

As many as 1 in 4 older people in residential and nursing care will have diabetes. As part of the modernisation of the regulatory system, national standards for care homes for older people were published in 2001. They ensure that residents’ health care needs are recognised and met, and that they are cared for by staff who are properly trained (based on NSF Inequalities supplement; 2002).

Inequalities of care are common in many healthcare systems due to variations in clinical practice, particularly in relation to older people. This may be manifest as lack of access to services, inadequate specialist provision, poorer clinical outcomes and patient and family dissatisfaction. Alternatively, older people may experience discrimination in the degree and timing of active management offered compared with younger people.

Other issues which are important include:

  • Age discrimination issues
  • Patient safety (relates to timely access to diagnosis and treatment and minimising adverse effects of treatments such as hypoglycaemia)
  • care of those with cognitive impairment, (diabetes independent risk factor for some dementias)
  • management of pain relief,
  • access to specialist services,
  • informal carer issues,
  • reduced empowerment,
  • inpatient care,
  • delay in treatment with appropriate glucose-lowering therapies,
  • neglect within care homes for diabetic residents,
  • attitudes amongst GPs and other primary and community based staff towards elderly care may affect the quality of care delivered to older patients with diabetes.

These issues overlap with other important key areas: inpatients, ethnicity, self care, equality and commissioning.  They also have the potential to address the special issue of the QOF (Quality Outcomes Framework) exception reporting (housebound, care home resident, etc).

Several of the key projects from this work are presented below.

A Survey of Health Professional Attitudes in Managing Older People with Diabetes

The purpose of this survey was to assess the views and opinions of health professionals on how older people with type 2 diabetes are managed. This was a joint IDOP-NHS Diabetes partnership project. We developed a questionnaire based on the following domains: Hypoglycaemia, Insulin Therapy, Issues of Co-Morbidity, Glucose Targets, Family and Carers Perspectives, Education, the Management of Diabetes within Care Homes, Patient Safety and Respect, Dignity and Culture. We also collected demographic information on the participants.

The questionnaire was sent (online and hard copy) to NHS health professionals: consultant diabetologists, hospital doctors, GPs, staff nurses, practices nurses, community nurses, diabetes specialist nurses (DSNs), dieticians, care home managers, health care assistants (HCAs), in hospitals, care homes and in the community. One hundred and three (n=103) health professionals completed the questionnaire.

This survey identified some key findings and views among health professionals which included some lack of consistency, in most categories. Some of the key points of the Survey are given below:

  • Barriers to effective diabetes care in the community: insufficient diabetes training among health professionals was considered to be the most important barrier, with the second most important barrier being vulnerability to hypoglycaemia.
  • Maintaining qualify of life was considered to be the most important clinical aim amongst health professionals.
  • 29% of health professionals considered that a blood glucose level of <3mmol/L was the definition of hypoglycaemia!
  • One in four health professionals do not consider lipid management to be important.
  • The majority of health professionals felt that at least 50% of all older patients do not manage self-titration with insulin.
  • 50% of health professionals consider an HbA1c of <7% (53mmol/mol) to be indicative of good glycaemic control, with 16% indicating that an HbA1c of <6% (42mmol/mol) to be good glycaemic control!
  • 44% only of health professionals felt that the care plan for residents of care homes was adhered to on a regular basis in management decisions.
  • 54% only of health professionals felt that patients with diabetes understood the importance of adherence to treatment.

These findings are probably indicative of a number of important issues in managing older people with diabetes where lack of knowledge, inconsistent approaches to care, and system failures contribute to a quality of care that is often sub-optimal. The Older People’s Diabetes Network (OPDN) will be taking forward some strategies to deal with these concerns.

The Bedfordshire and Hertfordshire Care Home Pilot Audit

This audit was carried out by IDOP and overseen by a multi-agency group (Diabetes UK, ABCD, NHS Diabetes, RCN, RCP, CQC. The audit proforma was based on the recommendations of the Diabetes UK national diabetes guidance for care homes ((Good Clinical Practice Guidelines for Care Home Residents with Diabetes (2010) available at www.diabetes.org.uk)

Some of the provisional results demonstrated included:

(a) variations in diabetes service provision across both geographical counties

(b) a lack of empowerment and knowledge of diabetes among residents

(d) a high rate of hospitalisation of residents with diabetes in the preceding year

(e) a lack of awareness of key diabetes publications in the area by care home managers

(f) a lack of a written diabetes care policy in one-third of care homes and in those with a policy, a lack of information about hypoglycaemia and annual review procedures, etc

(g) a lack of screening procedures for diabetes on admission

These finding indicate considerable evidence of likely shortcomings in quality diabetes care within care homes. The Diabetes UK national guidance should go some way to  addressing these concerns but work by the OPDN will assist in disseminating best clinical practice. A partnership between IDOP and the NDIS will lead to a national audit of diabetes care within care homes being undertaken in 2012.

Phase 2

Older People’s Diabetes Network

IDOP has been commissioned by NHS Diabetes in a collaborative extension of existing work to develop a national (England) Older People’s Diabetes Network consisting of identifying regional Working Groups led by Regional Champions in the four major geographical regions. Each region is being supported by a dedicated Network Coordinator.

The primary objectives of this work have been identified as follows:

(a)   Identify and establish a group of regional champions for diabetes in the elderly

(b)   Establish a priority list of ‘working areas’ within diabetes and older people that address the key issues of quality of life/well being, hospital avoidance, and patient safety that will form the task platform for the regional leads (champions)

(c)    Provide resources that support a series of working groups comprising regional leads

(d)   Working with the RCGP, PCDS and ABCD, agree a series of diabetes standards for older people within primary and community care: these will complement existing NICE standards and the European Diabetes Working Party for Older People (EDWPOP) which are in press.

(e)   Professor Sinclair, as national clinical lead for diabetes in older people, to CHAIR a ‘network’ of regional champions and be responsible for leading on strategy

Leads

Professor Alan Sinclair, IDOP Director and Chair of National Steering Group

Julian Backhouse, NHS Diabetes Lead

Network Champions

North – Dr Ahmed H Abdelhafiz Consultant Geriatrician Rotherham General Hospital

Midlands (inc East Anglia) – Fiona Kirkland Consultant Nurse for Diabetes

South Staffordshire Primary Care Trust

South – Dr Simon Croxson Consultant physician Bristol Royal Infirmary

London – Professor Angus Forbes The Florence Nightingale School of Nursing and Midwifery King’s College London

Network Coordinators

North – Julia Hobbs

Midlands – Binal Anandji

South – Alison Fowler

London – Lisa Philimore

Diabetes Self-management and Cognitive Function

As part of the educational approach to improving diabetes care, health professionals encourage people with diabetes to self-manage their condition. This often involves acquiring knowledge about diabetes and blood glucose monitoring skills, meal planning, and how to manage diabetes on sick days. A certain level of mental performance is required to successfully self-manage diabetes and for those whose mental or cognitive performance is impaired, self-management skills may be affected.

Ali Tomlin is a final year PhD student working within IDOP who has investigated the key components of diabetes self-management in older people and her thesis will provide new insights into the relationship between diabetes and cognition. This work may provide a platform for more routine testing of cognition in people with diabetes in order for early changes to management being implemented.

The Mini-Cog Project

Routine testing of cognition in people with diabetes is infrequent, even in hospital settings. This project, supported by NHS Diabetes and its Clinical Director, Dr Rowan Hillson, aims to identify a suitable, rapid, valid measure of cognition that can be used to screen for cognitive impairment in people with diabetes.

201 patients were seen in four primary care settings, three in Luton, Bedfordshire and one in Nuneaton, Warwickshire. Eligible subjects were aged 55 years and older, diagnosed with type 1 or 2 diabetes, without a prior diagnosis of cognitive impairment. Most patients were screened by a practice nurse at a routine primary care clinic appointment.

This work is being undertaken in partnership with Professor Roger Gadsby of Warwick University. The analysis of the data is being carried out by Professor Tony Bayer of Cardiff University and a paper for publication is being prepared.

Early detection of infection in older subjects with diabetes

People with diabetes may be at increased risk of developing infections in their skin, urine, and chest. This may be more prevalent when their metabolic control is poor or they have other comorbidities or drugs which influence their immune status. In partnership with Cranfield University, IDOP is supporting David Pitts who is a doctorate student at Cranfield in developing an early febrile detection monitor using the latest medical technology. The device is shortly to be tested in small clinical trials, after ethics approval.