Toward a Comprehensive Diabetes Care Model for Older People

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1 Toward a Comprehensive Diabetes Care Model for Older People Professor L. Rodriguez Mañas Hospital Universitario de Getafe Madrid, Spain Professor Alan J Sinclair Professor of Medicine and Consultant Diabetologist University of Bedfordshire Luton, UK

2 WHY? MAJOR IMPACT ON POPULATION WITH A TENDENCY TO INCREASE Hossain P, et al. NEJM 2007;356:213-5.

3 DEMOGRAPHIC REASONS Global diabetes prevalence by age and sex for 2000 Estimated number of people with diabetes (millions) MAINLY IN OLDER PEOPLE Developed countries Wild et al. Diabetes Care 2004; 27:

4 WHY? With consequences on function and QoL Arthritis Obesity Diabetes HBP Dyslipidemia Microvascular Disease Macrovascular Disease Visual Impair. Muscle weakness Cognitive impairment CVD Disability Falls

5 Time of DM and its complications were related to the risk of functional impairment in older people Wu JH, Diabetes care 2003;26(2):314

6 Diabetes Mellitus as a Risk Factor for Admission to a Care Home Canadian Study of Health and Aging 1996 Cross-sectional evaluation of a sample of 1258 residents (aged 65y and over) and 9413 community-living older people across Canada Medical factors associated with institutionalisation were: OR Cognitive impairment (CIND) 29.1 A.D Functional impairment Diabetes mellitus 1.51 Stroke 1.58 Parkinson s Disease 2.06 Rockwood K et al, 1996

7 and modulated by comorbid chronic conditions Maggi S, Diabetologia 2004; 47:1957

8 Diabetes Models: Main Requirements Sinclair AJ 2002 Must be compatible with the main elements/events observed in clinical practice Assist in developing concepts in diabetes care, e.g. metabolic, vascular, rehabilitation approaches Provide a basis for developing a hypotheses or research question to be tested, e.g. benefit of one care model compared with another Should enable us to predict a likely event or scenario, e.g. development of an adverse event, e.g. care home dependency in an aged diabetic subject

9 What other Factors influence Model Development? Use of Diabetes in Older People as an Example Disability and frailty modulate the type of care to be provided New technologies open oportunities for a friendly management Different therapeutic targets in older people Opportunity to save costs (benefits for the system), improve quality of life (benefits for the patient), and promote innovation (benefits for enterprises)

10 Metabolic Targeting in Geriatric Diabetes: Single disease versus functional limitation model (including frailty) 1 / 3 1 / 3 1 / 3 Independent in self-care, mobile and mentally alert/single medical disorder: Aim - strict glycaemic and blood pressure control - active lipid lowering Relatively independent with some evidence of functional decline and several co-morbidities Aim - optimise glucose and blood pressure control - consider lipid lowering High dependency and frailty; may be in a nursing home Aim - symptom control - avoid hypoglycaemia and over-monitoring EWPDOP Guidelines, 2011

11 Intervention Models in Diabetes in Old Age Major Types and Basic Requirements Metabolic Model traditional; physician-orientated Vascular Model active assessment; combined physician / surgeon approach Functional Model disability and chronic disease theme; interdisciplinary approach Essential requirements: focused / targeted; clinically and cost effective Delay the onset of, or reduce likelihood of, frailty. Sinclair AJ. J Roy Coll Phys. 2000

12 Requirements of an Integrated Diabetes Care Model Focused on the patient and its functional status/quality of life Bridges cultural/ethnic boundaries Integrates structures and patient education Information system supported by?tele- Medicine approaches?internet-linked clinical support models Carer involvement strategies Cost-effect Diabetes Care Well-motivated and trained healthcare personnel

13 The Utrecht Diabetes Project: Use of Telemedicine to support Type 2 Diabetes Care Rutten et al, 2001 Review of service after 8 years (n = 336) Compared with entry: HbA 1 c, , p< Cholesterol, , p< TG, , p = Excellent record keeping Main reason for UDP aid: diabetics of recent onset, at risk of macrovascular complications, or needing insulin; about 1:3 were >75y

14 Identifying the Most Appropriate Model of Diabetes Care to adopt Category of Patient Single Disease Non-frail, nondisabled Some Functional Limitation Frail patients without disability Highly disabled older patients Proposed Model GP-led* or Integrated Care Integrated Care GP-led* Model Comments (* with Diabetes Specialist Nurse where possible) Equally appropriate Self-management essential AR mandatory Strict metabolic targets Most become Integrated Care after 5-10 years Commonest Model Requires Consensus Guidelines/Protocols Enhance Self-Management IT/information support essential Focuses on maintaining Functional Status/minimising vascular complications Often care home resident/carer support required Symptomatic relief/avoid metabolic decompensation Hypoglycaemia Maintain mobility and avoid falls

15 Care Model for Older People with Diabetes:Summary Diabetes mellitus in older people represents a unique challenge where the maintenance of the functional status is mandatory Several Diabetes Intervention and Care Models can be implemented although all of them would meet the following elements Elements Shared Care Continuum of Care Integration of Care Coordinated Care