Joint British Diabetes Societies for Inpatient Care (JBDS-IP) Clinical Guideline Inpatient care of the frail older adult with diabetes: an Executive Summary

Type 1 diabetes and frailty: A scoping review

AIMS

Advances in type 1 diabetes management are enabling more to reach older ages. Frailty is known to complicate type 2 diabetes. However, frailty in people with type 1 diabetes has not been extensively researched. This review summarises the available evidence on frailty in those with type 1 diabetes.

METHODS

A systematic search strategy was applied to multiple databases (Medline, Embase, CINAHL and Cochrane) including grey literature (Scopus, OAIster, OpenGrey, dissertation and thesis database). All evidence types were considered. English articles published after 2001 were eligible. For inclusion, participants must have been over 55 with type 1 diabetes. Frailty must have been clearly defined or assessed. The results were synthesised into a descriptive format to identify key themes.

RESULTS

Of 233 papers subject to full-text review, 23 were included. Older adult diabetes research frequently does not specify the type of diabetes; 100 articles were excluded for this reason. No articles were found specifically researching frailty in older adults with type 1 diabetes. Fourteen different definitions and nine assessments of frailty were outlined. Generally, the papers supported relaxation of glucose targets and greater adoption of diabetes technology.

CONCLUSIONS

This review highlights the paucity of evidence in older adults with type 1 diabetes and frailty. Consensus on standardised definitions and assessments of frailty would aid future research, which is urgently needed as more people with type 1 diabetes reach older ages. Identifying and addressing the key issues in this population is vital to support individuals through the challenges of ageing.

Guideline for the Management of Diabetes Mellitus in the Elderly in China (2024 Edition)

With the deepening of aging in China, the prevalence of diabetes in older people has increased noticeably, and standardized diabetes management is critical for improving clinical outcomes of diabetes in older people. In 2021, the National Center of Gerontology, Chinese Society of Geriatrics, and Diabetes Professional Committee of Chinese Aging Well Association organized experts to write the first guideline for diabetes diagnosis and treatment in older people in China, the Guideline for the Management of Diabetes Mellitus in the Elderly in China (2021 Edition). The guideline emphasizes that older patients with diabetes are a highly heterogeneous group requiring comprehensive assessment and stratified and individualized management strategies. The guideline proposes simple treatments and de-intensified treatment strategies for older patients with diabetes. This edition of the guideline provides clinicians with practical and operable clinical guidance, thus greatly contributing to the comprehensive and full-cycle standardized management of older patients with diabetes in China and promoting the extensive development of clinical and basic research on diabetes in older people and related fields. In the past 3 years, evidence-based medicine for older patients with diabetes and related fields has further advanced, and new treatment concepts, drugs, and technologies have been developed. The guideline editorial committee promptly updated the first edition of the guideline and compiled the Guideline for the Management of Diabetes Mellitus in the Elderly in China (2024 Edition). More precise management paths for older patients with diabetes are proposed, for achieving continued standardization of the management of older Chinese patients with diabetes and improving their clinical outcomes.

Treating the Side Effects of Exogenous Glucocorticoids; Can We Separate the Good From the Bad?

It is estimated that 2% to 3% of the population are currently prescribed systemic or topical glucocorticoid treatment. The potent anti-inflammatory action of glucocorticoids to deliver therapeutic benefit is not in doubt. However, the side effects associated with their use, including central weight gain, hypertension, insulin resistance, type 2 diabetes (T2D), and osteoporosis, often collectively termed iatrogenic Cushing's syndrome, are associated with a significant health and economic burden. The precise cellular mechanisms underpinning the differential action of glucocorticoids to drive the desirable and undesirable effects are still not completely understood. Faced with the unmet clinical need to limit glucocorticoid-induced adverse effects alongside ensuring the preservation of anti-inflammatory actions, several strategies have been pursued. The coprescription of existing licensed drugs to treat incident adverse effects can be effective, but data examining the prevention of adverse effects are limited. Novel selective glucocorticoid receptor agonists and selective glucocorticoid receptor modulators have been designed that aim to specifically and selectively activate anti-inflammatory responses based upon their interaction with the glucocorticoid receptor. Several of these compounds are currently in clinical trials to evaluate their efficacy. More recently, strategies exploiting tissue-specific glucocorticoid metabolism through the isoforms of 11β-hydroxysteroid dehydrogenase has shown early potential, although data from clinical trials are limited. The aim of any treatment is to maximize benefit while minimizing risk, and within this review we define the adverse effect profile associated with glucocorticoid use and evaluate current and developing strategies that aim to limit side effects but preserve desirable therapeutic efficacy.

A systematic review of perioperative clinical practice guidelines for care of older adults living with frailty

BACKGROUND

Perioperative frailty is prevalent and requires complex management, which could be guided by clinical practice guidelines (CPGs). The objective of this systematic review was to identify and synthesise CPGs that provide perioperative recommendations specific to older adults living with frailty.

METHODS

After protocol registration, we performed a systematic review of CPGs. MEDLINE, Embase, CINAHL, and 14 grey literature databases were searched (January 1, 2000 until December 22, 2021). We included all CPGs that contained at least one frailty-specific recommendation related to any phase of the perioperative period. We compiled all relevant recommendations, extracted underlying strength of evidence, and categorised them by perioperative phase of care. Within each phase, recommendations were synthesised inductively into themes. Quality of CPGs was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument.

RESULTS

From 4707 citations, 13 guidelines were included; 8/13 were focused on the perioperative care of older surgical patients in general. Among 110 recommendations extracted, 37 themes were generated, with the majority pertaining to preoperative care. Four themes were supported by strong evidence: performing preoperative frailty assessments, using multidimensional frailty instruments, reducing urinary catheter use, and following multidisciplinary care and communication throughout the perioperative period. Per AGREE II, most guidelines (8/13; 62%) were recommended for use with modifications.

CONCLUSIONS

Despite increasing numbers of patients living with frailty, few guidelines exist that address frailty-specific perioperative care. Given the lack of strong evidence-based recommendations, particularly outside the preoperative period, high-quality primary research is required to underpin future guidelines and better inform the care of older surgical patients with frailty.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO CRD42022320149.

Frailty is associated with the progression of prediabetes to diabetes and elevated risks of cardiovascular disease and all-cause mortality in individuals with prediabetes and diabetes: Evidence from two prospective cohorts

AIMS

To investigate the impacts of frailty on the progression of prediabetes to diabetes, cardiovascular disease (CVD) and all-cause mortality in individuals with prediabetes and diabetes.

METHODS

7,933 subjects with prediabetes and diabetes were included from the China Health and Retirement Longitudinal Study (CHARLS) and English Longitudinal Study of Ageing (ELSA). Frailty status was assessed by frailty index and classified as robust, pre-frail, and frail. Logistic regression was used to calculate risks of progression to diabetes. Cox regression was used to calculate risks of CVD and all-cause mortality.

RESULTS

In prediabetes, frail subjects had significantly increased risks of progression to diabetes (CHARLS, OR = 1.55, 95 %CI: 1.09-2.20; ELSA, OR = 1.86, 95 %CI: 1.02-3.37) compared with robust subjects. Frail subjects with prediabetes also presented significantly increased risks of CVD (CHARLS: HR = 1.90, 95 %CI: 1.45-2.48; ELSA: HR = 1.94, 95 %CI: 1.31-2.88) and all-cause mortality (CHARLS: HR = 2.45, 95 %CI: 1.79-3.36; ELSA: HR = 2.13, 95 %CI: 1.46-3.10) than robust subjects with prediabetes. In diabetes, frailty still increased risks of CVD (CHARLS, HR = 2.72, 95 %CI: 1.97-3.77; ELSA, HR = 2.41, 95 %CI: 1.43-4.06) and all-cause mortality (CHARLS, HR = 2.28, 95 %CI: 1.56-3.33; ELSA, HR = 2.28, 95 %CI: 1.47-3.53).

CONCLUSIONS

Frailty is associated with the progression of prediabetes to diabetes and elevated risks of CVD and all-cause mortality in individuals with prediabetes and diabetes.

A Practical Guide for the Management of Steroid Induced Hyperglycaemia in the Hospital

Glucocorticoids represent frequently recommended and often indispensable immunosuppressant and anti-inflammatory agents prescribed in various medical conditions. Despite their proven efficacy, glucocorticoids bear a wide variety of side effects among which steroid induced hyperglycaemia (SIHG) is among the most important ones. SIHG, potentially causes new-onset hyperglycaemia or exacerbation of glucose control in patients with previously known diabetes. Retrospective data showed that similar to general hyperglycaemia in diabetes, SIHG in the hospital and in outpatient settings detrimentally impacts patient outcomes, including mortality. However, recommendations for treatment targets and guidelines for in-hospital as well as outpatient therapeutic management are lacking, partially due to missing evidence from clinical studies. Still, SIHG caused by various types of glucocorticoids is a common challenge in daily routine and clinical guidance is needed. In this review, we aimed to summarize clinical evidence of SIHG in inpatient care impacting clinical outcome, establishment of diagnosis, diagnostic procedures and therapeutic recommendations.

Dexamethasone and oxygen therapy in care home residents with diabetes: a management guide and algorithm for treatment: a rapid response action statement from the European Diabetes Working Party for Older People (EDWPOP) and European Geriatric Medicine Society (EuGMS)

This statement addresses the need to provide clinically relevant and practical guidance for long-term care staff working in care homes and other stakeholders engaged in the care of residents who require consideration for dexamethasone and oxygen therapy. It had been provided following a series of consensus discussions between the EDWPOP and the EuGMS in January and February 2021. Its main aim is to minimise morbidity and mortality from serious acute illnesses including COVID-19 requiring these treatments within the long-term care sector.