1
|
Langerman C, Forbes A, Robert G. A qualitative study of the experiences of insulin use by older people with type 2 diabetes mellitus. BMC PRIMARY CARE 2024; 25:180. [PMID: 38778253 DOI: 10.1186/s12875-024-02318-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/22/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND There is a rising prevalence of type 2 diabetes among older people. This population also suffers from co-morbidity and a greater number of diabetes related complications, such as visual and cognitive impairment, which can potentially affect their ability to manage insulin regimens. Understanding the experiences of older people when they transition to insulin will help the development of healthcare interventions to enhance their diabetes outcomes, overall health and quality of life. AIMS The aims of this exploratory study were to (1) understand the experiences of older people with type 2 diabetes in relation to insulin treatment initiation and management and (2) use this understanding to consider how the insulin management support provided to older people by healthcare providers could be more tailored to their needs. METHOD A qualitative study using semi structured (remote) interviews with older people with diabetes (n = 10) and caregivers (n = 4) from the UK. Interviews were audio recorded and transcribed, and framework analysis was used to analyse the data. RESULTS Three main themes, along with six subthemes, were generated from the study data. Participants generally felt at ease with insulin administration following training, yet some reported feelings of failure at transitioning to insulin use. Participants were also frustrated at what they perceived were insufficient resources for effective self-management, coupled with a lack of professional interest in optimising their health as older people. Some also expressed dissatisfaction regarding the brevity of their consultations, inconsistent information from different healthcare professionals and poor treatment coordination between primary and secondary care. CONCLUSION Overall, the study emphasised that older people need better support, education and resources to help manage their insulin use. Healthcare professionals should be encouraged to adopt a more individualised approach to supporting older people that acknowledges their prior knowledge, physical and psychological capabilities and motivation for diabetes self-management. In addition, better communication between different services and greater access to specialist support is clearly needed for this older population. PRACTICE IMPLICATIONS An integrated care pathway for insulin use in older people could be considered. This would include an assessment of the older person's needs and capacity on their initiation to insulin; targeted education and training in self-management; timely access to appropriate emotional and peer support resources; care plans developed collaboratively with patients; and individualised glucose targets that recognise the needs and preferences of the older person.
Collapse
Affiliation(s)
- Chaya Langerman
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK.
| | - Angus Forbes
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Glenn Robert
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| |
Collapse
|
2
|
Reznik Y, Carvalho M, Fendri S, Prevost G, Chaillous L, Riveline JP, Hanaire H, Dubois S, Houéto P, Pasche H, Mianowska B, Renard E. Should people with type 2 diabetes treated by multiple daily insulin injections with home health care support be switched to hybrid closed-loop? The CLOSE AP+ randomized controlled trial. Diabetes Obes Metab 2024; 26:622-630. [PMID: 37921083 DOI: 10.1111/dom.15351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 10/15/2023] [Accepted: 10/15/2023] [Indexed: 11/04/2023]
Abstract
AIM The study aim was to evaluate the feasibility, safety and efficacy of automated insulin delivery (AID) assisted by home health care (HHC) services in people with type 2 diabetes unable to manage multiple daily insulin injections (MDI) at home on their own. PATIENTS AND METHODS This was an open label, multicentre, randomized, parallel group trial. In total, 30 adults with type 2 diabetes using MDI and requiring nursing support were randomly allocated to AID or kept their usual therapy over a 12-week period. Both treatments were managed with the support of HHC services. The primary outcome was the percentage time in the target glucose range of 70-180 mg/dl (TIR). Secondary outcomes included other continuous glucose monitoring metrics, glycated haemoglobin (HbA1c) levels, daily insulin doses, body weight, and of quality of life scores, fear of hypoglycaemia and satisfaction questionnaires. RESULTS Age (69.7 vs. 69.3 years) and HbA1c (9.25 vs. 9.0) did not differ in MDI and AID at baseline. Compared with MDI, AID resulted in a significant increase in TIR by 27.4% [95% CI (15.0-39.8); p < .001], a decrease in time above range by 27.7% and an unchanged time below range of <1%. A between-group difference in HbA1c was 1.3% favouring AID. Neither severe hypoglycaemia nor ketoacidosis occurred in either group. Patient and caregiver satisfaction with AID was high. CONCLUSIONS AID combined with tailored HHC services significantly improved glycaemic control with no safety issues in people with type 2 diabetes previously under an MDI regimen with HHC. AID should be considered a safe option in these people when lacking acceptable glucose control.
Collapse
Affiliation(s)
- Yves Reznik
- Endocrinology and Diabetes Department, CHU Côte de Nacre, Caen Cedex, France and Unicaen, Caen Cedex, France
| | - Martin Carvalho
- Diabetology Department, Vert Coteau Clinic, Marseille, France
| | - Salha Fendri
- Diabetology Department, Amiens University Hospital, Amiens, France
| | - Gaetan Prevost
- Normandie Univ, UNIROUEN, Inserm U1239, CHU Rouen, Department of Endocrinology, Diabetes and metabolic diseases and Inserm CIC-CRB 140, Rouen, France
| | - Lucy Chaillous
- Diabetology Department, Nantes University Hospital, Nantes, France
| | - Jean Pierre Riveline
- Centre Universitaire du diabète et de ses complications, APHP, Hôpital Lariboisière, Paris, Île-de-France, France and Institut Necker Enfants Malades, INSERM U1151, CNRS UMR 8253, IMMEDIAB Laboratory, Paris, France
| | - Hélène Hanaire
- Diabetology Department, Rangueil, Toulouse University Hospital, Toulouse, France
| | - Séverine Dubois
- Diabetology Department, Angers University Hospital, Angers, France
| | | | | | - Beata Mianowska
- Department of Pediatrics, Diabetology, Endocrinology and Nephrology, Medical University of Lodz, Lodz, Poland
| | - Eric Renard
- Department of Endocrinology and Diabetes, Montpellier University Hospital, Montpellier, France and Institute of Functional Genomics, University of Montpellier, CNRS, INSERM, Montpellier, France
| |
Collapse
|
3
|
Langerman C, Forbes A, Robert G. The experiences of insulin use among older people with Type 2 diabetes mellitus: A thematic synthesis. Prim Care Diabetes 2022; 16:614-626. [PMID: 36089508 DOI: 10.1016/j.pcd.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 08/17/2022] [Accepted: 08/22/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Type 2 diabetes mellitus is common in older people. Managing diabetes in older people can be challenging due to comorbidities and age-related disabilities, particularly in the context of insulin therapy. The purpose of this review is to explore older people's experiences of insulin use and to consider how these experiences might inform healthcare delivery. REVIEW METHODS A systematic review with thematic synthesis was conducted and reported in accordance with the PRISMA and ENTREQ statements. MEDLINE, Embase, PsycInfo, CINAHL and Web of Science were searched from 1985 to September 2019 with subsequent updates in December 2019 and June 2022. Included studies were quality appraised, findings tabulated, and results used to inform an integrated thematic synthesis. RESULTS Fourteen studies that reported insulin experiences with 274 patients aged 60 years and over were included; nine of the studies were qualitative and five used questionnaires surveys. Seven themes emerged that were grouped into treatment-related factors (physical impact of insulin, physical capacity to administer insulin, insulin self-management behaviours) and person-centred factors (emotional factors, social factors, daily living, and personal knowledge/beliefs). Three analytical themes to guide clinical practice were derived from the data: addressing physical capacity and ability, supporting social and emotional issues and improving interactions with healthcare professionals. CONCLUSION The review indicates issues surrounding the technical aspects of insulin administration, side effects of treatment and reactions to insulin administration are common amongst older people. However, research evidence is limited, and there is an urgent need for empirical, participatory research with older insulin dependent adults with type 2 diabetes. IMPLICATIONS FOR PRACTICE Healthcare professionals need to ensure that older type 2 diabetes people on insulin are actively involved in their own care, to allow their insulin regimens to be personalised and aligned with their goals and expectations. Tailored educational interventions to reduce treatment hazards and promote physical and psychological wellbeing are also needed for this population.
Collapse
Affiliation(s)
- Chaya Langerman
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, United Kingdom.
| | - Angus Forbes
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, United Kingdom
| | - Glenn Robert
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA, United Kingdom
| |
Collapse
|
4
|
Sloane PD, Pandya N. Individualizing Diabetes Care in Older Persons With Multimorbidity. J Am Med Dir Assoc 2021; 22:1884-1888. [PMID: 34456012 DOI: 10.1016/j.jamda.2021.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 07/21/2021] [Accepted: 07/21/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Philip D Sloane
- Cecil G. Sheps Center for Health Services Research and Departments of Family Medicine and Internal Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Naushira Pandya
- Department of Geriatrics, Nova Southeastern University, Ft Lauderdale, FL, USA
| |
Collapse
|
5
|
Estrada AK, Delgado-Maldonado T, Lara-Ramírez EE, Martínez-Vázquez AV, Ortiz-Lopez E, Paz-González AD, Bandyopadhyay D, Rivera G. Recent Advances in the Development of Type 2 Sodium-Glucose Cotransporter Inhibitors for the Treatment of Type 2 Diabetes Mellitus. Mini Rev Med Chem 2021; 22:586-599. [PMID: 34353256 DOI: 10.2174/1389557521666210805112416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 06/09/2021] [Accepted: 06/16/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Type 2 diabetes mellitus (T2DM) is one of the most serious and prevalent diseases worldwide. In the last decade, type 2 sodium-glucose cotransporter inhibitors (iSGLT2) were approved as alternative drugs for the pharmacological treatment of T2DM. The anti-hyperglycemic mechanism of action of these drugs involves glycosuria. In addition, SGLT2 inhibitors cause beneficial effects such as weight loss, a decrease in blood pressure, and others. OBJECTIVE This review aimed to describe the origin of SGLT2 inhibitors and analyze their recent development in preclinical and clinical trials. RESULTS In 2013, the FDA approved SGLT2 inhibitors as a new alternative for the treatment of T2DM. These drugs have shown good tolerance with few adverse effects in clinical trials. Additionally, new potential anti-T2DM agents based on iSGLT2 (O-, C-, and N-glucosides) have exhibited a favorable profile in preclinical evaluations, making them candidates for advanced clinical trials. CONCLUSION The clinical results of SGLT2 inhibitors show the importance of this drug class as new anti-T2DM agents with a potential dual effect. Additionally, the preclinical results of SGLT2 inhibitors favor the design and development of more selective new agents. However, several adverse effects could be a potential risk for patients.
Collapse
Affiliation(s)
- Ana Karen Estrada
- Laboratorio de Biotecnología Farmacéutica, Centro de Biotecnología Genómica, Instituto Politécnico Nacional, 88710 Reynosa. Mexico
| | - Timoteo Delgado-Maldonado
- Laboratorio de Biotecnología Farmacéutica, Centro de Biotecnología Genómica, Instituto Politécnico Nacional, 88710 Reynosa. Mexico
| | - Edgar E Lara-Ramírez
- Unidad de Investigación Biomédica de Zacatecas, Instituto Mexicano del Seguro Social (IMSS), 98000 Zacatecas. Mexico
| | - Ana Verónica Martínez-Vázquez
- Laboratorio de Biotecnología Farmacéutica, Centro de Biotecnología Genómica, Instituto Politécnico Nacional, 88710 Reynosa. Mexico
| | - Eyra Ortiz-Lopez
- Laboratorio de Biotecnología Farmacéutica, Centro de Biotecnología Genómica, Instituto Politécnico Nacional, 88710 Reynosa. Mexico
| | - Alma D Paz-González
- Laboratorio de Biotecnología Farmacéutica, Centro de Biotecnología Genómica, Instituto Politécnico Nacional, 88710 Reynosa. Mexico
| | | | - Gildardo Rivera
- Laboratorio de Biotecnología Farmacéutica, Centro de Biotecnología Genómica, Instituto Politécnico Nacional, 88710 Reynosa. Mexico
| |
Collapse
|
6
|
van Mark G, Tittel SR, Welp R, Gloyer J, Sziegoleit S, Barion R, Jehle PM, Erath D, Bramlage P, Lanzinger S. DIVE/DPV registries: benefits and risks of analog insulin use in individuals 75 years and older with type 2 diabetes mellitus. BMJ Open Diabetes Res Care 2021; 9:9/1/e002215. [PMID: 34083247 PMCID: PMC8183199 DOI: 10.1136/bmjdrc-2021-002215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 03/24/2021] [Accepted: 03/28/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The aims of this study were to characterize insulin-treated individuals aged ≥75 years with type 2 diabetes using basal insulin analogs (BIA) or regular insulins (human insulin (HI)/neutral protamine Hagedorn (NPH)) and to compare the benefits and risks. RESEARCH DESIGN AND METHODS The analysis was based on data from the DPV (Diabetes-Patienten-Verlaufsdokumentation) and DIVE (DIabetes Versorgungs-Evaluation) registries. To balance for confounders, propensity score matching for age, sex, diabetes duration, body mass index and hemoglobin A1c (HbA1c) as covariates was performed. RESULTS Among 167 300 patients aged ≥75 years with type 2 diabetes (mean age, 80.3 years), 9601 subjects used insulin regimens with basal insulin (HI/NPH or BIA). Of these 8022 propensity score-matched subjects were identified. The mean diabetes duration was ~12 years and half of the patients were male. At the time of switch, patients provided with BIA experienced more dyslipidemia (89.3% vs 85.9%; p=0.002) and took a greater number of medications (4.3 vs 3.7; p<0.001) and depression was more prevalent (8.4% vs 6.5%; p=0.01). Aggregated to the most actual treatment year, BIA was associated with a higher percentage of patients using basal-supported oral therapy (42.6% vs 14.4%) and intensified conventional insulin therapy (44.3% vs 29.4%) and lower total daily insulin doses (0.24 IU/kg/day vs 0.30 IU/kg/day; p<0.001). The study did not reveal significant differences in efficacy (HbA1c 7.4% vs 7.3%; p=0.06), hospitalizations (0.7 vs 0.8 per patient-year (PY); p=0.15), length of stay (16.3 vs 16.1 days per PY; p=0.53), or rates of severe hypoglycemia (4.07 vs 4.40 per 100 PY; p=0.88), hypoglycemia with coma (3.64 vs 3.26 per 100 PY; p=0.88) and diabetic ketoacidosis (0.01 vs 0.03 per 100 PY; p=0.36). CONCLUSION BIA were used in more individually and patient-centered therapy regimens compared with HI/NPH in patients with a mean age of 80 years. Both groups were slightly overtreated with mean HbA1c <7.5%. The risk of severe hypoglycemia was low and independent of insulin type. Further analyses of elderly patients with type 2 diabetes are needed to provide evidence for best practice approaches in this age group.
Collapse
Affiliation(s)
- Gesine van Mark
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Sascha R Tittel
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany
- German Center for Diabetes Research (DZD), München-Neuherberg, Germany
| | - Reinhard Welp
- Department of Internal Medicine, Knappschaftskrankenhaus Bottrop, Bottrop, Germany
| | - Jörg Gloyer
- Center for Diabetes Ludwigsburg, Ludwigsburg, Germany
| | | | - Ralf Barion
- Medical Practice for Internal Medicine and Diabetology Rhein-Sieg, Niederkassel-Rheidt, Germany
| | - Peter M Jehle
- Department of Internal Medicine I, Martin-Luther-University Halle-Wittenberg, University Medicine, Academic Hospital Paul-Gerhardt-Stift, Lutherstadt Wittenberg, Germany
| | - Dieter Erath
- Medical Practice for Internal Medicine Rottweil, Rottweil, Germany
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Stefanie Lanzinger
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany
- German Center for Diabetes Research (DZD), München-Neuherberg, Germany
| |
Collapse
|
7
|
Pandya N, Hames E, Sandhu S. Challenges and Strategies for Managing Diabetes in the Elderly in Long-Term Care Settings. Diabetes Spectr 2020; 33:236-245. [PMID: 32848345 PMCID: PMC7428662 DOI: 10.2337/ds20-0018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Diabetes affects a large number of patients in the long-term care (LTC) setting, and their care is often complicated because of multimorbidity, diabetes-related complications, disability, dependency on caregivers, and geriatric syndromes, including frailty and cognitive impairment. This population includes patients receiving short-term rehabilitation in skilled nursing facilities, those who are residents in LTC facilities, and those receiving palliative or end-of-life care. An individualized approach to care based on clinical complexity, diabetes trajectory, and patients' preferences and goals is required. Such patients may experience one or more transitions of care and decline in condition. They are also prone to adverse drug events, cardiovascular events, and hypoglycemia. Facility-related challenges include varying staff competencies and practitioner preferences, inconsistent interdisciplinary communication, overly complex medication regimens, and poorly implemented care transitions.
Collapse
Affiliation(s)
- Naushira Pandya
- Department of Geriatrics, Nova Southeastern University, Fort Lauderdale, FL
| | - Elizabeth Hames
- Kiran Patel College of Osteopathic Medicine, Fort Lauderdale, FL
| | | |
Collapse
|