Assessment of frailty in the person with type 2 diabetes mellitus: Expert analysis

INTRODUCTION

People with type 2 diabetes mellitus (DM2) have a higher prevalence of frailty compared to those without DM2. However, there is a lack of consensus on the diagnosis and clinical management of frail individuals with DM2.

OBJECTIVES

This study aims to identify limitations and current needs in the use of the frailty concept in PCDM2 (people with DM2), as well as define and evaluate the dimensions that should be included in its routine clinical assessment.

METHODS

A multidisciplinary team of eight health professionals from different hospitals in Spain participated in a process based on the nominal group technique.

RESULTS

The study identified eight limitations in the assessment of frailty in PCDM2, categorized by importance, and 10 unmet needs related to the diagnosis and follow-up of the disease. Additionally, seven dimensions were identified that should be included in the definition of frail individuals with DM2, prioritized by importance and novelty.

CONCLUSIONS

This article aims to increase knowledge and usage of the frailty concept in individuals with DM2 within the medical community. It also suggests the potential for future projects to develop a consensus definition of frailty tailored to this specific group.

[Prevention and treatment of infectious diseases in diabetic patients]

The bidirectional relationship between infectious diseases and diabetes is well-known. On the one hand, diabetes patients are at a higher risk of presenting with infectious diseases, possibly with more severity, and on the other hand, infectious diseases impair metabolic control in patients with diabetes. Population ageing arises partly due to an increased survival rate in chronic diseases, of which diabetes is amongst them. Improving infectious disease prevention could reduce complications arising from the former diseases, consequences of decompensated diabetes condition (morbidity, incapacity, hospital admissions, healthcare costs, and mortality rates) and result in improved quality of life in patients with diabetes. The current review presents the treatment of infectious diseases in patients with diabetes and the dealing with immuno-preventable diseases with the currently advised vaccinations.

[Treatment of type 2 diabetes mellitus in elderly patients]

The prevalence of type 2 diabetes mellitus (DM2) increases markedly with age. Antidiabetic treatment and the objectives of glycaemic control in elderly patients with DM2 should be individualised according to their biopsychosocial characteristics. In elderly patients for whom the benefits of intensive antidiabetic treatment are limited, the basic objectives should be to improve the quality of life, preserve functionality and avoid adverse effects, especially hypoglycaemia. Treatment of DM2 in the elderly was the subject of a consensus document published in 2012 and endorsed by several Spanish scientific societies. Since then, new therapeutic groups and evidence have emerged that warrant an update to this consensus document. The present document focuses on the therapeutic aspects of DM2 in elderly patients, understood as being older than 75 years or frail.

Treatment of type 2 diabetes mellitus in elderly patients

The prevalence of type 2 diabetes mellitus (DM2) increases markedly with age. Antidiabetic treatment and the objectives of glycaemic control in elderly patients with DM2 should be individualised according to their biopsychosocial characteristics. In elderly patients for whom the benefits of intensive antidiabetic treatment are limited, the basic objectives should be to improve the quality of life, preserve functionality and avoid adverse effects, especially hypoglycaemia. Treatment of DM2 in the elderly was the subject of a consensus document published in 2012 and endorsed by several Spanish scientific societies. Since then, new therapeutic groups and evidence have emerged that warrant an update to this consensus document. The present document focuses on the therapeutic aspects of DM2 in elderly patients, understood as being older than 75 years or frail.

[Methodological aspects of integrated care pathways]

An Integrated Healthcare Pathway (PAI) is a tool which has as its aim to increase the effectiveness of clinical performance through greater coordination and to ensure continuity of care. PAI places the patient as the central focus of the organisation of health services. It is defined as the set of activities carried out by the health care providers in order to increase the level of health and satisfaction of the population receiving services. The development of a PAI requires the analysis of the flow of activities, the inter-relationships between professionals and care teams, and patient expectations. The methodology for the development of a PAI is presented and discussed in this article, as well as the success factors for its definition and its effective implementation. It also explains, as an example, the recent PAI for Hypoglycaemia in patients with Type 2 Diabetes Mellitus developed by a multidisciplinary team and supported by several scientific societies.

[Contributions of SGLT-2 and new drugs under investigation]

DeFronzo spoke of the "ominous octet", in which he referred to the existence of distinct pathways and organs related to the physiopathology of type 2 diabetes mellitus (DM2). One of these key organs is the kidney, which plays an important role in regulating glucose metabolism through gluconeogenesis and through glomerular filtration and glucose reabsorption in the proximal convoluted tubules. Approximately 180 g of glucose are filtered to the renal tubule from the blood stream through the glomerulus. The filtrate is subsequently reabsorbed from the tubules to the peritubular capillaries through the action of sodium glucose cotransporters (SGLT). There are 2 main cotransporters in the kidney, SGLT1 and SGLT2, which reabsorb the glucose (10% and 90%, respectively) and return it to the blood. In persons with DM2, SGLT2 is increased, leading to greater renal absorption of glucose, which has adverse effects as it contributes to the maintenance of hyperglycemia. Selective pharmacological SGLT2 inhibition increases renal glucose excretion and secondarily reduces its plasma values. SGLT2 inhibitors act exclusively on the kidney, reduce glycosylated hemoglobin (HbA1c) by about 0.66%, decrease blood pressure, and induce a weight loss of approximately 1.8 kg. These drugs have a low risk of hypoglycemia but carry an increased risk of genitourinary infections. Several clinical trials have shown that dapagliflozin (10mg/day), the first SGLT2 inhibitor commercialized in Spain, produces a statistically significant reduction in HbA1c of 0.82-0.97%, both in monotherapy and in combination with metformin, glimepiride, pioglitazone, or insulin. Its use produces a weight loss of between 2 and 3 kg and reduces both systolic and diastolic blood pressure, while the risk of hypoglycemias is low.

[Blood pressure control in a population of hypertensive diabetic patients treated in primary care: PRESCAP-Diabetes Study 2010]

OBJECTIVES

To determine the level of blood pressure (BP) control in hypertensive diabetic patients treated in primary care and to determine the factors associated with poor control.

MATERIAL AND METHODS

A cross-sectional, multicentre study that enrolled hypertensive diabetics recruited by consecutive sampling by family doctors in Spain in June 2010. A mean BP of less than 140/90mmHg was considered as good control of arterial hypertension. The percentages of patients with<130/80mmHg PA, 140/80mmHg, and 140/85mmHg, respectively, were also determined. Sociodemographic, clinical, cardiovascular risk factors, and pharmacological treatments were recorded.

RESULTS

A total of 3,993 patients were enrolled (50.1% female) with a mean age (standard deviation) of 68.2 (10.2) years, of whom 73.9% received combination therapy. The figures showed good control of both blood pressure values (<140/90mmHg) in 56.4% (95% CI: 54.3 to 58.4) of the cases, with 58.5% (95% CI: 57.0-60.0) only in systolic BP, and 84.6% (95% CI, 83.2 to 85.8) only in diastolic BP. The variables with strongest association with poor control were the presence of albuminuria, elevated total cholesterol, physical inactivity, and not taking the medication on the day of the interview.

CONCLUSIONS

The PRESCAP-Diabetes 2010 study results indicate that 43.6% of diabetics with hypertension seen in primary care have a poorly controlled BP, in particular, systolic BP.