NHS is urged to implement guidelines to improve care of older people with diabetes

BMJ 2013; 346 doi: (Published 06 March 2013) Cite this as: BMJ 2013;346:f1512
  1. Ingrid Torjesen
  1. 1London

Older people with diabetes are missing out on the essential care and aggressive treatment that can stop them developing complications, the Institute of Diabetes for Older People has warned.

The institute held a conference on 5 March to promote use of guidelines on type 2 diabetes in older people, developed by the European Diabetes Working Party for Older People.1 It launched a document outlining the particular problems faced by older people with diabetes and how doctors, nurses, and care home managers could deal with such problems.2

The prevalence of diabetes in people aged over 60 years is nearly seven times that in the 20-39 age group, it said. Over half (54%) of the 3.8 million people with diabetes in the United Kingdom are aged 60 years or over, and this proportion will reach 60% by 2030. Older people with diabetes account for 10% of health expenditure and take up 15% of hospital beds. By 2030 it is estimated that they will occupy 25% of beds. Furthermore, 27% of elderly people in residential care have the condition.

Yet while younger people are routinely offered newer, aggressive treatments, such as glucagon-like peptide-1 (GLP-1) agonists or dipeptidyl peptidase-4 (DPP-4) inhibitors to prevent complications of diabetes, elderly people often remained on older treatments, said Alan Sinclair, director of the Institute of Diabetes for Older People.

Older people also often missed out on the regular checks that they needed to manage their condition and to pick up the development of complications because they were frail and could not travel or had been admitted to residential care and slipped out of the system, he added.

“If nothing is done now to improve the care of older people with type 2 diabetes, the effect on patients and the NHS could be catastrophic. The impending diabetes time bomb could potentially bankrupt the already stretched service,” he said.

Rowan Hillson, national clinical director for diabetes at the Department of Health for England, said that the challenge was getting the guidelines implemented in practice.

“We need to ensure that GPs are aware of these guidelines, ensure that junior doctors training in hospitals are aware of them, and I think in particular we should try and get them into the curriculum for trainees in care of the elderly medicine,” she said.

People aged over 55 years were more likely as a group than younger people to receive the appropriate annual checks that they needed and to control their risk factors, but Hillson said, “Everyone over 55 is a considerable mix of people, and that conceals large numbers of older people with diabetes who are not necessarily getting the best care. And there is a particular issue for people with diabetes in care homes.”

Sinclair said that complications were an important factor in the development of disability, which further worsened a deteriorating quality of life of older people, in particular the most frail and those who had been admitted to care homes. “It is this disabling feature of diabetes which for many years has not been the focus of attention,” he said.

The European Diabetes Working Party for Older People’s 2011 guideline emphasises the need to actively look for diabetes in patients aged 70 years or over. Once the illness is identified, the guideline says that an individualised approach to diabetes care is needed, which takes into consideration the presence of change in physical performance, mental ability, and the ability of patients to care for themselves. Changes in mobility, visual performance, and cognitive performance need to be screened for at the time of diagnosis and regularly thereafter.

Sinclair said, “Enhancing the quality and quantity of diabetes care for older people in the UK requires those responsible for delivering diabetes care to be aware of this evidence based guidance, which sets new but realistic targets for care in multiple areas. Clinicians and commissioners should not rely on standard adult guidelines for diabetes, as these do not embrace the special needs of this often vulnerable population.”


Cite this as: BMJ 2013;346:f1512