Continuing diabetes treatment in frail, elderly patients – particularly those in nursing homes – could do more harm than good and reduce their quality of remaining life, according to Dr Roger Gadsby, a GP and diabetes research fellow at the University of Warwick.
Speaking at the 2015 MIMS Clinical Update in London, he warned that the frail elderly, who have difficulty with self-care, are actively excluded in many of the ‘gold standard’ trials that feed into NICE guidelines, meaning evidence for how best to treat these patients is ‘weak or non-existent’.
A NICE expert said its guidelines 'do take account of age', and current evidence showed that patients with multimorbidities can still benefit from the same interventions as those with only one condition.
But Dr Gadsby said that frail elderly patients 'who have reduced life expectancy' needed to be 'treated differently'.
‘The problem we have is that NICE guidelines don’t take any account of age. NICE guidelines are written on the basis that everybody has a single disease problem.
‘The frail elderly, those with cognitive impairment and co-morbidities, have been excluded from the trials that give us evidence for treatment. All the gold standard studies, regarded as the pinnacle of evidence we have, were done in fit healthy people and anybody with significant age-related co-morbidities was excluded.’
GP treatment decisions
The average life expectancy of elderly people going into nursing homes is just 11 months, he said, meaning that the majority of patients admitted to homes are entering their last year of life.
GPs ‘should have a conversation with patients and their families’ at this time and ‘consider changing their treatment’ to reduce polypharmacy and assess whether all aspects of their treatment are still in the patient’s best interest.
Adverse side effects caused by sulphonylurea tablets and insulin injections are the third most common drug-related cause of hospital admission in nursing home patients.
Overtreatment can lead to hypoglycaemia, which in turn can cause hypotension. This can cause falls and fractures and reduced quality of life.
‘We need to think about de-prescribing,’ he said. But it is a fine line, and GPs should keep in mind that being chronically hyperglycaemic can also have an adverse impact on quality of life.
‘One should always be aware that patients, even in a terminal situation, may need to maintain some glucose lowering to protect quality of remaining life,’ he added.
GP patient guidelines
GPs should manage patients over 75 who are still considered to be fit, healthy and able to live independently in accordance with NICE guidelines, Dr Gadsby said.
For frail patients, he recommended freely-available guidance from the International Diabetes Federation (IDF), which provides guidelines specifically targeted at different groups of elderly patients.
Professor Mark Baker, director of the Centre for Clinical Practice at NICE, said: ‘To be clear, NICE clinical guidelines do take account of age and they don’t assume that everyone has single system disease.
‘All the evidence confirms that people who are old and have multimorbidity can also benefit from interventions which work for young people with single system disease. But we acknowledge, and take account of, their different ability to benefit.
‘NICE has mainly been asked to produce guidelines on single conditions, but we are currently developing a guideline on the assessment, prioritisation and management of care for people with commonly occurring multimorbidity. We hope this new work will help inform a practical, tailored approach to managing co-existing conditions.’