The British Journal of Diabetes & Vascular Disease

Frailty and sarcopaenia are commonly used terms in the medical management of older people but their relationship to those with diabetes has not been explored in great detail. In this review, we hypothesise that diabetes and frailty are related conditions, and we attempt to explain the nature of this relationship, and consider the possibility that sarcopaenia is an intermediate step.

Diabetes and frailty may be causally related and operate through each of the key components of the frailty phenotype or via the associated medical co-morbidities. The presence of frailty in a setting of diabetes increases the level of disability and leads to poorer clinical outcomes. The vascular complications of diabetes (both macro- and microvascular) are implicated in this aetiopathogenesis of frailty and any associated mood disturbance or cognitive impairments worsen the outcome. Research into exploring this relationship further is needed and this may lead to more effective interventional strategies.

The objective of this study was to evaluate current practice in the management of glycaemia in patients with diabetes undergoing elective surgical procedures in a single renal unit. We performed an audit of the hospital records of 83 patients undergoing elective surgical procedures at a regional renal unit between January and March 2011. Of these patients 22 had diabetes: four with type 1 diabetes and 18 with type 2 diabetes. During their hospitalisation, glucose control was suboptimal with good diabetic days accounting for 52% of the hospital admission. There was over-reliance on variable rate intravenous insulin, which was prescribed in 59% of patients, of which the majority were deemed inappropriate. Prescription errors were more common when insulin was used, with 67% of prescription charts having at least one dose of insulin omitted or not signed. Oral agents were prescribed and administered accurately in 87% of patients. A hypoglycaemic event was experienced by 22% of patients. In conclusion, patients with diabetes and chronic kidney disease are at risk of suboptimal glycaemic management during hospitalisation for elective surgery. These findings have led to improved pre-operative planning, blood glucose management protocols and targeted education programmes.

Familial hypercholesterolaemia (FH) presents a significant risk for early cardiovascular morbidity and mortality. Several new international guidelines on FH have been published in the last year and similarities and differences between them are described and summarised in this review. New European guidelines discuss other familial dyslipidaemias as well as FH. These guidelines should improve the quality and cost effectiveness of care provided.

Diabetes may become a disabling disease due to diverse mechanisms. Many patients have evidence of physical or cognitive impairments that can markedly influence their ability to diabetes self manage and adversely affect possible outcomes of diabetes care. A screening process for impairment is therefore needed and in frail patients a comprehensive gerontological assessment should be used to improve the efficiency of care. A diabetes educational programme adapted to this population, which has involved the main care-giver has shown its efficacy to improve risk factor control and quality of life in a safer way. The experience of case-managers according to a model of heart failure may be promising for the future.

Type 2 diabetes is historically associated with older adults, and glucose tolerance is known to decline with advancing age. During the course of natural ageing, changes in many peripheral tissues contribute to this deterioration of glucose homeostasis. Included in this process are changes to the structure and function of the pancreatic islets, which undergo deviation in endocrine responses to glycaemic challenge. Current knowledge about the changes seen in the ageing pancreas is reviewed here.

Hyperglycaemia is a significant contributor to the morbidity and premature mortality of type 2 diabetes. There are several glucose lowering agents, with each class having a different mechanisms of action, but their utilisation has to be considered within the context of disease pathogenesis; appropriateness of the agent for the patient, patient lifestyle and personal circumstance, and to some extent treatment costs. The most recent joint policy statement from the American Diabetes Association and the European Association for the Study of Diabetes addresses these issues and provides guidance on strategies for a patient centred approach to the implementation of evidence based medicine. Glycaemic targets are flexible, but early intervention, and therapy as intensive as individual circumstance dictates are recommended.