Older people with type 2 diabetes

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1 Institute of Diabetes for Oder Peope Oder peope with type 2 diabetes European chaenges and the need for improved care

2 Foreword The incidence of type 2 diabetes meitus in Europe is now at epidemic eves. With an estimated 66.5 miion aduts expected to have the condition in ess than 20 years time, individuas, governments and heathcare systems need to address the probems of obesity, sedentary ifestye and diet among popuations to hep reduce the impact of the condition. Diabetes meitus is a highy prevaent metaboic condition in ageing societies associated with high eves of morbidity, mutipe therapies and functiona deterioration that chaenges even the best of heathcare systems to deiver high-quaity, individuaised care. Despite this, internationa cinica guideines have ignored the often-unique issues of fraity, functiona imitation, changes in menta heath and increasing dependency that characterise many aged patients with diabetes. The origina European Diabetes Working Party for Oder Peope (EDWPOP) was estabished in December 2004 to ensure that oder peope in societies across the European Union have consistent and high-quaity diabetes care throughout their ives. Its atest European Guideines address this probem and demonstrate that something can be done to ensure that oder peope with type 2 diabetes are treated appropriatey. This means they can effectivey manage their condition, whie heathcare systems aren t overoaded by oder peope with avoidabe conditions reated to type 2 diabetes. The EDWPOP guideines have been aunched and address care gaps identified in a Position Statement deveoped by the Internationa Association of Gerontoogy and Geriatrics (IAGG), the European Diabetes Working Party for Oder Peope (EDWPOP) and the Internationa Task Force of Experts in Diabetes. The coaborative expert group expored the key issues that affect diabetes in oder peope using a rigorous consensus approach, aong with an evidence-based review of iterature. The Position Statement confirmed the need for specific guideines as previous guideines did not focus on the needs of oder peope. The EDWPOP guideines ca upon a governments, heathcare systems and heathcare professionas in Europe to have a mutidimensiona approach, with an emphasis on prevention of diabetes and its compications and eary intervention, in order to avert a diabetes crisis among oder peope. Professor Aan Sincair Professor of Medicine and Director, Institute of Diabetes for Oder Peope

3 Introduction There is ampe proof of the economic, socia and heath burden of diabetes in the edery popuation. Despite this recognition, diabetes care of oder peope has been reativey negected. In addition, there is itte evidence of structured diabetes care in many nationa diabetes care systems and virtuay no specific provision for those who are housebound or iving in institutiona care. This report highights the growing incidence of type 2 diabetes in Europe among oder peope and its impact on patients and society. The report then provides a summary of the EDWPOP guideines aimed at providing equaity of care for oder peope with diabetes and ensuring that treatment and care pathways are consistent across Europe to hep prevent a diabetes crisis.

4 Diabetes A European Epidemic The number of peope in Europe with diabetes continues to grow. In 2010, there were 55.4 miion peope diagnosed with diabetes a massive 90% of those having type 2 diabetes. 1 The European average prevaence in aduts equates to around 1 in Shockingy though, by 2030 it is estimated that prevaence wi increase to 8.1%, or 66.5 miion aduts with diabetes, a growth of over haf a miion per year. 1 Numbers (in thousands) of aduts with diabetes in Europe, 2010 and Country Numbers/000s (Prevaence) 2010 Numbers/000s (prevaence) 2030 Mean annua increment Europe 55,400 (6.9%) 66,500 (8.1%) 550,000 Begium 610 (8.0%) 750 (9.6%) 7,000 France 4,164 (9.4%) 4,201 (11.0%) 52,000 Germany 7,494 (12.0%) 8,014 (13.5%) 26,000 Itay 978 (12.2%) 1,143 (14.4%) 8,000 Netherands 922 (7.7%) 1,178 (9.5%) 12,800 Portuga 795 (9.9%) 911 (11.5%) 5,800 Spain 2,939 (8.7%) 3,866 (11.1%) 46,000 Sweden 484 (7.3%) 556 (8.0%) 4,000 United Kingdom 2,140 (4.9%) 2,549 (5.4%) 20,000 Shaw Begium France Germany Itay Netherands Portuga Spain Sweden United Kingdom

5 by 2030, it is estimated that prevaence wi increase to 8.1% Rosi Othman / Shutterstock.com

6 Diabetes Increases with age Up to one in five oder peope has diabetes, and a simiar proportion may have undiagnosed diabetes. This is not a trivia disease and it poses many significant chaenges to the deivery of effective care. In peope over 60 years, the prevaence of diabetes is neary seven times that of the age group 1 and over haf (54%) of a peope with diabetes in Europe are aged over It is estimated that over 60% of diabetics wi be aged over 60 by Aduts with diabetes (thousands) in Europe, 2010 and Numbers of aduts with diabetes, thousands, years years years Europe 4,473 (8.1%) 20,739 (37.6%) 29,982 (54.3%) European prevaence 0.7% 3.2% 4.6% Numbers of aduts with diabetes, thousands, 2030 Europe 3,713 (5.6%) 21,839 (33%) 39,831 (60.2%) European prevaence 0.6% 3.3% 6.0% Shaw 2010 Numbers of aduts with diabetes, thousands, years years years Begium France Germany 652 2,792 4,050 Itay 121 1,224 2,581 Netherands Portuga Spain 161 1,009 1,770 Sweden United Kingdom ,306 Shaw years years years

7 over haf of a peope with diabetes in Europe are aged over 60

8 Compications of Diabetes are devastating, but argey avoidabe According to the Internationa Diabetes Federation, compications due to diabetes are a major cause of disabiity, reduced quaity of ife and death. Diabetes compications can affect various parts of the body, manifesting in different ways for different peope. Good management of diabetes reduces the risk of compications. 2 Diabetes is the most common cause of ower imb amputations 10 with 100 amputations a week being carried out due to diabetes. 11 Wordwide, the rate of eg amputations in peope with diabetes is at east 15 times higher than in peope without. 12 Up to 70% of peope die within five years of having a diabetes-reated amputation. 13 Peope with diabetes have around twice the risk of deveoping cardiovascuar disease compared to those without. 3 Amost one in three peope with type 2 diabetes deveop overt kidney disease 4 and diabetes is the singe most common cause of end stage rena disease. 5 Diabetes is the eading cause of bindness in peope of working age in the UK. 6, 7 Peope with diabetes are twice as ikey to have cataracts or gaucoma 8 and 10 to 20 times more ikey to go bind than peope without. 9 Diabetes is the most common cause of ower imb amputations

9 Diabetes care consumes around 10% of European heathcare budgets The demographic changes outined in this report wi produce a wave of oder peope with diabetes up to 2030 and beyond which wi significanty stretch pubic heath resources. Peope with diabetes incur average expenditures per year that are ~2.3 times higher than those for peope without diabetes ( 8,900 per year) biion is spent on diabetes in Europe. 15 This is equivaent to 10% of tota heathcare expenditure and is projected to rise to 94 biion by A European countries are facing an increase in heath spending on diabetes ranging from around 8% to over 30% in some cases. The estimated average yeary cost per patient in Europe is 2, Of these costs, hospitaisations account for the greatest proportion, 55%, with the average ength of stay in hospita annuay being 23 days. In contrast, drug costs are reativey ow, accounting for ony 7% of the tota heathcare costs for diabetes. 16 In a Europe-wide study, 72% of diabetic patients had at east one compication. The most common microvascuar compications were neuropathy, rena damage and retinopathy. 17 The singe factor having the argest impact on costs with type 2 diabetes is the management of diabetes-reated ate compications. 16 Management of compications increases the cost of care by a factor of 2 to More than three-quarters of the goba expenditure in 2010 was used for persons between 50 and 80 years of age. Expenditure wi grow more quicky than the popuation because the prevaence of diabetes wi increase as a resut of ageing. The prevaence of diabetes is much higher in oder age-groups, and because peope who have ived with diabetes for many years have higher rates of compications, which are expensive to treat. Cost of care impact Prevaence Impact on average cost of care compared to patient without compication Average direct medica cost No compications 28% - 1,100 Ony microvascuar 19% 1.7 1,900 compications Ony macrovascuar 9.6% 2.0 2,400 compications Both types of compication 24% 3.5 4,000

10 Caring for the oder person with Diabetes The effective management of the oder patient with diabetes requires an emphasis on safety, diabetes prevention, eary treatment for vascuar disease and functiona assessment of disabiity because of imb probems, eye disease and stroke. Additionay, in oder age, prevention and management of other diabetes-reated compications and associated conditions, such as fraity, cognitive dysfunction, functiona dependence and depression, become a priority. There is a need for specific guideines as previous guideines did not focus on the needs of oder peope: No specia discussion of frai oder peope. Absence of gucose targets for patients with cognitive, depressive or significant physica disabiity. No insight into the deveopment of best cinica practice in subjects with both diabetes and dementia, or those at end of ife. Litte practica advice in taioring therapy to minimise hypogycaemia. The effective management of the oder patient with diabetes requires an emphasis on safety

11 Diabetes Meitus in Oder Peope: Position Statement on behaf of the Internationa Association of Gerontoogy and Geriatrics (IAGG), the European Diabetes Working Party for Oder Peope (EDWPOP) and the Internationa Task Force of Experts in Diabetes Most internationa cinica guideines in diabetes ignore the issues of fraity, functiona imitation, changes in menta heath and increasing dependency that characterise many oder peope with diabetes. In response to this, a coaborative expert group of the IAGG and EDWPOP and an Internationa Task Force expored the key issues that affect diabetes in oder peope using a rigorous consensus approach, aong with an evidence-based review of iterature. The aim of the group is to infuence the cinica behaviour and approach of a heath professionas who deiver diabetes care to oder peope. The resut is the first comprehensive expert-based review of the management of diabetes in oder peope in which evidence-based recommendations have been deveoped. During the course of the review, major research areas within diabetes of od age were identified that need attention. These are summarised in priority order as foows: Methods to decrease hypogycaemia rates in various cinica settings. Heath economic evauations of metaboic treatment. Interventions to deay/prevent diabetes-reated compications that are important in oder age, such as cognitive impairment and functiona dependence. Deveopment of technica devices that hep to maintain autonomy and safety for oder peope with diabetes. These issues need to be part of the foundation for future poicy deveopment in this area and shoud infuence the cinica behaviour and approach of a heath professionas engaged in deivering diabetes care to oder peope. The use of exercise-, nutrition- and gucose-owering therapies in the effective management of type 2 diabetes in oder peope. Practica community-based interventions to reduce hospitaisation. Diabetes Meitus in Oder Peope: Position Statement on behaf of the Internationa Association of Gerontoogy and Geriatrics (IAGG), the European Diabetes Working Party for Oder Peope (EDWPOP), and the Internationa Task Force of Experts in Diabetes. Sincair A, Morey J, et a. Juy 2012.

12 Summary of EDWPOP 2011 Guideines The EDWPOP guideines provide an evidencebased and detaied summary of what heathcare professionas across Europe shoud be doing now to give patients the best diabetes care possibe. They incude: An evidence-based review of treatment for oder peope with diabetes, and are intended as a resource for cinica decision making. A user-friendy set of recommendations for primary care, the community and secondary care settings. Guidance in 18 areas of cinica interest, such as screening and diagnosis, prevention, secondary compications, hypogycaemia, cognitive impairment, fas and immobiity. A section on enhancing the practice and quaity of diabetes care incudes advice on aims of care, education and nutrition, screening and diagnosis, prevention and ifestye changes. A recommendations are supported by sound evidence and are intended to hep carers and cinicians identify probems at an eary stage and reduce the risk of further compications and disabiity. Oder patients often have a number of co-existing conditions for which they may be taking mutipe medications. Recommendations for treatment provides: Cear guidance on gucose reguation in these patients taking into account their ifestye, diet, eve of fraity, other medica conditions and the need to minimise hypogycaemia. Hypogycaemia is undesirabe in any patient, but in the vunerabe oder person it may be particuary dangerous if it eads to confusion and fas. A high percentage of peope in care homes have diabetes but care is often not we-structured, eading to high rates of admission to hospita. The guideines provide practica advice on how to manage diabetes in the care home based around reguar monitoring and education. Finay, the guideines dea with specia categories such as diabetic foot disease, cognitive impairment, fas and immobiity. Sincair AJ, Paoisso G, Castro M, Bourde-Marchasson IB, Gadsby R, Manas LR. European Diabetes Working Party for Oder Peope 2011 Cinica Guideines for Type 2 Diabetes Meitus (EDWPOP). Diabetes & Metaboism 37 (2011) S27-S Shaw JE, Sicree RA, Zimmet PZ. Goba estimates of the prevaence of diabetes for 2010 and Diab Res Cin Prac 2010;7: Stratton IM, Ader AJ, Nei HAW, et a. Association of gycaemia with macrovascuar and microvascuar compications of Type 2 diabetes (UKPDS 35): prospective observationa study. BMJ 2000;321: Emerging Risk Factors Coaboration. Diabetes meitus, fasting bood gucose concentration, and risk of vascuar disesae: a coaborative meta-anaysis of 102 prospective studies. Lancet 2010;375: Department of Heath (2006). Turning the corner: improving diabetes care 5. Department of Heath (2007). Improving diabetes services: the NSF four years on 6. Kohner E, Awinke J, Andrews J, et a. Saint Vincent and improving diabetes care: report of the Visua Handicap Group. Diab Med 1996;13:S Arun CS, Ngugi N, Loveock L, et a. Effectiveness of screening and preventing bindness due to diabetic retinopathy. Diab Med 2003;20: Ederer F, Tayor HR. Senie ens changes and diabetes in two popuation studies. Am J Ophthamo 1981;91: Hamiton AMP, Ubig MW, Pokinghorne P. Management of diabetic retinopathy. BMJ Pubishing Amputee Statistica Database for the United Kingdom (2007). Lower imb amputations. 11. Yorkshire and Humber Pubic Heath Observatory (2011). Hospita Episode Statistics data Bouton AJM. Foot probems in patients with diabetes. In: Hot RIG, Cockram CS, Fyvbjerg A, et a, eds. Textbook of diabetes. Fourth ed. Oxford: Wiey-Backwe. 13. Singh B, et a. Research presented at the Diabetes UK Annua Professiona Conference American Diabetes Association. Economic costs of diabetes in the U.S. in Diabetes Care 2008;31: Zhang P, Zhang X, Brown J, Vistisen D, Sicree R, Shaw J, et a. Goba Heathcare expenditure on diabetes for 2010 and Diabetes Research and Cinica Practice 2010;87: Jonsson B, CODE-2 Advisory Board. Reveaing the cost of Type II diabetes in Europe. Diabetoogia 2002;45:S Wiiams R, Van Gaa L, Lucioni C. Assessing the Impact of Compications on the Costs of Type II Diabetes. Diabetoogia 2002;45:S13-S7.

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