DIABETES DIABETES Nearer the End of LifeNearer the End of Life

Ken McHardy &Benjamin Franklin

Inverness 11th Nov 2011

QUOTE for TODAYQUOTE for TODAY

“In this world nothing can be said to be certain, except death and taxes.”

Benjamin Franklin 1789

BENJAMIN FRANKLIN BENJAMIN FRANKLIN [1706-90][1706-90]

• Founding Father of USA• Printer, writer, statesman, soldier, scientist• Lightning rod + Bifocals• Practical democratic puritan values: thrift, hard

work, education, community spirit, opposition to political or religious authoritarianism!

DIABETES NEARER the END DIABETES NEARER the END of LIFEof LIFE

• EPIDEMIOLOGY

• IMPLICATIONS OF DIABETES

• IMPLICATIONS OF BEING OLDER AND LESS ABLE FOR MANAGEMENT OF DIABETES

PREVALENCE OF DIABETESPREVALENCE OF DIABETES• SCOTTISH DIABETES SURVEY (2010)

– Scotland 237,468 (4.6%)– Highland 13,914 (4.5%)

• RATE of INCREASE in GRAMPIAN – May 2002 : 10,500– Dec 2010 : 23,855 (+ 127%)

Prevalence of Type 2 DM: Scotland (SDS 2008)

Prevalence of Type 1 DM in Scotland (SDS 2008)

Proportion of Elderly DiabetesProportion of Elderly Diabetes

WHAT ARE THE RISKS?WHAT ARE THE RISKS?• ACUTE COMPLICATIONS

– DKA & HHS– HYPOGLYCAEMIA

• LONG-TERM COMPLICATIONS– NERVES– EYES– CARDIOVASCULAR– KIDNEYS– FEET

Complication Type 1NHSH

%

Type 1 Scot

%

Type 2NHSH

%

Type 2Scot

%

M.I. 3.9 5.7 10.0 9.8

Stroke 2.3 2.1 5.0 5.4

Renal Replacement 1.2 1.2 0.4 0.4

Retinopathy 51.0 50.2 24.8 25.7

Blindness n = 37 0.0/0.8 0.0/0.7

Foot Ulcer 2.8 7.0 1.9 4.0

LL Amputation 1.1 0.7 0.7 0.5

Prevalence of Complications Prevalence of Complications [2010 Scottish Diabetes Survey][2010 Scottish Diabetes Survey]

www.diabetesinscotland.org.uk/Publications/SDS%202010.pdf

FRAILTY & COMORBIDITYFRAILTY & COMORBIDITY• ASSOCIATED WITH AGE

• ASSOCIATED WITH CHRONIC ILLNESS

• DIFFICULTY IN CLINICAL ENGAGEMENT:– Access - Investigation– Treatment - Application– Susceptibility - Expectations

• THEY DEMAND ADJUSTMENT OF ‘COPING’ STRATEGIES / TARGETS

AGE-RELATED ‘ADAPTATIONS’AGE-RELATED ‘ADAPTATIONS’

• LIMITED EVIDENCE IN ELDERLY• FEW SPECIFIC RESOURCES• WELL-UNDERSTOOD PRINCIPLES• COMPLEXITIES IN DIABETES

– SELF-MANAGEMENT– INDEPENDENCE/DEPENDENCE– COMPLICATIONS BEGET COMPLICATIONS– STANDARDS & PROFESSIONALISM

POTENTIAL RESOURCES FOR DIABETES IN ELDERLY

INSTITUTE FOR DIABETES IN OLDER PEOPLE

Prof Alan Sinclair, University of Bedford

http://instituteofdiabetes.org/

CLINICAL GUIDELINES FOR TYPE 2 DIABETES MELLITUS – European Diabetes Working Party for Older People (2001-4)

GRAMPIAN DIABETES GUIDELINES 2011

www.nhsgrampian.org/guidelines/diabetes/

WHAT IS GOOD CONTROL?WHAT IS GOOD CONTROL?

• NORMOGLYCAEMIA / HbA1C

• LOWER RISK OF COMPLICATIONS• DIMINISHING RETURNS

– LESS LONG-TERM BENEFIT– LESS LONG-TERM!

• HYPOGLYCAEMIC RISK– HIGHER RISK WITH TIGHTER CONTROL– GREATER IMPACT IN FRAIL ELDERLY

SO WHAT is BEST for PATIENTS?SO WHAT is BEST for PATIENTS?

• SENSE AND SENSITIVITY• PATIENT-CENTRED APPROACH• INDIVIDUALLY TAILORED• RANKED PRIORITIES• QUALITY OF LIFE• SUPPORTIVE (HEALTH) CARE• CAPABLE, COMPETENT CARERS• PERMISSION TO MAKE THE BEST CHOICES

The Memoirs of Benjamin Franklin

..including his 13 life principles or virtues [1726]

..or how to approach diabetes management in the elderly [2011]

FRANKLIN’S 13 VIRTUESFRANKLIN’S 13 VIRTUES

• TEMPERANCE. Eat not to dullness; drink not to elevation.

• SILENCE. Speak not but what may benefit others or yourself; avoid trifling conversation.

• ORDER. Let all your things have their places; let each part of your business have its time.

• RESOLUTION. Resolve to perform what you ought; perform without fail what you resolve.

FRANKLIN’S 13 VIRTUESFRANKLIN’S 13 VIRTUES• FRUGALITY. Make no expense but to do good to

others or yourself; i.e., waste nothing.

• INDUSTRY. Lose no time; be always employ'd in something useful; cut off all unnecessary actions.

• SINCERITY. Use no hurtful deceit; think innocently and justly, and, if you speak, speak accordingly.

• JUSTICE. Wrong none by doing injuries, or omitting the benefits that are your duty.

FRANKLIN’S 13 VIRTUESFRANKLIN’S 13 VIRTUES• MODERATION. Avoid extremes; forbear resenting

injuries so much as you think they deserve.

• CLEANLINESS. Tolerate no uncleanliness in body, cloaths, or habitation.

• TRANQUILLITY. Be not disturbed at trifles, or at accidents common or unavoidable.

• CHASTITY. Rarely use venery but for health or offspring, never to dullness, weakness, or the injury of your own or another's peace or reputation.

• HUMILITY. Imitate Jesus and Socrates

THE ENDTHE END

Benjamin Franklin d. 1790buried Philadelphia, Pennsylvania