A hospital survey of the care of elderly patients with diabetes mellitus

Age and Ageing,  Sept, 1996  by A.K. Fletcher,  J. Dolben

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Introduction

Elderly patients are at particular risk of developing the complications of diabetes, with hypoglycaemia, ocular complications and foot ulcers being particular problems in this group [1-6]. Characteristics of elderly patients that compound the risk, such as living alone, poor eyesight and the presence of neuropathy are very common [7]. The elderly population should have easy access to chiropody and ophthalmic services [7-9], but the availability and uptake of these services has not been clearly described.

The purpose of this study was to examine the care of elderly patients with diabetes mellitus. We had four main aims: first to assess the general supervision of the patients' diabetes; second to document the treatments of these patients and identify inappropriate drug therapy; third to assess the level of uptake of chiropody services and correlate this with the number of risk factors for foot problems; and fourth to determine the number of patients examined by fundoscopy and the prevalence of diabetic retinopathy.

Methods

One hundred patients with diabetes mellitus who were over the age of 65 years were studied after admission to the medicine for the elderly unit of St James's University Hospital. All patients with diabetes mellitus were studied sequentially, irrespective of their treatment with diet, oral hypoglycaemic agents or insulin. Inclusion in the study was restricted to those patients with a pre-hospital diagnosis of diabetes mellitus as reported by the patient, their relatives, the general practitioner, or the hospital notes. No exclusions were made on the basis of intercurrent illness or inability to answer questions. At the time of the study, the medicine for the elderly unit in this large teaching hospital comprised nine integrated wards for patients over the age of 65 years. The patients were medically supervised by a team of six consultant physicians for the elderly.

Details of patients' age and treatment were recorded. Type of diabetes was recorded as treated with diet alone, oral hypoglycaemic agent treated, or insulin treated. In a structured interview, questions were asked about the uptake of chiropody services and the presence or absence of risk factors for foot problems. Risk factors were considered to be the presence of foot deformity (such as corns, bunions), the presence of sensory neuropathy, blindness or partial sight, living alone and the development of past or present foot ulcers. The responsibility for supervision of the patient's diabetes was recorded. The interview established whether the patient underwent annual fundoscopy by a medical practitioner, and whenever the patient had been examined by an ophthalmologist. In those patients unable to answer questions because of intercurrent illness or cognitive impairment, information was sought from the patients' relatives and/or general practitioners.

Each patient was interviewed and examined by the same observer (A.K.F.). The feet were examined for deformity (corns, callus, nail pathology, hallux valgus, hammer toe, overriding toes) and for the presence of sensory neuropathy. This was identified by standard neurological examination of both lower limbs, using pinprick, vibration and light touch modalities of sensation. Neuropathy was considered present if all three modalities were absent in one or both of the patient's feet. Fundoscopy was performed after dilatation of both pupils with 0.5% tropicamide and the presence of diabetic retinopathy documented.

Results

One hundred patients from all medicine for the elderly wards were studied over a period of 3 months; 33 patients were men and 67 women. The mean age was 82.7 years (range 66-97 years). Complete assessment was possible in 90 patients. Information about chiropody service uptake and annual fundoscopy was not available in ten patients (due to patients' or relatives' uncertainty or patients' intercurrent illness). In these ten patients, however, all other aspects of the assessment were possible.

Forty patients had diabetes controlled by diet alone 44 were controlled by oral hypoglycaemic agents and 16 were treated with insulin.

Supervision of diabetes had been undertaken by general practitioners in 41 cases; by hospital clinic in 40 cases and 19 patients received no specific supervision of their diabetes. The responsibility for the supervision of each type of diabetic patient is shown in Figure 1.

[Figure 1 ILLUSTRATION OMITTED]

Of those patients who were treated with oral hypoglycaemic agents, 24 patients were treated with gliclazide, 13 were treated with glibenclamide, seven were treated with metformin, three were treated with chlorpropamide and one was treated with acarbose. Four patients treated with glibenclamide were treated concurrently with metformin and one patient treated with glibenclamide was treated concurrently with acarbose.

Five of those patients treated with glibenclamide or chlorpropamide were being supervised by their general practitioner, seven at a hospital clinic and one was not receiving any supervision.