The DIADEM project was devised to address the knowledge gap in managing patients with diabetes and dementia. The aim was to assess all patients admitted with both conditions and focus on medication review, 'de-intensification' or simplification, and an individualised care plan. The combined co-morbidity and cost of diabetes and dementia is increasing, but current evidence, especially clinically-relevant studies, is poor, with no clear understanding of ‘real-world’ management.
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This project is unique in targeting this subgroup of patients. People with diabetes and dementia are particularly vulnerable, with significant care needs and management concerns. Though awareness of the older adult with diabetes is not new, few initiatives focus on this subgroup, let alone the particularly vulnerable group of those with cognitive impairment. People with diabetes and dementia are often overlooked in diabetes care due to the nature of their condition; they may not attend reviews and can be particularly frail or unable to get to reviews. Current guidance on the older adult does not always specify patients with dementia and, until recently, guidelines were not specific in their advice on medications to use or discontinue. Evidence has only assessed current management and offered suggestions for ‘common-sense’ approaches, with no data on practical application or how to approach such patients. The DIADEM project used a considered, novel approach to address this significant gap in care and knowledge and provide a solution to this long-standing concern. The project required detailed planning. A large number of these patients are admitted to secondary care services owing to various acute illnesses and this presented an ideal initial setting to address their unmet care needs. All patients admitted with diabetes and dementia, regardless of reason for admission, were reviewed using a DIADEM assessment tool to provide a focused management plan and an up-to-date log of their diabetes. In a primary care setting it can be difficult to assess control as a current blood test may not be available (and obtaining blood tests may be difficult due to patient compliance) and gaining understanding blood sugars and nutritional needs may not be straightforward. As all patients admitted had a blood test or were in an environment where blood tests could be obtained, up-to-date Hba1c and glycaemic parameters could be assessed. A clear plan was documented in the notes and followed, with focus on individualised glycaemic targets and medication management, as well as complication risk. This allowed a truly holistic approach to managing the diabetes, drawing on the latest test results, blood glucose monitoring, nutritional intake, vascular risk and care requirements, as well as subsequent care plans with family involvement.
Once the DIADEM tool had been created for the assessment team, elderly care doctors and nurses (including matrons and ‘think glucose’ champions), acute medical unit teams and diabetes nurses were asked to identify patients with both co-morbidities and refer or notify the team. The online ‘think glucose’ system was adapted to allow referrals to be made for ‘dementia’. The service was advertised in the local Trust magazine and the regional Royal College of Physicians’ newsletter. The tool was presented at diabetes and elderly care departmental meetings and in junior doctor induction and teaching sessions. Regular rounds were implemented once a week on two sites as an outreach service, to identify patients on medical and surgical wards. Details were suggested for highlighting in discharge summaries and sometimes dictated letters were sent to primary care. An up-to-date database was created of patients seen, characteristics, outcomes and whether they were readmitted.
Retrospectively, 350 patients were reviewed, with a median age of 84 and median HbA1c of 51mmol/mol. Medication history was obtained for 256 (73.1%) patients. Three had medication adjusted on discharge, with the remainder continuing on admission medication. All those assessed would benefit from focused diabetes care and medication management. Subsequently, 148 patients were prospectively reviewed by the DIADEM team, 75 (50.6%) female, with a mean age of 81. Mean Hba1c 59mmol/mol. 29 vs 44 (21% vs 41.9%) patients were on no medications pre vs post review; 64 vs 40 (46.4% vs 38.1%) were on one medication; 33 vs 18 (23.9% vs 17.1%) on two medications and 12 vs 3 (8.7% vs 2.9%) on over two medications. Insulin prescriptions reduced from 43 to 25 (31.2% to 23.8%) and overall hypoglycaemia-causing medications reduced 57 to 33 (41.3% to 31.4%). 28 (18.9%) patients were readmitted within the following four months for non-diabetes/glycaemia- related conditions. Cost saving from medication cessation alone was £5,897.47/year (based on BNF data), but further cost savings from reduced hypoglycaemia and ambulance call-outs/admission reduction added to this. DIADEM is a validated method of inpatient assessment with proven benefits financially, to patient safety (via reducing hypoglycaemia risk) and reduced polypharmacy.
Sustainability and Spread
This project used existing resources and time. It could easily be implemented in other settings. The initial project was for one year, but the Trust diabetes team is committed to continuing it. Given that new inpatient older adult guidelines are being drafted, this project is one step ahead and can be used as a template for other Trusts. It will also be shared with Diabetes UK as part of its shared care initiative. Articles were written for the RCP West Midlands newsletter and the Trust magazine to highlight the project both regionally and locally. Data from the project was presented at Diabetes UK APC and submitted for EASD 2018. Following the project, the lead was involved in the development of JBDS inpatient guidelines for older adults and specifically the section on diabetes and dementia. Sharing of practice and ideas has continued at various conferences and national/local talks. The next stage will be primary care and care home implementation.
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