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Transferring elderly type 2 patients to insulin:a prospective study of diabetes nurses’,physicians’ and patients’ perceptions

C Taylor*, K Towse, M Reza†, JD Ward, T J Hendra

ABSTRACTWe have prospectively studied the decision and expectations associated with starting insulin for elderly type 2 patients. Thirty con-secutive patients who were referred to start insulin were studied; most started treatment promptly though more than 25% experi-enced delays of more than three months. Patients, diabetes nurses and physicians did not differ in their reasons for starting insulinthough there were differences in treatment goals, with physicians, but not nurses or patients, identifying glucose level targets asimportant aims of treatment (p < 0.05). Most patients injected insulin twice daily, and performed regular capillary glucose moni-toring, but hypoglycaemia was not a problem. We conclude that elderly patients differ from health professionals in their expectationsof insulin, but that with careful patient selection this treatment is a safe option for elderly patients. Copyright © 2002 John Wiley& Sons, Ltd.

Practical Diabetes Int 2002; 19(2): 37-39

KEY WORDS type 2 diabetes mellitus; elderly patients; insulin treatment; treatment goals

IntroductionSustained improvement in quality of life isthe goal of diabetes care for elderly patients.However patients and health professionalsmay differ in their priorities as to what con-stitutes quality care in the clinic environ-ment. Patients may place a greater empha-sis upon seeing the same doctor than uponmedical investigations and interventions1.

Clinic doctors may be good at addressingmetabolic control but pay less attention toconcerns about medication, other illnessand the social issues of coping with dia-betes2. Differences may also exist betweeninsulin and tablet treated patients as to theweighting placed upon different aspects ofthe clinic interaction such as treatment,education and complications3.

For the elderly type 2 patient with poorglycaemic control the decision to startinsulin may be delayed because of concernsabout their ability to administer injectionsand monitor capillary glucose levels, as wellas the effects of hypoglycaemia. Delays instarting insulin may, however, lead tochronic hyperglycaemic malaise, poor qual-ity of life, patient dissatisfaction with tak-ing large numbers of tablets, as well as therisk of microvascular complications. Thedecision to start insulin will involve bothpatient and doctor though each may havediffering perceptions of the need, urgencyand goals of this treatment. This paperdescribes the process and reasons for start-ing insulin, the duration and reasons forany delay in starting insulin and also theaims/goals of insulin treatment as perceivedby the patient, diabetes nurse and physi-cian, in elderly people with type 2 diabetesattending our clinics.

Method and patientsData was prospectively collected on 30consecutive elderly type 2 subjects referred

from the adult diabetes clinics and the dia-betes for the elderly clinic, at the RoyalHallamshire Hospital, to diabetes special-ist nurses (DSNs) to start insulin. Allpatients were aged over 60 years and hadsymptomatic poor glycaemic controldespite maximum tolerated doses of oralmedication.

Following referral each patient, DSNand physician was asked to prospectivelyidentify their perceptions of the reasons forand goals of insulin treatment. Individualpatient’s notes were perused to determinewhether there had been any delay in start-ing insulin on the basis of written entriesin the notes. Patient cognitive functionwas formally assessed using the HodkinsonAbbreviated Mental Test Score3 andFolstein Minimental State4 questionnaires.Each patient’s ability to perform the activ-ities of daily living was also assessed usingthe modified Barthel Index5.

ResultsThe median age of the patients was 72years (range 62–90 years), the majority ofwhom (60%) were women. Ten patients(33%) were living alone while 20 (67%)lived with a spouse, partner or other fami-ly member. Patients had very poor gly-caemic control as demonstrated by mean(SD) total glycated haemoglobin (HbA1)levels of 13.0 (1.7)% (normal non-diabet-ic range 3.5–6.8%). As a group thepatients were also cognitively intact with

Caroline Taylor, RGN Dip N, DiabetesSpecialist NurseK Towse, RGN, Diabetes Specialist NurseM Reza, MRCP, Senior RegistrarJD Ward, MD FRCP, Consultant Physicianand DiabetologistT J Hendra, MD FRCP, ConsultantPhysician and GeriatricianThe Diabetes Centre, Royal HallamshireHospital, Sheffield, UK

*Correspondence to: Miss C. Taylor,Diabetes Specialist Nurse, DiabetesCentre, A Floor, Royal HallamshireHospital, Glossop Road, Sheffield, SouthYorkshire, S10 2JF, UKEmail: Carolin.Taylor@sth.nhs.uk

†Present post: Consultant Physician andGeriatrician, Royal Hospital, Chesterfield,UK.

Contract/grant: Lilly Industries (UK)

Received: 24 March 2000Accepted in revised form: 22 November 2001

Pract Diab Int March 2002 Vol. 19 No. 2 Copyright © 2002 John Wiley & Sons, Ltd. 37

the majority having the maximum score of10 on the Abbreviated Mental Test(AMT), and the median score on theFolstein Minimental Test (FMMT) being27/30. Ninety per cent of patients scoredmore than 7/10 on the AMT, and 77%scored more than 23/30 on the FMMS,which are the recognised cut-off scoresbelow which patients may be regarded asbeing cognitively impaired and possiblysuffering with dementia. Also mostpatients were independent in their abilitiesto perform the activities of daily livingwith a median Barthel Index of 19/20.

Patients, DSNs and physicians did notdiffer in their reasons for starting insulin(Table 1 – χ2, p = ns). Although all threegroups identified relief of hyperglycaemicsymptoms as a reason for insulin treat-ment, whereas DSNs and physiciansidentified poor glycaemic control as a rea-son for starting insulin, most patients didnot.

Treatment goals, however, differedbetween patients, DSNs and physicians(χ2, p < 0.05). In this patient group morephysicians identified target glucose levelsas an important aim of insulin treatment.Although some patients were relativelyasymptomatic, the majority expectedinsulin to improve well-being by relievingsymptoms of hyperglycaemic malaise,tiredness and lethargy.

Delays of more than three monthsbetween the question of insulin beingmentioned in the notes and starting treat-ment were identified in eight cases (27%),whereas the majority of patients (16(53%)) started insulin promptly.

Most patients (22 (73%)) injected theirown isophane or soluble/isophane insulinmixtures, while 10% of patients reliedupon a carer. Only one patient, who wasseverely cognitively impaired, received asingle injection of insulin zinc suspensionby the district nurse. The median dailyinsulin dosage was 32 U (range 16–106U), reflecting an insulin requirement of0.45 ± 0.14 U kg-1 to maintain glucose val-ues usually between 9 and 11 mmol L-1.Most patients (67%) performed capillaryglucose testing themselves while theremainder were monitored by their careror district nurse. Hypoglycaemia was aninfrequent problem in this patient cohortin that six (20%) patients had minor hypo-glycaemic episodes whilst only once did apatient require help from a third party. Allpatients continued with insulin except onewho reverted to tablets due to new stroke-related disability.

DiscussionThis was a prospective study of clinicalpractice in a hospital that has a dedicatedclinic for elderly patients. Interpretation ofthe findings should take into account thatat the outset these patients were selected bytheir doctors as being suitable for insulintreatment, which is reflected in the num-ber of patients whose mental test scoreswere within the normal range and whowere also independent with the activitiesof daily living. Most patients could betaught about capillary glucose testing, tar-get glucose values and the management ofhypoglycaemia.

Identified reasons for starting insulinwere similar for patients, DSNs and physi-cians. However the goals of insulin dif-fered between the groups with patientsbeing interested in symptoms and well-being whereas physicians also had con-cerns about glucose targets. The latterreflected both concerns about improvingglycaemic control in order to avoid

microvascular complications and avoid-ance of low glucose values, which couldincrease the risk of hypoglycaemia. Thepatient-centred approach resulted in somepatients being set relatively high glucosetargets well away from the hypoglycaemicrange but sufficient to avoid osmoticsymptoms whilst others with microvascu-lar complications were set and achievedtarget glucose values of 6–9 mmol L-1.

Insulin treatment for poorly controlledelderly type 2 patients is a trial that reliesupon good patient selection, the settingand monitoring of appropriate glycaemictargets6 and the expertise of DSNs to edu-cate and supervise elderly patients andtheir carers in the community2. The DSNneeded to spend more time than foryounger adults with one to one (asopposed to group) education sessions andalso visited most patients at home to eval-uate their circumstances and accuratelyunderstand the hypoglycaemic risks foreach patient. Contact and support from

38 Pract Diab Int March 2002 Vol. 19 No. 2 Copyright © 2002 John Wiley & Sons, Ltd.

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Transferring elderly type 2 patients to insulin

Keypoints● In elderly patients with type 2 diabetes, around one-quarter will experience delays

in the medical decision to commence insulin, leading to chronic hyperglycaemicsymptoms and poor quality of life.

● Although doctors may place a greater emphasis on improved glycaemic control withinsulin treatment, diabetes nurses and patients are more concerned with improvedwell-being.

● The decision to start insulin should involve not just the doctor and patient, but thediabetes nurse and carers too.

● A full social, physical and mental functional assessment is vital to identify potentialdifficulties in self-care for elderly patients starting on insulin.

Table 1. Perceptions for starting, and goals of, insulin treatment

Patient Diabetes nurse Physician

(i) Reasons for startinginsulin treatment

Symptoms 22 (73) 23 (77) 23 (77)

Weight loss 6 (20) 8 (27) 7 (23)

Poor glycaemic control 8 (27) 26 (87) 21 (70)

Frequent infections 2 (7) 2 (7) 6 (20)

Foot problem 1 (3) 1 (3) 1 (3)

Other 2 (7) 3 (10) 4 (13)

(ii) Goals of insulin treatment

Well-being 26 (87) 26 (87) 20 (67)

Weight gain 6 (20) 8 (27) 6 (20)

Target glucose levels 6 (20) 9 (30) 20 (67)

Values are expressed as number of patients (% of all patients).

Pract Diab Int March 2002 Vol. 19 No. 2 Copyright © 2002 John Wiley & Sons, Ltd. 39

O R I G I N A L A R T I C L E

Transferring elderly type 2 patients to insulin

carers was an important issue in startinginsulin for many patients.

Starting insulin for elderly patients canpose particular problems due to difficultieswith drawing up7 and giving injectionsassociated with age-related changes in visionand manual dexterity, as well as the issues ofrecognising and dealing with hypogly-caemia8. The decision to start insulin willinvolve both patient and doctor thougheach have differing perceptions of the need,urgency and goals of this treatment, basedupon knowledge at that time as well as fromprevious contact with the diabetes services.

AcknowledgementsThe authors gratefully acknowledge finan-cial support from Lilly Industries (UK) forthe DSN (CT) salary and also thankLifescan for the glucose meters used bytheir patients.

References1. Hendra TJ, Sinclair AJ. Improving the care of elderly

diabetic patients: the final report of the St VincentJoint Task Force for Diabetes. Age Ageing 1997; 26:3–6.

2. Sinclair AJ, Turnbull CJ, Croxson SCM. Document ofcare for older people with diabetes. Post Grad Med J1996; 72: 334–338.

3. Jitapunkul S, Pillay I, Ebrahim S. The abbreviatedmental test: its use and validity. Age Ageing 1991; 20:332–336.

4. Folstein MF, Folstein SE, McHugh PR. ‘Mini-mentalstate’: a practical method for grading the cognitive stateof patients for the clinician. J Psychiatry Res 1975; 12:189–198.

5. Collins C, Wade DT, Davies S, Horne V. The BarthelADL index: a reliability study. Int Disabil Studies 1988;10: 61–63.

6. Gilden JL, Casia C, Hendryx M, Singh SP. Effects of self-monitoring of blood glucose on quality of life in elderlydiabetic patients. J Am Geriatr Soc 1990; 38: 511–515.

7. Coscelli C, Calabrese G, Fedele D et al. Use of pre-mixed insulin among the elderly. Diabetes Care 1992;15: 1628–1630.

8. Mutch WJ, Dingwell-Fordyce I. Is it a hypo?.Knowledge of the symptoms of hypoglycaemia in eld-erly diabetic patients. Diabet Med 1985; 2: 54–56.

PRIMARY CARE DIABETES EUROPESt Vincent Declaration in Practice5th International Conference

“MANAGING THE EPIDEMIC”10-11 May 2002

City Conference Centre, Stockholm, SwedenConference Chairman: Dr Eugene Hughes (UK)

This important Conference will bring together leading experts in diabetes and epidemiology to address the issues raised by the global epidemic of diabetesand to explore strategies for containing it. The meeting will provide a forum in which all primary care health workers can listen, contribute and share. Theformat of lectures, workshops, debate and presentations will provide something for everyone, in the setting of a beautiful and historic city.

WORKSHOPSA realistic approach to obesity (Facilitator: Lena Insulander)

Excerise – its value and applicationComparative healthcare (Facilitators: Margalit Goldfracht, Eugene Hughes)

Psychology and diabetes (Facilitators: Roseline Debaille, Johan Wens)When and how to start insulin treatment in type 2 diabetes (Facilitator: Paul Cromme)

Developing the Community Diabetes Team (Facilitator: Tony O’Sullivan)Compliance in diabetes care (Facilitator: Line Kleinebreil)

Hypertension management (Facilitators: Anne-Marie Felton, Neil Munro)

PLUS LECTURES, DISCUSSIONS AND DEBATESCall for Abstracts: Closing date for submissions: 1 March 2002

Accommodation: Special delegate rates negotiated at a range of nearby hotelsFurther enquiries and Delegates Registration Form:

Paula Laterveer, Za Parkem, 16/651, 140 00 Prague 4-Kunratice, Czech Republic. Email: lacro@compuserve.com

RCN Diabetes Nursing Forum NewsThe Royal College of Nursing Forum represents nursing on a number of national groups and committees as well as within the RCN

New horizonsThe RCN Diabetes Nursing Forum is about to enter an innovativeand exciting phase of its existence, with new committee memberson board and a soon to be elected new Chair.

With regret, I have found it necessary to step down from the com-mittee for reasons of ill health. It has been a very real privilege toserve as Chair for the past year with this unique organisation that canlay claim to reflect all aspects of diabetes nursing in its membershipof over 6,000. The committee is in a position of strength and readyto move forward with an ambitious agenda from the first of April.

What tasks will face the forum in the next 5 years of diabetes care? Firstly, it has committed itself to playing a leading role in devel-

oping a career and competency framework for all nurses workingin diabetes care, regardless of title or status. This is an imperativesupported by the Department of Health and well researched by the

RCN Institute. As part of the broader RCN Primary Care and PublicHealth Field of Practice, the diabetes nursing forum is committedto develop this area for its own speciality whilst liaising with otherforums over core competencies.

Secondly, the diabetes nursing forum anticipates offering amajor contribution towards the nursing aspect of the NationalService Framework.

Thirdly, the forum is in the process of setting up a web sitethrough which to communicate with the nursing population on theresults of these and other initiatives.

I would like to take this opportunity of wishing the new commit-tee and new Chair my best wishes for the future. I have no doubtat all that their work will be a major force for the improvement ofdiabetes services.Eileen Padmore, Chair. E-mail: eileen.padmore@leedsth.nhs.uk

The Royal College of Nursing: The Voice of Nursing20 Cavendish Square, London, W1M 0AB. Telephone 020 7409 3333 Fax: 020 7647 3435