Older People with Diabetes – Why Frailty Imposes an Additional Challenge During the COVID-19 Pandemic

Alan J Sinclair^1,2 and Angus Forbes²

1. Foundation for Diabetes Research in Older People, Diabetes Frail Ltd, Droitwich Spa, UK

2. Kings College London, Diabetes Clinical Research, London, UK

Diabetes is a highly comorbid and complex illness in ageing societies with a significant personal and public health burden,¹ and occurs in about one in five people aged 65–99 years, globally.² Frailty is defined as a state of increased vulnerability to physical or psychological stressors because of a decreased physiological reserve in multiple organ systems limiting a persons’ capacity to maintain homeostasis.³ Frailty is now considered a new complication of diabetes affecting more than 20% of those with type 2 diabetes.⁴ The presence of frailty in an individual with diabetes is associated with poor clinical outcomes, including increased hospitalisation and reduced survival.⁵

The current global pandemic of COVID-19 poses a serious risk for older people with diabetes and comorbid frailty. COVID-19 (severe acute respiratory syndrome coronavirus 2 [SARS-Cov-2] of the genus Betacoronavirus) is an infectious and potentially deadly virus, first identified in Wuhan, China.⁶ COVID-19 is primarily transmitted through respiratory droplets, and has a symptom profile of raised temperature (fever), cough, fatigue and dyspnoea. In a proportion of cases, the disease progresses to life-threatening pneumonia and respiratory failure.⁷

It is highly likely that advanced age, the presence of frailty and diabetes will individually and collectively impose additional risks to safety from COVID-19.⁸ Factors such as age-related impairment in immune function, low-grade chronic inflammatory states, and the increased health hazard of co-existing comorbidities such as cardiovascular disease, hypertension and diabetes may increase the hazard of a poor clinical outcome.⁸ Many older people who are frail are residents in care homes. Care-home residents with diabetes pose significant challenges to care staff and health professionals during the COVID-19 pandemic. More than half of residents will be frail and those with lowered nutritional status and reduced immune competence will be at increased risk of infection and mortality. It is important, therefore, that this vulnerable population of older people that the risk of exposure to the virus with rigorous personal hygiene (hand washing), minimal direct social contact and the use of personal protective equipment (PPE) by staff. While the first two of these protective processes are readily achievable with robust processes, it is acknowledged that there are significant limitations in respect to PPE, as there are shortages in PPE equipment.⁹

Social isolation, can also be challenging, as without contact with their family members or the stimulation from social contact, their mental well-being may deteriorate. Hence, instigating measures to compensate for this, are important (conversations with staff, contact via phone or other correspondence). While the national healthcare system is dramatically stretched by the COVID-19 pandemic, many frail older people with diabetes will have to manage their condition without the support of the clinical services they are used to. Hence, it is vital that frail older people with diabetes are protected and extra vigilance is required in ensuring that they are both protected from the virus and that their diabetes needs are attended to.

In the UK, various diabetes organisations have now produced advice for managing COVID-19, including guidance via key website links and fact sheets.^10–12 Common essential steps for all people with or without diabetes (also applicable to those with frailty) are given, including strict adherence to government guidance relating to staying at home, social distancing and maintaining a sensible nutritional plan and daily exercise to reduce the risk of infection with coronavirus and to enhance physical and mental health status.¹³ This should include frequent washing of hands, and ensuring that those who are the most vulnerable of people with diabetes should maintain daily contact with close friends and family via telephone/video conversations if possible, and be on a local council’s list which identifies them at greater need of support, receipt of food parcels, and in communication with a local volunteer support network. Whilst no specific guidance on managing diabetes in those who are frail is available, a major target for healthcare workers is to detect those who are frail, provide sufficient advice to them and their carers, and in a sense create a ‘protective shield’ to minimise the risk of this vulnerable group becoming infected with coronavirus as the outcomes are likely to be severe. This would require a long period of staying at home and involve close liaison between primary care and community services. As no standard management templates exists detailing a care pathway for this vulnerable population in these circumstances, it is incumbent on local services to identify a local plan to address the needs of this significant group of people living with diabetes.

Specific COVID-19 advice for people with diabetes has also been given to support diabetes self-management and carers, and this is directly applicable to those with frailty.^10–12 This includes maintaining hydration and an acceptable level of glucose control, and to follow ‘sick-day’ rules during any intercurrent illness which emphasise the need for glucose-lowering therapies (usually increases) because of illness-related glucogenic hormones and associated hyperglycaemia. Some people may require the addition of new agents such as insulin to maintain their glucose levels in a safe range while minimising the risk of hypoglycaemia. Those already using insulin need to be supported with more vigilant glucose testing. If they do become ill, even if their nutrition intake is minimal, they should not stop using their insulin and they may require increased doses. Those on sodium–glucose cotransporter-2 inhibitors should have their treatment reviewed by their GP as there may be an increased risk of diabetic ketoacidosis if they become acutely unwell. As entry of the coronavirus into the cell membrane may be facilitated via the angiotensin converting enzyme (ACE)2 receptor, which may be over expressed in those taking angiotensin receptor blockers or ACE inhibitors, there has been concern that this may increase the risk of infection or severity of COVID-19.¹⁴ However, any decision to change these medications to other antihypertensives such as a calcium channel blocker (which, up to now, has not been implicated so far in coronavirus transmission), must be a cautious decision made by each person and their GP.

Whilst all nations are rising to the challenges of this crisis, we should be able to identify where persistent shortfalls in health services and medical equipment leave the frail and vulnerable at greatest risk and plan better for the future.

References

1. Sinclair A, Dunning T, Rodriguez-Mañas L. Diabetes in older people: new insights and remaining challenges. Lancet Diabetes Endocrinol. 2015;3:275–85.
2. Sinclair A, Saeedi P, Kaundal A, et al. Diabetes and global ageing among 65-99-year-old adults: Findings from the International Diabetes Federation Diabetes Atlas, 9th edition. Diabetes Res Clin Pract. 2020:108078.
3. Bergman H, Ferrucci L, Guralnik J, et al. Frailty: An emerging research and clinical paradigm-issues and controversies. J Gerontol A Biol Sci Med Sci. 2009;62A:731–7.
4. Sinclair AJ, Abdelhafiz AH, Rodríguez-Mañas L. Frailty and sarcopenia – newly emerging and high impact complications of diabetes. J Diabetes Complications. 2017;31:1465–73.
5. Sinclair A, Morley J. Frailty and diabetes. Lancet. 2013;382:1386–7.
6. Yang J, Zheng Y, Gou X, et al. Prevalence of comorbidities in the novel Wuhan coronavirus (COVID-19) infection: a systematic review and meta-analysis. Int J Infect Dis. 2020; pii: S1201-9712(20)30136-3.
7. Wu C, Chen X, Cai Y, et al. Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China. JAMA Intern Med. 2020; doi:10.1001/jamainternmed.2020.0994. [Epub ahead of print].
8. Sinclair AJ, Abdelhafiz A. Age, frailty and diabetes – triple jeopardy for vulnerability to COVID-19 infection. EClinicalMedicine 2020 (In press)
9. Iacobucci G. Covid-19: Lack of PPE in care homes is risking spread of virus, leaders warn. BMJ. 2020;368:m1280. doi: 10.1136/bmj.m1280.
10. Diabetes UK. Coronavirus (Covid-19). Advice for people with diabetes and their families. 2020. Available at: https://www.diabetes.org.uk/about_us/news/coronavirus (accessed 8 April 2020).
11. Association of British Clinical Diabetologists (ABCD). Covid-19 Information for Healthcare Professionals. 2020. Available at: https://abcd.care/coronavirus (accessed 8 April 2020).
12. Primary Care Diabetes Society (PCDS). At-a-Glance Fact Sheet: Covid-19 and Diabetes. 2020. Available at: www.pcdsociety.org/resources/details/glance-factsheet-covid-19-and-diabetes-dpc (accessed 9 April 2020).
13. UK Government. Coronavirus (COVID-19): what you need to do. Available at: www.gov.uk/coronavirus (accessed 8 April 2020).
14. Patel AB, Verma A. COVID-19 and angiotensin-converting enzyme inhibitors and angiotensin receptor blockers: what is the evidence? JAMA. 2020; doi: 10.1001/jama.2020.4812. [Epub ahead of print].

Support: Commissioned, edited and funded by Touch Medical Media

Published: 9 April 2020