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Preference: Anaesthesia and Intensive Care

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Managing elderly diabetes no simple task

Most elderly diabetics are prescribed glucose-lowering medications, and only one in five use insulin to manage their diabetes, according to a report by the Australian Institute of Health and Welfare.

Highlighting the complexity of treating type 2 diabetes in older patients, the AIHW used linked data from the Pharmaceutical Benefits Scheme and the National Diabetes Services Scheme (NDSS) to show that while most (85 per cent) of patients 65 years and older were on glucose lowering medications, just 40 per cent used a single medication. One in five used two glucose lowering therapies simultaneously, and 11 per cent were on triple therapies.

In addition, 77 per cent were also using agents to lower their blood pressure, 74 per cent were using drugs to modify lipids (68 per cent were using both), 24 per cent were being supplied with anti-depressants, 20 per cent were using insulin and 4 per cent were on anti-psychotics.

Generally, the authors of the report said, the longer since type 2 diabetes was diagnosed, the more likely it was that a patient would be prescribed with all medicine types, and the more intensive (dual or triple therapy) their glucose lowering treatment regimens would be.

Increasingly, type 2 diabetes in older patients is being treated with drugs rather than diet and exercise alone.

This was significant, the authors said, because the high prevalence of co-morbidities in such patients made the balance of risks and benefits in using medicines a finely-tuned calculation.

The release of the report coincides with changes to the NDSS that came into effect on 1 July.

Under the changes, people with diabetes can continue to access NDSS products such as needles, syringes, blood glucose test strips and urine test strips from NDSS community pharmacies, but can no longer access the products from Diabetes Australia or local state and territory diabetes organisations.

In addition, people with type 2 diabetes not using insulin will receive an initial six month supply of subsidised blood glucose test strips under the NDSS. After six months, they will only be eligible for further access to subsidised test strips if their doctor or other authorised health professional considers it clinically necessary to use test strips.

The change follows advice from the Pharmaceutical Benefits Advisory Committee which recommended restrictions to access blood glucose test strips based on research which found there was limited evidence that self-monitoring of blood glucose improved blood glucose control, quality of life or long term complications in people with type 2 diabetes who are not using insulin.

Patients with diabetes using insulin or women with gestational diabetes will not be affected by these changes.

The restrictions will come into effect six months from the date of a NDSS Registrant’s first test strip purchase.

There is no limit on the number of extensions to access that may be obtained from an authorised health professional while there is a continuing clinical need.

For more information about the changes visit https://www.ndss.com.au/important-changes-to-the-ndss

The AIHW report can be found at http://www.aihw.gov.au/publication-detail/?id=60129555607

Kirsty Waterford

 

News briefs

Unnecessary EOL treatment widespread

University of New South Wales reviewers, reporting in the International Journal for Quality in Health Care, have found that more than a third of elderly patients hospitalised at the end of their life received “invasive and potentially harmful medical treatments”. The analysis of 38 studies over 2 decades, based on data from 1.2 million patients, bereaved relatives and clinicians in 10 countries including Australia, found that the practice of doctors initiating excessive medical or surgical treatment on elderly patients in the last 6 months of their life continues in hospitals worldwide. Dr Magnolia Cardona-Morrell, who led the research at UNSW’s Simpson Centre for Health Services Research, said rapid advances in medical technology have fuelled unrealistic community expectations of the healing power of hospital doctors and their ability to ensure patients’ survival. “It is not unusual for family members to refuse to accept the fact that their loved one is naturally dying of old age and its associated complications and so they pressure doctors to attempt heroic interventions,” Dr Cardona-Morrell said. “Doctors also struggle with the uncertainty of the duration of the dying trajectory and are torn by the ethical dilemma of delivering what they were trained to do, save lives, versus respecting the patient’s right to die with dignity.” The study revealed 33% of elderly patients with advanced, irreversible chronic conditions were given non-beneficial interventions such as admission to intensive care or chemotherapy in the last two weeks of life while others who had not-for-resuscitation orders were still given CPR. The researchers also found evidence of invasive procedures, unnecessary imaging and blood tests, intensive cardiac monitoring and concurrent treatment of other multiple acute conditions with complex medications that made little or no difference to the outcome, but which could prevent a comfortable death for patients.

Breast cancer treatment impacts independent living

Researchers from the US have found one in five women undergoing breast cancer treatment for a year became “incapable of performing some of the basic tasks required for independent living”. Published in Cancer, the study also found that a simple survey can help identify which women are at risk of such functional decline. Cynthia Owusu from Case Western Reserve University in Cleveland, Ohio, and her colleagues studied a group of 184 women aged 65 years and older who had been recently diagnosed with stage I to III breast cancer. The researchers used the Vulnerable Elders Survey, a 13-item self-administered tool that has been validated in community-dwelling elders to predict functional decline or death within 12 months. Patients completed the survey just prior to breast cancer treatment. Within 12 months, 34 of the 184 patients developed functional decline and seven died. The risk of functional decline or death rose with increasing survey scores. Women without an education beyond high school were disproportionately affected. “Our findings are important because the study validates the Vulnerable Elders Survey as a useful tool for identifying older women with breast cancer who may be at increased risk for functional decline within a year of treatment initiation,” she said. “This instrument offers the opportunity for early identification and will inform the development of interventions to prevent and address functional decline for those particularly at risk, such as women with low socioeconomic status.”

[Review] Perioperative thermoregulation and heat balance

Core body temperature is normally tightly regulated to within a few tenths of a degree. The major thermoregulatory defences in humans are sweating, arteriovenous shunt vasoconstriction, and shivering. The core temperature triggering each response defines its activation threshold. General anaesthetics greatly impair thermoregulation, synchronously reducing the thresholds for vasoconstriction and shivering. Neuraxial anaesthesia also impairs central thermoregulatory control, and prevents vasoconstriction and shivering in blocked areas.

[Correspondence] Association between Guillain-Barré syndrome and Zika virus infection

Van-Mai Cao-Lormeau and colleagues1 reported that Guillain-Barré syndrome was associated with Zika virus infection. They recommended that affected countries should ensure adequate intensive care capacity to manage patients with Guillain-Barré syndrome. We argue that these findings are unfounded and probably result from confirmation bias (details and evidence in support of these arguments could be requested from the authors). The authors applied Brighton criteria2 to diagnose Guillain-Barré syndrome.

[Correspondence] Association between Guillain-Barré syndrome and Zika virus infection – Authors’ reply

We thank the correspondents for their comments on our study linking Zika virus to Guillain-Barré syndrome.1 About the concern regarding the non-specificity of Brighton criteria for diagnosing Guillain-Barré syndrome, we would like to emphasise that besides having typical clinical manifestations, all patients tested during the first week (37 [88%] of 42; the five remaining were in intensive care) had nerve conduction abnormalities, 39 (93%) of 42 patients had increased cerebrospinal fluid protein concentrations, and 16 (38%) of 42 required intensive care, substantiating the objective nature and severity of the disease.

Burma inspires proud Kamilaroi man

Darren Hartnett’s father had always urged him to go into medicine, but it was not until the critical care nurse travelled to Burma as part of a medical team that he decided to take up the challenge.

Mr Hartnett went to Burma in 2010 as part of the Operation Open Heart Team organised through Sydney Adventist Hospital, when he was struck by the thought: “We are making a difference here; why am I not making a difference back at home?”

The question was given added potency when he learned not long after his grandfather died that he learned of his Aboriginal heritage.

“My grandfather never spoke about it because of the hurt involved – he was separated from his family when he was young and sent to work for a farmer. He did not have a choice,” Mr Hartnett said. “It was one of those taboo subjects that was never spoken of when he was alive.”

Now into the third year of a medical degree at Newcastle University, Mr Hartnett, who has spent much of his career as a nurse working in intensive care and coronary care at a major Sydney hospital, is considering working the New England area in critical care or as a rural GP – roles he hopes will involve helping Indigenous patients.

“I have always thought I would end up in critical care, but recently I have done placements with rural GPs and I have found it very rewarding,” he said.

“Knowing that within the next few years I can be out in the community assisting our own Indigenous population makes me proud of the fact that I am a Kamilaroi man.”

He is already contributing to the Indigenous community through his work for the Miroma Bunbilla Pre Medicine entry program, where he is helping aspiring Indigenous doctors.

His path ahead has been made easier by the fact he has been awarded the AMA Indigenous Peoples’ Medical Scholarship for 2016.

To help make ends meet Mr Hartnett, who has two young children, has had to combine the workload of a full-time student with part-time work as a nurse. He said the $10,000 a year scholarship would make a huge difference in helping his family get through while he completes his studies.

The scholarship was established in 1995 with a contribution from the Commonwealth, and the AMA is looking for further sponsorships to support its commitment to Indigenous health.

Adrian Rollins

[Comment] Acting in the Anthropocene: the EAT–Lancet Commission

Expanding waistlines are a problem not just for dietitians and population health specialists but, increasingly, for Earth system scientists too. The waistlines belong largely to the growing global middle class. The world is undergoing a dramatic nutrition transition to western diets. Wealth, industrialisation, and rapid urbanisation are driving a surge in resource-intensive meat and dairy products and ultra-processed foods. This dietary shift is the main cause of an exponential rise in obesity and non-communicable diseases (NCDs).

[Correspondence] Intensive blood pressure lowering

Xinfang Xie and colleagues (Jan 30, p 435)1 report that intensive blood pressure lowering provided greater vascular protection than standard regimens, especially in high-risk individuals. However, we are concerned about whether the incidence of vascular events was a primary endpoint or not in the studies included in their meta-analysis. As stated in the accompanying Comment by Mattias Brunström and Bo Carlberg,2 this meta-analysis included trials with a wide range of patient populations, and wide variations must have been observed in the incidence of vascular events according to patient background.

[Correspondence] Intensive blood pressure lowering – Authors’ reply

Yuki Sonoda and colleagues raise two issues about our meta-analysis1 of randomised controlled trials that compared more versus less intensive blood pressure targets. First, the possibility that trials with major vascular events as a primary endpoint are different from trials in which major vascular events were not primary endpoints. Second, along with Mattias Brunström and Bo Carlberg,2 Sonoda and colleagues note the variety of patient populations included in our systematic review. We believe that the ability to compare and contrast treatment effects across different patient populations is a strength of systematic reviews.