1. DIABETES Nearer the End of Life Ken McHardy & Benjamin Franklin Inverness 11 th Nov 2011

2. QUOTE for TODAY “In this world nothing can be said to be certain, except death and taxes.” Benjamin Franklin 1789

3. BENJAMIN FRANKLIN [1706-90] Founding Father of USA Printer, writer, statesman, soldier, scientist Lightning rod + Bifocals Practical democratic puritan values: thrift, hard work, education, community spirit, opposition to political or religious authoritarianism!

4. DIABETES NEARER the END of LIFE EPIDEMIOLOGY IMPLICATIONS OF DIABETES IMPLICATIONS OF BEING OLDER AND LESS ABLE FOR MANAGEMENT OF DIABETES

5. PREVALENCE OF DIABETES SCOTTISH DIABETES SURVEY (2010) –Scotland 237,468(4.6%) –Highland 13,914(4.5%) RATE of INCREASE in GRAMPIAN –May 2002 : 10,500 –Dec 2010 : 23,855(+ 127%)

6. Prevalence of Type 2 DM: Scotland (SDS 2008)

7. Prevalence of Type 1 DM in Scotland (SDS 2008)

8. Proportion of Elderly Diabetes

9. WHAT ARE THE RISKS? ACUTE COMPLICATIONS –DKA & HHS –HYPOGLYCAEMIA LONG-TERM COMPLICATIONS –NERVES –EYES –CARDIOVASCULAR –KIDNEYS –FEET

10. ComplicationType 1 NHSH % Type 1 Scot % Type 2 NHSH % Type 2 Scot % M.I. 3.9 5.7 10.0 9.8 Stroke 2.3 2.1 5.0 5.4 Renal Replacement 1.2 0.4 Retinopathy 51.0 50.2 24.8 25.7 Blindness n = 370.0/0.80.0/0.7 Foot Ulcer 2.8 7.0 1.9 4.0 LL Amputation 1.1 0.7 0.5 Prevalence of Complications [2010 Scottish Diabetes Survey] www.diabetesinscotland.org.uk/Publications/SDS%202010.pdf

11. FRAILTY & COMORBIDITY ASSOCIATED WITH AGE ASSOCIATED WITH CHRONIC ILLNESS DIFFICULTY IN CLINICAL ENGAGEMENT: –Access- Investigation –Treatment- Application –Susceptibility- Expectations THEY DEMAND ADJUSTMENT OF ‘COPING’ STRATEGIES / TARGETS

12. AGE-RELATED ‘ADAPTATIONS’ LIMITED EVIDENCE IN ELDERLY FEW SPECIFIC RESOURCES WELL-UNDERSTOOD PRINCIPLES COMPLEXITIES IN DIABETES –SELF-MANAGEMENT –INDEPENDENCE/DEPENDENCE –COMPLICATIONS BEGET COMPLICATIONS –STANDARDS & PROFESSIONALISM

13. POTENTIAL RESOURCES FOR DIABETES IN ELDERLY INSTITUTE FOR DIABETES IN OLDER PEOPLE Prof Alan Sinclair, University of Bedford http://instituteofdiabetes.org/ CLINICAL GUIDELINES FOR TYPE 2 DIABETES MELLITUS – European Diabetes Working Party for Older People (2001-4) GRAMPIAN DIABETES GUIDELINES 2011 www.nhsgrampian.org/guidelines/diabetes/

14. WHAT IS GOOD CONTROL? NORMOGLYCAEMIA / HbA 1C LOWER RISK OF COMPLICATIONS DIMINISHING RETURNS –LESS LONG-TERM BENEFIT –LESS LONG-TERM! HYPOGLYCAEMIC RISK –HIGHER RISK WITH TIGHTER CONTROL –GREATER IMPACT IN FRAIL ELDERLY

15. SO WHAT is BEST for PATIENTS? SENSE AND SENSITIVITY PATIENT-CENTRED APPROACH INDIVIDUALLY TAILORED RANKED PRIORITIES QUALITY OF LIFE SUPPORTIVE (HEALTH) CARE CAPABLE, COMPETENT CARERS PERMISSION TO MAKE THE BEST CHOICES

16. The Memoirs of Benjamin Franklin..including his 13 life principles or virtues [1726]..or how to approach diabetes management in the elderly [2011]

17. FRANKLIN’S 13 VIRTUES TEMPERANCE. Eat not to dullness; drink not to elevation. SILENCE. Speak not but what may benefit others or yourself; avoid trifling conversation. ORDER. Let all your things have their places; let each part of your business have its time. RESOLUTION. Resolve to perform what you ought; perform without fail what you resolve.

18. FRANKLIN’S 13 VIRTUES FRUGALITY. Make no expense but to do good to others or yourself; i.e., waste nothing. INDUSTRY. Lose no time; be always employ'd in something useful; cut off all unnecessary actions. SINCERITY. Use no hurtful deceit; think innocently and justly, and, if you speak, speak accordingly. JUSTICE. Wrong none by doing injuries, or omitting the benefits that are your duty.

19. FRANKLIN’S 13 VIRTUES MODERATION. Avoid extremes; forbear resenting injuries so much as you think they deserve. CLEANLINESS. Tolerate no uncleanliness in body, cloaths, or habitation. TRANQUILLITY. Be not disturbed at trifles, or at accidents common or unavoidable. CHASTITY. Rarely use venery but for health or offspring, never to dullness, weakness, or the injury of your own or another's peace or reputation. HUMILITY. Imitate Jesus and Socrates

20. THE END Benjamin Franklin d. 1790 buried Philadelphia, Pennsylvania