What works for whom in the management of diabetes in people living with dementia: a realist review

Abstract

BackgroundDementia and diabetes mellitus are common long-term conditions and co-exist in a large number of older people. People living with dementia (PLWD) may be less able to manage their diabetes, putting them at increased risk of complications such as hypoglycaemia. The aim of this review was to identify key mechanisms within different interventions that are likely to improve diabetes outcomes in PLWD.MethodsThis is a realist review involving scoping of the literature and stakeholder interviews to develop theoretical explanations of how interventions might work, systematic searches of the evidence to test and develop the theories and their validation with a purposive sample of stakeholders. Twenty-six stakeholders — user/patient representatives, dementia care providers, clinicians specialising in diabetes or dementia and researchers — took part in interviews, and 24 participated in a consensus conference.ResultsWe included 89 papers. Ten focused on PLWD and diabetes, and the remainder related to people with either dementia, diabetes or other long-term conditions. We identified six context-mechanism-outcome configurations which provide an explanatory account of how interventions might work to improve the management of diabetes in PLWD. This includes embedding positive attitudes towards PLWD, person-centred approaches to care planning, developing skills to provide tailored and flexible care, regular contact, family engagement and usability of assistive devices. An overarching contingency emerged concerning the synergy between an intervention strategy, the dementia trajectory and social and environmental factors, especially family involvement.ConclusionsEvidence highlighted the need for personalised care, continuity and family-centred approaches, although there was limited evidence that this happens routinely. This review suggests there is a need for a flexible service model that prioritises quality of life, independence and patient and carer priorities. Future research on the management of diabetes in older people with complex health needs, including those with dementia, needs to look at how organisational structures and workforce development can be better aligned to their needs.Trial registrationPROSPERO, CRD42015020625. Registered on 18 May 2015.

Potentially inappropriate prescribing in dementia: a state-of-the-art review since 2007

“…People living with dementia, particularly those in advanced stages, are often excluded from trials 27 28. As a result, existing evidence for the pharmacological management of chronic conditions (eg, diabetes) does not fully reflect the needs of people with dementia, nor does it provide conclusive evidence that it improves health outcomes or quality of life 44 51 52. A 2018 systematic review on management of chronic conditions in people with dementia identified only six studies, covering depression, osteoporosis, diabetes and cardiovascular disease 44.…”

<p>Improving Exercise-Based Interventions for People Living with Both COPD and Frailty: A Realist Review</p>

“…Realist reviews have been used to understand a variety of complex health interventions with multimorbid populations. 31,32 The methods draw on a realist philosophy, taking a "generative" view of how interventions work (including contextual factors), as opposed to a more positivist "successionist" view. 33 Realist reviews are explanatory, seeking to unpick the important mechanisms underlying sets of interventions.…”

Diabetes-Related Topics in an Online Forum for Caregivers of Individuals Living With Alzheimer Disease and Related Dementias: Qualitative Inquiry

“…This is unsurprising, as diabetes is largely a self-managed disease that necessitates high-level cognitive capabilities for patients to properly adhere to medication and lifestyle regimens. However, memory loss, impaired problem-solving, and other ADRD symptoms make diabetes management extremely difficult for people living with ADRD and their family caregivers [ 14 , 60 ]. Previous recommendations and studies have suggested that for people with cognitive impairment, diabetes care should be individualized and patient-centered [ 60 ].…”

“…However, memory loss, impaired problem-solving, and other ADRD symptoms make diabetes management extremely difficult for people living with ADRD and their family caregivers [ 14 , 60 ]. Previous recommendations and studies have suggested that for people with cognitive impairment, diabetes care should be individualized and patient-centered [ 60 ]. The glycemic target (eg, hemoglobin A 1c , fasting glucose, and postprandial glucose) should also be relaxed [ 14 ].…”