Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK.
School of Healthcare Sciences, Bangor University, Bangor, UK.
Health Technol Assess. 2017 Dec;21(75):1-140. doi: 10.3310/hta21750.
Dementia and diabetes mellitus are common long-term conditions that coexist in a large number of older people. People living with dementia and diabetes may be at increased risk of complications such as hypoglycaemic episodes because they are less able to manage their diabetes.
To identify the key features or mechanisms of programmes that aim to improve the management of diabetes in people with dementia and to identify areas needing further research.
Realist review, using an iterative, stakeholder-driven, four-stage approach. This involved scoping the literature and conducting stakeholder interviews to develop initial programme theories, systematic searches of the evidence to test and develop the theories, and the validation of programme theories with a purposive sample of stakeholders.
Twenty-six stakeholders (user/patient representatives, dementia care providers, clinicians specialising in dementia or diabetes and researchers) took part in interviews and 24 participated in a consensus conference.
The following databases were searched from 1990 to March 2016: MEDLINE (PubMed), Cumulative Index to Nursing and Allied Health Literature, Scopus, The Cochrane Library (including the Cochrane Database of Systematic Reviews), Database of Abstracts of Reviews of Effects, the Health Technology Assessment (HTA) database, NHS Economic Evaluation Database, AgeInfo (Centre for Policy on Ageing - UK), Social Care Online, the National Institute for Health Research (NIHR) portfolio database, NHS Evidence, Google (Google Inc., Mountain View, CA, USA) and Google Scholar (Google Inc., Mountain View, CA, USA).
We included 89 papers. Ten papers focused directly on people living with dementia and diabetes, and the rest related to people with dementia or diabetes or other long-term conditions. We identified six context-mechanism-outcome (CMO) configurations that provide an explanatory account of how interventions might work to improve the management of diabetes in people living with dementia. This includes embedding positive attitudes towards people living with dementia, person-centred approaches to care planning, developing skills to provide tailored and flexible care, regular contact, family engagement and usability of assistive devices. A general metamechanism that emerges concerns the synergy between an intervention strategy, the dementia trajectory and social and environmental factors, especially family involvement. A flexible service model for people with dementia and diabetes would enable this synergy in a way that would lead to the improved management of diabetes in people living with dementia.
There is little evidence relating to the management of diabetes in people living with dementia, although including a wider literature provided opportunities for transferable learning. The outcomes in our CMOs are largely experiential rather than clinical. This reflects the evidence available. Outcomes such as increased engagement in self-management are potential surrogates for better clinical management of diabetes, but this is not proven.
This review suggests that there is a need to prioritise quality of life, independence and patient and carer priorities over a more biomedical, target-driven approach. Much current research, particularly that specific to people living with dementia and diabetes, identifies deficiencies in, and problems with, current systems. Although we have highlighted the need for personalised care, continuity and family-centred approaches, there is much evidence to suggest that this is not currently happening. 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 the needs of people living with dementia and diabetes.
This study is registered as PROSPERO CRD42015020625.
The NIHR HTA programme.
痴呆症和糖尿病是常见的长期疾病，在大量老年人中同时存在。患有痴呆症和糖尿病的人可能由于其管理糖尿病的能力降低而面临低血糖发作等并发症的风险增加。
确定旨在改善痴呆症患者糖尿病管理的计划的关键特征或机制，并确定需要进一步研究的领域。
真实主义审查，采用迭代、利益相关者驱动的四阶段方法。这包括对文献进行范围界定并进行利益相关者访谈，以制定初始方案理论；系统搜索证据以测试和制定理论；并与利益相关者的目的样本一起验证方案理论。
26 名利益相关者（用户/患者代表、痴呆症护理提供者、专门从事痴呆症或糖尿病的临床医生和研究人员）参加了访谈，24 名利益相关者参加了共识会议。
从 1990 年到 2016 年 3 月，以下数据库进行了搜索：MEDLINE（PubMed）、护理与联合健康文献累积索引、Scopus、Cochrane 图书馆（包括 Cochrane 系统评价数据库）、效应摘要数据库、卫生技术评估（HTA）数据库、NHS 经济评估数据库、年龄信息（英国老龄化政策中心）、社会护理在线、国家卫生研究院（NIHR）投资组合数据库、NHS 证据、谷歌（谷歌公司，山景城，CA，美国）和谷歌学术（谷歌公司，山景城，CA，美国）。
我们包括了 89 篇论文。其中 10 篇直接关注患有痴呆症和糖尿病的人，其余的则与患有痴呆症或糖尿病或其他长期疾病的人有关。我们确定了六个上下文-机制-结果（CMO）配置，这些配置提供了一个解释性的解释，说明干预措施如何改善患有痴呆症的人的糖尿病管理。这包括对痴呆症患者的积极态度、以患者为中心的护理计划方法、制定技能以提供量身定制和灵活的护理、定期联系、家庭参与和辅助设备的可用性。一个出现的一般元机制涉及干预策略、痴呆症轨迹和社会环境因素之间的协同作用，特别是家庭参与。一种针对痴呆症和糖尿病患者的灵活服务模式将以一种能够改善痴呆症患者糖尿病管理的方式实现这种协同作用。
尽管包括更广泛的文献提供了可转移的学习机会，但与痴呆症患者的糖尿病管理相关的证据很少。我们的 CMO 中的结果主要是经验性的，而不是临床性的。这反映了现有的证据。增加自我管理参与等结果是改善糖尿病临床管理的潜在替代指标，但这尚未得到证实。
本综述表明，需要优先考虑生活质量、独立性以及患者和护理人员的优先事项，而不是采用更以生物医学为导向、以目标为导向的方法。目前许多研究，特别是针对患有痴呆症和糖尿病的人的研究，都指出了当前系统的缺陷和问题。尽管我们强调了个性化护理、连续性和以家庭为中心的方法的必要性，但有很多证据表明，目前这种情况并未发生。需要对患有复杂健康需求（包括痴呆症）的老年人的糖尿病管理进行未来研究，研究如何更好地调整组织结构和劳动力发展以满足痴呆症患者和糖尿病患者的需求。
本研究在 PROSPERO CRD42015020625 注册。
英国国家卫生研究院 HTA 计划。
