DIABETES MANAGEMENT AND THE ELDERLY
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DIABETES MANAGEMENT AND THE ELDERLY

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  • Risk for Type 2 DM increases with age. ~50% of currently affected PWD are 60 yrs or older Approximately 18.3% (8.6 million) people in the US age 60 and older have diabetes The pop of people over age 65 yrs in US is expected to greatly increase reaching 70 million by the year 2030.
  • Intrinsic factors include: Beta cell Dysfunction which leads to low or altered insulin secretion Increased adipose tissue which leads to Insulin resistance Genetics which can predispose a person to any pre-diabetes condition Extrinsically: Coexisting Illness which can increase stress and stress counter regulatory hormones Decreased Physical Activity or mobility can lead to decreased glucose disposal And Medications (including B-Blockers and diuretics) can impair insulin action or secretion
  • Loss of 1 st phase insulin response means fasting is the last to be abnormal. Estimated that diagnosis is made an average of 6.5 years after onset of disease.
  • Mention onset of complications such as impotence and CVD diagnosed with dm Symptoms of Type 2 Diabetes are often subtle and misdiagnosed as aging.
  • Sugar in the blood stream is NOT a preservative.
  • Older adults are a very heterogenous group which is no different for older adults with diabetes. They can lead full and actives lives that typically differ significantly from those 10-20 years younger. Experts in the field of aging recognize that the term elderly does not mean one specific set of characteristics that can be defined simply by being older than a specific age. Typically elderly is used for those >70 years. young old/middle old and old old Impt to assess PWDs for potential areas which may affect overall quality and quantity of life
  • Older PWD are at greater risk of common geriatric syndromes these may interfere with provision of appropriate care- ID and mgmt of these may enhance effectiveness of DM mgmt. These syndromes were identified and selected by …based on either pop-based evidence that these syndromes were more prevalent in PWDs, or strong pathophysiological reason to believe that PWDs were at greater risk for these syndromes or expert consensus
  • Cataracts exacerbated by poor DM control. Decreased Acuity, slowed light/dark adaption, decreased color perception Renal: Renal function declines with age, and remember when impaired, medication action is extended. Decreased GFR Altered ability to concentrate or dilute urine Decreased active renin production decreased antiduiretic hormone responsiveness Immune system: Impaired with elevated BG levels- Increased risk for morbidity and mortality Much higher rate of occurrence of infections eg. herpes zoster, influenza, pneumonia, uti, skin infections. Many commonly used drugs contribute to neutropenias and lymphocytopenia which impairs the immune system. analgesics, steroids, antithyroids, antibiotics, antipsychotics, antidepressants, sedatives, antihypertensives, diuretics, hypoglycemics, Chronic Illnesses impact immune system Polypharmacy
  • Orthostatic Hypotension Normal aging versus DM CVD may have been developing for 20 years prior to dx of diabetes d/t pp hyperglycemia Is the hypertension controlled. Often takes multiple drugs to get to 130/80. Lifestyle and habits include smoking, decreased activity, poorer eating habits Normal aging versus DM-remember diabetes in poor control will accelerate the aging process. HEART RATE In normal responses the heart rate should accelerate with exercise, Often in the person with diabetes this response may be reduced due to neuropathy. HYPERTENSION Is the hypertension controlled? 140/ 90 but endocrinologists have set new guidelines for diabetics 130/80. It often takes several medications to reach this. Older adults may not tolerate meds well so must add slowly. INCREASED RISK OF CVA’S AND MI’S CVD may have been developing for 20 years prior to dx of diabetes. In fact 50% of newly diagnosed people with type 2 Just having diabetes + risk factor to those that have already had 1 heart attack.
  • In those >65yo. falls and fall related fractures are most common cause of injury and hospital admis for trauma and may account for >80% of fractures. PWD 3x risk of falling and twofold increase in having a fall that is injurious (gait, balance, musculoskeletal and neurological disabilities)
  • considerations: food consistency, lifelong eating habits, ability to purchase and prepare foods, financial considerations, cultural preferences and or religious practices Lifestyle changes include retirement, widowhood, move to group housing or in with extended family. Mobility or transportation issues can make consistently obtaining food difficult Approx 40% of those over 65 are endentulous which can lead to avoidance of coarse fiber and protein containing foods. Periodontal disease can occur in the edentulous. Should have an exam every 6 months whether or not they have teeth. People with diabetes have more decay and gum disease. - dental problems can also cause a decrease in mastication which can impair digestion and absorption.
  • Are they eating a healthy diet? Seniors tend to get in a rut and eat the same thing because it is easy, They tend to like sweets eating poorly because of tooth loss or mouth pain Economics decreased socialization polypharmacy Involuntary weight change requires assistance for self care >80 years of age Assess for vitamin and mineral deficiencies
  • GI tract contributes to inadequate nutrient intake. Bowel status
  • Changes in memory, information processing speed, and attention span normally decline with age, but may occur faster with poor glycemic control. Cognitive function better with good control Tight control may prevent or even reverse deterioration of cognitive function. Type 1 - 4 times more likely to suffer from dementia Memory – “Senior Moments” cueing If suspected depression, refer.
  • HEART-Silent heart attacks in DM BLADDER-physical and neurological SEXUAL FUNCTION-May decrease with age but is a big complaint for those that have diabetes. PROTECTIVE SENSATION-ability to feel is decreased...with diabetes feet No fever even with infection Thirst – may not recognize sx of hyper Taste / smell – may impact adequate food intake. Medications can affect taste
  • Assess Patients perceptions of diabetes and their feelings about it: How is the patient’s social support? (married, divorced, widowed, retired, etc) How do they view their diabetes and its impact on their quality of life DO they believe that they are in control of their health and that their actions play a role in their health status? Psychosocial isolation, depression, stress Loss of control Depression: People with DM 3 times more likely to be depressed Diabetes rate 25-33% Elderly – under recognized and under treated. Show handout of Depression facts.
  • Co-morbidities are worse or harder to manage when BG in poor control. Drug interaction with diabetes Beta blockers and hypoglycemia Examples of inappropriate meds with situation. Safety – Falls, Wearing ID bracelet
  • Solid evidence supports the above treatment recommendations for effective DM care but very few of the data supporting these interventions were obtained from research studies including older persons. Some groups of elderly for which intensive management of these conditions may not provide same benefit as observed for younger persons and can instead result in harm such as hypoglycemia or hypotension. Main emphasis of general public DM guidelines focuses on achieving tight glycemic control to prevent microvascular complications. In older adult greater reductions in morbidity and mortality may be achieved by decreasing cardiovascular risk factors. Major aims in managing older adults w/DM: freedom fm hyperglycemic symptoms prevention of undesirable wt loss avoidance of hypoglycemia and other adverse drug rxns estimation of CVD risk as part of screening and for preventing vascular complications detection of cognitive impairment, depression and functional disabilities at early stage achievement of normal life expectancy- when possible Possible Factors that influence DM mgmt in older adults: socioeconomic situation Social isolation or loneliness Depression or cognitive impairment Nursing home residency reliance on formal or informal caregivers polypharmacy Frailty or limited life expectancy significant comorbidities- that my limit ADL (recognizing and txing hypoglycemia)
  • Among unanswered questions that need to be addressed are: when and how to prioritize interventions that target glycemia, blood pressure, lipids and aspirin use AND How to stratify older adults by their likelihood of risk or benefit from intensive therapies Some are frail and have other underlying chronic conditions and numerous DM related comorbidities or limited physical or cognitive functioning others have little comorbidity and are active. Life expectancies are also highly variable Clinicians must take heterogeneity into consideration when setting treatment goals
  • Clinical trials have indicated that ~8 yrs are needed before benefits of glycemic control are reflected in reductions microvascular complications 2-3 years are needed to see benefits from better BP and lipid control Likely that there is an association between moderate glycemic control and improved wound healing, decreased symptoms of hyperglycemia and possibly maximization of cognitive function However the data suggests that many of these shorter term benefits may be achieved with less intensive glycemic goals than what is recommended in most of the national DM guidelines.
  • Quality of life issues: Although several intervantions have been shown to greatly reduce morbidity and mortality in PWD it is clear that the potential benefits may e associated with reduced quality of life. Complicated, costly or uncomfortable treatment regimens may result in deleterious side effects, reduction in adherence to treatment regimens or a decrement of overall well-being.
  • Sleep disturbance a concern for NH staff
  • Immune system impacted when BG >180 Increased risk of decubitus Poor wound healing Insulin may be drug of choice to avoid drug interactions and organ dysfunction. Dosage adjusted with age due to kidney function.
  • Keep treatment at bedside. Need to look for other symptoms
  • Strong evidence that drug therapy for BP management reduces CV events and mortality for older adults and those with DM
  • No studies have evaluated the effect of monitoring electrolytes or appropriate monitoring intervals in persons using duiretics. One RCT found Thiazide duiretics associated with increased risk of hypokalemia and ventircular arrhythmias Hypertensive patients on Higher doses of thiazide duiretics have been associated with increased risk of caridac arrest
  • PWDs have similar risk of CV event as someone with prior hx of CV event. Persons with DM have high rates of lipid abnormalities that may contribute to this increased risk: high LD , low HDL and high TGs Lowering LDL and raising HDL has been shown to have beneficial effects on CV health in PWDs. Rates of prescribing statins in older individuals are suboptimal and when prescribed there is poor adherence
  • Several random controlled studies have shown an association bn aspirin use and acute MI and other CV events as well as a reduction in CV mortality for older adults and PWDs
  • From UKPDS- ~1% of pts with no retinopathy at baseline required photocoagulation at 3-6 yr Highest risk: males with hypertension and hyperglycemia Prevalence associated with level of glycemic control over past 6 years and hypertension
  • Education on medication, monitoring and recognizing hypo and hyperglycemia symptoms can significantly improve glycemic control
  • ASK:What can I do for you? Try to keep patient in the “driver’s seat”
  • Evaluate care recommendations with consideration for cost, accessibility, safety, support systems and the effect on perceived quality of life.
  • Keep field of work narrow Do not move person’s belongings Allow longer time to change visual focus Use more verbal explanations and touch. Non glare paper
  • Write or draw important points Repeat frequently Use gestures and objects if possible Enunciate Referral for hearing aid?
  • Limit instruction to content that matches patient’s specific diabetes-related goals. Modify instruction so that key information is presented in easily read or heard messages. Use active learning methods Regular reassessment of tx goals and management skills is integral to DM ed and that reinforcement my be necessary to make and sustain behavior change. This is especially improtant for the older adult whose functional and cognitive status may change over short periods of time.
  • patients

DIABETES MANAGEMENT AND THE ELDERLY DIABETES MANAGEMENT AND THE ELDERLY Presentation Transcript

  • Diabetes Management in the Older Adult Presented by Carolyn Jennings, MPH, RD, CDE SouthEast Michigan Diabetes Outreach Network (SEMDON) www.diabetesinmichigan.org
  • Myths: DM in the Older Adult
    • High prevalence of diabetes in older adults is inevitable
    • Hyperglycemia in older adults is usually a benign condition
    • Reduced life expectancy makes the consequences of uncontrolled diabetes irrelevant
    • The majority of older adults with type 2 DM are obese and need to lose weight
    • Older adults are less capable of self-monitoring their blood glucose
  • Prevalence of Diabetes
  • Pathogenesis of Hyperglycemia in Elderly Poor Nutrition Coexisting Illness Reduced Insulin Secretion Increased Adipose Tissue Decreased Physical Activity Medications Genetics
  • Diabetes in Older Adults
    • 50% under-diagnosed – WHY??
    • Early signs: Metabolic Abnormalities
      • Insulin resistance
      •  1 st phase insulin release
      •  PPG with normal FPG
    • Early symptoms: (if any)
      • Often gradual onset
      • Commonly mistaken for signs of normal aging
  • Case of Mistaken Identity
    • Blurred Vision
    • Polyuria and nocturia
    • Fatigue
    • MI and CVA’s 2 times more common
    • High Blood Pressure
    • Neuropathy and foot deformities
    • Restlessness/confusion with high and low BG.
    • Needing glasses
    • More frequent urination
    • Can’t do things like you did when you were 20
    • Atherosclerosis
    • High Blood Pressure
    • Change in gait
    • Restlessness, confusion, slower cognition.
    Signs of Diabetes Signs of Aging
  • Aging and Diabetes
    • Poor diabetes control exacerbates the aging process.
    • Poor diabetes control causes age related disease to develop earlier.
    • Poor diabetes control makes co-morbid conditions worse and harder to manage.
  • OBJECTIVES
    • State three areas of assessment for the older adult with diabetes.
    • State two recommendations for the care of the older adult with diabetes.
    • List education strategies appropriate for the older adult with diabetes.
  • Diabetes Assessment in the Older Adult
    • Physical Assessment
      • Mobility/ Physical Activity
      • Nutritional Assessment
    • Neurological Assessment
    • Psychosocial Assessment
    • Other Areas
  • Diabetes Assessment in the Older Adult
    • Common Geriatric “Syndromes”
    • Depression
    • Polypharmacy
    • Cognitive Impairment
    • Urinary incontinence
    • Injurious falls
    • Persistent pain
  • Physical Assessment
    • Ophthalmic
      • Higher rates of cataracts, glaucoma and macular degeneration.
    • Auditory
    • Renal
      • Thickening of basement cell membranes .
    • Immune system
        • Flu, herpes zoster, cancer
  • Physical Assessment
    • Cardiovascular System
      • Reduction in CVD risk factors may have greatest impact on morbidity and mortality
        • Hypertension
        • Lipids
      • Increased risk of CVA’s and MI’s.
      • Heart rate  in response to exercise reduced.
      • Thickening of basement cell membranes.
      • 50% of newly diagnosed people with T2DM have CVD.
  • Physical Assessment
    • Dexterity/coordination
      • History of injurious falls
    • Mobility/Physical Activity
      • Joint disease/  Bone mass
      •  Aerobic capacity
      •  Lean body mass
      •  Fat mass
      • Activity
        • Current level?
        • Limitations, preferences
  • Nutritional Assessment
    • Preferences and Lifelong habits
    • Meal Planning considerations
    • Food Preparation
    • Lifestyle changes
    • Mobility issues
    • Dentition
    • High Risk considerations
  • Nutritional Assessment
    • Malnutrition
      • Altered nutrient absorption
      • Vitamin deficiencies (B 12 )
      • CHO intolerance
      • Decline in renal function
    • Depression
    • Cognitive Impairment
  • Nutritional Assessment
    • Nutritional status
      • Change in nutrient needs
      • Change in body composition
      • Hydration status
      • Alcohol use/abuse
      • Supplement/herbal use
    • Gastrointestinal tract
      •  Absorption
      • Gastroparesis
      •  Appetite
  • Neurological Assessment
    • Cognitive Impairment
      • Increased rate in PWD
    • Mini-mental status exam recommended
    • Check for reversible causes:
      • B12 levels
      • Thyroid hormone
      • Neuroimaging
      • Depression screening
      • Blood glucose control
  • Neurological Assessment
    • Autonomic and peripheral neuropathies:
      • Heart
      • Incontinence
      • Sexual function
      • Protective sensation
      • Hypoglycemia unawareness
      • Body Temperature regulation
      • Reduced ability to sense:
        • Thirst, Smell, Taste
  • Psychosocial Assessment
    • Depression
    • Support systems
      • Loss of peers
      • Change in family role
    • Health Beliefs
    • Locus of Control
      • Internal vs. External
  • Other Areas of Assessment
    • Co-morbidities
    • Pain
    • Polypharmacy
      • Diabetes medications appropriate?
      • Drug interactions
      • Ability to administer medications
    • Safety
    • Finances
  • OBJECTIVES
    • State three areas of assessment for the older adult with diabetes.
    • State two recommendations for the care of the older adult with diabetes.
    • List education strategies appropriate for the older adult with diabetes.
  • Treatment Recommendations
    • Glycemic Control
    • Hypertension
    • Lipids
    • Tobacco cessation
    • Eye care
    • Foot care
    • Nephropathy
    • Diabetes Self-Management Training
  • Treatment Recommendations
    • When and how to prioritize interventions?
    • Stratifying older adults:
      • Comorbities
      • Complications
      • Risks vs. benefits of (intensive) therapies
  • Glycemic Control
    • A1c-
      • <7% in healthy adults with good functional status
      • <8% appropriate in:
        • Frail older adults
        • Life expectancy less than 5 years
        • Those whom risk of intensive glycemic control outweighs benefits
      • Frequency
  • Risks of Intensive Glycemic Control
    • Hypoglycemia
    • Polypharmacy
    • Drug to drug interactions
    • Drug to disease interactions
  • Who benefits most from Intensive Glycemic Control?
    • Older adults in good health
    • Those with microvascular complications
    • Frail elderly without microvascular complications will probably not live long enough to develop them
  • Hyperglycemia
    • Can cause:
      • Delirium
      • Mood swings and irrationality
      • Appetite changes
      • Sleep disturbances
    • Increases risk for:
      • Diabetic Ketoacidosis
      • Hyperglycemic Hyperosmolar State (HHS)
  • Hyperglycemia
    • Impairs cognitive ability
    • Reduces energy
    • Impairs memory
    • Decreased wound healing
    • Increased risk of HHS
    • Increases urine output
      • Impacts incontinence/dehydration
    • Increased risk of UTI
    • Impairs immune system
    • Aging increases risk of hypoglycemia:
      • Reduced hormonal counter regulation
      • Renal and hepatic changes
      • Hydration status
      • Inadequate or irregular nutrition
      • Decreased intestinal absorption
      • Autonomic neuropathy
      • Polypharmacy
      • Use of alcohol, other sedating meds
    Hypoglycemia
  • Hypoglycemia
    • May cause:
      • Heart arrhythmias
      • Increased risk of falls
      • Signs and symptoms may be masked by co-morbidities (i.e. Parkinson’s)
      • Impairs concentration and cognition
      • Impairs reaction time
  • Hypertension
    • Goal: Less than 140/80 if tolerated
    • Less than 130/80 may produce further benefit
    • Blood pressure reduction should be done gradually to minimize complications (no more than 20mm/hg reduction in systolic BP/3 mo)
  • Hypertension: Medication Precautions
    • ACE-I or ARB Therapy
      • Monitor K 1-2 weeks after initiating therapy and with each dose increase
      • ACE-I associated with decreased renal function in elderly
      • Hyperkalemia common at moderate and high doses
  • Hypertension: Medication Precautions
    • Thiazide or loop diuretic
      • Check electrolytes within 1-2 weeks of initiation and at least yearly
      • Hypokalemia associated with ventricular arrhythmias.
  • Lipids
    • Secondary to overall health status assessment
    • Goals: LDL< 100mg/dl
          • HDL > 40 men, 50 women
          • TG < 150mg/dl
    • LDL<100 reassess q 2yrs
    • LDL 100-129: MNT w/  physical activity
    • LDL > 130 pharmacologic therapy + lifestyle intervention
  • Lipids: Medication Precautions
    • Increased side effects
      • Myalgias and myositis
      • Rhabdomyolysis
      • Elevated liver function?
        • Niacin or Statin: Measure ALT w/in 12 weeks of initiation or dosage change
        • Fibrate: evaluate liver enzymes at least annually
      • Precaution with reduced renal function
  • Aspirin Use
    • The older adult (who is not on any other anticoagulant therapy and has no contraindications to aspirin) should be offered 81-325mg/d.
  • Tobacco Cessation
    • 12% of PWD over age 65 smoke
    • Assess use/willingness to quit
    • Offer counseling and/or pharmacologic interventions to assist with cessation
  • Retinopathy Screening
    • Dilated eye exam at diagnosis
    • High risk (symptoms of eye disease, retinopathy, glaucoma, cataracts, A1c>8, T1DM or BP>140/80mm/hg):
      • at least yearly follow-up exams
    • Low(-er) risk : every 2 years
  • Foot Screening
    • At least annual comprehensive foot exam and at all non-urgent outpatient visits. Assess changes in:
      • Skin integrity
      • Loss of protective sensation
      • Early detection of neuropathy
      • Decreased perfusion
      • Bone deformity
  • Nephropathy Screening
    • Screen for microalbumin and GFR at diagnosis and (at least) annually
  • Diabetes Self-Mangement Training
    • More likely to include family members and/or other caregivers
    • Essential topics:
      • Hypoglycemia prevention and treatment
      • Benefits of MNT and physical acitvity
      • Medication review
      • Evaluation of foot care- amputation prevention
      • Evaluate Geriatric Conditions
  • OBJECTIVES
    • State three areas of assessment for the older adult with diabetes.
    • State two recommendations for the care of the older adult with diabetes.
    • List education strategies appropriate for the older adult with diabetes.
  • The Adult Learner
    • Perceives need
    • Self-directed
    • Experienced
    • Problem-oriented
    • Task-centered
    • Internally motivated
  • Patient Centered Education
    • Assessment of where patient is with disease “Health Beliefs”
    • Assessing where patient is in regard to “readiness to change” current behaviors to improve (diabetes) health
    • 
    • WITH THIS INFORMATION the patient and educator can work together to develop individualized self-management plan
  • Patient Centered Education
    • Patients Role:
      • Determine personal self-care goals
      • Find solution
      • Take responsibility for own health
    • HCP’s Role:
      • Active Listener
      • Source of accurate Information
      • Provide essential knowledge and skills training
      • Understand client’s perspective
      • Acknowledge the client’s feelings
      • Support Person
      • Facilitator
  • Education Strategies
    • LISTEN, LISTEN, LISTEN…
    • Positive attitude
    • Provide meaningful practical individualized information.
      • Prioritize needs with the patient
      • Assist with problem solving and goal setting
      • Empowerment Model- Patient Centered
  • Education Strategies
    • Assess baseline knowledge.
      • Dispel any misinformation
      • Update information
    • Overcome generational barriers.
    • Consider financial, accessibility, safety, support systems and the effect on perceived quality of life
  • Education Strategies
    • Assess functionality and special needs
    • Adaptive teaching strategies
      • Visual accommodations
        • Low vision aids
        • Bright illumination
        • Large print and bright contrast
        • Detailed verbal explanations
        • Use support system.
    • Auditory Accommodations
      • Eliminate distractions
      • Minimize background noise.
      • Reinforce with written materials.
      • Speak slowly in short sentences.
      • Speak to best hearing side.
      • If patient reads lips, keep mouth uncovered and do NOT chew gum.
    Education Strategies
  • Education Strategies
    • Cognitive Accommodations
      • Simplify instruction.
      • Frequently summarize.
      • Focus on single topics.
      • Teach simple tasks first then move on to more complex.
      • Use memory aids.
      • Evaluate learning often.
  • Education Strategies
    • What is the present degree of Blood Glucose control?
    • If currently Hypo or Hyperglycemic :
      • Teach Survival Skills
      • Schedule follow-up when BG control improved
      • Give educational materials for reinforcement
  • Education Strategies: Nursing Care Facilities
    • Assess patient’s ability to participate in self care.
    • Prioritize care to patient and family.
    • Involve family in education.
      • Appropriate snacks to bring.
      • Reinforce behaviors that promote optimal control.
  • Education Strategies: Nursing Care Facilities
    • Safety issues
      • Hyper/hypoglycemia signs/symptoms
    • Adult Learner Guidelines
    • Evaluate level of control with respect to quality of life, safety.
    • Advocate for your patients whose diabetes control is sub optimal.
  • Summary- Education Goals
    • Assist older adults to optimally self-manage diabetes.
      • Individualized BG goals to avoid both hyper- and hypoglycemia.
      • Prevent or delay progression of complications.
    • Promote optimal control for all older PWDs
      • Hospitalized • Residential care
      • Group living
  • Resources
    • Guidelines for Improving Care of the older person with diabetes
    • AM J Geriatric Soc 51(2003): S265-S280
    • Geriatric Resource Directory www.bphc.hrsa.gov
    • Working Together to Manage Diabetes
    • Diabetes Medications Supplement
        • www.ndep.nih.gov/diabetes/publications
    • Oral Health Care for Older Adults www.nohic.nidcr.nih.gov
    • Working with Your Older Patient, a clinician’s handbook www.nia.nih.gov
    • Exercise, A Guide from the National Institute on Aging www.nia.nih.gov