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- 1. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Grand Rounds Dylan Fox: PharmD. Dr. Calvo: Physician Topic: Age-Friendly Health Systems: Diabetes Mellitus in the Older Adult Feel free to chat in the chat box. Remember to change your chat to ‘Everyone’ so we may all benefit from your comments. To Unmute your line: Click on your screen and then the microphone at the top of screen. Then click Unmute Call Valerie Jenek NP Mary McCormack NP
- 2. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Providing Age-Friendly Care The goal is for all care with older adults to be Age-Friendly care, which: • Follows an essential set of evidence-based practices; • Causes no harm; and • Aligns with What Matters to the older adult and their family caregivers. AFHS-specific Grand Rounds cases focus on the 4Ms Framework as it pertains to patients 65 years of age and older What Matters, Medication, Mentation, and Mobility will be addressed as a set and ASSESSED and ACTED ON in each case scenario. The 4Ms include: • What Matters: Know, align and act on each older adult’s specific health outcome goals and care preferences • Medication: Optimize medication use to reduce harm and burden, focusing on medications affecting mobility, mentation, and what matters; If medication is necessary, use Age-Friendly medication that does not interfere with What Matters to the older adult, Mobility, or Mentation • Mentation: Focus to prevent, identify, treat, and manage dementia, depression and delirium in older adults • Mobility: Focus to maintain mobility and function and prevent/treat complications of immobility in older adults; Ensure that older adults move safely in order to maintain function and do What Matters
- 3. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. How to Integrate 4Ms Care into the Clinic Visit What Matters: These are some guiding questions or statements to help patients discuss what matters most to them: • What is most important for you during today’s visit? • What are you looking forward to this week? • What activities do you enjoy? If applicable, can ask: What is preventing patient from accomplishing tasks or participating in activities? • Consider discussion about advance care planning if appropriate for the visit • During development of care plan: I would like to individualize your treatment with what matters most to you Medication • Ask about all prescriptions: prescribed, over-the-counter, laxatives, vitamins, supplements, herbal remedies • Reconcile medications with electronic health record • Cross-check for medications that may be on the AGS Beers© Criteria list Mentation • Assess patient’s ability to register, use kiosk, follow directions • Screen for depression using the PHQ-2© and, if positive, continue with the PHQ-9© • Screen for dementia using the Mini-Cog™ • Assess for delirium for any acute change in mental status using the Confusion Assessment Method Mobility • Assess mobility, gait, gait speed, balance, footwear beginning when the patient walks in using the Modified Get Up and Go test • Assess hand dexterity, fine motor movements as patient removes insurance cards from wallet or writes or signs name
- 4. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Learning Objectives At the end of this session, providers will be able to: • Identify common geriatric syndromes associated with older adults with diabetes • Recognize factors contributing to non-adherence to treatment plans/medication self-management • Empower older adults in diabetes self-management • Identify the interrelationship of the 4Ms in the context of a chronic condition • Integrate Age-Friendly care using the 4Ms Framework in care of older adults 65 years of age and over
- 5. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Case Scenario: Diabetes (S) Situation: William is a 74 year old who presents to clinic accompanied by daughter to have a non- healing wound on his foot evaluated. (B) Background: PMH: HTN, hyperlipidemia, depression Medications: amlodipine 5 mg PO daily, atorvastatin 20 mg PO daily, escitalopram 10 mg PO daily, started on metformin 500 mg PO daily 3 months ago Labs: Does not know his most recent Hgb A1c or comprehensive metabolic panel (CMP) results
- 6. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Case Scenario: Diabetes (Cont.) (A) Assessment: VS: BP 144/86 mmHg, HR 76/min, Temp 97.6F, RR 14/min, SpO2 96% on room air Mentation: Alert and oriented to person, place, time. Normal affect. PHQ-2 = 1 (negative); Mini-Cog = 4 (negative). Mobility: Patient walks in unassisted wearing appropriate footwear; walks slowly Skin: Circular, draining 10x10mm ulcer noted on lateral left great toe. Bilateral hallux valgus noted. Monofilament testing demonstrates loss of protective sensation on toes bilaterally. Mouth: Moist mucous membranes Respiratory: Lungs clear bilateral all lobes Cardiac: S1, S2 regular rate no murmur, capillary refill less than 2 sec. PV: Pulses intact and equal bilaterally, no edema Point-of-Care Testing (POCT): Hgb A1c 8, Non-FBS is 145. (R) Recommendation: Superficial wound treated with mupirocin ointment, refer to podiatry. Diabetes not at goal: Discuss adherence to medication and lifestyle recommendations. Order CMP, CBC and Hgb A1c or comprehensive metabolic panel results and schedule follow up appointment to review results and increase in metformin dose if GFR is > 45. Let’s discuss…
- 7. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Diabetes in Older Adults Cognitive function and the possibility of depression should be assessed in older diabetics with: • Nonadherence with treatment plan • Frequent episodes of hypoglycemia • Deterioration of glycemic control without obvious explanation Issues important to successful diabetes management in the community: • Availability of social support • Ability to take oral medicines • Good living conditions • Management of any underlying psychiatric issues • Management of any cognitive and/or functional impairment • Ability to perform activities of daily living • Access to pharmacy, food https://www.cdc.gov/learnmorefeelbetter/programs/diabetes.htm
- 8. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Diabetes in Older Adults (Cont.) Patient outcomes improved with • Cardiovascular risk reduction: Hypertension and hyperlipidemia management • Lifestyle modification: Diet and exercise/mobility Empower self-management • Understanding disease and treatment plan, what to do for high and low blood sugars, frequency of checking fasting blood sugar levels • Healthy food choices, portion sizes, eating habits • Foot and skin exams • Routine eye exams • Mobility and physical activity • Management of concurrent chronic conditions • Coping with living with diabetes
- 9. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Treatment Goals The appropriate target for Hgb A1c is: • Individualized based on overall health and life expectancy • Patient-specific based on risks for hypoglycemia • Based on ability of the patient to adopt and adhere to specific treatment regimens • ADA Guideline recommendations: goal varies per setting (e.g. community, long-term care, hospice) Identify: • Patient-specific risks for hypoglycemia • Ability to adopt and adhere to specific regimens • Ability to afford the medication • Other co-morbidities (e.g. Chronic Kidney Disease or Atherosclerotic Cardiovascular Disease)
- 10. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Treatment Goals (Cont.) Avoid hypoglycemia! Choose medications wisely. Note: GLP1-RA, SGLT2, DPP4i, TZD all have low incidence of hypoglycemia, especially when compared to insulin products and sulfonylureas. If glycemic goals are not met with a single agent, assess older adults for contributing causes: • Difficulty adhering to the medication, side effects • Poor understanding of the nutrition plan • Cognitive and/or functional decline, depression • Socioeconomic factors Communicate and collaborate with interprofessional team members: dietitians, pharmacists, podiatrists, and wound care specialists Consider use of a continuous glucose monitor if the insurance pays for it like Dexcom 6 or FreeStyle Libre. Non-invasive and easy to apply and use.
- 11. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Back to the case… Summary: ASSESS and ACT ON the 4Ms as a set What Matters: Know and act on each patient’s specific health outcome goals and care preferences • Prevent hypoglycemia; Minimize blood glucose testing; Skin care; Refer to wound care specialist if treatment ineffective; Podiatry evaluation and follow up; Dietitian for dietary counseling; Decide on Hgb A1c goal (e.g. suggest 7.5 in 3 months) Medication: Optimize use to reduce harm and burden, focusing on medications affecting mobility, mentation, and what matters • Treat superficial wound with mupirocin ointment; Good skin care; Choose medications that decrease risk of hypoglycemia; Consider cost and safety; Medication reconciliation to fewest necessary drugs: Consider deprescribing https://deprescribing.org Mentation: Focus on dementia and depression and delirium • Optimize socialization such as diabetes support group, monitor for adverse drug events, screen for dementia and depression Mobility: Maintain mobility and function and prevent/treat complications of immobility • Walk multiple times daily; Physical therapy if needed to promote mobility Provide 4Ms brochure with suggestions for patient/family to share with primary care provider: Include the need for diabetes education, how to promote wound healing • Don’t forget to scan into the EHR whenever individualized.
- 12. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Interprofessional Team Discussion…
- 13. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Acknowledgements Age-Friendly Health Systems is an initiative of The John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI) in partnership with the American Hospital Association (AHA) and the Catholic Health Association of the United States (CHA). MinuteClinic’s commitment to be an Age-Friendly Health System is supported by a grant from The John A. Hartford Foundation to the Case Western Reserve University Frances Payne Bolton School of Nursing.
- 14. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020. Thank You
Editor's Notes
- Today’s topic is: Diabetes in the Older Adult
- The goal is for all care with older adults to be Age-Friendly care, which follows an essential set of evidence-based practices, causes no harm, and aligns with What Matters to the older adult and their family caregivers. AFHS-specific Grand Rounds cases will focus on the 4Ms Framework as it pertains to our patients 65 years of age and older. What Matters, Medication, Mentation, and Mobility will be addressed as a set and ASSESSED and ACTED ON in each case scenario. The 4Ms include: What Matters: Know, align and act on each older adult’s specific health outcome goals and care preferences Medication: Optimize medication use to reduce harm and burden, focusing on medications affecting mobility, mentation, and what matters; If medication is necessary, use Age-Friendly medication that does not interfere with What Matters to the older adult, Mobility, or Mentation Mentation: Focus to prevent, identify, treat, and manage dementia, depression and delirium in older adults Mobility: Focus to maintain mobility and function and prevent/treat complications of immobility in older adults; Ensure that older adults move safely in order to maintain function and do What Matters
- This slide provides information to help integrate 4Ms care into the clinic visit. This is the basis of providing Age-Friendly care. You will become familiar with the Age-Friendly Health Systems 4Ms Framework logo. What Matters: These are some guiding questions or statements to help patients discuss what matters most to them: What is most important for you during today’s visit? What are you looking forward to this week? What activities do you enjoy? If applicable, can ask: What is preventing patient from accomplishing tasks or participating in activities? Consider discussion about advance care planning if appropriate for the visit During development of care plan: I would like to individualize your treatment with what matters most to you Medication Ask about all prescriptions: prescribed, over-the-counter, laxatives, vitamins, supplements, herbal remedies Reconcile medications with electronic health record Cross-check for medications that may be on the AGS Beers© Criteria list Mentation Assess patient’s ability to register, use kiosk, follow directions Screen for depression using the PHQ-2© and, if positive, continue with the PHQ-9© Screen for dementia using the Mini-Cog™ Assess for delirium for any acute change in mental status using the Confusion Assessment Method Mobility Assess mobility, gait, gait speed, balance, footwear beginning when the patient walks in using the Modified Get Up and Go test Assess hand dexterity, fine motor movements as patient removes insurance cards from wallet or writes or signs name
- At the end of this session, providers will be able to: Identify common geriatric syndromes associated with older adults with diabetes (e.g. functional disabilities, depression, fall, urinary incontinence, pain, dementia) Recognize factors contributing to non-adherence to treatment plans Empower older adults in diabetes self-management Identify the interrelationship of the 4Ms in the context of a chronic condition Integrate Age-Friendly care using the 4Ms Framework in care of older adults 65 years of age and over
- S: Situation: William is a 74 year old who presents to clinic for evaluation of a non-healing wound on his foot. He is accompanied by his daughter. B: Background: PMH: HTN, hyperlipidemia and depression. Medications: amlodipine 5 mg PO daily, atorvastatin 20 mg PO daily and escitalopram 10 mg PO daily, and placed on metformin 500 mg PO daily 3 months ago. He does not know his most recent Hgb A1c or comprehensive metabolic panel results.
- A: Assessment: VS: BP 144/86 mmHg, HR 76/min, Temp 97.6F, RR 14/min. SpO2 96% on room air Mentation: Alert and oriented to person, place, time. Normal affect. PHQ-2 is 1; Mini-Cog 4. Mobility: Patient walks in unassisted wearing appropriate footwear; walks slowly Skin: Circular, draining 10x10mm ulcer noted on lateral left great toe. Bilateral hallux valgus noted. Monofilament testing demonstrates loss of protective sensation on toes bilaterally. Mouth: Moist mucous membranes Respiratory: Lungs clear bilateral all lobes Cardiac: S1, S2 regular rate no murmur, capillary refill less than 2 sec. PV: Pulses intact and equal bilaterally, no edema Point-of-Care Testing (POCT): Hgb A1c 8, Non-FBS is 145. R: Recommendation: Superficial wound treated with mupirocin ointment, refer to podiatry. DM not at goal: Discuss adherence to medication and lifestyle recommendations. Order CMP, CBC and Hgb A1c. Schedule follow up appointment to review results and increase metformin dose if GFR is > 45.
- Older adults with diabetes experience increased morbidity and mortality compared with older individuals without diabetes. In addition, they are at high risk for polypharmacy, functional disabilities, and common geriatric syndromes that include cognitive impairment, depression, urinary incontinence, falls, and persistent pain. Screening for geriatric syndromes may be beneficial in selected patients, particularly when identification and treatment may help achieve better glycemic control and self-management. In particular, cognitive function and the possibility of depression should be assessed in older diabetic patients when there is: Nonadherence with the treatment plan Frequent episodes of hypoglycemia Deterioration of glycemic control without obvious explanation For older adults, issues important to successful management in the community include availability of social support, ability to take oral medicines, good living conditions, management of underlying psychiatric issues, management of cognitive and/or functional impairment, ability to perform ADLs, and access to pharmacy and food.
- Older patients are more likely to improve morbidity and mortality outcomes through cardiovascular risk reduction, particularly treatment of hypertension and lipid lowering with statin therapy, than from tight glycemic control. Older patients with diabetes should receive individualized counseling regarding lifestyle modification, including a nutrition evaluation and exercise counseling. Older adults should be empowered to self-manage their diabetes including understanding their disease and treatment plan, what to do for high and low blood sugars, healthy food choices and eating habits, how to do foot exams, importance of routine eye exams, importance of mobility and physical activity, management of concurrent chronic conditions, coping with living with diabetes. For further education and engagement, refer to diabetic educator, dietitian, and podiatrist. The nutrition plan with food suggestions and portion sizes is tailored for older people with diabetes based upon medical, lifestyle, and personal factors. Exercise is beneficial to help maintain physical function, reduce cardiac risk, and improve body composition and insulin sensitivity in older patients with diabetes. Fasting sugar levels should be checked and medications taken as recommended by the primary care provider. Collaborate with the primary care provider to ensure this is done.
- The overall goals of diabetes management in older adults are similar to those in younger adults and include management of both hyperglycemia and risk factors. Older adults with diabetes includes persons residing independently in communities, in assisted care facilities, or in nursing homes. The appropriate target for Hgb A1c should be individualized based on overall health and life expectancy, as well as on identified patient-specific risks for hypoglycemia and the ability of the patient to adopt and adhere to specific treatment regimens. ADA Guidelines have acknowledged the different facilities in which older adults reside and have recommended different goals based on where the patient is residing Example: Long-term care goals, hospice goals. Consider use of a continuous glucose monitor if the insurance pays for it like Dexcom 6 or FreeStyle Libre which makes monitoring so much easier and less painful. These are now so non-invasive and easy to apply and use. When choosing a treatment plan, identify patient-specific risks for hypoglycemia, the ability of the patient to adopt and adhere to specific regimens, their ability to afford the medication, and other co-morbidities they may have such as CKD or ASCVD.
- Overall avoidance of hypoglycemia is critical when caring for older adults and choosing therapeutic agents. For instance, GLP1-RA, SGLT2, DPP4i, TZD all have low incidence of hypoglycemia, especially when compared to insulin products and sulfonylureas. If glycemic goals are not met with a single agent, the older patient should be evaluated for contributing causes, such as difficulty adhering to the medication, side effects, or poor understanding of the nutrition plan. In addition, they should be screened for cognitive and/or functional decline, depression, and socioeconomic factors. Communication and collaboration with interprofessional team members such as dietitians, pharmacists, podiatrists, and wound care specialists is important for the holistic management of older adults with diabetes.
- Age-Friendly health care seeks to incorporate all 4Ms (What Matters, Mobility, Medication, Mentation) into your assessment and provision of care of your patients 65 years of age and over. Here are some recommendations referring back to the case. Keep in mind the need to ASSESS and ACT ON the 4Ms as a set. What Matters: Know and act on each patient’s specific health outcome goals and care preferences Prevent hypoglycemia; Minimize blood glucose testing; Skin care; Refer to wound care specialist if treatment ineffective; Podiatry evaluation and follow up; Dietitian for dietary counseling; Decide on HgA1c goal (e.g. suggest 7.5 in 3 months) Medication: Optimize use to reduce harm and burden, focusing on medications affecting mobility, mentation, and what matters Treat superficial wound with mupirocin ointment; Good skin care; Choose medications that decrease risk of hypoglycemia; Consider cost and safety; Medication reconciliation to fewest necessary drugs: Consider deprescribing. The website for deprescribing.org is provided: https://deprescribing.org Mentation: Focus on dementia and depression and delirium Optimize socialization such as diabetes support group, monitor for adverse drug events, screen for dementia and depression Mobility: Maintain mobility and function and prevent/treat complications of immobility Walk multiple times daily; Physical therapy if needed to promote mobility Provide 4Ms brochure with suggestions for patient/family to share with primary care provider, diabetes education, how to promote wound healing Don’t forget to scan into the EHR whenever individualized.
- Team discussion: NP, pharmacist, physician, other