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Promoting Health Along the Continuum of Care for Older Adults with Diabetes

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Title: Promoting Health Along the Continuum of Care for Older Adults with Diabetes


1
Promoting Health Along the Continuum of Care for
Older Adults with Diabetes
  • Barbara Nakanishi, RD, LD, CDE
  • Suzanna Theodoras, RN, CDE

2
Diabetes in the Older Adult
  • With age--an increased prevalence of functional
    disabilities illnesses increases the complexity
    of managing diabetes.
  • Wake Forest University Baptist Medical Center
    study of 300,000 people 94-99
  • 4 higher annual mortality rate
  • Age 65 with diabetes 10 mortality rate
  • Age 65 without diabetes 6 mortality rate

3
Physiology of Aging as it relates to Diabetes
  • Clinical presentation
  • May not present with classic symptoms
  • Renal threshold for glucose ?
  • High concentration of sugar in urine pulls fluid
    from the body
  • Plus, Altered thirst perception leads to
  • Dehydration
  • Confusion
  • Incontinence
  • Complications related to diabetes may be what
    brings the person in for medical care then the
    diagnosis of Diabetes is made

4
Physiology of Aging as it relates to Diabetes
(Continued)
  • Alteration in Carbohydrate Metabolism
  • Obese PatientsInsulin Resistance
  • Lean to Normal PatientsImpaired Glucose-Induced
    Insulin Release
  • Pharmacokinetic changes affect drug choices
    dosing decisions
  • Altered drug absorption, distribution,
    metabolism, clearance

5
Diagnosis of Diabetes
  • Fasting Serum Glucose
  • Normal 70-100 mg/dl
  • Values 126 mg/dl more than oncediabetes
  • May miss 31 of cases in the elderly
  • Random Serum Glucose non-fasting 200 mg/dl
  • Oral Glucose Tolerance (OGTT)More useful in
    elderly
  • 2hr post glucose
  • 2hr PG 140 mg/dl and
  • 2hr PG 200 mg/dldiabetes
  • Impaired Fasting Glucose (IFG)
  • Fasting 100 mg/dl but

6
Diabetes in the Older Adult
  • Challenges for Health Care Professionals
  • Challenges for Family/Caregivers
  • Challenges for the Community

7
Challenges for the Health Care Team
  • Communication with Team Members
  • Creating an Individualized Treatment Plan
  • Communications with Clients Family Members
  • Appropriate Referrals

8
Challenges for the Health Care Team
  • Communication with team members
  • Creating an Individualized Treatment Plan
  • Goals may be different/Standards of Care
  • Types of treatment
  • Finances
  • Family Support
  • Safety Issues
  • Communications with Family Members
  • Appropriate Referrals

9
Challenges for the HCT Communication with Team
Members
  • Nurse--Family practice
  • Liaison between members
  • Coordinator/Glue that holds it together
  • Has patients trust/Knows their family
  • Suggests Referrals/Paperwork to accomplish
  • Social Workers, Dietitians, DM Educators
  • Always helpful, but are frequently consulted late
    in the treatment planning

10
Challenges for the HCT
  • Communication with team members
  • Creating an Individualized Treatment Plan
  • Goals may be different
  • Standards of Care
  • Types of treatment
  • Finances
  • Family Support
  • Safety Issues
  • Communications with Family Members
  • Appropriate Referrals

11
Challenges for the HCT Individualized Treatment
Plan
  • Goals may be different with Older Adult
  • Life Expectancy
  • Coexisting medical conditions
  • Coexisting psychiatric conditions
  • Willingness/ability to comply with treatment
  • Most importantwhat is their desire for treatment
    and what are their goals?

12
Challenges for the HCT
  • Communication with team members
  • Creating an Individualized Treatment Plan
  • Goals may be different
  • Standards of Care
  • Types of treatment
  • Finances
  • Family Support
  • Safety Issues
  • Communications with Family Members
  • Appropriate Referrals

13
Challenges for the HCT Individualized Treatment
Plan
  • Standards of CareADA
  • Blood Pressure (130/80)(Strokes, MI, Kidney)
  • Weight (Each Visit)Cant seeCHF, Wt Loss
  • Foot Inspection/Examination Each Visit--? Vision
  • A1c 7 (6.5) (2 to 4 x year)
  • Fasting Lipid Profile (Yearly) LDL-C 40, Triglycerides
  • Dilated Retinal Eye Examination (Yearly)
  • Microalbumin/Urine test (Yearly)
  • Flu (Yearly)
  • Pneumonia Vaccines before age 65/after ?w doctor

14
Challenges for the HCT
  • Communication with team members
  • Creating an Individualized Treatment Plan
  • Goals may be different
  • Standards of Care
  • Types of treatment
  • Finances
  • Family Support
  • Safety Issues
  • Communications with Family Members
  • Appropriate Referrals

15
Challenges for the HCT Individualized Treatment
Plan
  • Usual Treatment
  • Type 1 always includes Diabetes Education,
    Monitoring, Insulin, Meal Planning and Exercise
  • Type 2 is usually done in stages or phases
  • Diabetes Education
  • Monitoring/recordkeeping
  • Meal planningfrequently weight reduction
  • Exercise
  • Oral medicines
  • Insulin
  • Combination insulin/oral medicines

16
Challenges for the HCT Individualized Treatment
Plan
  • Types of Oral Diabetes Medications
  • Sulfonylureasinsulin secretagogue
  • Meglitinidesinsulin secretagogue
  • Biguanidesinsulin sensitizer
  • Thiazolidinedionesinsulin sensitizer
  • Alpha-glucosidase inhibitordelays glucose
    absorption

17
Challenges for the HCT Individualized Treatment
Plan
  • Sulfonylureas
  • Combination Drugs/Glucovance Metaglip
    (Glyburide Metformin) (Glipizide Metformin)
  • Adverse effects
  • Hypoglycemia1st generation long ½ life
  • Weight gain
  • Skin rashes, sun sensitivitySun Screen?
  • Gastrointestinal symptoms
  • Avoid with Liver disease
  • Caution with Renal dysfunction

18
Challenges for the HCT Individualized Treatment
Plan
  • Meglitinide
  • Prandin and Starlix
  • Taken 15 minutes before each meal or snack it is
    designed to treat post-meal hyperglycemia, but in
    waiting the 15 min. the elderly get distracted or
    fall asleep before eating. Safer with elderly to
    take with first bite of meal.
  • Very rapid-acting insulin secretagogues that
    stimulates insulin secretion, so it is important
    that it not be taken if skipping a meal.
    Difficult concept for some to understand.
  • HypoglycemiaWith alcohol, exercise, or
    insufficient food
  • Do not use in combination with sulfonylureasRemem
    ber waste notbe sure to take away old meds
    before giving new

19
Challenges for the HCT Individualized Treatment
Plan
  • Meglitinide (Prandin Starlix)
  • Use cautiously in the elderly and in persons with
    liver damage.
  • Adverse effects
  • Mild hypoglycemia
  • Dizziness
  • Diarrhea
  • Back pain
  • Upper respiratory infections
  • Weight gainbut less than with sulfonylureas
  • Drug Interactions
  • LopidFinnish Study not FDA? risk for
    Hypoglycemia

20
Challenges for the HCT Individualized Treatment
Plan
  • Biguanides
  • Glucophage and Glucophage XR (Metformin)
  • Adverse effects
  • Diarrhea, nausea, vomiting, abdominal bloating,
    flatulence, anorexia
  • Unpleasant or metallic tasteproblem if poor
    appetite already
  • Lactic acidosis
  • Possible drug interactions Lasix and
    Tagametdrugs frequently prescribed

21
Challenges for the HCT Individualized
Treatment Plan
  • Biguanides (MetforminGlucophage)
  • Not appropriate for people with liver or kidney
    damage or heart failure
  • Renal dysfunction with serum creatinine levels
    1.5 mg/dl in males or 1.4 mg/dl in females.
    (Creatinine Clearance in elderly /or 24 hour
    urine sample 70 yrs.old )
  • May need to be discontinued for 24-48 hours with
    certain tests using dyes.

22
Challenges for the HCT Individualized Treatment
Plan
  • Thiazolidinediones (TZDs) Insulin Sensitizers
    Avandia, Actos, Avandamet
  • Adverse effects are
  • Weight gain
  • Mild to moderate edema (CHF)
  • Headache
  • Pharyngitis
  • Jaundice
  • Nausea, vomiting, stomach pain
  • Dark urine
  • Elevated hepatic enzymesliver function tests
    should be done before starting drug and
    periodically thereafter
  • 2 to 6 weeks to be effectiveimpatient/want
    immediate results/may stop taking if they dont
    understand

23
Challenges for the HCT Individualized Treatment
Plan
  • Alpha-glucosidase Inhibitors
  • Precose Glyset
  • Taken with first bite of mealseasy to forget
  • Not recommended if serum creatinine levels
  • 2.0 mg/dl
  • Adverse effects Bloating, gas, and diarrhea
  • May cause them to be socially unacceptable
  • May reduce Digoxin concentrationmonitor closely
  • Treat lows with oral glucose, milk or glucagon

24
Challenges for the HCT Individualized Treatment
Plan
  • Insulin
  • Risk of severe hypoglycemia ? with age
  • Complete geriatric assessment before initiating
    to identify potential complicating factors
  • Visionaccuracy
  • Dexterity
  • Ability to recognize treat hypoglycemia

25
Challenges for the HCT Individualized Treatment
Plan
  • Mixing Insulins
  • Rapid-acting or short-acting can be mixed with
    NPH or Lente in one syringe, but it is
    recommended to administer within 5 min.
  • Lantus cannot be mixed with any other insulin nor
    pre-drawn ahead of timeNew Pen helpful but
    expensive
  • Detemircan be mixed
  • Requires 2 injections/day
  • Slow release/less potency/need 1.4 to 4 times

26
Challenges for the HCT Individualized
Treatment Plan
  • Storage of Insulin
  • Current insulin vial can be kept at room
    temperature (
    Lantus 30 days for others.
  • Diabetes Care 26 2665-2669, 2003
  • Check expiration dates when purchasing before
    using vial. Keep extra bottles in the
    refrigerator.
  • When traveling insulin cannot be put in checked
    luggage or left in a parked car/truck.

27
Challenges for the HCT
  • Communication with team members
  • Creating an Individualized Treatment Plan
  • Goals may be different/Standards of Care
  • Types of treatment
  • Finances
  • Family Support
  • Safety Issues
  • Communications with Family Members
  • Appropriate Referrals

28
Challenges for the HCT Individualized
Treatment Plan
  • Finances
  • Elderly have a very limited income
  • Many have no prescription benefits
  • Drug company indigent programstakes swallowing
    pride, paperwork and time limitations
  • Family assistance/gift certificates for holidays
  • Do they have any financial resources for hiring
    help, assisted living, long-term care

29
Challenges for the HCT
  • Communication with team members
  • Creating an Individualized Treatment Plan
  • Goals may be different/Standards of Care
  • Types of treatment
  • Finances
  • Family Support
  • Safety Issues
  • Communications with Family Members
  • Appropriate Referrals

30
Challenges for the HCT Individualized Treatment
Plan
  • Family Support
  • Are there several member to share the
    responsibility?
  • What is the health strength of the caretaker
  • Time availability
  • Does caretaker work and/or have other family
    responsibilities
  • Are they caring for more than one family member?
  • What are their financial resources?

31
Challenges for the HCT Individualized Treatment
Plan
  • Communication with team members
  • Creating an Individualized Treatment Plan
  • Goals may be different/Standards of Care
  • Types of treatment
  • Finances
  • Family Support
  • Safety Issues
  • Communications with Family Members
  • Appropriate Referrals

32
Challenges for the HCT Individualized Treatment
Plan
  • Safety IssuesHCT and Family
  • Right Medication at the Right Time in the Right
    Dose
  • 80 take meds improperlynot just elderly
  • Take as PrescribedHearing Vision Problems
  • Pill containers and Written Instructions helpful
    sometimes
  • Establish Routinesame time each day
  • If a dose is forgotten, instruct not to double
    up
  • Confusion after a nap/think it is a new day
    take meds
  • Complicated if there are multiple medications to
    be taken at different times
  • Insulin pens, magnifying glasses, gadgets may
    help or they may confuse

33
Challenges for the HCT Individualized Treatment
Plan
  • Safety IssueHCT and Family
  • Provide a safe environmentCommon Sense?
  • Prevent Falls
  • Communication in an EmergencyFallen I cant
    get up
  • Medic Alert Many Varieties now, even Shoe Tags
  • UtilitiesLighting, Heat, Air Conditioning/Fans
  • Daily Check-in with Someone
  • Provisions for Emergency/DisasterMinimum 3 day
    supply
  • Food Water
  • Testing supplies Medications
  • Help patient family make decision as to when a
    new level of care is neededassisted living or
    nursing home

34
Challenges for the HCT Individualized Treatment
Plan
  • Safety IssueHCT and Family
  • Hypoglycemia can occur with
  • SulfonylureasGlipizide and Glyburide
  • GlimepirideAmaryl
  • MeglitinidesPrandin , Starlix
  • CombinationsGlucovance, Metaglip
  • Hypoglycemia does not occur when taken alone
  • Metaformin--Glucophage
  • Acarbose--Precose
  • Miglitol--Glyset
  • TZDsAvandia or Actos, Avandamet
  • If combined with sulfonylureas then hypoglycemia
    may occur

35
Challenges for the HCT
  • Communication with team members
  • Creating an Individualized Treatment Plan
  • Goals may be different/Standards of Care
  • Types of treatment
  • Finances
  • Family Support
  • Safety Issues
  • Communications with Family Members
  • Appropriate Referrals

36
Challenges for the HCT Communications with
Family Members
  • Time consuming
  • Necessary for good medical care
  • Availability to HCT
  • Need a real live person
  • Telephone Menu very confusing
  • Difficulty hearing
  • Messages returned in timely manner

37
Challenges for the HCT
  • Communication with team members
  • Creating an Individualized Treatment Plan
  • Goals may be different/Standards of Care
  • Types of treatment
  • Finances
  • Family Support
  • Safety Issues
  • Communications with Family Members
  • Appropriate Referrals

38
Challenges for the HCT Appropriate Referrals
  • Physician Ologists Endo, Cardio, Neuro, Nephro,
    Opthal, Psycho,
  • Psychiatrist
  • Social Workers
  • Pharmacists
  • Dentist
  • Podiatrist
  • Dietitians
  • Diabetes Educators
  • Community Resources
  • Service Clubs
  • Senior Citizen Groups
  • Churches

39
How are people doing in meeting therapy goals for
diabetes and CVD?
  • Among surveyed adults with diabetes
  • 45 had A1C
  • 62 had B/P levels
  • 11 had LDL cholesterol level
  • 20 used aspirin regularly
  • 22 smoked cigarettes.

40
Challenges for the Family
  • Changing Physical Abilities
  • Safety Issues
  • Eating Healthy
  • Taking Medication
  • Remaining Active
  • Driving/Transportation Issues
  • Changing Mental Status
  • Changing Roles
  • Maintaining Quality of Life

41
Challenges for the Family Changing Physical
Abilities
  • Safety Issues for Family
  • HCT can guide, but responsibility belongs to
    family
  • How long is it safe for the older adult to live
    alone?
  • Do they need assistance with Medications?
  • Do they need assistance with Meal Preparation?
  • Do they need assistance with Activities of Daily
    Living?
  • Is there a Disaster Plan?
  • Sibling differences can be obstacle to good care
  • Gradual changes vs Sudden changes

42
Challenges for the Family
  • Changing Physical Abilities
  • Safety Issues
  • Eating Healthy
  • Taking Medication
  • Remaining Active
  • Driving/Transportation Issues
  • Changing Mental Status
  • Changing Roles
  • Maintaining Quality of Life

43
Challenges for the Family Changing Physical
Abilities
  • Eating Healthy
  • Shopping
  • Cooking
  • Eating Alone
  • Dentures
  • Cost of Fresh Fruits/Vegetables/Choice cuts of
    Meat
  • Storage of Food

44
Challenges for the Family Changing Physical
Abilities Healthy Eating
  • Shopping
  • Transportation to and within the store
  • Many food choices-overwhelming
  • Location of food-too high or low, especially from
    a wheelchair
  • Bagging the food-too heavygallon of milk weighs
    8.62

45
Challenges for the Family Changing Physical
Abilities Healthy Eating
  • Cooking
  • Energy
  • Strength
  • Effort to cook for one or two
  • Size of packages
  • Eating out higher fat lower fiber

46
Challenges for the Family Changing Physical
Abilities Healthy Eating
  • Eating Alone
  • No social interaction
  • Depressionfamily may be first to notice
  • Diminished appetite
  • May lead to inadequate nutrition and weight
    loss.
  • Made need diabetes medication dosage adjustment

47
Challenges for the Family Changing Physical
Abilities Healthy Eating
  • Dental Issues
  • Teeth in poor repair
  • Dentures do not fit
  • Family may not be aware of the difficulty
  • Affordability

48
Challenges for the Family Changing Physical
Abilities Healthy Eating
  • Food Costs
  • Fresh fruits and vegetables
  • Choice cuts of meat

49
Challenges for the Family Changing Physical
Abilities Healthy Eating
  • Food Storage
  • Expiration date too small to read
  • Cognitive impairment-lose track of time-keep
    leftovers too long
  • Leave food on counter or table from one meal to
    the next
  • Taste impairment-do not notice something spoiled

50
Challenges for the Family
  • Changing Physical Abilities
  • Safety Issues
  • Eating Healthy
  • Taking Medication
  • Remaining Active
  • Driving/Transportation Issues
  • Changing Mental Status
  • Changing Roles
  • Maintaining Quality of Life

51
Challenges for the Family Changing Physical
Abilities
  • Taking Medication
  • A designated person to organize medications daily
    or weekly (back up person trained)
  • Remember it is confusing when doses keep
    changingInsulin, Coumadin
  • Remove old written instructions when replacing
    with new ones.
  • Remove old prescription drugs when prescription
    has changed

52
Challenges for the Family
  • Changing Physical Abilities
  • Safety Issues
  • Eating Healthy
  • Taking Medication
  • Remaining Active
  • Driving/Transportation Issues
  • Changing Mental Status
  • Changing Roles
  • Maintaining Quality of Life

53
Challenges for the Family Changing Physical
Abilities
  • Remaining active
  • WalkingNo sidewalks, balance issues,
    coordination, foot/leg problems
  • Armchair exercises
  • Walking around house during commercialsbut not
    to the refrigerator
  • Family support necessary to get the elderly out
    of the house for activities simulation even if
    it is a Sat. morning at Farmers Market or a Sun.
    afternoon drive

54
Challenges for the Family
  • Changing Physical Abilities
  • Safety Issues
  • Eating Healthy
  • Taking Medication
  • Remaining Active
  • Driving/Transportation Issues
  • Changing Mental Status
  • Changing Roles
  • Maintaining Quality of Life

55
Challenges for the Family Changing Physical
Abilities
  • Driving/Transportation Issues
  • A major personal, family community issue
  • When is it time to give up driving?
  • How do they get anywhere?
  • Limited mass transit
  • Physical ability to use?
  • Mental ability to use?
  • Who is responsible? Family Issues
  • Feels like a burden

56
Challenges for the Family
  • Changing Physical Abilities
  • Safety Issues
  • Eating Healthy
  • Taking Medication
  • Remaining Active
  • Driving/Transportation Issues
  • Changing Mental Status
  • Changing Roles
  • Maintaining Quality of Life

57
Challenges for the Family Changing Mental
Status
  • Some studies say that the cognitive decline is
    greater/faster with Diabetes
  • Difficult to assess
  • Difficult to accept
  • Undiagnosed depression
  • Dementia or Psychiatric illnesses
  • Alzheimers Disease is 65 higher in people with
    diabetes

58
Challenges for the Family
  • Changing Physical Abilities
  • Safety Issues
  • Eating Healthy
  • Taking Medication
  • Remaining Active
  • Driving/Transportation Issues
  • Changing Mental Status
  • Changing Roles
  • Maintaining Quality of Life

59
Challenges for the Family Changing Roles
  • When does the child become the parent
  • How and when does the switch take place?
  • Sometimes it is a gradual process/sometimes
    illness or accident causes an immediate switch
  • When a family member is no longer able to care
    for themselves in one aspect, we have to be
    careful not to assume that they are incapable in
    all areas of their life.

60
Challenges for the Family
  • Changing Physical Abilities
  • Safety Issues
  • Eating Healthy
  • Taking Medication
  • Remaining Active
  • Driving/Transportation Issues
  • Changing Mental Status
  • Changing Roles
  • Maintaining Quality of Life

61
Challenges for the Family Maintaining Quality of
Life
  • Complications
  • Macrovascularconsiderable functional
    impairmentMI, Stroke, Amputations
  • Cardiovascular Disease
  • Cerebrovascular Disease
  • Peripheral Vascular Disease
  • Microvascular
  • RetinopathyCataracts, Glaucoma, Blindness
  • NephropathyRenal Failure
  • Neuropathy50 60 yrs old w DM affected
  • Erectile Dysfunction

62
Challenges for the Family Maintaining Quality of
Life
  • Activities of Daily Living
  • According to Dr. Allison Batchelor,
  • Department of Geriatric Medicine
  • 3 stages--Independent, Intermediate, Basic
  • Independent Activities of Daily Living would be

  • To continue in their profession
  • To play golf or tennis or bowl
  • To travel by themselves/air, train, or bus

63
Challenges for the Family Maintaining Quality of
Life
  • Instrumental Activities of Daily Living or
    Intermediate Skills
  • Using the phone
  • Shopping
  • Preparing Meals
  • Housekeeping
  • Doing Laundry
  • Using Public Transportation
  • Taking Medication
  • Handling Finances

64
Challenges for the Family Maintaining Quality of
Life
  • Basic Activities of Daily Living
  • Bathing
  • Dressing
  • Transferring
  • Toilet
  • Continence
  • Feeding Self

65
Challenges for the Community
  • Meal Services
  • Transportation Services
  • Systems to Check on Elderly w/o Family
  • Reasonably Priced Services
  • Respite Care for Everyone

66
Challenges for the Community Meal Services
  • Meals on Wheels
  • Personal Chefs
  • Community Center
  • Community ChurchesM thru F one free meal a day

67
Challenges for the Community Transportation
  • Athens transit
  • Helping hands
  • Hickory Creek
  • Taxi
  • Family

68
Challenges for the Community Who Checks On
Elderly?
  • Systems to Check on Elderly without Family
  • Neighbor
  • Church

69
Challenges for the Community Reasonably Priced
Services
  • Plumbing
  • Electric
  • Yard care
  • Housecleaning
  • Taxi Service
  • Adult Daycare

70
Summary
  • Ideal geriatric care requires a multidisciplinary
    approach including family/caregivers.
  • Goals of therapy should aim toward optimizing
    function and minimizing complications that may
    cause loss of independence or early
    institutionalization.

71
Conclusion
  • Life is not a journey to the grave with the
    intention of arriving safely in a pretty and well
    preserved body, but rather to skid in broadside,
    thoroughly used up, totally worn out, and loudly
    proclaiming WOW What a Ride! Author
    Unknown
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