Diabetes Management in the Older Adult

1. Diabetes Management in the Older Adult Presented by Carolyn Jennings, MPH, RD, CDE SouthEast Michigan Diabetes Outreach Network (SEMDON) www.diabetesinmichigan.org

2. 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

3. Prevalence of Diabetes

4. Pathogenesis of Hyperglycemia in Elderly Coexisting Illness Reduced Insulin Secretion Poor Nutrition Increased Adipose Tissue Genetics Decreased Physical Activity Medications

5. Diabetes in Older Adults • 50% under-diagnosed – WHY?? • Early signs: Metabolic Abnormalities • Insulin resistance •  1st phase insulin release •  PPG with normal FPG • Early symptoms: (if any) • Often gradual onset • Commonly mistaken for signs of normal aging

6. 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. Case of Mistaken Identity Signs of Aging Signs of Diabetes

7. 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.

8. 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.

9. Diabetes Assessmentin the Older Adult • Physical Assessment • Mobility/ Physical Activity • Nutritional Assessment • Neurological Assessment • Psychosocial Assessment • Other Areas

10. Diabetes Assessmentin the Older Adult Common Geriatric “Syndromes” • Depression • Polypharmacy • Cognitive Impairment • Urinary incontinence • Injurious falls • Persistent pain

11. Physical Assessment • Ophthalmic • Higher rates of cataracts, glaucoma and macular degeneration. • Auditory • Renal • Thickening of basement cell membranes. • Immune system • Flu, herpes zoster, cancer

12. 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.

13. 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

14. Nutritional Assessment • Preferences and Lifelong habits • Meal Planning considerations • Food Preparation • Lifestyle changes • Mobility issues • Dentition • High Risk considerations

15. Nutritional Assessment • Malnutrition • Altered nutrient absorption • Vitamin deficiencies (B12) • CHO intolerance • Decline in renal function • Depression • Cognitive Impairment

16. 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

17. 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

18. Neurological Assessment • Autonomic and peripheral neuropathies: • Heart • Incontinence • Sexual function • Protective sensation • Hypoglycemia unawareness • Body Temperature regulation • Reduced ability to sense: • Thirst, Smell, Taste

19. Psychosocial Assessment • Depression • Support systems • Loss of peers • Change in family role • Health Beliefs • Locus of Control • Internal vs. External

20. Other Areas of Assessment • Co-morbidities • Pain • Polypharmacy • Diabetes medications appropriate? • Drug interactions • Ability to administer medications • Safety • Finances

21. 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.

22. Treatment Recommendations • Glycemic Control • Hypertension • Lipids • Tobacco cessation • Eye care • Foot care • Nephropathy • Diabetes Self-Management Training

23. Treatment Recommendations • When and how to prioritize interventions? • Stratifying older adults: • Comorbities • Complications • Risks vs. benefits of (intensive) therapies

24. 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

25. Risks of Intensive Glycemic Control • Hypoglycemia • Polypharmacy • Drug to drug interactions • Drug to disease interactions

26. 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

27. Hyperglycemia • Can cause: • Delirium • Mood swings and irrationality • Appetite changes • Sleep disturbances • Increases risk for: • Diabetic Ketoacidosis • Hyperglycemic Hyperosmolar State (HHS)

28. 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

29. Hypoglycemia • 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

30. 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

31. 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)

32. 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

33. Hypertension: Medication Precautions • Thiazide or loop diuretic • Check electrolytes within 1-2 weeks of initiation and at least yearly • Hypokalemia associated with ventricular arrhythmias.

34. 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

35. 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

36. 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.

37. Tobacco Cessation 12% of PWD over age 65 smoke • Assess use/willingness to quit • Offer counseling and/or pharmacologic interventions to assist with cessation

38. 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

39. 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

40. Nephropathy Screening • Screen for microalbumin and GFR at diagnosis and (at least) annually

41. 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

42. 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.

43. The Adult Learner • Perceives need • Self-directed • Experienced • Problem-oriented • Task-centered • Internally motivated

44. 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

45. Patient Centered Education • 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 • Patients Role: • Determine personal self-care goals • Find solution • Take responsibility for own health

46. 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

47. 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

48. 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.

49. Education Strategies • 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.

50. 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.