Educating Older People with Diabetes

1. Educating Older People with Diabetes Professor Trisha Dunning AM Chair in Nursing and Director Centre for Nursing and Allied Health Deakin University and Barwon Health, Australia

2. Common misconceptions about older people’s capacity to learn Older people with diabetes are not a homogenous group but they are adult learners and have considerable life experience and often significant experience living with diabetes Older people do use technology You can ‘teach an old dog new tricks’ and, in the process, can often Learn new tricks from old dogs

3. Some key considerations • Older people with diabetes often do not receive adequate or appropriate diabetes education • Teaching styles are often not appropriate to older people’s learning needs or learning styles • Learning can be compromised by multimorbidities, sensory and functional changes and environmental issues • Most existing diabetes education guidelines do not encompass the specific education needs of older people • Inconsistent information from the range of health professionals who manage the individual is confusing and disempowering • Older people may not regard diabetes as a significant life priority • Lecture content

4. Teaching and learning Teaching and learning is an inter-related process The process should reflect an approach where information is cogenerated between the health professional and the individual older person and in some cases their family/carers

5. Teaching The actual aim of a skilled educator is to create an environment in which the person can learn Teaching is an art and a science as well as a creative endeavour

6. Learning • Learning is a complex cognitive process that involves processing information to construct neural pathways and making neural connections with information already stored and consolidated in memory • Information in store is retrieved when needed but many factors affect memory and the ability to retrieve and use information

7. Personalise teaching • Teaching must be personalised to make sure it is relevant to the individual: • Ask the individual what they want to learn/know • Individual’s literacy and numeracy level, learning style and physical and cognitive capabilities • Learning goals and outcomes considering family/carers if relevant • Can apply the learning • Receives the information in an appropriate format and in an environment conducive to learning • In addition, the teaching must be appropriately documented and communicated to relevant care providers so everybody ‘sings from the same hymn book’

8. Survival education • Dietary advice, which must be tailored to the individual rather than ‘standard diet education’ • Older people often have nutritional deficits that need to be considered • Exercise/activity suitable to their functional ability and that is safe e.g. tai chi and progressive weight lifting build muscle strength and help reduce falls risk • Medicines self-management including how to recognise and manage hypoglycaemia, other medicine side effects and adverse events • Recognising and managing hyperglycaemia/sick days to prevent HHS/DKA

9. Ongoing education Ongoing education may be planned or opportunistic - teach at the teachable moment Ongoing education might encompass eating out, travel, new technologies The importance of regular health checks in addition to regular diabetes complication assessments Could encompass discussion about what the individual learned experientially, from friends and relatives and on the Internet Information about planning to stop driving Information about end of life e.g. advance care plans and directives and living wills

10. Characteristics of older learners • Have established beliefs, attitudes and decision- making and problem-solving processes • Have a great deal of life and often diabetes-related experience • Like to know what information will be provided so they can decide whether it is relevant to their needs • Learn by sharing (peer education) • Like to receive information in a range of formats

11. Factors that affect older people’s learning capacity Several inter-related factors affect an older person’s ability to learn; these include: • Beliefs, attitudes and culture and health status • Cognitive, physical and environmental factors • Health professionals knowledge and skills as well as their beliefs about what older people can and cannot do and what they should and should not do – sadly ageist attitudes are still prevalent • The health professional-older person relationship

12. Cognitive Short term memory deficits and other sensory deficits including social isolation Reduced reaction time (approximately 20%) that affects information processing and decision-making especially when: Complex decisions are needed The stimulus or cue to action is not relevant to the person The motor sequence needed to complete a task is complex Reduced ability to understand concepts Unwillingness to change Cognitive reserve is exhausted from long teaching sessions requiring extended concentration time or repeated tasks

13. Physical/sensory Decline in simple and complex motor skills such as eye hand coordination and fine motor skills Unrelieved pain Hearing and vision deficits – ensure the person has their glasses and hearing aid with them and the hearing aid is switched on Hyper- or hypoglycaemia, which affect memory and concentration in the short and longer term

14. Environment A quiet environment free from unnecessary distractions such as noise, busy posters and pictures, passers by and loud music is more conducive to learning Adequate lighting Comfortable temperature The teaching materials are suitable to older people e.g. Adequate contrast between text and background Appropriate font type and font size Sufficient white space and breaks in the text to rest the eye and reduce the effort involved in reading Appropriate illustrations in context rather than disembodied body parts The education session does not conflict with other activities important to the individual Access for people in wheel chairs, and walking frames

15. Health professionals • Teaching competence and communication skills • Health status when teaching • Knowledge about diabetes in particular, and diabetes in older people • Beliefs and attitudes about: • Older people’s capacity and willingness to learn • What older people need to know

16. Effective education • Education is more likely to be effective if the person believes they: • Need the information i.e. it is relevant to them • Can use the information in their particular situation and the task is within their physical and cognitive capabilities • Will benefit from the education i.e. it will make a difference • Is able to practise key tasks/skills

17. Effective education • Proceeds from simple to more complex information • Does not provide too much information at once • Uses practical examples relevant to the individual • Uses a variety of teaching styles • Allows the person time to absorb the information and practice new skills • Uses clear concise handouts relevant to the individual, the information provided, and culture and literacy level to optimise knowledge retention and provide cues to action

18. Summary • Educating older people is a joy and a challenge • It involves adopting an holistic, personalised approach to the teaching-learning process • Physical and cognitive capacity need to be considered and family/carers involved when indicated and the individual agrees • Older people might need information outside the ‘standard diabetes’ education usually provided • Older people living in aged care homes can benefit from diabetes education