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Special Considerations in the Management and Education of Older Persons with Diabetes

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References 

  1. National Center for Health Statistics. Health, United States, 2015: With Special Feature on Racial and Ethnic Health Disparities. Hyattsville, MD. 2016.
  2. Centers for Disease Control and Prevention. National diabetes statistics report: estimates of diabetes and its burden in the United States, 2014 [Internet]. Available at: http://www.cdc.gov/diabetes/data/statistics/2014statisticsreport.html. Accessed 18 May, 2016.
  3. Kirkman MS, Briscoe VJ, Clark N, et al. Diabetes in older adults. Diabetes Care. 2012;35: 2650–2664
  4. Funnell MM, Brown TL, Childs BP, et al. National standards for diabetes self-management education. Diabetes Care. 2012;35 Suppl 1:S101-108.
  5. AADE. Measurable behavior change is the desired outcome of diabetes education Available at:
    http://medicine.emory.edu/documents/endocrinology-diabetes-aade7-self-care-
    behaviors.pdf Accessed 6/3/2016.
  6. American Diabetes Association. Standards of Medical Care in Diabetes. Diabetes Care. 2016; 3
    (Supplement 1): S1-112.
  7. AADE. The Art and Science of Diabetes Self-Management Education: A Desk Reference for
    Healthcare Professionals, 3rd Ed. Chicago, Illinois: American Association of Diabetes Educators;
    2014.
  8. Inzucchi SE, Bergenstal RM, Buse JB, Diamant M et al. Management of Hyperglycemia in Type 2
    Diabetes, 2015: A Patient-Centered Approach. Update to a Position Statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2015;38:140–149.
  9. Ismail-Beigi F, Moghissi E, Tiktin M, Hirsch IB, Inzucchi SE, Genuth S. Individualizing glycemic targets in type 2 diabetes mellitus: implications of recent clinical trials. Ann Intern Med. 2011;154:554–559
  10. Dorner B, Friedrich EK, Posthauer ME. Practice paper of the American Dietetic Association: Individualized nutrition approaches for older adults in health care communities. J Am Diet Assoc. 2010;110:1554–1563.
  11. Migdal A, Yarandi SS, Smiley D, Umpierrez GE. Update on diabetes in the elderly and in nursing home residents. J Am Med Dir Assoc. 2011;12:627–632.e2
  12. Sinclair A, Dunning T, Colagiuri S. Managing older people with type 2 diabetes: Global guideline. International Diabetes Federation, 2013
  13. Colberg SR, Sigal RJ, Fernhall B, et al.; American College of Sports Medicine; American care.diabetesjournals.org Foundations of Care and Comprehensive Medical Evaluation S33 Diabetes Association. Exercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association: joint position statement. Diabetes Care. 2010;33: e147–e167
  14. Bird SR, Hawley JA. Exercise and type 2 diabetes: new prescription for an old problem. Maturitas. 2012;72(4):311-316.
  15. Katzmarzyk PT, Church TS, Craig CL,Bouchard C. Sitting time and mortality from all causes, cardiovascular disease, and cancer. Med Sci Sports Exerc. 2009;41:998–1005
  16. U.S. Department of Health and Human Services. 2008 physical activity guidelines for Americans [Internet], 2008. Available at: http://www.health.gov/paguidelines/guidelines/default.aspx. Accessed May 31st 2016.
  17. Wang J, Zgibor J, Matthews JT et al. Self-Monitoring of Blood Glucose Is Associated With Problem- Solving Skills in Hyperglycemia and Hypoglycemia. Diabetes Educ. March/April 2012; vol. 38, 2: pp. 207-218.
  18. Valencia WM, Florez H. Pharmacological treatment of diabetes in older people. Diabetes Obes Metab. 2014;16:1192–1203
  19. Munshi MN, Maguchi M, Segal AR. Treatment of type 2 diabetes in the elderly. Curr Diab Rep. 2012;12(3):239-245.
  20. Association AP. Why practitioners need information about working with older adults Available at: http://www.apa.org/pi/aging/resources/guides/practitioners.pdf. Accessed May 31st, 2016.
  1. American Association of Diabetes Educators. Diabetes and disabilities. Diabetes Educ. 2012;38(1):133-136.
  2. McAndrew L, Schneider SH, Burns E, et al. Does patient blood glucose monitoring improve diabetes control? A systematic review of the literature. Diabetes Educ. 2007;33(6):991-1011; discussion 1012-1013
  3. American Geriatrics Society Expert Panel on the Care of Older Adults with Diabetes. Mellitus Guidelines Abstracted from the American Geriatrics Society Guidelines for Improving the Care of Older Adults with Diabetes Mellitus: 2013 Update. J Am Geriatr Soc. 2013; 61(11): 2020-2026.
  4. Fisher WA, Kohut T, Schachner H, et al. Understanding self-monitoring of blood glucose among individuals with type 1 and type 2 diabetes: an information-motivation-behavioral skills analysis.
    Diabetes Educ. 2011;37(1):85-94.
  5. Bernstein M, Munoz N. Position of the academy of nutrition and dietetics: food and nutrition for
    older adults: promoting health and wellness. J Acad Nutr Diet. 2012;112(8):1255-1277.
  6. Johnson EL BJ, Soule M, Kolberg J. Treatment of Diabetes in Long-Term Care Facilities: A Primary
    Care Approach. Clinical Diabetes. 2008;26(4):152-156

 

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Double monitoring of insulin doses offers minimal protection against in-hospital errors

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A.A.D.E. 2015 Highlights
August 6, 2015

NEW ORLEANS – An insulin double-checking procedure was ineffective at preventing insulin errors when compared with usual care procedures in patients with diabetes, according to study findings presented here.
In a prospective, comparative, two-group research study involving five inpatient units conducted at Cleveland Clinic, researchers found that a subcutaneous insulin double-checking procedure did lead to fewer insulin administration errors; however, most errors were due to the timing of insulin administration, which double-checking did not reduce.
“After controlling for clinical nurses who administered insulin, the double-checking intervention was effective in reducing omission errors, but not effective in wrong time, preparation, dose or a combination of two errors,” Mary Beth Modic, DNP, RN, CNS, CDE, a clinical nurse specialist in diabetes at the Cleveland Clinic told Endocrine Today. “The research findings do not support the practice of requiring a subcutaneous insulin double-checking procedure.”

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When Diabetes Treatment Goes Too Far

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Excerpt from an article
By Kasia Lipska
New York Times
Jan. 12, 2015

NEW HAVEN – ONE of my elderly patients has Type 2 diabetes and heart disease. He takes a number of medications, including insulin to control his blood sugar levels. A few years ago, he was driving when his blood sugar suddenly dropped. He felt lightheaded for a moment and then ran into a tree.

There are roughly 11 million Americans over age 65 with diabetes. Most of them take medications to reduce their blood sugar levels, The majority reach an average blood sugar target, or “hemoglobin A1C,” of less than 7 percent. Why? Early studies showed that this can reduce the risk of diabetes complications, including eye, kidney and nerve problems. As a result, for more than a decade, medical societies, pharmaceutical companies and diabetes groups have campaigned with a simple concrete message – to get below seven. Many patients carry report cards with their scores to clinic appointments. Doctors are often rewarded based on how many of their patients hit the target.

All of this sounds great. But, at least for older people, there are serious problems with the below-seven paradigm.

To begin with, the health benefits of this strategy are uncertain for older people. Those early studies that were the rationale for going below seven were conducted in people with Type 1 diabetes or with younger patients with newly diagnosed Type 2 diabetes. Subsequent trials of older patients raised doubts about the benefits.

Worse, targeting low blood sugar levels can cause harm. In one instance, investigators actually had to stop a trial early because patients who were targeting hemoglobin A1C levels of six or below had significantly higher rates of death than patients targeting levels in the sevens. We don’t know exactly why this happened. What we do know is that aiming for levels below seven increases the risk of “hypoglycemia,” or low blood sugar reactions. Severe reactions can result in confusion, coma, falls, fractures, abnormal heart rhythms and even death.

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Are Seniors With Diabetes Overtreated?

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An article from HealthDay® Magazine:

Very tight blood sugar control can pose problems without benefits, study says

By Dennis Thompson
HealthDay Reporter

MONDAY, Jan. 12, 2015 (HealthDay News)

Many older people with diabetes may be exposed to potential harm because doctors are trying to keep overly tight control of their blood sugar levels, a new study argues.

Researchers found that nearly two-thirds of older diabetics who are in poor health have been placed on a diabetes management regimen that strictly controls their blood sugar, aiming at a targeted hemoglobin A1C level of less than 7 percent.

But these patients are achieving that goal through the use of medications that place them at greater risk of hypoglycemia, a reaction to overly low blood sugar that can cause abnormal heart rhythms, and dizziness or loss of consciousness, the researchers said.

Further, tight diabetes control did not appear to benefit the patients, the researchers report Jan. 12 in JAMA Internal Medicine. The percentage of seniors with diabetes in poor health did not change in more than a decade, even though many had undergone years of aggressive blood sugar treatment.

“There is increasing evidence that tight blood sugar control can cause harm in older people, and older people are more susceptible to hypoglycemia,” said lead author Dr. Kasia Lipska, an assistant professor of endocrinology at Yale University School of Medicine. “More than half of these patients were being treated with medications that are unlikely to benefit them and can cause problems.”

Diabetes is common among people 65 and older. But doctors have struggled to come up with the best way to manage diabetes in seniors alongside the other health problems they typically have, researchers said in background information with the study.

For younger and healthier adults, the American Diabetes Association has recommended therapy that aims at a hemoglobin A1C level of lower than 7 percent, while the American Association of Clinical Endocrinologists recommends a target of lower than 6.5 percent, the authors noted. The A1C test provides a picture of your average blood sugar levels for the past two to three months.

By tightly controlling blood sugar levels, doctors hope to stave off the complications of diabetes, including organ damage, blindness, and amputations due to nerve damage in the limbs.

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Senior Citizen Information

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From HealthDay® News for Healthier Living

SENIOR CITIZEN INFORMATION

Senior citizens have a variety of concerns when it comes to health and well-being. As people grow older, many health problems become more likely to occur, including problems that affect the body and mind. And though some of these problems are unavoidable, becoming a senior citizen does not doom someone to a life of health problems. A number of steps can be taken to help preserve good health well into the golden years.

Common Senior Citizen Health Problems
As adults grow older, their risk for a number of chronic health problems begins to rise. Heart disease, diabetes and cancer are all conditions that become increasingly likely as people age. Other problems related to aging include the weakening of the bones known as osteoporosis, as well as hearing and vision problems. Injuries caused by falls also increase, sometimes as a result of osteoporosis but also because of balance problems that are more common in older people.

Mental health problems also become more prevalent as people grow older. Perhaps the most well-known is Alzheimer’s disease, a condition that causes declining mental function and other debilitating behaviors in older adults. In addition, a common but under-treated mental health condition in senior citizens is depression. Often, older adults develop depression in concurrence with another debilitating health condition like heart disease or cancer.

Preventing Health Problems in Senior Citizens
People can take a number of steps to preserve good health as they age, including actions taken earlier in life but also those that become everyday practice when older. Research suggests that maintaining a healthy weight is critically important to reduce the risk for such chronic health problems as heart disease, diabetes and osteoporosis, among others. This can be accomplished through eating a healthy diet and regular exercise. Other steps that can help with good health as people age include maintaining good sleep patterns, abstaining from smoking and staying socially active with friends and family and involved in the community.

SOURCES: U.S. National Library of Medicine; U.S. National Institute of Mental Health; U.S. National Institute of Diabetes and Digestive and Kidney Diseases

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