Diabetes Treatment for the Elderly

Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association

American Diabetes Education A.D.E., Diabetes Education, Diabetes Education PA, Diabetes Health Care, Diabetes Management, Managing Diabetes in the Elderly, Online Diabetes Education PA , , , , ,

Abstract
Diabetes is more common in older adults, has a high prevalence in long-term care (LTC) facilities, and is associated with significant disease burden and higher cost. The heterogeneity of this population with regard to comorbidities and overall health status is critical to establishing personalized goals and treatments for diabetes. The risk of hypoglycemia is the most important factor in determining glycemic goals due to the catastrophic consequences in this population. Simplified treatment regimens are preferred, and the sole use of sliding scale insulin (SSI) should be avoided. This position statement provides a classification system for older adults in LTC settings, describes how diabetes goals and management should be tailored based on comorbidities, delineates key issues to consider when using glucose-lowering agents in this population, and provides recommendations on how to replace SSI in LTC facilities. As these patients transition from one setting to another, or from one provider to another, their risk for adverse events increases. Strategies are presented to reduce these risks and ensure safe transitions. This article addresses diabetes management at end of life and in those receiving palliative and hospice care. The integration of diabetes management into LTC facilities is important and requires an interprofessional team approach. To facilitate this approach, acceptance by administrative personnel is needed, as are protocols and possibly system changes. It is important for clinicians to understand the characteristics, challenges, and barriers related to the older population living in LTC facilities as well as the proper functioning of the facilities themselves. Once these challenges are identified, individualized approaches can be designed to improve diabetes management while lowering the risk of hypoglycemia and ultimately improving quality of life.

Introduction
The epidemic growth of type 2 diabetes in the U.S. has disproportionately affected the elderly. In 2012, the prevalence of diabetes among people aged ≥65 (25.9%) was more than six times that of people aged 20–24 years (4.1%) (1). In the long-term care (LTC) population, the prevalence of diabetes ranges from 25% to 34% across multiple studies (2–4). The high prevalence of diabetes among older adults has contributed to the unsustainable growth of health care costs in the U.S. The estimated total cost of diabetes in 2012 was $245 billion. Average medical expenditures for people with diagnosed diabetes were 2.3 times higher than among people without diabetes. LTC costs for people with diabetes were estimated at $19.6 billion in 2012 (5).
The high prevalence of diabetes in older adults is due to age-related physiological changes, such as increased abdominal fat, sarcopenia, and chronic low-grade inflammation, that lead to increased insulin resistance in peripheral tissues and relatively impaired pancreatic islet function (6). Diabetes increases the risk of cardiovascular and microvascular complications but also increases the risk of common geriatric syndromes, including cognitive impairment, depression, falls, polypharmacy, persistent pain, and urinary incontinence (7,8). The older diabetes population is highly heterogeneous in terms of comorbid illnesses and functional impairments. These characteristics have frequently been used to exclude older individuals from randomized clinical trials. The heterogeneity of the population and the lack of clinical trial data represent challenges to determining standardized intervention strategies that can work for all older adults with diabetes. As the vast majority of the patients with diabetes in LTC facilities have type 2 diabetes, most recommendations in this position statement are directed toward that population. However, we have suggested specific recommendations for patients with type 1 diabetes when appropriate.

To see original article, Click HERE

Brenda Schlesinger MSN, APRN, CDE
American Diabetes Education LLC
americandiabeteseducation.net
Brendascde@gmail.com
Office:  215.208.8474

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

American Diabetes Education A.D.E., American Diabetes Education, LLC, Diabetes Education, Diabetes Education PA, Diabetes Health Care, Diabetes Management, Managing Diabetes in the Elderly, Online Diabetes Education PA , , , , , , , , ,

1-special-considerations-in-the-management-of-older-persons-with-diabetes2-special-considerations-in-the-management-of-older-persons-with-diabetes3-special-considerations-in-the-management-of-older-persons-with-diabetes4-special-considerations-in-the-management-of-older-persons-with-diabetes

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

 

to read original article, click HERE

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

American Diabetes Education A.D.E., American Diabetes Education, American Diabetes Education, LLC, Diabetes, Diabetes Education, Diabetes Education PA, Diabetes Health Care, Managing Diabetes in the Elderly, Online Diabetes Education PA , , , , , , , , , , , , , , ,

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.”

Click HERE to read the full article.

When Diabetes Treatment Goes Too Far

American Diabetes Education American Diabetes Education, American Diabetes Education, LLC, Diabetes, Diabetes Education, Diabetes Health Care, Diabetes Management, Managing Diabetes in the Elderly , , , , , , , , , , , , , , , , ,

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.

…….continued HERE