Transcript Continuum of Care - SouthEastern Ohio Regional Freenet

Promoting Health Along the
Continuum of Care for Older
Adults with Diabetes
Barbara Nakanishi, RD, LD, CDE
Suzanna Theodoras, RN, CDE
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
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
Physiology of Aging as it relates
to Diabetes (Continued)
• Alteration in Carbohydrate Metabolism
– Obese Patients—Insulin Resistance
– Lean to Normal Patients—Impaired GlucoseInduced Insulin Release
• Pharmacokinetic changes affect drug
choices & dosing decisions
– Altered drug absorption, distribution,
metabolism, & clearance
Diagnosis of Diabetes
• Fasting Serum Glucose
– Normal 70-100 mg/dl
– Values ≥ 126 mg/dl more than once=diabetes
– 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 < 140 mg/dl=normal glucose
– 2hr PG ≥140 mg/dl and < 200 mg/dl=IGT
– 2hr PG ≥200 mg/dl=diabetes
• Impaired Fasting Glucose (IFG)
– Fasting ≥ 100 mg/dl but < 140 mg/dl
Diabetes in the Older Adult
1. Challenges for Health Care
Professionals
2. Challenges for Family/Caregivers
3. Challenges for the Community
Challenges for the Health Care
Team
1. Communication with Team Members
2. Creating an Individualized Treatment
Plan
3. Communications with Client’s Family
Members
4. Appropriate Referrals
Challenges for the Health Care
Team
1. Communication with team members
2. Creating an Individualized Treatment Plan
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Goals may be different/Standards of Care
Types of treatment
Finances
Family Support
Safety Issues
3. Communications with Family Members
4. Appropriate Referrals
Challenges for the HCT
Communication with Team Members
• Nurse--Family practice
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Liaison between members
Coordinator/Glue that holds it together
Has patient’s 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
Challenges for the HCT
1.
Communication with team members
2. Creating an Individualized Treatment Plan
– Goals may be different
– Standards of Care
– Types of treatment
– Finances
– Family Support
– Safety Issues
3. Communications with Family Members
4. Appropriate Referrals
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 important—what is their desire for
treatment and what are their goals?
Challenges for the HCT
1.
Communication with team members
2. Creating an Individualized Treatment Plan
– Goals may be different
– Standards of Care
– Types of treatment
– Finances
– Family Support
– Safety Issues
3. Communications with Family Members
4. Appropriate Referrals
Challenges for the HCT
Individualized Treatment Plan
• Standards of Care—ADA
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Blood Pressure (130/80)—(Strokes, MI, Kidney)
Weight (Each Visit)—Can’t see—CHF, Wt Loss
Foot Inspection/Examination Each Visit--↓ Vision
A1c 7 % (6.5%) (2 to 4 x year)
Fasting Lipid Profile (Yearly) LDL-C <100 (New <70),
HDL-C >40, Triglycerides <150
Dilated Retinal Eye Examination (Yearly)
Microalbumin/Urine test (Yearly)
Flu (Yearly)
Pneumonia Vaccines before age 65/after w doctor
Challenges for the HCT
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Communication with team members
2. Creating an Individualized Treatment Plan
– Goals may be different
– Standards of Care
– Types of treatment
– Finances
– Family Support
– Safety Issues
3. Communications with Family Members
4. Appropriate Referrals
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
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Diabetes Education
Monitoring/recordkeeping
Meal planning—frequently weight reduction
Exercise
Oral medicines
Insulin
Combination insulin/oral medicines
Challenges for the HCT
Individualized Treatment Plan
• Types of Oral Diabetes Medications
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Sulfonylureas—insulin secretagogue
Meglitinides—insulin secretagogue
Biguanides—insulin sensitizer
Thiazolidinediones—insulin sensitizer
Alpha-glucosidase inhibitor—delays glucose
absorption
Challenges for the HCT
Individualized Treatment Plan
• Sulfonylureas
• Combination Drugs/Glucovance & Metaglip
(Glyburide & Metformin) (Glipizide & Metformin)
– Adverse effects:
• Hypoglycemia—1st generation long ½ life
• Weight gain
• Skin rashes, sun sensitivity—Sun Screen?
• Gastrointestinal symptoms
– Avoid with Liver disease
– Caution with Renal dysfunction
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.
• Hypoglycemia—With alcohol, exercise, or insufficient food
• Do not use in combination with sulfonylureas—Remember
waste not—be sure to take away old meds before giving
new
Challenges for the HCT
Individualized Treatment Plan
• Meglitinide (Prandin & Starlix)
– Use cautiously in the elderly and in persons with
liver damage.
– Adverse effects:
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Mild hypoglycemia
Dizziness
Diarrhea
Back pain
Upper respiratory infections
Weight gain—but less than with sulfonylureas
• Drug Interactions
– Lopid—Finnish Study not FDA—↑ risk for Hypoglycemia
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 taste—problem if poor
appetite already
– Lactic acidosis
– Possible drug interactions: Lasix and Tagamet—
drugs frequently prescribed
Challenges for the HCT
Individualized Treatment Plan
• Biguanides (Metformin—Glucophage)
– 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.
Challenges for the HCT
Individualized Treatment Plan
• Thiazolidinediones (TZD’s) Insulin Sensitizers
Avandia, Actos, Avandamet
– Adverse effects are:
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Weight gain
Mild to moderate edema (CHF)
Headache
Pharyngitis
Jaundice
Nausea, vomiting, stomach pain
Dark urine
Elevated hepatic enzymes—liver function tests should be
done before starting drug and periodically thereafter
• 2 to 6 weeks to be effective—impatient/want immediate
results/may stop taking if they don’t understand
Challenges for the HCT
Individualized Treatment Plan
• Alpha-glucosidase Inhibitors
Precose & Glyset
– Taken with first bite of meals—easy 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 concentration—monitor closely
– Treat low’s with oral glucose, milk or glucagon
Challenges for the HCT
Individualized Treatment Plan
• Insulin
– Risk of severe hypoglycemia ↑ with age
– Complete geriatric assessment before initiating to
identify potential complicating factors
• Vision—accuracy
• Dexterity
• Ability to recognize & treat hypoglycemia
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 time—New Pen helpful but
expensive
– Detemir—can be mixed
• Requires 2 injections/day
• Slow release/less potency/need 1.4 to 4 times
Challenges for the HCT
Individualized Treatment Plan
• Storage of Insulin
– Current insulin vial can be kept at room
temperature (<86°F) after opening for 28
days for 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.
Challenges for the HCT
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Communication with team members
2. Creating an Individualized Treatment Plan
– Goals may be different/Standards of Care
– Types of treatment
– Finances
– Family Support
– Safety Issues
3. Communications with Family Members
4. Appropriate Referrals
Challenges for the HCT
Individualized Treatment Plan
• Finances
– Elderly have a very limited income
• Many have no prescription benefits
• Drug company indigent programs—takes
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
Challenges for the HCT
1.
Communication with team members
2. Creating an Individualized Treatment Plan
– Goals may be different/Standards of Care
– Types of treatment
– Finances
– Family Support
– Safety Issues
3. Communications with Family Members
4. Appropriate Referrals
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?
Challenges for the HCT
Individualized Treatment Plan
1.
Communication with team members
2. Creating an Individualized Treatment Plan
– Goals may be different/Standards of Care
– Types of treatment
– Finances
– Family Support
– Safety Issues
3. Communications with Family Members
4. Appropriate Referrals
Challenges for the HCT
Individualized Treatment Plan
• Safety Issues–HCT and Family
– Right Medication at the Right Time in the Right Dose
• 80% take meds improperly—not just elderly
– Take as Prescribed—Hearing & Vision Problems
• Pill containers and Written Instructions helpful sometimes
– Establish Routine—same 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
Challenges for the HCT
Individualized Treatment Plan
• Safety Issue–HCT and Family
– Provide a safe environment—Common Sense?
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Prevent Falls
Communication in an Emergency—”Fallen & I can’t get up”
Medic Alert– Many Varieties now, even Shoe Tags
Utilities—Lighting, Heat, Air Conditioning/Fans
Daily Check-in with Someone
Provisions for Emergency/Disaster—Minimum 3 day supply
– Food & Water
– Testing supplies & Medications
• Help patient & family make decision as to when a new level
of care is needed—assisted living or nursing home
Challenges for the HCT
Individualized Treatment Plan
• Safety Issue–HCT and Family
– Hypoglycemia can occur with:
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Sulfonylureas—Glipizide and Glyburide
Glimepiride—Amaryl
Meglitinides—Prandin , Starlix
Combinations—Glucovance, Metaglip
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Metaformin--Glucophage
Acarbose--Precose
Miglitol--Glyset
TZD’s—Avandia or Actos, Avandamet
If combined with sulfonylureas then hypoglycemia may occur
Challenges for the HCT
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Communication with team members
Creating an Individualized Treatment Plan
– Goals may be different/Standards of Care
– Types of treatment
– Finances
– Family Support
– Safety Issues
3. Communications with Family Members
4. Appropriate Referrals
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
Challenges for the HCT
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Communication with team members
Creating an Individualized Treatment Plan
– Goals may be different/Standards of Care
– Types of treatment
– Finances
– Family Support
– Safety Issues
3. Communications with Family Members
4. Appropriate Referrals
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
How are people doing in meeting therapy
goals for diabetes and CVD?
• Among surveyed adults with diabetes :
– 45 % had A1C < 7 percent
– 62 % had B/P levels < 140/90
– 11 % had LDL cholesterol level < 100 mg/dl
– 20 % used aspirin regularly
– 22 % smoked cigarettes.
Challenges for the Family
1. Changing Physical Abilities
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Safety Issues
Eating Healthy
Taking Medication
Remaining Active
Driving/Transportation Issues
2. Changing Mental Status
3. Changing Roles
4. Maintaining Quality of Life
Challenges for the Family
Changing Physical Abilities
• Safety Issues for Family
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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
Challenges for the Family
1. Changing Physical Abilities
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Safety Issues
Eating Healthy
Taking Medication
Remaining Active
Driving/Transportation Issues
2. Changing Mental Status
3. Changing Roles
4. Maintaining Quality of Life
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
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 heavy—gallon of milk
weighs 8.62#
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
Challenges for the Family
Changing Physical Abilities
Healthy Eating
• Eating Alone
– No social interaction
– Depression—family may be first to notice
– Diminished appetite
– May lead to inadequate nutrition and weight
loss.
– Made need diabetes medication dosage
adjustment
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
Challenges for the Family
Changing Physical Abilities
Healthy Eating
• Food Costs
– Fresh fruits and vegetables
– Choice cuts of meat
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
Challenges for the Family
1. Changing Physical Abilities
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Safety Issues
Eating Healthy
Taking Medication
Remaining Active
Driving/Transportation Issues
2. Changing Mental Status
3. Changing Roles
4. Maintaining Quality of Life
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
changing—Insulin, Coumadin
– Remove old written instructions when
replacing with new ones.
– Remove old prescription drugs when
prescription has changed
Challenges for the Family
1. Changing Physical Abilities
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Safety Issues
Eating Healthy
Taking Medication
Remaining Active
Driving/Transportation Issues
2. Changing Mental Status
3. Changing Roles
4. Maintaining Quality of Life
Challenges for the Family
Changing Physical Abilities
• Remaining active
– Walking—No sidewalks, balance issues,
coordination, foot/leg problems
– Armchair exercises
– Walking around house during commercials—
but 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 Farmer’s Market
or a Sun. afternoon drive
Challenges for the Family
1. Changing Physical Abilities
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Safety Issues
Eating Healthy
Taking Medication
Remaining Active
Driving/Transportation Issues
2. Changing Mental Status
3. Changing Roles
4. Maintaining Quality of Life
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
Challenges for the Family
1. Changing Physical Abilities
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Safety Issues
Eating Healthy
Taking Medication
Remaining Active
Driving/Transportation Issues
2. Changing Mental Status
3. Changing Roles
4. Maintaining Quality of Life
Challenges for the Family
Changing Mental Status
Some studies say that the cognitive decline is
greater/faster with Diabetes
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Difficult to assess
Difficult to accept
Undiagnosed depression
Dementia or Psychiatric illnesses
Alzheimer’s Disease is 65% higher in people with
diabetes
Challenges for the Family
1. Changing Physical Abilities
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Safety Issues
Eating Healthy
Taking Medication
Remaining Active
Driving/Transportation Issues
2. Changing Mental Status
3. Changing Roles
4. Maintaining Quality of Life
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.
Challenges for the Family
1. Changing Physical Abilities
– Safety Issues
– Eating Healthy
– Taking Medication
– Remaining Active
– Driving/Transportation Issues
2. Changing Mental Status
3. Changing Roles
4. Maintaining Quality of Life
Challenges for the Family
Maintaining Quality of Life
• Complications
– Macrovascular—considerable functional
impairment—MI, Stroke, Amputations
• Cardiovascular Disease
• Cerebrovascular Disease
• Peripheral Vascular Disease
– Microvascular
• Retinopathy—Cataracts, Glaucoma, Blindness
• Nephropathy—Renal Failure
• Neuropathy—50% >60 yrs old w DM affected
– Erectile Dysfunction
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
Challenges for the Family
Maintaining Quality of Life
• Instrumental Activities of Daily Living or
Intermediate Skills
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Using the phone
Shopping
Preparing Meals
Housekeeping
Doing Laundry
Using Public Transportation
Taking Medication
Handling Finances
Challenges for the Family
Maintaining Quality of Life
• Basic Activities of Daily Living
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Bathing
Dressing
Transferring
Toilet
Continence
Feeding Self
Challenges for the Community
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Meal Services
Transportation Services
Systems to Check on Elderly w/o Family
Reasonably Priced Services
Respite Care for Everyone
Challenges for the Community
Meal Services
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Meals on Wheels
Personal Chefs
Community Center
Community Churches—M thru F one free
meal a day
Challenges for the Community
Transportation
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Athens transit
Helping hands
Hickory Creek
Taxi
Family
Challenges for the Community
Who Checks On Elderly?
• Systems to Check on Elderly without
Family
– Neighbor
– Church
Challenges for the Community
Reasonably Priced Services
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Plumbing
Electric
Yard care
Housecleaning
Taxi Service
Adult Daycare
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.
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