diabetic ederly

1. Diabetes Management in the
Older Adult
Presented by
Carolyn Jennings, MPH, RD, CDE
SouthEast Michigan Diabetes Outreach
Network
(SEMDON)
www.diabetesinmichigan.org
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2. 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
3

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

5. 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. Case of Mistaken Identity
Signs of Diabetes
• 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.
Signs of Aging
• 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.
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7. 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. 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 Assessment
in the Older Adult
• Physical Assessment
– Mobility/ Physical Activity
– Nutritional Assessment
• Neurological Assessment
• Psychosocial Assessment
• Other Areas
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10. 10
Diabetes Assessment
in 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
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12. 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 13

14. Nutritional Assessment
• Preferences and Lifelong habits
• Meal Planning considerations
• Food Preparation
• Lifestyle changes
• Mobility issues
• Dentition
• High Risk considerations
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15. Nutritional Assessment
• Malnutrition
– Altered nutrient absorption
– Vitamin deficiencies (B12)
– CHO intolerance
– Decline in renal function
• Depression
• Cognitive Impairment
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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
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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
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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 18

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

20. Other Areas of Assessment
• Co-morbidities
• Pain
• Polypharmacy
– Diabetes medications appropriate?
– Drug interactions
– Ability to administer medications
• Safety
• Finances
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21. 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. 22
Treatment Recommendations
• Glycemic Control
• Hypertension
• Lipids
• Tobacco cessation
• Eye care
• Foot care
• Nephropathy
• Diabetes Self-Management Training

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

24. 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. 25
Risks of Intensive Glycemic
Control
• Hypoglycemia
• Polypharmacy
• Drug to drug interactions
• Drug to disease interactions

26. 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)
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28. 28
• Impairs co
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• 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. 29
• 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
Hypoglycemia

30. 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. 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. 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. 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. 34
Lipids
• Secondary to overall health status
assessment
• Goals: LDL< 100mg/dl
– HDL > 40 men, 50women
– TG <150mg/dl
• LDL<100 reassess q 2yrs
• LDL 100-129: MNT w/ physical activity
• LDL > 130 pharmacologic therapy + lifestyle
intervention

35. 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. 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. 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. 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. 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. 40
Nephropathy Screening
• Screen for microalbumin and GFR at
diagnosis and (at least) annually

41. 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. 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
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44. 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. 45
Patient Centered Education
• Patients Role:
– Determine
personal self-
care goals
– Find solution
– Take
responsibility for
own health
• 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

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
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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
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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.
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49. • 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.
Education Strategies
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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.
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51. Education Strategies
What is the present degree of Blood
Glucose control?
• If currently Hypo or Hyperglycemic:
– Teach Survival Skills
– Schedule follow-up when BG control
improved
– Give educational materials for
reinforcement
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52. 52
Education Strategies:
Nursing Care Facilities
• Assess patient’s ability to participate in
self care.
• Prioritize care to patient and family.
• Involve family in education.
– Appropriate snacks to bring.
– Reinforce behaviors that promote optimal
control.

53. 53
Education Strategies:
Nursing Care Facilities
• Safety issues
– Hyper/hypoglycemia signs/symptoms
• Adult Learner Guidelines
• Evaluate level of control with respect to
quality of life, safety.
• Advocate for your patients whose diabetes
control is sub optimal.

54. 54
Summary- Education Goals
• Assist older adults to optimally self-manage
diabetes.
– Individualized BG goals to avoid both hyper-
and hypoglycemia.
– Prevent or delay progression of
complications.
• Promote optimal control for all older PWDs
– Hospitalized • Residentialcare
– Group living

55. Resources
• Guidelines for Improving Care of the older person with
diabetes
AM J Geriatric Soc 51(2003): S265-S280
• Geriatric Resource Directory www.bphc.hrsa.gov
• Working Together to Manage Diabetes
Diabetes Medications Supplement
www.ndep.nih.gov/diabetes/publications
• Oral Health Care for Older Adults www.nohic.nidcr.nih.gov
• Working with Your Older Patient, a clinician’s handbook
www.nia.nih.gov
• Exercise, A Guide from the National Institute on Aging
www.nia.nih.gov
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