Best Diabetes Care for Frail and Elderly Beverly Dyck Thomassian, - - PowerPoint PPT Presentation
Best Diabetes Care for Frail and Elderly Beverly Dyck Thomassian, RN, MPH, BC-ADM, CDE President, Diabetes Education Services Sesssion 1 October 24,2020 www.DiabetesEd.net Best Diabetes Care for Frail and Elderly Mahalo Hawaii ADCES
Beverly Dyck Thomassian, RN, MPH, BC-ADM, CDE President, Diabetes Education Services Sesssion 1 October 24,2020
Mahalo Hawai’i ADCES Chapter, with special thanks to: Naomi Fukuda, APRN-Rx, BC-ADM, CDCES, CPT, WCC
Describe the impact of aging
List the impact of aging on
Discuss screening tools to
Challenges and Strategies for Diabetes Management in Community‐ ‐ ‐ ‐Living Older Adults 1.Alan J. Sinclair1,2 and 2.Ahmed H. Abdelhafiz3 + Author Affiliations Diabetes Spectrum 2020 Aug; 33(3): 217-227. https://doi.org/10.2337/ds20-0013
"The aging process is a
Age is also subject to
In the developed
In developing world,
Biological age
“present position of the
individual relative to their life span” (ie telomeres)
Biological age closely related
to chronological age, but the two are not identical
Psychological age
Adaptive capacities and
subjective reactions relative to their group in society
https://www.encyclopedia.com/medicine/anatomy-and-physiology/anatomy-and- physiology/aging Ruth Bader Ginsburg
Social Age
Social habits and
roles of the individual
Societies hold age-
status systems that lead to expectations
should behave in relation to others
Hsu Sho-er, 84, and her husband Chang Wan-ji, 83, have been operating a laundry in the Houli district of Taiwan for the past 70 years.
60
21.4
65
17.7
70
14.3
75
11.2
80
8.5
85
6.3
90
4.5
95
3.3
100
2.5
What percent of the population
A.
B.
C.
26% of Americans age 65 or older have
diabetes (11.8 million seniors)
50% of people with diabetes, 65 yrs plus
50% of older adults have prediabetes Rate of older population with diabetes
growing rapidly due to increasing life expectancy.
Diabetes prevalence to double in next 20
years, in part due to the aging population
Diabetes prevalence peaks age 75-79 yrs
Genes + Environment +
Contributes to degree of Vascular disease Physical and neuropathic
complications
Mental dysfunction Synergistic effect that can
lead to a cycle of deterioration, disability and frailty
Challenges and Strategies for Diabetes Management in Community‐ ‐ ‐ ‐Living Older Adults Diabetes Spectrum 2020 Aug; 33(3): 217-227. https://doi.org/10.2337/ds20-0013
low grip strength, low energy, slowed waking speed, low physical activity,
unintentional weight
1 or 2 criteria are
Identifies a subset at
! " ! " ! " #$% Physical & Neuropathic Complications
Vascular Disease
Disability
Challenges and Strategies for Diabetes Management in Community‐ ‐ ‐ ‐Living Older Adults Diabetes Spectrum 2020 Aug; 33(3): 217-227.
72-year-old Lives by self Recently lost his twin
Had his phone
Kids want to him to
Diabetes Management includes:
A1c more relaxed
Glucose goals
' '
Social support
Who do they live with? Anyone helping with self-care?
Feelings Finances
Housing, food, transportation
Activity, Nutrition
Lives by self No one outside of diabetes
Attends support group Admits to feeling depressed
House paid off but has limited
Can still drive and shop, but
Doesn’t drink alcohol or use
Diabetes Medications
BID
Often forgets morning insulin dose and other meds
15-20% of older adults with diabetes live with
Assess other factors that may impact QOL
lack of income isolation loss of partner, family, friends limited mobility alcohol or substance use
1 million adults, 65+
Admission for SUD
Alcohol is most used
65% report high risk
drinking (exceeding guidelines at least weekly).
10% report binge
drinking (4-5 drinks at
https://www.drugabuse.gov/pu blications/substance-use-in-
One study documented a 107%
Alcohol increases risk of:
pancreatitis (hyperglycemia) high blood pressure, triglycerides hypoglycemia, malnutrition liver and bone problems neuropathic pain memory issues and mood disorders. https://www.drugabuse.gov/publications/substa nce-use-in-older-adults-drugfacts 2020
Cannabis use is on
Opioid and heroin
About 8-10% of
https://www.drugabuse.gov/publications/substance-use-in-older-adults-drugfacts 2020
Although the diabetes
Which of the following is true
depressed.
low risk for depression.
evaluation for depression
symptom of depression in older adults
Older Adults (65 years
ADA Standards of Care Older Adults, 2020 https://care.diabetesjournals.org/content/43/Supplement_1/S152
Which of the following
A.
B.
C.
Depression:
Over the last 2 weeks,
have you felt down, depressed or hopeless?
Over the last 2 weeks,
have you felt little pleasure in doing things?
If they say yes to either of these, action is required.
Patient Health Questionnaire – Depression Screen
Quick Depression Assessment
If there are at least four 3s
in the shaded section (including Questions #1 and #2), consider a depressive
determine severity.
Consider Major Depressive
Disorder - if there are at least five 3s in the shaded section (one of which corresponds to Question #1
Consider Other Depressive
Disorder - if there are two to four 3s in the shaded section (one of which corresponds to Question #1
PHQ-9
https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit- materials/asq-tool/information_sheet_asq_nimh_toolkit_155866.pdf
Screens positive for depression,
anxiety, FoH*
Disordered eating or disrupted eating
patterns
Not taking insulin/meds to lose weight Serious mental illness is suspected Cognitive impairment or impairment of
DSME
Diabetes distress even after tailored
education
*FoH – Fear of Hypoglycemia
Assess Determine if help is needed Have a list of mental health
Resource list of phone helplines Help individual problem solve to
If individual cannot act on
A 68 year old enters your office and says,
A.
Based on your A1c level, it looks like you have diabetes.
B.
We don’t use the term “borderline diabetes anymore
C.
Let’s just start with carb counting.
D.
It sounds like you aren’t sure why you are here.
(Kubler-Ross, Rubin RR, WHPolonsky)
Denial
Don’t agree, but listen Acknowledge Survival Skills only!
Anger
Indicates: Awareness, Learning Begins Be clear, concise instructs No long WHY answers
Bargaining
ID’s w/ others Group classes good Ed: “what” pt. wants to know
Depression & Frustration
Realize permanency of DSC Tx Psycho-social support referral Emphasize + change made
Accept & Adapt
Sense of responsibility for Self-care;
DRED - unique emotional issues directly
More than worry: can overlap with
depression, anxiety and stress.
Normal-to some extent Associated with stress of living with
diabetes
Express high levels stress and depressive
symptoms; but not clinical depression
Not rare: linked to poor health outcomes
Yields a total Diabetes Distress Scale score plus 4
Emotional burden Physician related Distress Regimen related Distress Interpersonal Distress
Begin a conversation with any item rated 3 or more – See Distress Scale in your resources page
44.5% of patients reported diabetes distress Only 24% of providers asked pts how diabetes
energy every day.
diabetes care/ doesn't give me clear enough directions .
efforts (planning activities that …, encourage me to eat the "wrong" foods).
1 thing at a time Take it slowly Speak up to:
Set Appropriate Goals!!! Small, discreet
HCProviders (you!)
Handle 1 thing at a time Take it slowly
Set Appropriate Goals.
Small, discreet
Be mindful, mundane, careful
about the goal set- do not rush
Paired testing before/after
(more tangible)
Annual screening for early
detection of mild cognitive impairment or dementia
High priority population for
depression screening and treatment
Avoid hypoglycemia in this
high risk group
ADA Standards of Care Older Adults, 2020 https://care.diabetesjournals.org/content/43/Supplement_1/S152
. / . ! .
Challenges and Strategies for Diabetes Management in Community‐ ‐ ‐ ‐Living Older Adults Diabetes Spectrum 2020 Aug; 33(3): 217-227. https://doi.org/10.2337/ds20-0013
“I am going to say three words
that I want you to remember now and later.
The words are banana, sunrise,
chair.
Please say them now.” Give the
person three tries to repeat the words.
You may repeat the words to
them for each try.
If they are unable to repeat the
words back to you after three tries, go directly to the clock drawing.
Next, ask them to draw a clock
https://mini-cog.com/mini-cog- instrument/standardized-mini-cog- instrument/
Score 1 for each task
A score less 3 of the 5
Tasks - “Please draw
“Put all the numbers
“Now set the hand
Recall the 3 items
Example of the same person drawing a clock
PHQ-9 – had 3 checks
Scored 2 on the Mini-
Ran out of insulin a
Forgot to check
Blood sugar “high” Diabetes Medications
Hyperglycemia is
Longer duration of
Vascular Dementia Alzheimer’s
Perform annual
Treatment:
Refer to specialist for
Achieve optimal BG
Pharmacist to evaluate
Keep physically active
Let provider know
Referral to Gerontologist
Not taking insulin
Found free service
where volunteers would call every day to remind to check glucose and take insulin
RT to check in with
Diabetes Educator weekly
Bought extra 70/30
insulin from Walmart, $25 a vial
Poor sleep associated
People with dementia
How much sleep are
Do you wake up well
Have you had a sleep
Oral health affects
Gums swollen? Brushing frequency Flossing frequency Dental visits Tooth abscess? Dentures fitting?
Weekly groups Volunteering Social Media
Family nearby Places of worship Pets Is key to healthy aging. Studies have shown
https://www.healthinaging.org/blog/social- connectedness-a-key-to-healthy-aging/
A daughter of an 83-year-old with diabetes
Associated with
Cognitive decline Falls Arrythmias.
Screen for hypo on regular
Prevent and determine
Make needed med /food
ADA Standards of Care Older Adults, 2020 https://care.diabetesjournals.
1/S152
Hypoglycemia indicates TOO MUCH Diabetes
Have plan in case of low blood glucose ahead
For People with diabetes - When to contact Health Care Team
BG < 70 – Eat and call provider immediately If BG 70 – 100 – Eat and call provider within 24 hours BG > 250 within 24 hr period BG > 300 on 2 consecutive days, unusually high BG If sick, risk of dehydration and/or hyperglycemic crises
Evaluate Kidney function
If creat >1.4, GFR < 60
Give long acting insulin in morning Made need lower dinner bolus insulin Avoid long acting sulfonylureas –
Evaluation Hypoglycemia awareness
Assess food access and timing Ongoing monitoring and problem solving
Eval ability to afford diabetes
Well phrased questions can
Next Class is Oct 31st
Treatment Goals, Type 2
Medication and Safety Concerns for older adults
Last Class November 7
Managing Co-Morbidities
and Lifestyle recommendations
Autonomic Anxiety Palpitations Sweating Tingling Trembling Hypoglycemic Unawareness
If blood glucose 70mg/dl or below: 10-15 gms of carb to raise BG 30 - 45mg/dl
Approved for ages 4 + Absorbed nasally No reconstitution or
Kept in temps up to 86 Raises BG 67-73 mg/dl Don’t use in those with Pheochromocytoma insulinoma
Eval ability to afford diabetes
Well phrased questions can
Next Class is Oct 31st
Treatment Goals, Type 2
Medication and Safety Concerns for older adults
Last Class November 7
Managing Co-Morbidities
and Lifestyle recommendations