Download Proq Tables - EliScholar

PREVENTING HYPOGLYCEMIA AMONG ELDERLY VETERANS
1
Table 1
A1C Targets for non-pregnant adults with diabetes
More stringent A1C
Usual A1C
Less stringent A1C
A1C < 6.5 %
A1c < 7.0 %
A1C < 8.0%
For patients with:
Short Diabetes duration
Long life expectancy
No significant CVD
Usual patients
For patients with:
Severe hypoglycemia history
Limited life expectancy
Advanced microvascular/
macrovascular complications
Extensive comorbidities
Long-term diabetes &
general A1C target
difficult to attain*
*(despite diabetes self-management, appropriate glucose monitoring, effective doses of
antihyperglycemic agents, including use of insulin)
Note: Targets should be individualized based on age/life expectancy, comorbid conditions,
duration of diabetes, hypoglycemia status, individual patient considerations and known
CVD/advanced microvascular complications. More or less stringent targets may be appropriate
if achieved without significant hypoglycemia or adverse events.
Source: 14
PREVENTING HYPOGLYCEMIA AMONG ELDERLY VETERANS
2
Table 2
Definitions of hypoglycemia
Type
Severe hypoglycemia
Documented
symptomatic
hypoglycemia
Asymptomatic
hypoglycemia
Probable symptomatic
hypoglycemia
Relative
hypoglycemia
Definition of event
Comments
Requiring assistance of
another person to actively
administer carbohydrate,
glucagons, or other
resuscitative actions. May
be associated with sufficient
neuro-glycopenia to induce
seizure or coma.
Typical symptoms of
hypoglycemia are
accompanied by a measured
PG of <70 mg/dl.
While plasma blood glucose
(PG) levels may not always be
available, the fact that the
patient recovered neurologically
after restoration of PG, is
considered sufficient evidence
that the event was indeed
induced by a low PG.
None
Glycemic threshold for
activation of glucagon and
epinephrine secretion as glucose
levels decline is usually 65–70
mg/dl. Prior PG of < or equal to
Measured PG < 70mg/dl but
70mg/dl reduces sympathonot accompanied by typical
adrenal responses to subsequent
symptoms of hypoglycemia.
hypoglycemia.
Conservative lower limit PG
level for non- pregnant
individuals with/without DM
has been set at 70 mg/dl.
Since many patients with DM
Symptoms of hypoglycemia
choose to treat symptoms with
are not accompanied by PG
oral carbohydrate without
determination but were
testing PG, it is important to
presumed to have been
recognize these events as
caused by PG <70 mg/dl.
“probable” hypoglycemia.
Typical symptoms of
Patients with chronically poor
hypoglycemia, and
glycemic control can experience
interpreted as such by
symptoms of hypoglycemia at
patient, but with a measured PG levels >70 mg/dl as PG
PG >70 mg/dl.
levels decline toward that level.
Note: ADA workgroup suggests that, at a minimum, hypoglycemic events should be reported in
each of the first three categories: severe hypoglycemia, documented symptomatic hypoglycemia,
and asymptomatic hypoglycemia.
Source 33
PREVENTING HYPOGLYCEMIA AMONG ELDERLY VETERANS
3
Table 3
Expert Panel Biographies
(in alphabetical order)
Name
Dr. Paul R.
Conlin (MD)
Dr. Linda Haas
(PhC, RN, CDE)
Current position
Other
Chief Medical
Service at Veterans
Affairs (VA) Boston
Healthcare System,
MA.
--Professor of Medicine at
Harvard Medical School,
Boston, MA.
--Chair of the VA
DiabetesEndocrinology
Field Advisory
Committee.
--Chair of Executive
Committee of the VA
Diabetes Quality
Enhancement Research
Initiative.
--Served on development
committee for VADepartment of Defense
Diabetes Clinical Practice
Guidelines.
--Certified Diabetes
Educator--Endocrinology
Clinical Nurse Specialist
at the Veterans Affairs
Puget Sound Healthcare
System, Seattle, WA, for
34 years.
--Past President American
Association of Diabetes
Educators (AADE)
--past Chair of the Older
Adult Workgroup Chair of
National Diabetes
Education Program.
--Co-chaired task force
that revised National
Standards for Diabetes
Self-management
Education and Support.
--Presenter and co-author
on ADAs consensus report
on Diabetes in the Older
Clinical Assistant
Professor in the
Department of
Biobehavioral
Nursing and Health
Systems at the
University of
Washington, Seattle,
WA.
Education and
research interests
--Education:
University of
Massachusetts
Medical School,
Boston, MA (MD).
--Research interests:
investigate methods
to improve diabetes
and blood pressure
control through
lifestyle changes,
care management
and telehealth
technologies.
--Education:
Skidmore College,
NY (BS Nursing)
University of
Washington, WA
(MN)
University of
Washington, WA
(PhC)
--Research interests:
diabetes among
veterans.
PREVENTING HYPOGLYCEMIA AMONG ELDERLY VETERANS
Dr. Elbert S.
Huang, (MD,
MPH, FACP)
--Associate
Professor of
Medicine, and
Director of Center
for Translational and
Policy Research of
Chronic Diseases,
and Associate
Director of the
Chicago Center for
Diabetes Translation
Research at
University of
Chicago, IL.
Dr. Vanessa
Jefferson (DNP,
BC-ANP, CDE)
--Lecturer Diabetes
Concentration Yale
University School of
Nursing, New
Haven, CT.
--Chronic disease
coordinator, diabetes
educator, NP Yale
University Health
Center, New Haven,
CT.
-- Director Joslin
Geriatric Diabetes
Program, Boston,
MA.
--Assistant Professor
of Medicine at
Harvard Medical
School, Boston, MA.
--Staff geriatrician
Beth Israel
Dr. Medha N.
Munshi (MD)
Adult
--Recipient of American
Association of Diabetes
Educators (AADE) Living
Legend Award (2013).
--Senior Advisor Office of
Assistant Secretary for
Planning and Evaluation,
Department of Health and
Human Services (2010 –
2011).
-- Principal investigator
with Dr. Andrew Karter
(Kaiser Permanente) of
NIH-sponsored Diabetes
and Aging Study.
--Member American
Diabetes Association and
Connecticut Association
of Diabetes Educators.
--Developed unique
Geriatric Diabetes
Program at Joslin
Geriatric Diabetes Center:
interdisciplinary program,
beyond the traditional
diabetes programs, that
considers clinical,
functional and
psychosocial barriers
4
--Education: Harvard
University, MA.
(A.B., M.D., and
M.P.H.).
--Research interests:
clinical and health
care policy issues at
the intersection of
diabetes, aging, and
health economics.
Focus is medical
decision making for
elderly patients with
type 2 diabetes
regarding how to best
individualize
diabetes treatments
based on clinical
parameters and
patient preferences.
Education: Yale
University School of
Nursing, New
Haven, CT (MSN),
George Washington
University,
Washington, DC
(DNP).
Education: Baroda
Medical School,
India (MD).
Board certified in
Internal Medicine,
Geriatric Medicine,
and Endocrinology
and Metabolism.
Research: identifying
PREVENTING HYPOGLYCEMIA AMONG ELDERLY VETERANS
Deaconess Medical
Center, Boston, MA.
faced by older adults
before formulating
individualized treatment
strategies.
--Co-edited book
“Geriatric Diabetes” with
Dr. Lewis Lipsitz.
--Member subcommittee
for older adults with
diabetes American
Diabetes Association.
--Participated in writing
national consensus report
on managing diabetes in
older adults.
5
barriers to diabetes
management and
developing novel
strategies to improve
care of older adults.
PREVENTING HYPOGLYCEMIA AMONG ELDERLY VETERANS
6
Table 4
Results Table
Is the category
Is the category
relevant?
important?
100%
100%
80%
60%
b. Morbidity & mortality
100%
80%
c. Elders with T2DM
100%
80%
d. Veterans with T2DM
80%
40%
100%
100%
100%
100%
a. Definition
80%
80%
b. Signs & symptoms
80%
80%
c. Prevalence
100%
100%
d. Morbidity & mortality
100%
100%
e. Elders with hypoglycemia
100%
100%
III. Adverse consequences of hypoglycemia
100%
100%
a. Cardiovascular
100%
100%
b. Other consequences
80%
80%
c. Marker of frailty in elders
Unclear rating1
Unclear rating1
Categories & sub-categories
I. Importance of Type 2 Diabetes Mellitus
a. Prevalence
e. Tight glycemic control & link to
hypoglycemia
II. Introduction to hypoglycemia
PREVENTING HYPOGLYCEMIA AMONG ELDERLY VETERANS
IV. Prevention of hypoglycemia
7
100%
100%
a. ADA updated guidelines
60%
60%
b. A1C goals
100%
100%
c. Plasma glucose levels
80%
80%
d. Individualized targets
100%
100%
100%
100%
a. Life expectancy & functional status
100%
100%
b. Healthy eating
80%
60%
c. Physical activity
80%
80%
d. Cognitive impairment
100%
100%
e. Stress & depression
80%
80%
f. Adherence to medication regimens
100%
100%
100%
100%
100%
100%
V. Special considerations in managing
diabetes in elderly
g. Treatment & education should be
individualized, simplified and
conducted in step-wise manner
h. Treatment and education should
involve family members and care
givers
1
This category was not included in final content due to some confusion about its meaning.
PREVENTING HYPOGLYCEMIA AMONG ELDERLY VETERANS
Table 5
Topical Outline of the Educational Program
VI. Introduction
a. Type 2 Diabetes Mellitus
b. Morbidity and Mortality of T2DM
c. Elders with T2DM
d. Veterans with T2DM (only if patients are veterans)
VII.
Introduction to hypoglycemia
a. Landmark studies
b. Definition of hypoglycemia
c. Signs and symptoms of hypoglycemia
d. Counter regulatory hormones
e. Prevalence of hypoglycemia
f. Morbidity and mortality of hypoglycemia
g. Risk factors for hypoglycemia
h. Elders with hypoglycemia
VIII.
Adverse consequences of hypoglycemia
a. Cardiovascular consequences
b. Other consequence
IX. Prevention of hypoglycemia
a. American Diabetes Association Guidelines
b. Veterans Affairs/Department of Defense Guidelines
c. A1C goals
8
PREVENTING HYPOGLYCEMIA AMONG ELDERLY VETERANS
d. Plasma glucose levels
e. Individualized targets
X. Special consideration in managing diabetes in elders
a. Life expectancy and functional status
b. Main geriatric syndromes and interaction with hypoglycemia
c. Polypharmacy
d. Malnutrition and Frailty
e. Physical Activity
f. Stress and depression
g. Cognitive impairment
h. Syncope and delirium
i. Falls
j. Urinary incontinence
k. Treatment & education should be individualized, simplified and conducted in stepwise manner
l. Treatment and education should involve family members and care givers
9