Download Quality of Life

NOT TOO HIGH…
NOT TOO LOW…
Quality of Life Matters
A PLAN FOR OPTIMIZING DIABETES
MANAGEMENT
IN NURSING HOMES
2. Understanding Diabetes
Understanding Diabetes
Carol Nicholson, RN BN CDE
Overview:
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Diabetes Basics “101”
CDA Clinical Practice Guidelines
Appropriate targets: blood glucose & A1c
Frailty
Relationship between BG readings & A1c; story they tell
re glycemic control
Hypoglycemia
Hyperglycemia
Quality of life
Foot care
Prevalence of DM in Elderly
• 20 – 30% of individuals aged 70 – 84 will have diabetes
• Optimal diabetes care
– saves money
– reduces care burden
– improves quality of life.
Diabetes in Canada: Prevalence of Diagnosed
Diabetes by age and sex
Prevalence of diagnosed diabetes among individuals aged ≥ 1 year, by age group and sex, 2008/09
Overall Prevalence
30
Females
6.4%
Males
7.2%
Total
6.8%
Prevalence (%)
25
20
15
10
5
0
Age group (years)
1-19
20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84
≥85 Canada
Prevalence increased with age. The sharpest increase occurred after age 40 years.
The highest prevalence was in the 75-79 year age group.
Public Health Agency of Canada. Diabetes in Canada: Facts and figures from a
public health perspective. Ottawa, 2011.
Understanding Diabetes basics:
• improves care by empowering caregivers…
– Report what you see..
– Examples…
– Information is vital for decision-makers
– The more information  better care decisions
That doesn’t mean more BG testing, just
testing for a reason
– More discussion to follow…
Let’s talk about diabetes…
• Your Questions…
LET’S GET STARTED…
Conversation Maps
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Copyright 2009 Healthy Interactions Inc.
www.diabetes.healthyi.com
All trademarks owned by How Diabetes Works
Conversation Maps. Healthy I.
Copyright 2009 Healthy Interactions Inc.
www.diabetes.healthyi.com
All trademarks owned by How Diabetes Works Conversation Maps. Healthy I.
Copyright 2009 Healthy Interactions Inc.
www.diabetes.healthyi.com
Type 1
…no insulin produced
…need to replace
Type 2…
Sources of sugar or “glucose”
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Copyright 2009 Healthy Interactions Inc.
www.diabetes.healthyi.com
How is sugar used / managed
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Cells need sugar
for Energy
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Copyright 2009 Healthy Interactions Inc.
www.diabetes.healthyi.com
Insulin resistance
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www.diabetes.healthyi.com
High blood sugars sticky blood, poor circulation, damage to
blood vessels, organs and nerve cells.
“Complications”
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Copyright 2009 Healthy Interactions Inc.
www.diabetes.healthyi.com
Standards for diabetes care
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Experts…..
Canadian Diabetes Association (CDA)
Clinical Practice Guidelines (CPG) 2013
Internationally recognized as among the best in the world
Reviewed and revised every 5 years
Available on line
guidelines.diabetes.ca
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Copyright 2009 Healthy Interactions Inc. www.diabetes.healthyi.com
2013
Targets Checklist
 A1C
≤ 7.0% for MOST people with diabetes

A1C ≤ 6.5% for SOME people with T2DM

A1C 7.1-8.5% in people with specific features
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
2013
Individualizing A1C Targets
Consider 7.1-8.5% if:
which must be
balanced
against the risk
of
hypoglycemia
Guidelines.diabetes.ca 1-800-banting (226-8464)- diabetes.ca
Copyright ©2013. Canadian Diabetes Association
2013
Frail Elderly
Parameter
A1C
Target
≤ 8.5%
FPG or
preprandial
glucose
5.0-12.0 mmol/L
(depending on level of frailty)
AVOID HYPOGLYCEMIA
FPG= fasting plasma glucose
Guidelines.diabetes.ca 1-800-banting (226-8464)- diabetes.ca
Copyright ©2013. Canadian Diabetes Association
TOOLS
• HBA1c
• Blood sugar readings
A1c 8.0 %
= avg BG 11.5
What if the A1c is 6% ?
What if the A1c is 12 % ?
All trademarks owned by How Diabetes Works Conversation Maps. Healthy I.
Copyright 2009 Healthy Interactions Inc.
www.diabetes.healthyi.com
Moorhouse P, Rockwood K.
J R Coll Physicians Edinb 2012;42:333-340.
Appropriate Glycemic Control…
– Not too low…
– Not too high…
Improved Quality of Life
for Residents!
Reduced CARE burden!!
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(Novo Nordisk Canada Inc. 300-2680 Skymark Ace. Mississauga, ON, L4W 5L6
TEL: (906-629-4222)
www. Novonordisk.ca
How do low blood sugars affect your
residents?
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Fall risk
Cognitive decline
Behaviour changes
Fatigue
Confusion
Feel unwell
Risk for cardiac events
• FREQUENTLY MISSED IN FRAIL ELDERLY!!!
Definition of Hypoglycemia
1. Typical Symptoms
Neurogenic (autonomic)
Neuroglycopenic
Trembling
Difficulty Concentrating
Palpitations
Confusion
Sweating
Weakness
Anxiety
Drowsiness
Hunger
Vision Changes
Nausea
Difficulty Speaking
Dizziness
1. Low blood glucose = <4 mmol/L
if on insulin or medications that can cause lows
3. Symptoms! Always check BG!
Guidelines.diabetes.ca 1-800-banting (226-8464)- diabetes.ca
Copyright ©2013. Canadian Diabetes Association
Here’s the tricky part…
HYPOGLYCEMIA UNAWARENESS!!
VERY PREVALENT IN THE ELDERLY AND THE FRAIL
ELDERY
General rule…. …
• YOU know your residents….
– if they “don’t seem like themselves, changes in patterns or
behavior”…
– if they are diabetic…
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Check blood sugar!
• low, high or acceptable range ….
• All of that information is of value!
• LOW  TREAT ASAP (next slide)
• HIGH why?
• Within acceptable range for resident…. It’s not related to their
diabetes…. So look for another reason if appropriate
Steps to Address Hypoglycemia
1. Recognize autonomic or neuroglycopenic symptoms
2. Confirm if possible (blood glucose <4.0 mmol/L)
3. Treat with “fast sugar” (simple carbohydrate) (15 g) to relieve
symptoms (See next slide)
4. Retest in 15 minutes to ensure the BG >4.0 mmol/L and
retreat (see above) if needed
5. Eat usual snack or meal due at that time of day or a snack with
15 g carbohydrate plus protein
guidelines.diabetes.ca
| 1-800-BANTING
(226-8464)
| diabetes.ca
Guidelines.diabetes.ca
1-800-banting
(226-8464)diabetes.ca
Copyright © 2013 Canadian Diabetes Association
Copyright ©2013. Canadian Diabetes Association
Examples of 15 g Simple Carbohydrate
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15 g of glucose in the form of glucose
tablets
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15 mL (3 teaspoons) or 3 packets of sugar
dissolved in water
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175 mL (3/4 cup) of juice or regular soft
drink
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6 Lifesavers (1=2.5 g of carbohydrate)
•
15 mL (1 tablespoon) of honey
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca
Copyright © 2013 Canadian Diabetes Association
All trademarks owned by Novo Nordisk A/S and used by Novo Nordisk Canada Inc.
(Novo Nordisk Canada Inc. 300-2680 Skymark Ace. Mississauga, ON, L4W 5L6
TEL: (906-629-4222)
www. Novonordisk.ca
All trademarks owned by Novo Nordisk A/S and used by Novo Nordisk Canada Inc.
(Novo Nordisk Canada Inc. 300-2680 Skymark Ace. Mississauga, ON, L4W 5L6
TEL: (906-629-4222)
www. Novonordisk.ca
Hyperglycemia
Do high blood sugars affect your residents….?
• Fall risk
• Cognitive decline
• Behaviour changes
• Fatigue
• Confusion
• Feel unwell/ general malaise
• Infection risk
...YES
Hyperglycemia treatment
1. Monitor …
2. Potential Causes…
– Illness
– Food
– Stress
– Medications
3. Watch for dehydration.
4. Glucose free fluids
5. If BG stay above acceptable levels medical consult.
Quality of Life
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Blood glucose in reasonable targets prevent:
polyuria
nocturia
fatigue
falls
confusion
declined cognition
Reduces ER visits and hospital admissions
Appropriate targets?
• INDIVIDUALIZE!
• CDA 2013 clinical practice guidelines…
2013
Consider A1C 7.1-8.5% if …
• Limited life expectancy
• High level of functional dependency
• Extensive coronary artery disease at high risk of
ischemic events
• Multiple co-morbidities
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History of recurrent severe hypoglycemia
Hypoglycemia unawareness
Longstanding diabetes for whom is it difficult to
achieve an A1C ≤ 7%, despite effective doses of
multiple antihyperglycemic agents, including
intensified basal-bolus insulin therapy
Guidelines.diabetes.ca 1-800-banting (226-8464)- diabetes.ca
Copyright ©2013. Canadian Diabetes Association
2013
Recommendation 2
• In the frail elderly, while avoiding symptomatic
hyperglycemia, glycemic targets should be an A1C of
≤8.5% and FPG or pre-prandial PG of 5.0-12.0 mmol/L,
depending on the level of frailty.
• Avoidance of hypoglycemia should take priority over
attainment of glycemic targets because the risks of
hypoglycemia are magnified in this patient population
[Grade D, Consensus].
Guidelines.diabetes.ca 1-800-banting (226-8464)- diabetes.ca
Copyright ©2013. Canadian Diabetes Association
Foot care
• Diabetic foot ulcers…
– Can lead to amputation
– Increase mortality
– Limit mobility
– May cause discomfort
– Negative effect on QoL
– Increase care burden and costs
PREVENTION !!
Proper foot care – The “DO’s”
DO …
Check feet every day for cuts, cracks, bruises, blisters, sores, infections, unusual markings
Check the color of legs & feet – seek help if there is swelling, warmth or redness
Wash and dry feet every day, especially between the toes
Apply a good skin lotion every day on your heels and soles. NOT BETWEEN TOES! Wipe off
excess
Change socks every day
Trim nails straight across. Nail care should be done by qualified person
Clean a cut or scratch with mild soap and water and cover with dry dressing
Wear good supportive shoes or professionally fitted shoes with low heels (under 5cm)
Avoid extreme cold and heat (including the sun)
Buy shoes in the late afternoon since your feet swell by then
See a foot care specialist if you need advice or treatment
Guidelines.diabetes.ca 1-800-banting (226-8464)- diabetes.ca
Copyright ©2013. Canadian Diabetes Association
Educate patients on proper foot care –
The “DON’Ts”
DO NOT …
Cut your own corns or callouses
Treat in-growing toenails or slivers with a razor or scissors. See doctor or foot care
specialist
Use over-the-counter medications to treat corns and warts
Apply heat with a hot water bottle or electric blanket – may cause burns unknowingly
Soak feet
Take very hot baths
Use lotion between the toes
Walk barefoot inside or outside
Wear tight socks, garter or elastics or knee highs
Wear over-the-counter insoles – may cause blisters if not right for your feet
Sit for long periods of time
Smoke
QUESTIONS…
DISCUSSION...
References
Sources
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Building Competency in Diabetes Education: Advancing Practice http://www.diabetes.ca/membership/professional-membership/diabetes-educator-section-membership#sthash.TLjsNWPq.dpuf
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Building Competency in Diabetes Education: The Essentials http://www.diabetes.ca/membership/professional-membership/diabetes-educator-section-membership#sthash.TLjsNWPq.dpuf
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Calgary Zone Long Term Care Formulary. Alberta Health Services, 2013.
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Novo Nordisk Canada Inc. 300-2680 Skymark Ace. Mississauga, ON, L4W 5L6 TEL: (906-629-4222) www.diabetes.healthi.com
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Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in
Canada. Can J Diabetes 2013;37 (suppl 1):S1-S212.
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Cook, B., Mallery, L., Harrigan, L. & Ranson, T. Diabetes Guidelines for Elderly Residents in Long-Term Care (LTC) Facilities. Diabetes Care Program of Nova Scotia, 2010.
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Diabetes Guidelines for Elderly Residents in Long-Term Care (LTC) Facilities Pocket Reference. Diabetes Care Program of Nova Scotia, 2010.
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Diabetes Guidelines for Elderly Residents in Long-Term Care (LTC) Facilities, Diabetes Care Program of Nova Scotia Supporting Document – Background. Diabetes Care Program of Nova Scotia, 2010.
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Diabetes Management in the Long Term Care Setting. U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, 2014.
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Herzig Mallery, L.,Ransom, T.,Steeves, B. et al (2013). Evidence-Informed Guidelines for Treating Frail Older Adults With Type 2 Diabetes: From the Diabetes Care Program of Nova Scotia (DCPNS)
and the Palliative and Therapeutic Harmonization (PATH) Program. Journal of the American Medical Directors Association, 14, 801-808.
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How Diabetes Works Conversation Maps. Healthy I. Copyright 2009 Healthy Interactions Inc.www.diabetes.healthyi.com
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Individualizing Diabetes Care for Long Term Care Residents: A Guidebook. Long Term Care Working Group of Health Care Professionals working in the Central Local Health Integration Network
(Ontario), 2013.
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Kirkman , M., Briscoe, V., Clark, N. et al (2012). Diabetes in Older Adults : A Consensus Report. Journal of the American Geriatrics Society, 60, 2342-2356.
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Managing Older People With Type 2 Diabetes Global Guideline. International Diabetes Federation, 2013.
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Management of Diabetes in the Long-Term Care Population: A Review of Guidelines. Canadian Agency for Drugs and Technology in Health, 2013.
Self-monitoring of Blood Glucose in People with Type 2 Diabetes: Canadian Diabetes Association Briefing Document for Healthcare Providers. Canadian Journal of Diabetes, Vol. 35, Issue 4, p317–
319, 2011
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Sinclair, A., Paolisso, G., & Castro, M. (2011). European Diabetes Working Party for Older People 2011 Clinical Guidelines for Type 2 Diabetes Mellitus. Executive Summary.. Diabetes & Metabolism,
37, S27-S38. Retrieved from http://www.sciencedirectcom.
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Standards of Medical Care in Diabetes 2013. American Diabetes Association, 2013.