Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 – – – – – 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 – – – – 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 – – – – – – – – – 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 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 • Usual Treatment – Type 1 always includes: Diabetes Education, Monitoring, Insulin, Meal Planning and Exercise – Type 2 is usually done in stages or phases • • • • • • • 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 – – – – – 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: • • • • • • 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: • • • • • • • • 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 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 • 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? • • • • • • 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: • • • • Sulfonylureas—Glipizide and Glyburide Glimepiride—Amaryl Meglitinides—Prandin , Starlix Combinations—Glucovance, Metaglip – Hypoglycemia does not occur when taken alone: • • • • • Metaformin--Glucophage Acarbose--Precose Miglitol--Glyset TZD’s—Avandia or Actos, Avandamet If combined with sulfonylureas then hypoglycemia may occur Challenges for the HCT 1. 2. 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 1. 2. 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 – – – – – 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 – – – – – 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 – – – – – 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 – – – – – 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 – – – – – 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 – – – – – 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 – – – – – 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 – – – – – 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 – – – – – 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 – – – – – – – – 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 – – – – – – Bathing Dressing Transferring Toilet Continence Feeding Self Challenges for the Community 1. 2. 3. 4. 5. 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 • • • • Meals on Wheels Personal Chefs Community Center Community Churches—M thru F one free meal a day Challenges for the Community Transportation • • • • • 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 • • • • • • 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