Download Depression Fundamentals

Case Manager Workshop Series
Diabetes and Seniors
10th Annual Diabetes and
Obesity Conference: Linking
Partners to Address Diabetes
and Obesity
Ann Fiene FNP, MS, CDE
April 17, 2011
This presentation is sponsored by and the speaker is presenting on behalf of Lilly.
This workshop is not approved for continuing education credit.
HI 58712 0909 PRINTED IN USA ©2009, Lilly USA, LLC. ALL RIGHTS RESERVED.
Agenda
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Review of Diabetes
Seniors Case Study
Screening for Diabetes
Risk Factors Specific to Seniors
Diabetes in Long-term Care
Diabetes and Aging
• How aging affects diabetes
• Treatment Considerations
• Seniors Case Study
Important Project Information
Because this presentation offers general information,
it is ultimately your decision as to whether it needs to
be altered to fit the practices, settings, and unique
circumstances related to your members. Lilly USA,
LLC assumes no responsibility for:
• Any modification made to this material.
• Any practices you may or may not enact based on
this material.
This material is based on the references cited. The
guidelines represented in this material are not the
only guidelines that exist, so you may wish to consult
other guidelines in considering what best fits the
needs of your members.
Diabetes and Seniors
Goals of Today’s Workshop
The goal of the workshop is to provide information to
support the following activities:
• Coaching patients to understand diabetes as it relates to
seniors
• Providing information on how diabetes differs in the senior
population
• Understanding how to treat diabetes in seniors
What is Diabetes?
Diabetes Review
Comparison of Type and Type 2 Diabetes
Factor
Age of Onset
Type of Onset
Environmental
Factors
Nutritional Status
Symptoms at Onset
Type 1
Type 2
Usually in childhood or adolescence,
but may occur at any age
Usually abrupt
Usually over age 40, but may
occur in children
Gradual
Viruses or an autoimmune process
Obesity, poor nutrition,
sedentary
Usually obese but may have
normal weight
Frequently none, or mild
Thin, despite increased appetite,
catabolic metabolism
Present and abrupt
Control of Diabetes
Often difficult with wide glucose
fluctuation
Dietary Management Essential, will not suffice alone for
and Exercise
glycemic control
Oral Medications
Not effective – must receive insulin
Variable
Vascular or
Neurologic
Complications
Essential, may suffice alone to
attain glycemic control
Usually effective for a period
of time
May be present at diagnosis, if
patient went undiagnosed for
a long period of time
Seen in poorly controlled patients after
5 or more years of diabetes
Basic Tools for Diagnosing Diabetes35
• Casual plasma glucose test
• Fasting plasma glucose test (FPG)
• Oral glucose tolerance test (OGTT)
Diabetes range
following the FPG
Pre-diabetes range
following the FPG=
impaired fasting
glucose (IFG)
DIABETES
DIABETES
>126 mg/dL
<126 mg/dL
>200 mg/dL
<200 mg/dL
>100 mg/dL
>140 mg/dL
<100 mg/dL
<140 mg/dL
Normal range
following the FPG
Diabetes range
following the OGTT
Pre-diabetes range
following the OGTT=
impaired glucose
tolerance (IGT)
Normal range
following the OGTT
FPG*3*3
FPG
FPG
OGTT†3†3
OGTT
OGTT
Case Study
Meet Kim
• What screenings should Kim have?
• What complications should Kim and her caregivers be aware of?
• How does close family involvement affect diabetes care?
Screening Seniors for Diabetes1
AMDA Criteria for Diagnosis of Diabetes
Diabetes (two abnormal Normal
Diagnostic Test
readings on subsequent
days)
≥126 mg/dl (7.0 mmol/l)
<100 mg/dL (5.6 mmol/L)
FPG
Casual plasma glucose
≥200 mg/dl (11.1 mmol/l)
OGTT
Two hours post-load
glucose ≥200 mg/dl
(11.1 mmol/l)
Two-hour <140 mg/dL
(7.8 mmol/L)
Regular Screening of Patients with Diabetes
The AGS has recommended the following screening
protocol for seniors.
Foot Care2
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Foot hygiene and foot care practices
Skin and soft tissue integrity
Sensorimotor integrity (numbness and loss of protective sensation)
Vascular inefficiency (pedal pulse)
Gait and ability to walk
Foot shape, shoes, and socks
Older adults should have a foot exam at least annually.
Regular Screening of Patients with Diabetes
Eye Care4
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Eye infections
Eye pain not attributable to a readily treatable cause
Dilated eye examination at diabetes diagnosis and once or twice a year
thereafter
Older adults should have an initial comprehensive dilated eye examination by
an ophthalmologist after diagnosis of diabetes.5
Older adults at high risk for eye disease*, based on prior examination, should
have a comprehensive dilated eye exam at least annually.
Older adults at lower risk may have a comprehensive dilated eye exam at
least every 2 years. 6
*Risk factors for eye disease include: symptoms of eye disease present;
evidence of retinopathy, glaucoma, or cataracts on an initial dilated-eye
examination or subsequent examinations during the prior two years.
Regular Screening of Patients with Diabetes
Kidney Function7
To reduce the risk of end stage kidney disease nephropathy:
• Test for urine albumin excretion
• Measure serum creatinine
• Optimize blood pressure and blood glucose control
Patients with type 2 diabetes should be tested at the diagnosis of diabetes and
then annually for microalbuminuria and serum creatinine.
Regular Screening of Patients with Diabetes
Cardiovascular
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Blood pressure should be less than 130/80.9
In older adults with diabetes and hypertension, target blood pressure
should be 140/80. A blood pressure less than 130/80 may provide
further benefit.10
Lipids goals: Less than 100 mg/dL for individuals without overt CVD
and less than 70 mg/dL for those individuals with overt CVD.11
If an older adult’s LDL is:12
• ≤100 mg/dL, check every two years.
• 100-129 mg/dL, check every year, initiate medical nutrition therapy,
increase physical activity.
• If LDL is higher than 100 mg/dL after six months, initiate
pharmacological treatment.
• ≥130 mg/dL, initiate pharmacological treatment and lifestyle
modification, check at least annually.
Risk Factors Specific to Seniors
• Risks of developing type 2 diabetes
increase as patients age
• Older patients have declined beta cell
function and lower blood insulin levels
• Older patients usually have postprandial
hyperglycemia
Disease Management Considerations Differ with
Functioning Level
• Well-functioning seniors
• Self-management
• Same goals as younger patients
• Non-functioning seniors
• Need assistance with management
• Less intensive goals
Hyperosmolar Hyperglycemic State (HHS)13
MEDICAL EMERGENCY
HHS – Extremely high blood sugar (glucose) levels without
the presence of ketones14
HHS Precipitating Events
HHS Signs and
Symptoms
HHS Interventions
• Major medical problems
• Certain medications
• Decreased fluid intake
• Osmotic diuresis
• Fever
• Diarrhea
• Peritoneal and
hemodialysis
• Hypertonic feeding
• Impaired thirst mechanism
• New onset type 2 diabetes
• Severe hyperglycemia
• Profound dehydration
• Neurological changes
• Absence of significant
ketosis
• Primary treatment
goal: rehydration
• Glucose control with
insulin
• Assess and correct
any electrolyte
imbalances
• Assessment and
education
Diabetes in Long-term Care15
• Undiagnosed diabetes in long-term care can be hard to
identify
• Long-term care will play more of a role in providing care for
diabetes
Considerations in Long-term Care
• Residents have an increased number of chronic
conditions.
• Residents have limitations in the activities of
daily living.
Therefore, all staff must be knowledgeable of the
standards of care for diabetes mellitus.
Diabetes Symptoms and Aging16,17,18
Symptoms of diabetes and symptoms of aging can overlap. Therefore,
diabetes complications may be caused in part by the changes that
occur as a result of aging.
Change
Diabetes
Aging
Visual
Blurry vision
Vision changes
Weight
Unusual weight loss
Decreased ability to taste sweet,
sour, and bitter foods
Urinary
Frequent urination
Incontinence, changes in urinary
frequency
Energy
Increased fatigue
Decreased energy
Demeanor
Increased irritability
Behavioral changes
Other Causes of Abnormal Glucose Levels
• Many potential causes
• Causes more prevalent in older patients19
Medications associated with hyperglycemia:
• Antipsychotic agents
• Beta-adrenergic agonist (beta-blockers)
• Calcium channel blockers
• Glucocorticoids
• Estrogens
• Levodopa
• Megestrol acetate
• Nicotinic acid
• Opiates
• Phenytoin
• Protease inhibitors
• Thiazides
• Loop diuretics
• Thyroid hormone
Additional Risks for Older Patients with
Diabetes
Older persons with diabetes have higher rates of:
• Premature death
• Functional disability
• Coexisting illnesses including:
• Hypertension
• Coronary heart disease (CHD)
• Stroke
The following guidelines specify six areas where seniors are at
greater risk:
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Polypharmacy
Depression
Cognitive impairment
Urinary incontinence
Injurious falls
Pain
Clinical Treatment Goals
Targets should be identified for the management of:
• Hyperglycemia
• Hypertension
• Hyperlipidemia
Target
American Medical Directors
Association Treatment Goals
(AMDA)21
American Geriatrics
Society Treatment Goals
(AGS) 22
American Diabetes Association
Treatment Goals for General
Diabetes Population
(ADA) 23
<7%
A1C
<7%
Healthy ≤7%
Higher risk group ≤8%
BP
<130/80 mmHg
<130/80 mmHg
<130/80 mmHg
Cholesterol
LDL without overt CVD: <100 mg/dL
LDL <100 mg/dL
LDL without overt CVD: <100 mg/dL
LDL with overt CVD: <70 mg/dL
Treat all patients with a statin to
achieve an LDL cholesterol reduction
of 30% to 40%
LDL with overt CVD: <70 mg/dL
Overall Treatment Goals
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Glycemic goals should be individualized
Appropriate nutritional status
Control pain and neuropathic symptoms
Advance directives and end-of-life care
Diabetes education
Educate about complications
Goals of dyslipidemia management
Maximize functional status and physical activity
Reduce risks to extremities
Blood pressure management
Blood glucose control
Reduce progression of complications
Nonpharmacological Treatment
Diet
• Varied diet with consistent amount of carbohydrates
• Consistent meal times
• Adjust dosages and timing of medications to balance
food consumption
• Control portion size and total calorie consumption
• Increase fiber consumption
• Avoid excessive dietary fat restriction
Exercise
• Requirements for benefits vary with goals and
capabilities
• Older adults: 20-30 minutes per day
Case Study
Meet Mary
• What are some risk factors for developing cardiovascular disease?
• Of these risk factors, which ones should Mary be concerned
about?
• What can Mary do to help manage her diabetes and reduce her
risk of developing cardiovascular disease?
Conclusion and Wrap-up
HI 587120909 PRINTED IN USA ©2009, Lilly USA, LLC. ALL RIGHTS RESERVED.