ADA 2012 Conference, presented by Barbara Resnick, MD
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General principles of diabetes management
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Older adults with relatively good health should
have the same opportunity as younger adults for intensive diabetes management,
reduction of risks associated with diabetes, and treatment of comorbid
conditions
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For some older patients, intensive management of
diabetes and its complications may be logistically difficult, may not provide
benefit, may not be consistent with patient preferences and in some patients,
may even be harmful
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Diabetes
management goals and clinical targets should be individualized
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Clinical evaluation of complex older adults with
diabetes
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Evaluate risk factors for atherosclerotic
disease and presence of comorbid diseases
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Take thorough medication history
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Assess functional status
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Screen for geriatric syndromes: use of multiple
medications, depression, cognitive impairment, urinary incontinence, injurious falls,
and chronic pain
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Assess need for diabetes education and
self-management support, and whether to involve a caregiver
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Assess resident priorities and preferences
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Challenges to DM management/ prevention of
hyperglycemia
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Resident-specific issues
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Provider specific issues
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System related issues
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NO direction impact of poor diabetic management à patients don’t feel it
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Lac of standards or guidelines for optimal
management of diabetes across the full aging continuum
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Behaviour change is never easy…I know I should,
but….
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Practitioners’ ambivalence about the benefits
and risks of glycemic control
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Knowledge deficiencies among direct
caregivers/families/residents/non-geriatric focused PCPs
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Inadequate metabolic monitoring and review of
treatment by the practitioner
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Changing old beliefs as new knowledge is gained
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Getting the story straight (how much and when
did the patient eat?)
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Tidbits for successful behaviour change
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Don’t be afraid to address multiple behaviours
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Addressing multiple behavious allows you to
teach general behaviour change principles such as how to cope with barriers,
work with a partner, or establish goals and rewards
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Older individuals tend to choose to change
multiple behaviours rather than focus on a single behaviour
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Providers can change although work off what they
believe more so than what they know
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Process for change
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Component I
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Education
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To assure a philosophy of care that increases
awareness and concerns about hyperglycemia
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Does the environment facilitate management of
diabetes and hyperglycemia
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Equipment
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Sufficient staffing
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Exercise equipment and environment to support
and encourage physical activity
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Specific issues to teach to facilitate adherence
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Caregivers and older adults less likely to be
familiar with
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Atypical presentation of hyperglycemia
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Give tickler sheets of exactly what to look for
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Confusion,
delirium, feel lousy
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Blurred vision (eyesight)
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Feeling very tired
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Frequent urination
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Leg cramps
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More thirsty than usual
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Weight loss
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Dry eyes or mouth
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Weakness
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Dizziness
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Drowsiness or confusion/seizures
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At the institutional level
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Teach patients/caregivers to assess for
underlying cause of episodes of hyperglycemia – be a detective
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Teach rational for testing sugars at times
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Teach recognition of associated complications
from DM (wounds, fungal infection, memory changes)
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Review drug side effects à compliance
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Explore behaviours: ETOH, diet, exercise, meds
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Focused on outcomes – decrease wine and cake
intake
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Repeat, repeat, and repeat – each visit give
hyperglycemia prevention tidbits, trivia questions to staff
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What to eat and what not to eat
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What exercise to do and what not to do
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EASY website
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NIA workout to go
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Component II
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Evaluation of the resident and goal setting
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Establish goals for residents and settings
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Look at status of individual and mean glucose
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Look at hospitalization/ER visits for individual
settings
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Decreasing fingerpricks?
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Survey issues around medication management
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Need to help establish and accept realistic
treatment goals
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Explore goals with residents/family – which way
do they want to go?
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Optimal QOL – no versus some dietary management;
some exercise; ETOH use, medication adherence
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Avoidance of hypo or marked hyperglycemia
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Control of complications?
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Decreased hospitalizations
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Focus on symptom management
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Tie symptoms (e.g., increased urination, dry
mouth, confusion) to sugars
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Interpersonal Interactions
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Verbal encouragement
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Start with encouragement and reinforcement
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Find a buddy/family member to help motivate
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Physical encouragement via performance – tie
adherence to positive outcomes (weight loss à
less hyperglycemic episodes, reduce meds, etc)
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If no change in 6 weeks to 6 months (depending
on visit schedule) move on to tough love
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Encouragement tied to outcomes
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Threat of meds
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Eliminate the unpleasant sensations
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Address the common ones
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Pain
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Fear of falling
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Staff fear causing hypoglycemia
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Fatigue
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Hunger
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Finances
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Ask what stops them
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Observe what stops them
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Differentiate barriers from excuses
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Role modeling
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Share your own challenges and successes in diet,
exercise and mediation adherence
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Eat, play, and engage in physical activity with
residents and encourage families to do likewise
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Weigh real world issues with medication
management
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Carefully weigh the benefit/risk of medications
to determine how badly this is needed
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Can alternative methods of administration be
considered?
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Diet vs. pill, insulin pens, daily dosing
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Component III
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Mentoring and motivating of everyone
