Care of the Elderly Diabetic Client by Calvin Minds

CARE OF THE ELDERLY DIABETIC CLIENT Stephanie Postma

Introduction  Awarded Whitney Young Gerontological Nursing Scholarship for a second year  Last year’s internship and project  Employed at Clark as an aide in assisted living specialized in dementia  What should I do with the internship this semester?

The Idea

 A meeting with Prof. Flikkema, Clark’s DON, the educator, and myself  Ideas:  Something independent  Use adult med-surgical knowledge  Create something that would benefit Clark

 The project  Diabetes was chose by the DON as the education topic.  I will work with the educator and DON.  I will create a PowerPoint teaching module on the care of the elderly diabetic client.

 Use information from the Geriatric Nursing Education Consortium, funded by the John A. Hartford Foundation.  RNs and LPNs from Clark will complete the module and test and receive one contact hour credit.

Available Resources From GNEC  Designed to be used by nursing professors to teach students about older adults and their complex care needs  Research paper  100 slide PowerPoint  Case Study PowerPoint  What I liked about the resources and provided information

Assessment and Management of Type 2 Diabetes in Older Adults with Complex Care Needs Author: Kathleen McDonald, MSN, APRN, BC-ADM, CDE Deanna Gray-Miceli, DNSc, RN, GNP-BC, FAANP

Learner Objectives

ď Ź The Geriatric Nursing Education Consortium (GNEC) is a national initiative of the American Association of Colleges of Nursing (AACN) to enhance geriatric content in seniorlevel undergraduate nursing courses. This project is generously funded by the John A. Hartford Foundation.

Pre-Test  True or False: Diagnosis of diabetes is often made when the long-term effects of poor glucose control lead to an acute or long-term complication such as a stroke or myocardial infarction.  True or false: Neuropathy in a client with type 2 diabetes has been linked to the development of oralmandibular problems.

 Because diabetes has an insidious onset, the disease is slowly recognized. Older adults often present with complications of the disease before it is formally diagnosed. Some of these complications include all of the following except  Urinary tract infection  Peripheral neuropathy  Hypothyroidism  Cognitive impairment

Diabetes Statistics and Background

ď Ź Worldwide by 2025, adults over age 60 will comprise twothirds of the population with diabetes. With an aging population projected to be 70 million individuals over age 65 years by 2030, the impact of type 2 diabetes will only intensify. For those with type 2 diabetes, the greatest prevalence will be seen in those over age 80. ď Ź Because diabetes has an insidious onset, the disease is slowly recognized. As such, older adults often present with the complications of the disease before it is formally diagnosed. Evident in the medical history of these individuals are various problems ranging from infections to peripheral neuoropathy. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved

Information in the PowerPoint • Prevalence of diabetes in older adults

• Other age related changes that complicate management of diabetes

• Diagnostic Criteria for Type 1 and Type 2 Diabetes

• Nursing Responsibilities

• Atypical presentation of diabetes in older adults

• Physical activity

• Impact of Co-Morbidities

• Medications

• Geriatric Syndromes

• Educational Considerations

• Nutrition

Age-Related Changes Influencing the Diagnosis of Type 2 Diabetes Check

 The classic symptoms of diabetes are often absent or misdiagnosed in older adults.  Polyuria can be attributed to urinary tract infection in women and benign prostatic hypertrophy in males.  Polydyspia is often missed due to decreased sensation of thirst in the elderly individual.  Polyphagia is an atypical presentation in the elderly who experience decreases in appetite secondary to GI dysmotilities and depression.  Diagnosis is often made when the long-term effects of poor glucose control lead to an acute or long-term complication such as a stroke or myocardial infarction.

Impact of Comorbidities  All individuals with diabetes have higher rates of premature functional disability and coexisting illnesses such as:  Hypertension (HTN)  Coronary artery disease (CAD)  Stroke

2-3x risk of myocardial infraction or stroke

2x risk of death 1 of 5 unaware they have CAD

80% die due to cardiovascular disease: combination of hypertension, heart disease, and stroke

Impact of Geriatric Syndromes  Because type 2 diabetes is an all-inclusive, multi-system disease, its presence sets the stage for increased risk of several geriatric syndromes among older adults.  When present, each of these geriatric syndromes can influence the older adult’s ability to safely and accurately manage their disease in order to achieve or maintain normal glycemic levels.

Geriatric Syndromes  Polypharmacy  Depression  Cognitive impairment  Urinary incontinence  Injurious fall  Persistent pain

Depression  Because depression is a treatable condition, its recognition as part of a thorough nursing assessment is paramount in the early detection and management of the older adult with type 2 diabetes.  Not all older adults with type 2 diabetes and depressive symptoms will readily reveal these symptoms.

Case Study Depression contributed as much to mortality as did myocardial infarction or diabetes 1.6x higher risk than in older adults without diabetes

Falls  Chronic hyperglycemia causes cellular damage and its effect on the neuro-sensory system include symptoms of peripheral loss of sensation in the extremities (peripheral neuropathy).  orthostatic hypotension as a result of autonomic neuropathy  decreased cognition  Neuropathy of the lower limbs results in reduced sensation of one’s feet  When walking, there is deceased sensation of foot placement on the floor

Age Changes That Further Complicate Management of Type 2 Diabetes in Older Adults  Type 2 diabetes effects the vascularture of the kidney (nephropathy) by decreasing the glomerular filtration rate (GFR)  Physiological reasons:  Reduced renal blood flow  reduced number of functioning nephrons

Chronic kidney disease from Stage 1 through 5 based on GFR determinations

 ultimately decreased GFR

 Diabetic nephropathy compounded with the renal changes associated with aging and other causes of renal insufficiency can precipitate kidney failure  For those taking potentially nephrotoxic drugs, on-going dosage considerations and regular surveillance of lab data is vital. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved

Macrovascular Damage  Other large vessel changes  Elevated blood pressure  Hypertension which co-contributes to > Stroke > Renal failure > Myocardial infarction

Check

 Additional noted complications stem from congestive heart failure  Also, use of diuretics can result in noxious side effects including orthostatic hypotension, a condition predisposing older adults to falls. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved

Nursing Assessment of the Older Adult with Type 2 Diabetes

ď Ź Keen and timely assessment by the professional nurse is critical to quality management

Management: Management Principles for Older Adults with Complex Illness/Frailty

 What influences overall management?

Case Study

Approximately 8 years needed before benefits of glycemic control are reflected in reduction in  Functional disability microvascular  Presence of geriatric syndromes complications, such as retinopathy, renal disease, and neuropathy  Nursing care requires critical

 The mechanism for multiple comorbidities

analysis of all confounding factors influencing glycemic control.

 Benefits of early, tight glucose control in the prevention of cardiovascular disease have been demonstrated.

2-3 years required to see the benefits from better control of blood pressure and lipids

Management: Management Principles for Older Adults with Complex Illness/Frailty

 Mainstays of diabetes management  medical nutrition therapy  physical activity  medications  self-monitoring of blood glucose

Management: Physical Activity  Exercise has been shown to  Prevent and reverse some micro vascular/muscle changes in older individuals  Means to achieve improved hemoglobin A1c values

 Co-morbid medical problems such as coronary artery disease, arthritis, balance problems, and decreased mobility may prevent some types of physical exercise.

Case Study Overweight older men and women with Type 2 Diabetes in high intensity progressive resistance training combine with moderate weight loss significantly improved glycemic control

Management: Medications  Medication therapy goal  Achieve and maintain a physiological balance that includes the reduction of insulin resistance and promotion of insulin secretion.  Understanding where the individual is along the disease progression/treatment continuum can be a challenge.  The older adult and/or caregiver must understand the progressive nature of diabetes and the ongoing need for periodic changes in the treatment plan that could include the use of insulin to avoid hyperglycemia and prevent complications. Ensure

Management: Self-Management Education  Older adults with diabetes have special educational needs secondary to sensory and other deficits related to the aging process.  Educational plan:  Include an assessment of the individual’s priorities  Use easily read or heard messages and proceed at a slower pace utilizing significant others and caregivers in instruction  Elderly persons with diabetes need assistance with organization of information so they can slowly adapt it to their activities of daily living  Constant reinforcement of content needs to occur during each individual session especially when hyperglycemia or sensory or cognitive deficits are present. Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved

Post-Test

 What problem are older adults with type 2 diabetes at an increased for because of the high prevalence of peripheral neuropathy?

 What measurement of HbA1c is reasonable for frail older adults with a life expectancy of less than 5 years?  6%

 Daytime sleepiness

 7%

 Liver damage

 8%

 Chronic pain syndromes

 9%

 Excessive hair growth

Now What?  Nurse educator “test ran” the PowerPoint and quizzes.  Prof. Flikkema will work with Calvin and Clark regarding the contact hour credits.  We submitted our article to the Journal of Gerontological Nursing and were notified last week that it was accepted for publication!

Conclusion  Grateful to Clark and their kindness shown to me.  Felt good to create something beneficial for Clark using the internship/scholarship.  Publication is the perfect way to wrap-up this 2 year project and my experience.  Thanks to Prof. Flikkema for all her help and fun!