Overcoming Barriers To Diabetes Control For Older Adults

1
Overcoming Barriers To Diabetes ControlFor Older
Adults
Linda Pearce, RN,C, BSN, MEd., CDE Diabetes
Education Program Montgomery Regional
Hospital Linda.Pearce_at_HCAHealthcare.com 540-953-54
52
2
Objectives Overcoming Barriers To Diabetes
Control For Older Adults

• Upon completion of this teleconference
  participants will be able to identify
• Common barriers to diabetes control including
  benefits and risks for older adults
• Evidence based recommendations for diabetes
  target control goals for A1c, BP, and Cholesterol
  from the American Diabetes Association (ADA), and
  American Association of Clinical Endocrinologist
  (AACE)
• At least three special considerations necessary
  for diabetes management in older adults.
• Resources to help empower older adults with
  diabetes to overcome some of the barriers to
  disease management.

Barrier
Suggestions
3
Diabetes Challenges

• Diabetes is common, costly, complex, serious,
  and frustrating. High blood sugar is problematic
  even when Diabetes is not the primary diagnosis.

• Recognized Barriers
• System
• Provider
• Patient
• Society

Barriers
Diabetes affects 30 of home care patients.
2004 NAHC-CMS Report Diabetes was 8.1 of
Primary Diagnosis 20 over 65 have diabetes
in the U.S.
4
Diabetes Complications Are Costly
50
of patients diagnosed with type 2 diabetes
today already have complications many have one or
more comorbidities 60 of older adults with DM
have HTN 35 of older adults with DM have heart
disease 30 of older adults with DM have
dyslipidemia
The cost of treating the complications of
diabetes averages 10,000 per patient per
yr patients pay 1,566 of that out-of-pocket
5
Home Health Care Purpose

• promoting, maintaining, or restoring health, or
  for maximizing the level of independence while
  minimizing the effects of disability and illness,
  including terminal illness (National Home and
  Hospice Care Survey, CDC)
• To help patients become as self-sufficient as
  possible (Visiting Nurse/Hospice Atlanta,
  www.vnhs.org)

Suggestion
VNAA Chronic Care Clearinghouse
(Diabetes) http//www.chronicconditions.org
6
Perceived Barriers To Diabetes Care Differ
Between Patients and Healthcare Professionals

• Patients
• Strictness of regimen
• Influence of other health problems
• Systems barriers
• Knowledge (least important)

• Professionals
• Motivation
• Systems barriers
• Influence of other health problems (10th or less
  important)

N 3,890 patients with diabetes
N 436 Healthcare Professionals
7

• Diabetes is one of the few diseases where the
  victim is blamed for causing his/her diabetes

Attitudes
Barrier
Beliefs about diabetes affect the way HCPs treat
patients, and the way patients view the need or
importance of learning to control of their disease

• Beliefs about How serious
• Ability to affect short-term or long-term
  outcomes value sources of education

Negative Attitudes Toward Diabetes Are Costly
8
42 Of U.S. Diabetics Are Over Age 65

• By 2025 of the people in the U.S. with
  diabetes will be over age 65
• Over 50 with type 2 have no Sx of diabetes, and

53
Symptoms, if present Falls Urinary
Incontinence Fatigue Weight Loss
Decreased Cognition (not the polys)
no Sx relief
Barrier
with treatment
9
ADA Diagnostic Criteria (1997 Revision)

• Fasting (no caloric intake for the previous 8
  hours) BG greater than 126 mg/dL, repeated on
  another day.
• Casual BG greater than 200mg/dL, with symptoms,
  repeated on another day.
• On a 2 hr., 75 gram OGTT any BG greater than
  200mg/dL.

See VNAA Chronic Care Clearinghouse, (Diabetes,
Monitoring)
10
ADA Diagnostic Criteria Misses Elderly With
Diabetes
Barrier

• Depending on fasting plasma glucose to detect
  diabetes misses about
• of people with type 2 diabetes

31
Suggestion
All elderly should be screened for diabetes
11
Diabetes In Older Adults
Usually no symptoms
Care of older adults with diabetes is complicated
by their clinical and functional heterogenecity
Individualize care
Must consider both functional abilities and
chronological age
12
Older Adults Usually Prefer

• Practical information about their diabetes
• Focus on helping maintain independence and
  quality of life

Information Alone Is Not Enough
13
Patients Need Confidence To Manage Their
Diabetes
Diabetes Management Areas
Tips To Help Overcome Barriers
MMM A CPR M Medications M
Monitoring M Meal Planning A Activity C
Coping P Problem Solving R Risk Reduction
1. Assess for the individual patients barriers
in each of the areas of self-care 2. Mutually
consider suggestions to help overcome barriers
(Prioritize and set mutual Goals)
My Mneumonic
Pearce, L (2000), Diabetes Education and
Management in Home Healthcare, Homecare
University.
14
Adherence vs Compliance

• Compliance patients behavior matches medical
  advice (Noncompliantpatient disobeys (criminal)
• Negative attitude toward patients
• Patient is passive

Adherence Rates For Chronic Illness Regimens and
Lifestyle Changes are
50
HCP
Patient

• Adherence voluntary, collaborative involvement
  of patient in mutually acceptable course of
  behavior to produce therapeutic result
• Its patients choice
• Recognizes may adhere to one part and not other
  parts in a very complex plan like diabetes
  management

15
To Improve Adherence We Must Understand Why
Many factors (barriers) are documented in the
literature
Suggestion

• After establishing trust and rapport
• Listen to what is important to the patient
• Assess importance of diabetes control to patient
• Assess patients confidence they can make the
  changes needed
• Ask self for each patient
• How can I empower this patient to make daily
  informed choices about diabetes self-care?

16
To Overcome Barriers
We Must Understand That Patients Adhere When The
Treatment Regimen

• Makes sense
• Seems effective
• They believe benefits exceed costs
• They believe it is important
• They have confidence they can succeed at the
  regimen
• When the environment is supportive of
  regimen-related behaviors (especially family)

17
Progressive Decline of ?-Cell Function, UKPDS
(Type 2)
100
Type 2 Diabetes Is Serious ?-cell is 50 gone at
diagnosis
Diagnosis
80
60
?-Cell Function ( ?)
40
20
0
?10
?9
?8
?7
?6
?5
?4
?3
?2
?1
0
1
2
3
4
5
6
Years from Diagnosis
18
Annual Incidence of Diabetes Complications Per
1,000 Patients
Type 2 Diabetes Is Serious
19
Teach Patients Their Diabetes ABCs
(Under age 70, healthy)
A B C
A1c may change to ADAG or AG (A1c Derived Average
Glucose, or Average Glucose) after Sept. 2007
meeting in Europe.
See VNAA Chronic Care Clearinghouse, (Diabetes,
Monitoring)
20
Fasting Post-Prandial Contributions to A1c in
Type 2
Fasting Plasma Glucose
Encourage PPG Monitoring
Post Prandial Glucose
30
50
55
60
70
Contribution Fasting vs Post-Prandial
70
50
45
40
30
gt10.2
10.2-9.3
9.2-8.5
8.4-7.3
lt7.3
A1C
PostPrandial Glucose (PPG) 2 hrs. after start
of meal
21
Think Like A Pancreas(Normal Insulin Secretion)
Bolus
Basal
Basal 1 unit per hour in a healthy adult
without diabetes (2nd phase insulin
secretion) Bolus insulin secretion in response
to increase of about 3 mg/dL in blood glucose
(1st phase insulin secretion)
22
SIMPLE Prevent Diabetes Complications
Suggestion
S I M P L E
Don't Smoke Inspect feet daily, eyes yearly and
teeth 2/yr. Monitor blood sugar, A1c and urine
protein as recommended Lower Blood Pressure to
less than 130/80 Lose weight if needed Exercise
most days of the week for 30 minutes or more
See VNAA Chronic Care Clearinghouse, (Diabetes,
Risk Reduction)
23
Diabetes Management Recommendations
ADA, (2004), Standards of Medical Care in
Diabetes, Diabetes Care, 27(Suppl.1), S15-S35.
ADA, (2007), Standards of Medical Care 2007,
Diabetes Care, 30(Suppl 1), S4-S41. Updated
annually, 2007 available for FREE download
at http//care.diabetesjournals.org/cgi/reprint/3
0/suppl_1/S4
24
Smoking Recommendation
Advise all patients not to smoke. (A)
Level of evidence
About 25 of Americans Smoke
See VNAA Chronic Care Clearinghouse, (Diabetes,
Risk Reduction)
25
Smokers With DiabetesHave Higher Mortality
Barriers

• Smoking narrows arteries, reduces blood flow legs
  thereby increasing risk of heart attack and
  stroke, and slows wound healing, amputations more
  likely
• Smoking increases risk of nerve damage and kidney
  disease
• Smoking impairs the immune system, making smokers
  more susceptible to colds and respiratory
  infections

26
Smoking Cessation
Suggestion
www.chronicconditions.org
Stop Smoking 1pkg./ day (4.50/pkg. save 135
a month,16,400 in 10 years
http//www.smokefree.gov/info.html
Quit Line (Telephone support by each state)
1-800-QUITNOW, or 1-800-784-8669)
Its never too late to stop smoking !
See VNAA Chronic Care Clearinghouse, (Diabetes,
Risk Reduction)
27
Diabetes Standards of Care
Every visit (every 3 months)
At least yearly

• Lipids
• Eye Exams
• Kidney Function
• Influenza vaccine

• Blood Glucose
• BP
• Weight
• Foot Exams
• Physical Activity
• Tobacco Avoidance
• Aspirin use
• Depression Screening

Twice yearly

• Dental

As Recommended

• Pneumonia vaccine

See VNAA Chronic Care Clearinghouse, (Diabetes,
Monitoring and Risk Reduction)
28
1. What Gets Paid For Gets Done

• Basic Principle

Suggestion Let People Know How Much Diabetes
Control Saves (Value Of Control)
Share The Evidence
29
Medicare Coverage For Diabetes Supplies Services

• http//www.medicare.gov/Publications/Pubs/pdf/1102
  2.pdf (30 page booklet)
• Publication No. CMS-11022, Revised September 2004
• Available on Audiotape (English and Spanish) or
  in Braille, or Spanish
• Call 800-633-4227 to get the booklet

80 covered after annual deductibles are met
Centers for Medicare Medicaid Services7500
Security BoulevardBaltimore, MD 212441850
30
Medicare Covers (800-633-4227)

• Self-testing equipment (meters, strips, lancets)
  for all Medicare recipients with diabetes (pay
  20)
• -Special meters with medical reason e.g. low
  vision, decreased manual dexterity
• -note test frequency in order keep log
• Therapeutic shoes, shoe inserts if qualify (pay
  20)
• Diabetes Services (pay 20)
• Self-Management Training (pay 20)
• Medical Nutrition Therapy (pay 20)
• Flu and Pneumococcal pneumonia vaccine (pay 0)
• Glaucoma Screening every 12 months (pay 20)

http//www.medicare.gov/Health/Diabetes.asp
31
Medicares Monitoring Supply Limits

• Need prescription for items from HCP
• Show log book of BG checks for additional strips
• HCP justification may help obtain additional
  supplies

32
States Require Diabetes Supply Insurance Coverage

• 46 states have insurance laws that require
  coverage of diabetes treatment, equipment and
  supplies
• 4 states still have NO mandated insurance
  coverage for diabetes supplies Alabama, Idaho,
  North Dakota and Ohio 

Barrier

• 3 states require insurers to offer, but not
  necessarily include the coverage- Mississippi,
  Missouri and Washington

33
Medication Barriers For Older Adults
Barrier

• Inconvenience inflexibility of timing
• Cost
• 64 Medicare eligibles for Plan D had medication
  expenses in excess of 2,250 (Plan D donut
  hole)
• Weight Gain Fluid Retention (especially when
  patient also has cardiovascular disease)
• Physical and emotional side effects
• Hypoglycemia
• risk of falls and fractures
• Desire to avoid injections

34
Medication Assistance
Suggestions

• Samples from HCP via pharmaceutical
  representatives
• Order larger dose then split pills (meds that can
  be split include Glucophage, Glucotrol,
  Glucovance, Glycet)
• Combination pills
• Order medications in bulk (90 day supply) when on
  same medication for at least the past 6 months
• Discount drugs from Canada, Ireland, the UK are
  available in several states (WI, MO, IL, KS)
• Information for people who need help with meds
  (list of meds and companies with Pharmaceutical
  Assistance Programs (PAPS) including forms that
  need to be completed, etc.)
• http//www.needymeds.com/

35
4 For A 30-Day Supply of Generic
Medications
Suggestions
Images from various companies at http//www.drugs
.com/images.php

• Oral Diabetes Medications on List
• Glipizide 5 mg and 10 mg.
• Glyburide 2.5 mg and 5 mg.
• Glyburide MCR 3 mg. and 6 mg.
• Glimepiride 1 mg.
• Metformin 1,000 mg., 850 mg., 500 mg. and 500 mg.
  ER
• Blood Pressure Medications on List
• ACE Inhibitors Captopril, Enalapril, Lisinopril
  
• Beta Blockers Metoprolol and Propranolol.

36
Book
Suggestion

• Suggestions in book include
• how to buy medications through the mail or the
  Internet
• sources of free or low-cost health care
• ways to reduce food costs while increasing
  nutrition value

Dawson, Leslie, (2004), How to Save Up to 3,000
a Year On Your Diabetes Costs, American Diabetes
Association ISBN 1580401694, Cost 8.95
37
1. What Gets Paid For Gets Done

• Basic Principles

For Overcoming Barriers

• What Gets Monitored Gets Done

38
A1c Recommendations
ADA Evidence-Based Levels (A, B, C, E)

• Lowering A1C has been associated with a reduction
  of microvascular and neuropathic complications of
  diabetes (A) and possibly macrovascular disease
  (B)
• The A1C goal for patients in general is an A1C
  goal of lt7. (B)

39
63 of Patients With Diabetes are Not At ADA A1C
Goal lt7
National Health and Nutrition Examination Survey
(NHANES), 1999-2000.
Barrier
1 in 5 Have A1c gt 9
A1C
of Subjects n 404
Only 7 of adults attained A1c lt7, BP 130/80,
and Total Cholesterol lt200mg/dL
A B C
40
Lower A1c Saves Money
Suggestion

• When A1c lowered 1 for 1 yr.
• N 4,700
• Fewer hospitalizations
• Fewer trips to ER, and doctor visits
• (average savings 400/yr.)

CONTROL IS COST EFFECTIVE
41
Home Care Nurses Dont Teach Patients About A1c
Suggestion
Teach Patients Their Diabetes ABCs
Barrier
N 44 home care patients and 26 nurses

• Only 7 of patients report visiting nurse taught
  them about the A1c
• Almost 35 of nurses never educate patients about
  their A1c
• Most nurses never contacted the physician to
  obtain A1c results
• 58 of nurses could not identify the current A1c
  recommendation for patients

Setter, S.M., C.F. Corbett, R.K. Campbell, D.
Cook, B.J. Gates, (2003), A Survey of the
Perceptions, Knowledge, and Use of A1c Values By
Home Care Patients and Nurses, TDE, 29(1),
144-152.
42
Costs vs Benefits
Barriers

• It takes 8 to 9 yrs. of intensive glucose control
  to microvascular complication risks
• It takes only 2-3 yrs. of BP and Cholesterol
  control, plus aspirin to
• CV complication risks

43
2007 ADA Older Adult Recommendation

• Patients who can be expected to live long
  enough to reap the benefits of long-term
  intensive diabetes management ( 10 years) and who
  are active, cognitively intact, and willing to
  undertake the responsibility of self-management
  should be encouraged to do so and be treated
  using the stated goals for younger adults with
  diabetes.

A1c lt 7 for most older adults
44
Older Patients Need Individualized Care
American Diabetes Association recommends less
aggressive target goals for older patients with
advanced complications, comorbid illness,
cognitive, or functional impairment
FBG 140 mg/dL (vs 90-130 mg/dL) Postprandial
200-220 mg/dL (vs lt180mg/dL)

• American Geriatric Society (AGS) recommends less
  stringent A1c if life expectancy less than 5 yrs

A1c 7 reasonable, if relatively healthy and
good functional status
A1c 8 BP 140/80
but
45
Special Needs of Elderly with Diabetes
Suggestion
Visit when family or caregivers who cook and shop
can be present

• Individualize Education
• Listen
• e.g. Product selection--manual dexterity, vision,
  hearing, memory, fears, financial coverage
• Providing information does not guarantee behavior
  change
• Teach Problem solving
• Help Simplify Regimen
• Screen for depression (2-3 question test)
• Enhance social support (include family)

46
Diabetes is Associated with Functional Limitations

• N 3,075 between ages 70 79
• Poor glycemic control contributes to functional
  decline in older people with diabetes

Functional decline disability
Improved glycemic control improves QOL with fewer
physical symptoms (pain, fatigue, etc.)
Suggestion
47
Physical Disabilities Are Significantly Higher in
People With Diabetes

• Disabilities associated with diabetes affect up
  to 50 over age 70 and include visual
  impairment, decreased manual dexterity,
  neuropathy, cognitive problems, and paralysis
• Disabilities complicate and interfere with
  diabetes control

48 have hearing loss 53 have vision loss 33
have history of recent falls 38 have cognitive
disorders
48
Adaptations for Hearing Deficits
Suggestion

• 11 sessions
• Decrease background noise (quiet room)
• Request t.v. be turned off
• Plan visit when favorite programs are not on
• Decrease distractions (interruptions)
• Face patient (allows for lip-reading)
• Enunciate clearly, not loudly
• Speak in a lower tone and at slow pace
• Have patient wear hearing aid, if available

49
Adaptations for Vision Loss
Suggestion

• Use thick black markers
• Avoid red, yellow, blue, green, and orange or
  glossy paper
• Decrease glare
• Provide adequate lighting and magnification

50
Suggestions
For Vision Loss
5X and 10 X Illuminated Magnifiers, ILA, 29.95
10 x Iluminated Magnifier 40, 1-877-WASSCO1
(1-877-927-7261)
National Library Service for the Blind and
Physically Handicapped (NLS), FREE The
Library of Congress 1291 Taylor Street
N.W. Washington, D.C. 20542 [phone]
Colormates,ID Clothes, 34.95
Recording for the Blind Dyslexic
(Membership) 20 Roszel Road Princeton, NJ
08540 866-RFBD-585 (866-732-3585)
51
Talking Glucose Monitors
30
January 1, 2007 Roche ceased making VoiceMate
Prodigy 6 seconds
30
Advocate
Comfort Curve Strip
Suggestions
NFB best price
VoiceMate 475 - 495
Advocate Pharma Supply, 3381 Fairlane Farms
Road, West Palm Beach, FL 33414 phone Customer
Care Center, 866-373-2824
Prodigy Diagnostic Devices, 5900-A Northwoods
Business Park, Charlotte, NC 28269 phone
customer service, 800-366-5901, technical
support, 800-243-2636
VoiceMate National Federation of the Blind,
1800 Johnson St., Baltimore, MD 21230,
410-373-2814, www.nfb.org
52
Suggestions For Patients With Low Visionor
Hemiplegics
Suggestions
Tray for supplies when monitoring
Bright colored clothespins to hold strips
Dycem reel (3 3 by 16) 25 Cut shape to fit
items Place beneath items to prevent slipping
53
Insul-Cap
7.95 for 2
Ident-A-cap, 2 for 1.99 800-862-2348
4.95 Center-Aid Snaps on vial to help avoid
bent or blunt Needles, MaxiAids
7.95 Insul-Tray
Insuleeve 2 for 12 plus 2 S H
Suggestions
54
Visually Impaired Insulin Use

• Tape or rubber band on vial (e.g. thick rubber
  band for one kind of insulin, thin for another
  and no rubber band for a 3rd kind)
• Hold syringe and vial in vertically
• Expel air bubbles by pulling insulin into the
  syringe and pushing it back into vial 3 times

Suggestions
Count-a-dose, 60
See VNAA Chronic Care Clearinghouse, (Diabetes,
Problem Solving)
55
Insulin Pens
½ unit increments
Suggestions
Easy to select dose accurately
See VNAA Chronic Care Clearinghouse, (Diabetes,
Medications)
56
Adaptations for Cognitive Changes
Suggestion

• Limit information
• Combine verbal and written instructions
• Concrete examples
• Factual
• Short sentences
• Frequent repetition
• Obtain feedback
• Allow time

57
Memory Aids
Suggestions
E-Pill Multi-Alarm, E-pill 35
Pill Bottle Alarm, 16.95
Pill Box with Multiple Alarms ILA, 11
Vibrating 6-alarm watch E-pill 140
58
Fall Risks are Increased for Elderly with Diabetes

• Due to Diabetes Complications
• Peripheral Neuropathy (sensory and motorpain and
  loss of proprioception)
• Altered foot structure (Charcot foot)
• Muscle Weakness (decreased strength)
• Orthostatic Hypotension
• Decreased Vision
• Risk of hypo and hyperglycemia (nocturnal
  polyuria, incontinence)
• Use of 4 or more medications

59
Osteoporosis
Women with type 1 6.9 to 12 fold increased Fx
risk Women with type 2 1.7 fold increased Fx
risk

• Diabetes increases risk of OP leading to
  increased risk for falls and fractures
• Cause too little insulin leading to calcium
  loss through urine, and decreased absorption from
  food

Suggestion

• Decrease risks by increasing exercise, not
  smoking, avoiding alcohol

60
The Most Powerful Therapy for Diabetes Control
Suggestion
EDUCATION
Saudek, C.D. (2002), The Role of Primary Care
Professionals in Managing Diabetes,Clinical
Diabetes, 20(2), 65-66.
61
Without Education TheRisk Of Major Diabetes
Complications Increases 4-fold
Suggestion
AADE Home Health Care Diabetes Educators
Specialty Practice Group, Chairperson Regina
Bliss, RD, RN [phone], bacciagalupe_at_usa.ne
t Chairperson Elect Marcia Elliott, RN BSN
CDE, Community Health Professional, Van Wert, OH
[phone], melliot_at_wcoil.com
62
2003 AGS Recommendation

• Keep an updated medication list

• Package inserts use very small print
• Health literacy and language barriers are issues
  in reading labels, and inserts
• 67 dont understand label
• 39 cant read label

See VNAA Chronic Care Clearinghouse
(Diabetes) http//www.chronicconditions.org
63
Health Literacy

• the ability to read, understand and act upon
  health information

Health Literacy A Prescription to End Confusion
(2004), an Institute of Medicine Report notes
nearly ½ of American adults (90 Million) have
difficulty understanding and using health
information
This puts their health at risk
The Invisible Barrier
Report for sale from Institute of Medicine 500
Fifth Street NW Washington DC 20001
64
Health Literacy
Suggestion

• Request patient to teach back
• Use picture based materials
• Use colored dots (Match the dots)
• Use audiotapes, video tapes, DVDs that patient
  can listen to or watch over and over

See VNAA Chronic Care Clearinghouse (Problem
Solving)
65
Pictograms For Low Literacy
Use with verbal instruction
Resource
http//www.usp.org/audiences/consumers/pictograms/
form.html 81 are available for FREE Download
after registration at website
66
Screen Older Adults With Diabetes For Depression

• 64 over age 70 have symptoms of depression,
  dementia, or disability
• 53 ADL deficits

Health care costs are 50 higher when patient
depressed
Suggestion
Assess for depression and refer if needed
See VNAA Chronic Care Clearinghouse, (Diabetes,
Coping)
67
Depression Often Upsets Diabetes Self-care
Barriers

• Depressed people with diabetes are less likely
  to
• watch what they eat
• to exercise
• to take their medications

68
Assess For Depression
Suggestion
See VNAA Chronic Care Clearinghouse

• 3 Question Screening for Depression
• Ask the patient the following questions

• "Do you often feel sad or depressed?"
• "During the past month, have you been bothered by
  feeling down, depressed, or hopeless?"
• "During the past month, have you been bothered by
  little interest or pleasure in doing things?"

See VNAA Chronic Care Clearinghouse, (Diabetes,
Coping)
69
Use TV for Education
Suggestion
dLifeTV brings leading experts, timely medical
information, inspirational stories, and recipes
for healthy food right to your television screen.
Nicole Baker Johnson, author and Miss America
1999, anchors dLifeTV. Celebrity correspondents
include Mother Love, author and TV personality
J. Anthony Brown, comedian and co-host of the Tom
Joyner Radio Show and Jim Turner, actor.
J. Anthony Brown
Mother Love
Jim Turner
Nicole Johnson
70
Teach Relationships Among Control Factors
Suggestion

• Meals (food and alcohol)
• Monitoring
• Medication
• Activity
• Sick Days (Coping, Problem Solving, Risk
  Reduction)

Educate!
71
Meal Planning
72
Carbohydrate Counting

• Monitoring carbohydrate, whether by carbohydrate
  counting, exchanges, or experience-based
  estimation, remains a key strategy in achieving
  glycemic control. (A)
• Sucrose-containing foods can be substituted for
  other carbohydrates in the meal plan (A)

Suggestion
Teach people with diabetes to monitor
carbohydrate intake
73
Carbohydrate Counting
Suggestions
Staying On Target Carb CountingEat to
Win, 32 page booklet in pdf file available for
FREE download at http//www.bddiabetes.com/us/dow
nload/CarbCountWeb2007.pdf
Borushek, Allan, (2007), The Calorie King
Calorie Fat Carbohydrate Counter, Family
Health Publications Costa Mesa, CA
(7.99) ISBN-10 1930448112 ISBN-13
978-1930448117 www.Calorie.King.com
See VNAA Chronic Care Clearinghouse, (Diabetes,
Nutrition)
74
Alcohol Can Be A Barrier
If adults with diabetes choose to use alcohol,
daily intake should be limited to a moderate
amount (one drink per day or less for women and
two drinks per day or less for men). (E) To
reduce risk of nocturnal hypoglycemia in
individuals using insulin or insulin
secretagogues, alcohol should be consumed with
food. (E)

• One drink 12 oz. beer
• 5 oz. wine 1.5 oz. distilled
  spirits

See VNAA Chronic Care Clearinghouse, (Diabetes,
Nutrition)
75
Nutrition Barriers To Diabetes Control In Older
Adults
Barriers
Aging changes that affect diabetes nutrition

• Taste and smell changes
• Dentition changes
• Chewing
• Swallowing
• Changing food preferences
• Changing metabolic rate
• Decreasing activity
• Cooking capabilities

• Appetite changes
• Medications
• Financial constraints
• Emotional well-being
• Memory
• Fluid intake
• Interest in food
• Alcohol use

Think sugar-free is O.K. ?
76
High Blood Glucose Associated With Dementia In
Older Women

• N 1,983 post-menopausal women (average age 67)
• Risk of developing mild mental difficulties or
  dementia was 40 greater for each 1 increase in
  A1c, when A1c was 7 at beginning of study.

77
Nutrition Resources For Older Adults
Suggestions

• Meals on wheels
• Commodity foods
• In-home personal aids
• Centers on aging
• Social services

• Community nutrition sites
• Food stamps
• Adult day care centers
• County extension agents
• Grocery store delivery services

• If designing educational materials for older
  adults include
• Specific fluid recommendations
• Simple lists and tips vs narrative materials
• e.g. low cost protein sources, recipe alterations

78
Overcoming Nutrition Barriers In Older Adults
Suggestions

• Strengthen willpower for behavior change
• (elderly in Dyes study noted it is obtained
  through a belief in God)
• Make small changes and build on them weekly
• Communicate changes made with HCP and encourage
  HCP to reinforce those behaviors
• Time meals allowing just enough time to finish
  before favorite tv show in another room
• Use smaller salad plates
• Encourage family to eat same foods

See VNAA Chronic Care Clearinghouse, (Diabetes,
Nutrition)
79
Weight Loss For Older Adults

• Obese older adults with diabetes may benefit from
  modest energy restriction and an increase in
  physical activity energy requirement may be less
  than for a younger individual of a similar
  weight. (E)

In the institutionalized elderly, undernutrition
is likely and caution should be exercised when
prescribing weight loss diets. (B)
Weight loss is seldom a goal for older adults
with diabetes
80
Weight Issues And Poverty
Barriers

• Obesity
• Low-income families often rely on cheaper,
  high-calorie (energy dense) foods to stretch food
  budgets

Cost of food Difficulty with label reading
(literacy, small print) Time constraints Family
preferences Convenience Knowledge deficit
81
Nutrition Education Tips

• Emphasize blood glucose control, not weight
  loss.
• Focus on carbohydrate foods, portions, and number
  of servings per meal.
• Encourage physical activity.
• Use food records with blood glucose monitoring
  data.

Suggestions
Medical Nutrition Therapy
See VNAA Chronic Care Clearinghouse, (Diabetes,
Nutrition)
82
Nutritional Resources
Suggestion

• Buy less sweets
• Read labels (with assistance, e.g. with RD)
• Hands on assistance in grocery stores helpful
• Drink more water
• Increase fiber, and decrease fat
• Change to brown bread, rice, pasta
• Make aware of carbohydrates on food label
• Buy fresh or frozen vegetables instead of canned
  vegetables (healthier choices-higher cost)
• Decrease portion sizes

See VNAA Chronic Care Clearinghouse, (Diabetes,
Nutrition)
83
Monitoring
84
Predictors of SMBG Nonadherence

• Longer duration of diabetes
• Less-intensive diabetes therapy
• Fewer medical visits
• Lower educational attainment
• Excessive alcohol consumption
• Male gender
• Older age
• Ethnic minority

85
Reasons For Not Monitoring
Barriers

• Cost
• Pain, sore fingers
• Inconvenience
• Time
• Failure to understand control goals
• Not know how to use the information obtained

86
Factors Affecting BG Readings

• HematocritAnemia results in higher BG reading
• High hematocrit results in lower BG reading
• HydrationDehydration results in higher reading
• Failure to code
• Outdated strips

• Condition of hands
• Temperaturesome meters will not work in cold or
  hot climates
• Humidityhastens strip deterioration
• Altitudemeters respond to altitude changes

87
Tips To Encourage Monitoring
Suggestion

• ?E-Bay
• Store brand meters

• Community service monitoring free
• or low cost checks
• Clinical trials
• Meter swaps at area pharmacies
• Health fairs

• New technology
• Update meters

SOLUTION
EDUCATION
See VNAA Chronic Care Clearinghouse, (Diabetes,
Monitoring)
88
Meters
Suggestion
Manual dexterity, memory loss
Roche Diagnostics
Ascensia Bayer Diagnostics (no coding)
HDI
LifeScan
No need to change strip each time or coding
Abbott Diabetes Care
See VNAA Chronic Care Clearinghouse, (Diabetes,
Monitoring)
89
Lancing Devices
Arthritic and Hemiplegic
BD UltraFine II 30 gauge lancet 10/200

Mini Auto-Lancet, Palco
Thinnest lancet
Unistik 2, Owen Mumford, 0.25 each
EZ Let II, Palco
BD Genie Lancet 28 gauge, 36/200
Palco
LifeScan
Roche
BD
Bayer
Bayer
See VNAA Chronic Care Clearinghouse, (Diabetes,
Monitoring)
90
Hypoglycemia Recommendations

• Glucose (1520 g) is the preferred treatment for
  hypoglycemia, although any form of carbohydrate
  that contains glucose may be used, and treatment
  effects should be apparent in 15 min. (A)
• Treatment effects on hypoglycemia may only be
  temporarily corrected. Therefore, plasma glucose
  should be retested in 15 min, as additional
  treatment may be necessary. (B)

91
Symptoms of Hypoglycemia in Older Adults

• Symptoms are easily mistaken for Alzheimers or
  dementia

Suggestion

• Teach patient to recognize their own symptoms
• Empower patient to set own target goals
• Encourage active learner participation

Keep plastic sandwich bags at bedside Glucose
tablets Glucose gel Other rapid acting
glucose (no items containing fat)
92
Diabetes ID
Suggestion
Diabetes Research Wellness Foundation
FREE Send SASE to DRWF P. O. Box 3837
Merryfield, VA 22116-9956

• Medic Alert 800-432-5378
• Medicool, Inc 800-433-2469
• Goldware 800-669-7311
• LIFETAG, Inc. 888-LIFE TAG

93
Hyperglycemia
Suggestion
Hyperosmolar hyperglycemic nonketotic coma (HHNC)
mean age of onset is in the 70s
See VNAA Chronic Care Clearinghouse, (Diabetes,
Monitoring and Risk Reduction)
94
Hospitalizations For DKA
During acute illnesses, insulin and oral
glucose-lowering medications should be continued.
(A)

• Reasons hospitalized
• Stopped Insulin
• 50 said lacked money to purchase insulin
• Lacked transportation to hospital or clinic
• Unaware of dose adjustments for sick days
• Did not monitor ketones (urine or blood)

Educate
Suggestion
66 preventable with education and access to
care and education
95
Free Strips Do Not Improve Glycemic Control

• Patients with type 2 diabetes not using insulin
  do not know how to use the information obtained
  from SMBG

Suggestion
Educate! Reinforce!

• Look at the log book with patient, every visit
• Help patient figure out reasons numbers are at
  target or not at target, and patterns

96
Encourage SMBG
PPG as well as FBG
Suggestion
Match meter to patient needs

• Consider BEST Meter is one patient can and will
  use
• Visual acuity
• Fine motor skills (dexterity)
• Personal preferences
• Meter coding, control solution checks
• Expense of strips (Insurance coverage tier, mail
  order vs local supplier)
• Heat, humidity, altitude

97
Neuropathy Recommendations

• All patients should be screened for distal
  symmetric polyneuropathy (DPN) at diagnosis and
  at least annually thereafter, using simple
  clinical tests. (A)
• Education of patients about self-care of the feet
  and referral for special shoes/inserts are vital
  components of patient management. (B)

98
Footcare Education

• Up to 85 of amputations are preventable
• Common footcare and footwear errors in WA
• 28 wear inappropriate footwear
• 31 go barefoot

Suggestion
Revised Feet Can Last A Lifetime Kit
(Professionals) Your Feet Can Last A Lifetime
(NDEP-4), 25 Free National Diabetes Information
Clearinghouse 18008608747
See VNAA Chronic Care Clearinghouse (Monitoring
and Risk Reduction)
99
Medication Barriers
100
Medication Facts
Barriers

• 50 of all prescriptions are taken incorrectly
• 33 of prescriptions are never filled

Diabetes Drug Costs Could Rise 70 by
2009 According to Medcos 2007 Drug Trend Report
Expected use increase 8 to 10 per year
101
Diabetes is a Polypharmacy Disease

• Often more than one medication is required to
  achieve treatment goals for each of the
  following

Glucose Cholesterol BP Heart disease Neuropathy
Pain ASA
Barriers
Drug Interaction Checker Service (FREE).
Indicates the level of significance of the
interaction (major, moderate or minor), and will
also include food interactions with chosen drug.
http//www.drugs.com/drug_interactions.html
102
Polypharmacy In Older Adults

• Every time you add another medication, you
  decrease the chance of the drugs being taken
  correctly

• The average older adult takes 7 medications (that
  means about half of them take more than 7
  medications)

103
Medications Type 2What Color Is Your Pill?
Suggestion

• Insulin Secretagogues

Prandin 0.5 mg 1 mg 2 mg
Images of brand and generics from various
companies available at http//www.drugs.com/image
s.php
Glyburide 2.5 mg
Glipizide 10 mg
Glipizide 5 mg
Glipizide 2.5 mg
Glyburide 1.25 mg
Glyburide 5mg
104
Medication Considerations

• Type 2 progressive insulin secretory
  dysfunction
• Most older patients in generally good health can
  benefit from progressive treatment
  intensification to reach treatment goals.
• American College of Endocrinology (ACE) and
  American Association of Clinical Endocrinologists
  (AACE) recommend advancing to more intensified
  regimen if goals not reached in 2-3 months

Suggestion
Road Map for Prevention and Treatment of Type 2
Diabetes, available at http//www.aace.com/meeti
ngs/consensus/odimplementation/roadmap.pdf
See VNAA Chronic Care Clearinghouse, (Diabetes,
Monitoring)
105
Medication Barriers and Suggestions for Older
Adults
Suggestions

• Cant open container (Ask pharmacist for
  suggestions to help with medication container
  caps)
• Cant swallow pill (Ask pharmacist if a liquid is
  available e.g. Riomet for metformin or if drug
  can be crushed or split)
• Patients Medication List should include both
  prescription and over-the-counter (OTC)
  medicines, such as pain relievers, antacids, cold
  medicines, laxatives, eye drops, dietary
  supplements, vitamins, herbals, and topical
  medicines (e.g. creams and ointments)
• Potential food or medication interactions (Ask
  pharmacist to help check)

106
Aspirin Recommendations

• Use aspirin therapy (75162 mg/day) as a
  secondary prevention strategy in those with
  diabetes with a history of CVD. (A)
• Use aspirin therapy (75162 mg/day) as a primary
  prevention strategy in those with
• Type 2 diabetes at increased cardiovascular risk,
  including those who are gt40 years of age or who
  have additional risk factors (family history of
  CVD, hypertension, smoking, dyslipidemia, or
  albuminuria). (A)

107
Aspirin Use in Older Adults
Only 33 of people with diabetes (but no known
heart disease) used aspirin as recommended
Suggestion
See VNAA Chronic Care Clearinghouse, (Diabetes,
Medications)
108
Type 2 Diabetes Is A Progressive Disease

• Over time, most patients will need insulin to
  control glucose

109
Inhaled Insulin

• Exubera is a rapid-acting inhaled insulin

                                                
                  
150 per month
110
Insulin Pump Therapy
Continuous Subcutaneous Insulin Infusion (CSII)

• Benefits of pump therapy for include
• reduced risk of hypoglycemia
• better control as evidenced by A1c levels
• precision delivery of insulin

See CMS Coverage Criteria A B in Resources
Section

• N 107 gt 60yrs for 12 mo.
• In older subjects with insulin-treated type 2
  diabetes, both CSII and MDI achieved excellent
  glycemic control with good safety and patient
  satisfaction

111
Meds Skipped To Save
Barrier

• 11 of people with diabetes cut back on their
  meds
• 28 do without food to pay for meds
• If taking 7 or more meds more likely to skip some
  of meds
• Patients not taking meds had worse BG control,
  more symptoms, and worse physical and mental
  functioning

no Sx relief
Suggestions
Combination meds, generics, HCP samples, needy
meds
112
Complementary And Alternative Medicine (CAM) Use
Barriers

• 70 of adults age 70-85 with diabetes use some
  form of CAM
• Diabetes is an independent predictor of CAM use
• CAM is a widely used component of health
  self-management among rural among older adults
  with diabetes.

Suggestion
Drug Interaction Checker Service (FREE).
Indicates the level of significance of the
interaction (major, moderate or minor).
http//www.drugs.com/drug_interactions.html
113
Physical Activity
114
Physical Activity Recommendations

• To improve glycemic control, assist with weight
  maintenance, and reduce risk of CVD, at least 150
  min/week of moderate-intensity aerobic physical
  activity (5070 of maximum heart rate) and/or at
  least 90 min/week of vigorous aerobic exercise
  (gt70 of maximum heart rate) is recommended. The
  physical activity should be distributed over at
  least 3 days/week and with no more than two 2
  consecutive days without physical activity. (A)
• In the absence of contraindications, people with
  type 2 diabetes should be encouraged to perform
  resistance exercise three times a week, targeting
  all major muscle groups, progressing to three
  sets of 810 repetitions at a weight that cannot
  be lifted more than 810 times. (A)

115
Reasons Patients Give For Not Exercising
Barriers
Lack of Time
Forget
Embarrassment
No Safe Place
?
Physical Health
Fear
Dont Like to
Money
116
Encourage Patient To Identify Personal Benefits
Point out benefits
Suggestions

• Improves insulin sensitivity
• Decreases need for medication for glycemic
  control
• Helps reverse mild depression
• Increases muscle mass, strength and endurance
• Improves insomnia

117
Physical Activity Benefits
Point out benefits
Suggestions

• Reduces arthritis pain
• Improves longevity
• Diminishes fall risk
• Improve functional status
• Improves quality of life

• Improves bone strength
• Improves central nervous system
• functioning

118
Pedometer Use Increases Activity
Suggestions
Request referral to PT, OT or personal trainer as
appropriate
Use of a pedometer increases daily steps

• Numerous handouts, tracker logs, and other
  information available at VNAA Chronic Care
  Clearinghouse

See VNAA Chronic Care Clearinghouse, (Diabetes,
Exercise)
119
Sick Days
120
Sick Day Management
During acute illnesses, insulin and oral
glucose-lowering medications should be continued.
(A) During acute illnesses, testing of plasma
glucose and ketones, drinking adequate amounts of
fluids, and ingesting carbohydrate are all
important. (B)
121
Sick Day Care
Suggestions

• Make certain the patient understands when to call
  their HCP
• Sick Days and Diabetes, 2 page NDEP handout
  available at http//www.diabetesatwork.org/diabe
  tesatwork/_files/factsheets/II_B_04_FS.PDF

Establish guidelines with HCP or agency
See VNAA Chronic Care Clearinghouse, (Diabetes,
Risk Reduction)
122
RESOURCES
123
Books
Suggestion

• H. Peter Chase, (2006), Understanding
• Diabetes, 11th Edition, 25,
• ISBN 0-967-53985-4

• Children's Diabetes Foundation at Denver
• 777 Grant Street, Suite 302Denver, CO
  80203800-695-2873

Think Like A Pancreas, Gary Scheiner, Marlowe
Company, 11, (2004), ISBN 1569244367
124
Books
Suggestion
Using Insulin, John Walsh, Ruth Roberts, C.
Varma, T. Bailey, Torrey Pines Press, San Diego,
(2003), 18.95, ISBN 1-884804-85-3
Pumping Insulin,(3rd edition) John Walsh, PA,
CDE, Ruth Roberts, MA, Torrey Pines Press, San
Diego, (2000), 18.95, ISBN 1884804845
125
Conclusion Overcoming Barriers To Diabetes
ControlFor Older Adults Requires That We

• Continually update our knowledge about diabetes,
  control guidelines, and available resources
• Listen to what is important to each of our
  patients
• Empower our patients with the knowledge, skills,
  adaptations, and confidence they desire and need
  to live well with their diabetes and make
  informed daily decisions about their disease
  control

126
Linda Pearce, RN,C, BSN, MEd., CDE Diabetes
Education Program Montgomery Regional
Hospital Linda.Pearce_at_HCAHealthcare.com 540-953-54
52
127
Disability Resources

• Catalogs
• Independent Living Aids (ILA) (www.independentlivi
  ng.com)
• Maxi Aids (www.maxi-aids.com)
• Lighthouse International (http//lighthouse.org)
• E-pill (www.epill.com)
• Diabetes Action Network at the National
  Federation of the Blind (www.nfb.org)
• Diabetes Forecast,Resource Issue
  (www.diabetes.org)
• Diabetes Health (www.diabeteshealth.com)
• Websites (.gov .edu, plus www.childrenwithdiabe
  tes.com)
• Easter Seals (www.easterseals.com)
• Amputation Coalition of America
  (www.amputee-coalition.org)
• Local Library for information in individual
  communities

128
Videos and DVDs
Suggestion

• Armchair Aerobics
• 39.95
• 3 20 minute routines,
• stretching and strengthening with music

Active Videos, 20 Order Processing10 First Ave
EMobridge, SD 57601 800-342-4320
Gentle Exercise 39.95 30 minute program
800-453-6280 www.armchairfitness.com
129
Medication Cost Saving Suggestion
Suggestions
Cecil, M.P. (2005), Drugs For Less, Hatherleigh
Press Long Island City, NY ISBN 1578261929 12
Delux Pill Splitter 7.95, ILA
Magnifying Pill Cutter 6.25, ILA
130
Use Technology
Suggestion
Use a USB Jump Drive Record medical information
medications taken and known medical conditions,
allergies, previous surgeries, etc.

• The RxWise USB Flash Drive
• a personalized system on a portable flash
  drive. (One medical record per drive) 40

Iatrogen, LLC12801 World Gate Drive, Suite
500Herndon, VA 20170 Toll Free
866-RxWise4 www.rxwise.com
131
Rapid Acting Spray For Hypoglycemia
New Product
Suggestion
Raspberry or Orange Flavored 7
Glucose RapidSpray
Glucose RapidSpray Generex Biotechnology
Corporation 800-391-6755 www.glucoserapidspray.com
132
Diabetes Medications Resource for Professionals
Suggestion

• Diabetes Medications Supplement Working
  Together to Manage Diabetes, (2007), NDEP, 9
  pages., Publication NDEP 54-S, Revised 3/07
  (download a pdf file at http//ndep.nih.gov/diabe
  tes/pubs/PPODprimer_color.pdf
• or call 800-438-5383 (single copy free)

133
Medications Type 2

• Insulin Sensitizers and Combinations (save)

Suggestion
Images of brand and generics from various
companies available at http//www.drugs.com/image
s.php
Glyburide Metformin 5/500 and 2.5/500
Glucovance
Avandia
Actos
Metformin Glipizide
Metformin 500mg
Metformin 1000 mg
Metaglip
134
Insulins
See VNAA Chronic Care Clearinghouse
59
28 - 30
54
70 - 75
Onset like rapid acting, duration like regular.
135
Medicare Insulin Pump Coverage Criterion A B

• Criterion A New Pump Patient
• Has completed a comprehensive diabetes education
  program
• Uses multiple daily injections (at least 3)
• Frequent self-adjustment of insulin at least 6
  mo. prior to pump initiation
• Meets one or more of the following
• A1c gt7
• History of recurring hypoglycemia
• Fluctuations in blood glucose ac meals
• Dawn phenomenon with FBG gt200 mg/dL
• History of severe glycemic excursions

Criterion B Patient already on Pump prior to
Medicare
136
Medicare Insulin Pump Coverage Criteria

• Meets Criterion A B plus
• Lab for C-Peptide (lt 110 lower limit of th labs
  low reference range for normal with a FBG gt225
  mg/dL drawn concurrently)
• Lab for Beta Cell antibodies (if positive, no
  other criteria GAD antibodies usually easiest to
  show)

CMS regulations for insulin pumps after Dec. 17,
2004 www.cms.hhs.gov/transmittals/downloads/R513CP
.pdf www.cms.hhs.gov/Transmittals/downloads/R27NCD
.pdf on CMS website
137
Buying Meds Online Safely

• "Buying Prescription Medicines Online  A
  Consumer Safety Guide Brochure
• U.S. Department of Health and Human Services
  Food and Drug Administrationwww.fda.gov1-888-INF
  O-FDA (1-888-463-6332)
• National Council on Patient Information and
  Education www.talkaboutrx.org

http//www.fda.gov/cder/consumerinfo/brochureHiRez
.pdf
138
Overcoming Nutrition Barriers Patient Handout

• Quick Information for Your Health Eating Well
  As We Age, (3 page handout for older adults with
  what to do suggestions for nutrition problems
  e.g. Cant chew Cant shop Cant cook
  No appetite Short on money) available from
  FDA online at http//www.fda.gov/opacom/lowlit/e
  atage.pdf

139
Resources
The Newest Vital Sign A Health Literacy
Assessment Tool

• Tool to assess both numbers and words, validated
  against health literacy tool (TOFHLA)
• Requires about 3 minutes to administer
• Patient is given an ice cream food label and
  asked 6 questions (order a copy FREE)
• http//www.newestvitalsign.org/nvs-preorder.aspx

Pfizer Principles for Clear Health
Communication A Handbook for Creating Patient
Education Materials That Enhance Understanding
and Promote Health Outcomes, (2004), 2nd Edition
(86 pgs), pdf file
http//www.pfizerhealthliteracy.com/pdf/PfizerPrin
ciples.pdf
140
With Permission Contact Local Resources
Suggestion

• Lions Clubs International (vision care)
• Rotary Clubs (humanitarian and educational
  assistance)
• Elks Clubs (charitable activities that benefit
  youth and veteran
• Shriners (need-based treatment for children at
  Shriners hospitals throughout the country)
• Kiwanis Clubs (fund-raising events and projects
  to help the community and especially children)
• Religious Organizations (Parish Nurse Ministries,
  local mission activities)