elaine farley-zoucha - caring for the diabetic elder€¦ · •a person with type 1 diabetes must...

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Caring For the Diabetic Elder

Ronda Disney MEd, RD, CDE

What is diabetes?• Diabetes is a disease that changes the way a

person’s body uses food• It affects the level of sugar in the blood• Extra sugar harms the blood vessels and other organs

in the body over time• Diabetes can cause great damage before any

symptoms appear

What happens?• The body is not producing or has lost its sensitivity to

insulin

• Insulin is a hormone that is needed to convert sugar, starches and other food into energy

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Insulin is important• Insulin is produced by the pancreas (in a normal

healthy person) when the blood sugar level rises after eating

• When a person has diabetes, either the pancreas does not produce enough insulin or the body does not use its insulin effectively

So what is glucose?• When a person eats, his or her body digests the food

and turns it into sugar, or glucose

• Insulin helps the body’s cells use glucose to produce energy

• Glucose is one of the most important “fuels” that our bodies need to operate

• Glucose/blood sugar can’t be used by the cells and tissues of our bodies without insulin

• Diabetes is a chronic disease• There is no such thing as a little or borderline

diabetes• Diabetes can not be cured but it can be

controlled • Diabetes is not caused by

eating too much sugar

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Looking at the differences between Type 1 and

Type 2 diabetes

Type 1 Diabetes• A person with Type 1 diabetes must take insulin daily

because their bodies produce little or no insulin

• Type 1 diabetes can occur at any age but is most commonly seen in younger people and once was called “juvenile diabetes “

• About 5-10% of people with diabetes fall into this group

Type 1 Diabetes• Type 1 diabetes is an autoimmune disease

• An autoimmune disease is a condition in which the body produces antibodies that attack its own tissues

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Some famous people with Type 1 Diabetes

• Halle Berry Jay Cutler Bret Michaels Sharon Stone Mary Tyler Moore

Type 2 Diabetes

• Persons with Type 2 diabetes either do not produce enough insulin or cannot use the insulin properly in the body

• Type 2 diabetes may be controlled with proper eating and exercise

• Oral medications are often used to control Type 2 diabetes

Type 2 Diabetes

• Type 2 diabetes is often discovered during a routine blood test

• Many people with Type 2 diabetes may have the disease for many years and be unaware that their blood sugar is high

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Type 2 Diabetes

• Type 2 diabetes is caused by genetic and lifestyle factors

• People with Type 2 diabetes produce some insulin, but not enough

Some famous people with Type 2 Diabetes

• Tom Hanks Larry King Thomas Edison Drew Carey Elvis Presley Billie Jean King

Diabetes Facts

• Diabetes is the 7th leading cause of death

• Diabetes increases the risk of heart disease 2-4 times

• It increases the risk of stroke 2-4 times

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Diabetes Facts

• It is the leading cause of blindness

• It is the leading cause of kidney failure

• 60% of the amputations are related to Diabetes

• More than 30 million Americans currently have diabetes

• Numbers rising steadily since 1980

The Diabetes Epidemic

Diabetes Facts

• Another 84 million—more than double the current numbers—have pre-diabetes, a condition where blood sugar is higher than normal but not high enough to meet the definition of diabetes

• An additional 7.2 million may have the disease and not even know it

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Prediabetes• Prediabetes is a condition that comes before

diabetes. It means your blood glucose levels are higher than normal but aren’t high enough to be called type 2 diabetes.

• Without lifestyle changes, people with prediabetes are very likely to progress to type 2 diabetes.

Prediabetes• Prediabetes generally has no signs or symptoms

• The exact cause of prediabetes is unknown. But family history and genetics appear to play an important role. Inactivity and excess fat — especially abdominal fat — also seem to be important factors.

• People with prediabetes don't process sugar (glucose) properly anymore.

Can prediabetes be prevented?

• YES! Lifestyle changes including modest weight loss, good nutrition and regular exercise can prevent pre-diabetes

• Research also shows that these changes can prevent or delay type 2 diabetes in over half of patients with pre-diabetes

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Diabetes Facts

Diabetes Facts

• Skilled nursing facilities will see significant impact on resident care from diabetes, since the likelihood for the disease increases with age

• Currently, 25.2 % of people age 65 or older have diabetes, the majority of which is Type 2

• Almost half of seniors have pre-diabetes, the CDC report states

Diabetes Facts

• Diabetes is more common in older adults, has a high prevalence in long-term care facilities and is associated with significant disease burden and higher cost

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Diabetes Facts

• Diabetes increases the risk of cardiovascular and microvascular complications but also increases the risk of common geriatric syndromes, including cognitive impairment, depression, falls, polypharmacy, persistent pain, and urinary incontinence

Diabetes Facts

• Diabetes management in Long Term Care residents requires different approaches because of unique challenges faced by this population and the workings of Long Term Care facilities

Sign and Symptoms of Diabetes

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Symptoms of Diabetes

• Have to go the bathroom all the time

• Very thirsty, very dry mouth

• Tired, weak, fatigued

• Blurred vision

Symptoms of Diabetes

• Headaches

• Leg cramps, muscle aches

• Numbness, pain in the feet or legs

• Moodiness, Irritability, depression

Symptoms of Diabetes• Confusion

• Anxiety

• Rapid heart rate

• Sweating

• Pale, cool skin

• Tremors

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Symptoms of Diabetes• Slow healing cuts or sores

• Problems with sexual function

• Increased hunger

• Dry, itchy skin

• Frequent infections

Complicationsof Diabetes

Complications of Diabetes• Blindness

• Heart disease

• Stroke

• Kidney disease

• Nerve damage

• Wound and skin infections

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Complications of Diabetes• Amputations

• Hypoglycemia

• Hyperglycemia

• Cardiovascular disease

• Nephropathy

• Neuropathies

• Retinopathy

Hypoglycemia vs. Hyperglycemia

What is Hypoglycemia?• Hypoglycemia occurs when blood sugar drops too

low

• Low blood sugar reactions can develop quickly and should be confirmed with a blood glucose test

• A blood sugar below 70 is considered low

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What is Hypoglycemia?• In residents with chronic uncontrolled blood sugar

levels, hypoglycemic symptoms can occur at a higher blood sugar level

• Studies show that 50% of severe low blood sugar episodes occur between midnight and 8 a.m.

• Some residents might need their blood sugar tested in the middle of the night

• Miss or delay a meal, or eat too little at a meal• More physical activity than usual• Too much insulin or other diabetes medications• Drinking alcoholic beverages on an empty stomach• Other reasons• Sometimes it just happens

Can lead to a Low Blood Sugar

• Shaky • Fast heartbeat• Extreme sweating• Dizzy• Anxious

What are symptoms of Hypoglycemia?

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• Extreme hunger• Blurry vision• Weakness or fatigue• Headache• Irritable

What are symptoms of Hypoglycemia?

• Dietitians can help prevent by offering residents appropriate nutrition education

• Inform residents of the 15/15 rule for treating hypoglycemia

Help prevent Hypoglycemia

Eat something with sugar in itYou need 15 grams of carbohydrate

½ cup of juice 1 cup skim milk or 1% milk6 oz. regular soda (not diet)8 lifesavers2-3 pieces of hard candy2-3 glucose tabs or glucose gelSmall apple or orange1 tablespoon sugar or honey3 packets of table sugar (not sugar substitute)

Do NOT use chocolate candy (has fat in it – whichdelays the rise in blood sugar)

Treating low blood sugar

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• Wait 15 minutes and check blood sugar again• If not better, eat another 15 grams of carbs• Re-check in another 15 minutes• If not better or symptoms are worse, call for help


• If the blood sugar reading is 70 mg/dl or above on the recheck, but the next meal is more than an hour away, give resident a snack with a carbohydrate and protein, such as:

• 3-6 crackers and peanut butter or cheese• Half of a meat sandwich• Cereal with a cup of milk


• Staff can work with residents to determine patterns in their blood sugar levels

• For example - determine if there is a trend in low blood sugar after physical activity (working with physical therapy)

• Resident may need to have a snack before PT


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What can be done to prevent low blood sugar?

• Take correct amount of medication at the correct time

• Never skip or delay meals or snacks

• Plan your exercise time to avoid peaks of insulin or other medications

What can be done to prevent low blood sugar?

• Test your blood sugar regularly

• Look for patterns of low blood sugars

• Always carry a carbohydrate

source with you

Documentation of resident’s Health Record should include the following:

• Time of the hypoglycemia• Symptoms of hypoglycemia• Blood glucose monitoring results and times

Documentation of Hypoglycemic events

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Also include:• Treatment(s) provided, including the amount of

glucose, times of administration, any other snacks given

• Resident’s response(s) to treatment• Physician notification• Necessary revisions/additions to the care plan

Documentation of Hypoglycemic events

• Increased mortality, including cardiovascular mortality

• Increased risk/exacerbation of dementia• Cardiovascular events• Falls• Fall-related fractures• Other traumatic injury• Diminished health-related quality of life

Consequences of Hypoglycemia in Older Adults

• Provide resident education about causes of hypoglycemia and prevention

• Avoid using short acting insulin sliding scales, glyburide and chlorpropamide

• Increase contact with health care team and reevaluate treatment plan

Strategies for Avoiding Hypoglycemia in Older Adults

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Hypo vs. Hyper

• Some of the signs and symptoms of hypoglycemia and hyperglycemia are identical

• The only way to definitely distinguish between hypoglycemia and hyperglycemia is to check blood sugar

What is hyperglycemia?

• Hyperglycemia occurs when there is too much sugar in the blood

• If uncontrolled, hyperglycemia can damage the eyes, kidneys, heart, liver, nerves, and blood vessels

What causes hyperglycemia?

• Consuming too much food

• Taking too little insulin or forgetting to take insulin

• Medication interactions

• Too little exercise

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What causes hyperglycemia?

• Emotional stress • Physical stress (i.e. pain, infection, surgery)• Medications that have a side effect of increased

blood sugar (i.e. steroids)• Dehydrated – increase risk in elderly, decreased

intake, decreased thirst mechanism

What are the symptoms?Often there are no symptoms. If blood sugar is extremely high, a resident might experience:

• Headache

• Blurred vision

• Unconsciousness

• Thirst or hunger

• Frequent urination

• Upset stomach

What are the symptoms?• “Fruity” smell on breath

• Slow healing cuts or sores

• Frequent infections

• Rapid weight loss

• Dry skin and mouth

• Nausea

• Very deep, gasping breath

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How is hyperglycemia treated?

• You may feel fine with higher blood sugars levels but you should treat to prevent long term health risks

• If blood sugar levels are above 250 mg/dl on several occasions, contact physician about treatment

How is hyperglycemia treated?Physician will find ways to help lower blood sugar levels which may include:

• Test blood sugar level more often to determine the time of the day blood sugar is the highest

• Change medications or doses of diabetes medication

• Drink water or low calorie beverages

Therapeutic Diets for Diabetic patients

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Therapeutic Diet• Restrictive meals plans or “diabetic diet” should be

avoided

• Evidence that diabetic diet my lead to decreased food intake, unintentional weight loss, and undernutrition

• Recommended a liberal diet

Therapeutic Diet• Amount of carbohydrates should be consistent from

day to day at meals and snacks

• Nursing and other staff may require education to become proficient at monitoring the amount of carbohydrate residents eat or fail to eat at a given meal

Therapeutic Diet• The ADA position statement recommends health

care practitioners develop individualized meal plans for residents that include a wide variety of foods and beverages to avoid dehydration and unintentional weight loss versus issuing a “diabetic diet” or a one-size fits all meal plan

• Meal plans should be tailored to residents taste preferences and suggest food substitutions if consume less than 75% of meal

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Therapeutic Diet• Residents who eat a wide variety of foods still can

control blood sugars when given the right medications

• Liberalizing the diet allows the resident to enjoy this pleasure for as long as possible

Therapeutic Diet• Residents with diabetes can eat desserts and other

sugar-containing foods in the portions offered on the menu helps alleviate misunderstanding about residents receiving the “wrong diet” or that they are “cheating”

• Nutrient dense carbohydrates such as whole grains, fruit, starchy vegetables, and low-fat milk and yogurt should continue to be encouraged and offered at each meal

Therapeutic Diet• Total amount of carbohydrates eaten, rather than

sugar content or percentage of the meal eaten is the largest determinant of post meal blood sugars

• Nursing can learn to document carbohydrate intake as well as percentage of the meal eaten

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Therapeutic Diet• Reduce the mealtime insulin dose when needed

rather than force meals or snacks

• Give rapid-acting insulin immediately after a meal, based on actual carbohydrate consumed, to residents with inconsistent carbohydrate intake or poor appetite

Therapeutic Diet• Identify when feeding assistance is needed and offer

appropriate assistance

• Ensure that snacks and fluids are offered during activities

What is a Carbohydrate?• Carbohydrate gives you energy

• It affects blood sugar more than any other nutrient

• Intake of all forms for carbohydrate increases the blood sugar level

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How do carbohydrates affect blood sugar?

(A review)

When you take in carbohydrates, your body breaks it down to sugar (glucose), which is absorbed into the blood stream

The blood sugar (glucose) level rises and in response, the pancreas releases Insulin hormone

Insulin helps to take sugar from the blood and transport it in to the cells, which then can be used as energy fuel for the body

• Foods that contain the most carbs• Starches (for example,

bread)• Starchy vegetables• Fruits and fruit juices• Milk and yogurt• Sweets and other sugary

foods• Foods that don’t contain carbs

• Meats and eggs• Fats and oils

Which foods contain carbs?

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What is a Carbohydrate “choice”?• 15 grams of carbohydrate = one choice

• When sitting down to a meal or choosing a snack, a person can think in choices or in grams.

• One choice: 1 slice of bread, ½ cup hot cereal, ¼ of a large bagel.

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Grains

1 slice bread white, whole wheat (15gm) 1 corn tortilla (11gm)1 flour tortilla burrito size (30 gm)Hot dog or hamburger bun (30gm)3/4 cup of cheerios (15gms)1/3 cup rice1/3 cup pasta

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Starchy Vegetables

1/2 cup of mashed potatoes (15gm)1 med. corn on the cob (20gm)½ c. peas (15gm)½ cup sweet potatoes (15gm)

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Non-Starchy Vegetables

Vegetables with <5 gm of carbohydrates= Free food

Such as: Asparagus, cauliflower, spinach, lettuce, mushrooms, cucumbers, broccoli, celery, carrots

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Fruit

1 medium orange (15gm)

3/4 fresh cut up pineapple (15gm)

1/2 cup canned pineapple (15gm)

1 cup fresh whole strawberries (15gm)

4oz.Juice (apple, orange, grape) (15gm)

Juice substitutes: Water, propel, diet soda

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Milk

1 cup white milk (15gm)1/2 cup chocolate milk (15gm)6 oz. fruit yogurt (15gm)1 cup ice cream (30gm)Milk with < 5 gms of carbs = Free food

cheese, sour cream, cream cheese

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FatsFoods high in fats should be limited for a healthy diet.

There are NO carbohydrates in fats and protein.

They may slow the digestion of carbohydrates.

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Meat/Beans

It is best to chose lean meats for a healthy diet. There are NO carbohydrates in meat.

1/2 cup of kidney beans (15gm)

1 cup Tofu-Okara type (15gm)

1/3 cup baked beans(15gm)

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Meal plan examplesBreakfast: 3 carbohydrate servings or 45 gms

Cereal 1/2 cup=15 gmsMilk 1 cup= 15 gmsFruit (1/2 banana)= 15 gms

• Lunch: 3 carbohydrate servings or 45 gmsTurkey sandwich 2 slices of bread= 30 gmsTurkey meat = free food1 Cheese stick = free foodFruit (1 apple) = 15 gmsWater

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Meal sample continue• Dinner: 4 carbohydrate servings or 60 gms

1 hamburger 1 whole bun = 30 gms

Lean ground beef patty = free food

Lettuce, tomato, pickle, ketchup, mayo = free food

French fries 7 large (1 1/2oz) = 15 gms

Milk 1 cup= 15 gms

• Snack Ideas: 1 carbohydrate serving or 15 gms

2 small cookies

3/4 cup of yogurt

6 Ritz crackers with cheese

1 small apple with 1 tbsp of peanut butter

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Can you guess the carbohydrates in these foods?1 slice of wheat bread

a) 5 gms

b) 7.5 gms

c) 15 gms

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Can you guess the carbohydrates in these foods?

1/3 cup cooked brown rice

a) 5 gms

b) 20 gms

c) 15 gms

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Can you guess the carbohydrates in these foods?

Quaker instant 1 pack oatmeal

a) 25 gms

b) 20 gms

c) 15 gms

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Consistent Carbohydrate Meal Plan

• Females: 45-60 grams carbohydrates per meal

• Males: 60-75 grams carbohydrates per meal

• Snacks: 15-30 grams carbohydrates per meal

Treatments for Diabetes

• First-line therapy • Low hypoglycemia risk• Adverse event profile includes GI side effects and

modest weight loss• Tolerability increased by starting at 500 mg/day and

gradually increasing dose• Should be taken with meals if GI effects occur

Metformin in Older Adults

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• Metformin is affordable • Weight loss• GI upset in frail residents• May lead to vitamin B12 deficiency• The extended release version of Metformin has

fewer GI side effects

Metformin in Older Adults

• Initially effective• Usually inexpensive• Weight gain often occurs• Major adverse effect is hypoglycemia• Moderate amount of carbohydrates should be

eaten at meal and snack; meals should not be skipped

• Should be used with caution in patients with renal or hepatic impairment

Sulfonylureas in Older Adults

• May have more durable effectiveness than Metformin and sulfonylureas

• Not associated with hypoglycemia unless given with insulin or insulin secretagogue

• Cause weight gain• Fluid retention• Congestive heart failure

Thiazolidinediones in Older Adults

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Sliding Scale insulin not preferred method

• The term “sliding scale” refers to the progressive increase in the pre-meal or night time insulin dose based on predefined blood sugar ranges

• Sliding scale insulin use has been called a “relic of the past” but is still used in several health care settings today


• Sliding scale insulin is a reactive method of blood glucose control that involves chasing the blood sugar by treating the current glucometer reading rather than determining insulin dosage based on meal composition

• Alternatives to using sliding scale insulin are changing insulin delivery timing, correcting for high blood sugar and switching to noninsulin therapy


• Basal/bolus insulin regimen is effective for blood glucose control

• Sliding scale insulin is not an appropriate treatment in the long term care setting

• Importance of providing adequate training and protocols to LTC staff who may be operating without the presence of a physician for prolonger period of time

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What about those Residents Who Eat Sometimes and Not Other times?

• Use oral agents that are not as likely to cause hypoglycemia when intake is variable

• Alpha-glucosidase inhibitors , Biguanides, DPP4-inhibitors, Thiazolidinediones

• Use a short acting insulin that can be given after a meal and based on intake

End-Of-Life-Care

End-Of-Life-Care• The management of the older adult at the end of life

receiving palliative medicine or hospice care is a unique situation

• Overall, palliative medicine promotes comfort, symptom control and prevention (pain, hypoglycemia, hyperglycemia, and dehydration) and preservation of dignity and quality-of-life in patients with limited life expectancy

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End-Of-Life-Care• A patient has the right to refuse testing and

treatment, whereas providers may consider withdrawing treatment and limiting diagnostic testing, including a reduction in the frequency of finger-stick testing

• Glucose targets should aim to prevent hypoglycemia and hyperglycemia

• Treatment interventions need to be mindful of quality of life. Careful monitoring of oral intake is warranted

Recommendations for diabetes management in those with advanced

disease• A dying patient - for patients with type 2 diabetes, the

discontinuation of all medications may be a reasonable approach, as patients are unlikely to have any oral intake

• In patients with type 1 diabetes, there is no consensus, but a small amount of basal insulin may maintain glucose levels and prevent acute hyperglycemic complications

American Diabetes Association

Standards of Medical Care in Diabetics 2017

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ADA recommendations from January 2017

• Consider the assessment of medical, mental, functional, and social geriatric domains in older adults to provide a framework to determine targets and therapeutic approaches for diabetes management


• Annual screening for early detection of mild cognitive impairment or dementia is indicated for adults 65 years of age or older


• Older adults (≥65 years of age) with diabetes should be considered a high-priority population for depression screening and treatment

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• Hypoglycemia should be avoided in older adults with diabetes. It should be assessed and managed by adjusting glycemic targets and pharmacologic interventions


• Older adults who are cognitively and functionally intact and have significant life expectancy may receive diabetes care with goals similar to those developed for younger adults


• Screening for diabetes complications should be individualized in older adults. Particular attention should be paid to complications that would lead to functional impairment

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• When palliative care is needed in older adults with diabetes, strict blood pressure control may not be necessary, and withdrawal of therapy may be appropriate

• Similarly, the intensity of lipid management can be relaxed, and withdrawal of lipid-lowering therapy may be appropriate


• Consider diabetes education for the staff of long-term care facilities to improve the management of older adults with diabetes


• Patients with diabetes residing in long-term care facilities need careful assessment to establish glycemic goals and to make appropriate choices of glucose-lowering agents based on their clinical and functional status

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• Overall comfort, prevention of distressing symptoms, and preservation of quality of life and dignity are primary goals for diabetes management at the end of life

References• Munshi, M. N., Florez, H., Huang, E.S., Kalyani, R.R., Mupanomunda, M., Pandya, N., Swift, C.S., Taveira, T.H., &

Haas, L.B. ( Feb 2016). Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association. Diabetes Care, 39(2), 308-318.

• Liberalizing Diets in Long Term Care Lisa Stewart. www.nutritioncaresystems.com

• Long-Term Care Diabetes Management is Changing June 2013 page 4 Miriam E. Tucker Dada, J. (June 2106). Dynamics of Diabetes: Diabetes Management LTC Patients. Today’s Dietitian, Vol. 18, Number 6, page 12.

• Position of the American Dietetic Association: Individualized Nutrition Approaches for Older Adults in Health Care Communities. Journal American Dietetic Association. Oct 2010; 110: 1549-1553.

• Diabetes Management: The Hidden Challenge of Managing Hyperglycemia in Long-Term Care Settings. www.managedhealthcareconnect.com

• Resident-Focused and Evidence-Based Management of Diabetes Mellitus in the Nursing Home Setting. www.managedhealthcareconnect.com

• Hass, L.B. Special Considerations for Older Adults With Diabetes Residing In Skilled Nursing Facilities. Diabetes Spectrum: 2014 Feb, 27 (1): 37-43.

• American Diabetes Association. Diabetes Care 2017 Jan: 40(supplement 1): S99-S104. https://doi.org/10.2337/dc17-S014

Images• Retrieved from:

• https://www.gettyimages.com/photos

• https://badfirstdatefood.wordpress.com

• http://promyhealth.org/headache/

• http://ionizerresearch.com/alkaline-water-hydration-love-story/

• http://www.ibtimes.com/weight-loss-found-increase-sex-drive-obese-men-826075

• https://www.google.com/search?safe=off&biw=1020&bih=726&tbm=isch&sa=1&ei=89y3WqOgKYu7jwSR8JrYCg&q=lady+sleeping+with+head+on+desk&oq=lady+sleeping+with+head+on+desk&gs_l=psy-ab.3...47148.50438.0.51590.19.19.0.0.0.0.127.1762.13j6.19.0....0...1c.1.64.psy-ab..1.0.0....0.rGZm7ykNreQ#imgrc=IUEOCqf0S6DCHM:&spf=1521999145687

• https://www.google.com/search?safe=off&biw=992&bih=726&tbm=isch&sa=1&ei=Jdu3Wqv9EYn-jwTz6qOoAw&q=older+guy+giving+an+insulin+shot+in+stomach&oq=older+guy+giving+an+insulin+shot+in+stomach&gs_l=psy-ab.3...34647.43018.0.43313.24.24.0.0.0.0.127.2153.18j6.24.0....0...1c.1.64.psy-ab..0.0.0....0.4_peGIJjdn0#imgrc=E88le78IBPmMRM:&spf=1521998674912

• https://www.gettyimages.com/photos/sick-old-woman?sort=mostpopular&mediatype=photography&phrase=sick%20old%20woman#license

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Thank you!

Any Questions?

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