workshop 2 and 7 difficult cases in older adults · difficult cases in older adults kathy stroh,...

Workshop 2 and 7 Difficult Cases in Older Adults Kathy Stroh, MS, RD, LDN, CDE

Linda S. Gottfredson, PhD Saturday, February 18, 2017

2:00 p.m. – 3:30 p.m.

The 2017 ADA Standards of Medical Care in Diabetes state that older adults with diabetes are at higher risk of cognitive decline and that “cognitive impairment can make it challenging for clinicians to help their patients reach individualized glycemic…targets” (p. S100). The Standards also recognize that older adults “tend to have higher rates of unidentified cognitive deficits, causing difficulty in complex self-care activities” (p. S100). Our workshop explores these two sources of non-adherence: the greater cognitive demands of self-managing diabetes in old age and the declining cognitive abilities that older patients bring to the job. Older adults are a fast-growing part of the population, tripling from 4% of the US population in 1900 to 12% in 2000 and projected to almost double again, to 21%, by 2050. In 2012, the CDC estimated that 2 in 5 adults with diabetes were age 65 or over. Adherence to treatment is especially challenging for older adults. Normal age-related declines in mental and physical function reduce an individual’s ability to self-manage their diabetes. Serious patient errors occur both when cognitive ability declines and when the cognitive demands of self-management increase. Patient-centered care should include assessing the patient’s general cognitive level (not just health literacy) and adjusting the cognitive complexity of their diabetes self-management plan. We describe normal, age-related declines in mental and physical capacity, how they affect the patient’s diabetes self-management skills, and educational strategies to optimize those skills and prevent adverse outcomes. Participants will analyze examples to identify how the cognitive demands of self-management tasks can adversely affect patients whose learning, reasoning, and perceptual abilities are declining. References: 1. American Diabetes Association. (2017). Glycemic targets. Sec.6 in Standards of Medical

Care in Diabetes – 2017. Diabetes Care, 40 (Suppl.1), S48-S56. 2. American Diabetes Association. (2017). Older adults. Sec.11 in Standards of Medical

Care in Diabetes – 2017. Diabetes Care, 40 (Suppl.1), S99-S104. 3. American Geriatrics Society Expert Panel on the Care of Older Adults with Diabetes

Mellitus. (2013). Guidelines abstracted from the American Geriatrics Society Guidelines for Improving the Care of Older adults with Diabetes Mellitus: 2013 Update. Journal of the American Geriatrics Society, 61(11), 2020-2026.

4. Anderson, L. W., & Krathwohl, D. R. (2001.) A taxonomy for learning, teaching, and assessing: A revision of Bloom's taxonomy of educational objectives. NY: Addison Wesley Longman.

5. Benjamin, R. M. (2010). Surgeon General’s perspectives: Improving health by improving health literacy. Public Health Reports, 125, November-December, 784-785.

6. Budnitz, D., Lovegrove, M., Shehab, N., et al. (2011). Emergency hospitalizations for adverse drug events in older Americans. New England Journal of Medicine, 365, 2002-2012.

7. Centers for Disease Control and Prevention. (2014). National diabetes statistics report: Estimates of diabetes and its burden in the United States, 2014. National diabetes fact sheet. Atlanta, GA: U.S. Department of Health and Human Services.

8. Diabetes Disaster Averted series. Retrieved from http://www.diabetesincontrol.com/articles/practicum

9. Gellad, W. F, Grenard, J. L., & Marcum, Z. A. (2011). A systematic review of barriers to medication adherence in the elderly: Looking beyond cost and regimen complexity. American Journal of Geriatric Pharmacotherapy, 9(1), 11–23.

10. Geller, K. I., Shehab, N., Lovegrove, M.C., Kegler, S. R., Weidenbach, K. N., Ryan, G. J., & Budnitz, D. S. (2014). National estimates of insulin-related hypoglycemia and errors leading to emergency department visits and hospitalizations. JAMA Internal Medicine, 174(5), 678-686.

11. Gottfredson, L. S. (1997). Why g matters: The complexity of everyday life, Intelligence, 24(1), 79-132.

12. Hobbs, F., & Stoops, N. (2002). Demographic trends in the 20th century. Census 2000 Special Reports, Series CENSR-4, U.S. Census Bureau. Washington, DC: U.S. Government Printing Office.

13. Kirkman, M. S., et al. (2012). Diabetes in older adults: A consensus report. Diabetes Care, 60(12), 2650-2664. DOI: 10.1111/jgs.12035

14. Kirsch, I. (2001). The International Adult Literacy Survey (IAS): Understanding What Was Measured. Research Report RR-01-25. Princeton, NJ: Educational Testing Service.

15. Kirsch, I. S., Jungeblut, A., Jenkins, L., and Kolstad, A. (1993/2002). Adult literacy in America: A first look at the findings of the National Adult Literacy Survey. U.S. Department of Education, National Center for Education Statistics, Washington, DC.

16. Morris, N. S., MacLean, C. D., Chew, L. D, & Littenberg, B. (2006). The Single Item Literacy Screener: Evaluation of a brief instrument to identify limited reading ability. BMC Family Practice, 7(21). doi:10.1186/1471-2296-7-21

17. Reason, J. (1990). Human error. Cambridge: Cambridge University Press. 18. Salthouse, T. A. (2009). Selective review of cognitive aging, Journal of the International

Neuropsychological Society, 16, 754-760. 19. Salthouse, T.A. (2013). Effects of age and ability on components of cognitive change.

Intelligence, 41, 501-511. 20. Stroh, K., & Gottfredson, L. S. (2012, August 2). Beyond health literacy: Cognitive

demands of diabetes self-management. Paper presented at the annual meeting of the American Association of Diabetes Educators, Indianapolis.

21. White, S., & Dillow, S. (2005). Key concepts and features of the 2003 National Assessment of Adult Literacy. Report NCES 2006-471. Washington, DC: National Center for Education Statistics, U.S. Department of Education.

22. U.S. Census Bureau. (2002). Demographic trends in the 20th century. Report CENSR-4. Retrieved from https://www.census.gov/prod/2002pubs/censr-4.pdf .

23. U.S. Food and Drug Administration. (2016). Applying human factors and usability engineering to medical devices: Guidance for industry and Food and Drug Administration staff. Food and Drug Administration, Center for Devices and Radiological Health, Office of Device Evaluation.

24. West, L. A., Cole, S., Goodkind, D., & He, W. (2014). 65+ in the United States: 2010. Special Studies. Current Population Reports. Report 23-212. Washington, DC: U.S. Census Bureau.

25. Wilson, V. (2012). Cognitive impairment in patients with diabetes. Nursing Standard, 27(15-17), 44-49.

Difficult Cases in Older Adults:Improving Patient Outcomes

Kathy Stroh, MS, RD, LDN, CDEWestside Family Healthcare, Wilmington, DE

Linda Gottfredson, PhDUniversity of Delaware

ADA 64th Advanced Postgraduate CourseWashington, DCFebruary 18, 2017

1

Presenter Disclosure InformationIn compliance with the accrediting board policies, the American Diabetes Association requires the

following disclosure to the participants:

Kathy Stroh

Linda Gottfredson

Disclosed no conflict of interest.

Learning objectives

• Describe trends in the number of older adults in the total population and

the prevalence of diabetes among them.

• Describe the normal pattern of cognitive decline during adulthood.

• Explain several specific ways in which cognitive and physical decline makes it progressively more difficult for older adults to manage their diabetes.

• Explain how diabetes self‐care tasks that are more cognitively complex generate higher rates of patient error and non‐adherence among older adults with diabetes.

• Adopt educational strategies for older patients with diabetes to reduce the risk of self‐management errors.

3

Outline

1. Demography of diabetes: More older adults, with more diabetes

2. Abilities for diabetes self‐care—decline with age

3. Cognitive impairment and diabetes

4. Complexity of self‐care—increases with age (and diabetes)

5. Risk of patient error & non‐adherence—increases with age

6. Reduce error by increasing cognitive accessibility of self‐care

7. Examples of patient errors

4

U.S. population is getting older, and older

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

1990 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050

American Adults Ages 20 and Over

Ages 20‐64

Ages 65‐74

Ages 75‐84

Ages 85+

(thousands)

% of total population• 65 & over 4.1 8.1 12.4 20.9• Under 20 44.3 33.9 28.6 25.7

Source of data: U.S Bureau of Census population estimates in 1900‐1990 (1900: V2,Pt2,T.XVI; 1910: V1,Ch4,T19; 1920: V2,Ch3,T1; 1930: V2,Ch10,T3; 1940: V2,Pt1,Ch2,T3; 1950: V2,Pt1,Ch3,T37; 1960: V1,Pt1,Ch4,T45; 1970: T49; 1980: T43; 1990: T13; all available at http://www.census.gov/prod/www/decennial.html) and 2000‐2010 (Table 2, http://www.census.gov/prod/cen2010/briefs/c2010br3.pdf). U.S. Bureau of Census population projections for 2020‐2050 (for % <20 yrs, Table 1‐1, https://www.census.gov/content/dam/Census/library/publications/2014/demo/p23‐212.pdf; for absolute numbers of older adults in total population, Table A‐1, https://www.census.gov/prod/2014pubs/p25‐1140.pdf). 5

U.S. population is getting older…..

Source: Figure 1‐1 in West, L. A., Cole, S., Goodkind, D., & He, W. (2014). 65+ in the United States: 2010. Special Studies. Current Population Reports. Report 23‐212. Washington, DC: U.S. Census Bureau. Retrieved from https://www.census.gov/content/dam/Census/library/publications/2014/demo/p23‐212.pdf 6

……..and older

Source: Figure 1‐3 in West, L. A., Cole, S., Goodkind, D., & He, W. (2014). 65+ in the United States: 2010. Special Studies. Current Population Reports. Report 23‐212. Washington, DC: U.S. Census Bureau. Retrieved from https://www.census.gov/content/dam/Census/library/publications/2014/demo/p23‐212.pdf

7 Kaiser Family Foundation. 10 Essential Facts About Medicare’s Financial Outlook . Feb 02, 2017http://kff.org/medicare/issue‐brief/10‐essential‐facts‐about‐medicares‐financial‐outlook/?utm_campaign=KFF‐2017‐February‐Medicare‐Financial‐Outlook‐For‐Future&utm_source=hs_email&utmmedium=email&utm_content=41874262&_hsenc=p2ANqtz‐‐7MHH6CKPwzRhV7bPUqoYSF_W6_3Jreh5RXWKNhGlhigd_lcGXf8CWGwsy8EORm7XdMZ2AMCe_FrPoM1RdcPKKS0tNVVAxZUHa6eTyT5_h7T‐5y88&_hsmi=41874262

Prevalence of diabetes is much higher among older adults

2 out of 5 adults with diabetes

are =>65 years of age

Source: https://www.cdc.gov/diabetes/pubs/statsreport14/national‐diabetes‐report‐web.pdf

9

1 in 4 adults newly diagnosed with diabetes is >65 years old

¼ of newly diagnosed

Source: https://www.cdc.gov/diabetes/pubs/statsreport14/national‐diabetes‐report‐web.pdf 10

Forecast for seniors 2010‐2025: 50% increase in diabetes prevalence and costs

Source: Institute for Alternative Futures, 2011. www.altfutures.org

11

Outline




4. Complexity of self‐care—increases with age




12

Normal and abnormal functional declines with agein capacity for diabetes self‐management (DSM)

Sensory• Touch• Taste• Sight• Hearing• Balance

Motor• Swallowing• Chewing• Manual dexterity• Coordination• Mobility• Strength

Cognitive• Memory• Fluid intelligence

(executive function) • Functional literacy

13

% of persons aged 65 and over with functional impairments, 2010(self‐reported)

Source: West et al. (2014). 65+ in the United States: 2010. Special Studies. Current Population Reports. Report 23‐212. Washington, DC: U.S.

Census Bureau. Retrieved from https://www.census.gov/content/dam/Census/library/publications/2014/demo/p23‐212.pdf

14

Self‐care devices & medications often invite errors among patients with declining capacities

Source: Page 9 of Food and Drug Administration. (2016, February 3). Applying human factors and usability engineering to medical devices: Guidance for industry and Food and Drug Administration staff. Silver Spring, MD: Center for Devices and Radiological Health, Office of Device Evaluation. Retrieved from http://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/UCM259760.pdf

FDA Guidance

15

The impact of cognitive ability level depends on:

• Population variation in overall cognitive ability

• Normal, age‐related decline in overall cognitive ability

• Their meaning in the practical affairs of daily life

16

Functional literacy of American adults declines with ageNational Adult Literacy Survey (NALS), 1993

Adults dwelling in communities and prisons

Literacy Level = Most Difficult Level of Tasks Person Can Perform**

a

b

i

l

i

t

y

Examples

The “simple” becomes harder or impossible

to do

Some will have a diagnosable cognitive impairment

17

HANDOUT

NALS difficulty level

% US adults peaking at this level: Prose scale

Training potentialAge

16‐59 60‐69 70‐79 80+

5 4 1 1 0 Use calculator to determine cost of carpet for a room

Use table of information to compare 2 credit cards

4 20 8 5 1 Use eligibility pamphlet to calculate SSI benefits

Explain difference between 2 types of employee benefits

3 35 27 19 6 Calculate miles per gallon from mileage record chart

Write brief letter explaining error on credit card bill

2 25 33 22 27 Determine difference in price between 2 show tickets

Locate intersection on street map

1 16 30 42 66 Total bank deposit entry

Locate expiration date on driver’s license

18

Training potential differs by literacy level

18

• Can gather, infer information on own

• Learns well in college format

• Written materials & experience

• Mastery learning, hands‐on

• Very explicit, structured, hands‐on

• Slow, simple, concrete, one‐on‐one instruction

Source of training potentials by NALS literacy level: Gottfredson, L. S. (2008). How intelligence research can guide interventions to reduce error rates in health self‐management. Presented in the symposium “Causal models that integrate literacy, g, and health outcomes: A practical guide to more effective disease prevention and health promotion?” at the annual convention of the International Society for Intelligence Research, Decatur, GA, December 12, 2008. Retrieved from http://www1.udel.edu/educ/gottfredson/reprints/2008ISIR.pdf ; Wonderlic Personnel Test, Inc. (1992). Wonderlic Personnel Test and Scholastic Level Exam: User’s manual. Libertyville, IL: Author.

Difficult cases in older adults:

Improving patient outcomes

by recognizing cognitive decline

19

g ‐ Basic information processing(GF)

Basiccultural Knowledge(GC)

Normal age‐related cognitive decline

1. Learning & reasoning ability, on‐the‐spot problem solving

Age 8

Age 80

3. Great variation within all ages

2. Self‐care requires constant exercise of fluid intelligence

3 Key Points

20

“Crystallized” intelligence [past learning]• Breadth/depth of general knowledge

(e.g., language) • Accrued over lifetime based on fluid

intelligence, education, interests

“Fluid” intelligence [on‐the‐spot learning & reasoning]• Aptness in processing information (e.g., learning,

reasoning, abstract thinking, problem solving)• Includes executive function (e.g., working memory) • Reflects overall integrity of brain (speed,

connectedness, etc.)

This is the norm, but recall that individuals vary a lot around the norm!

Source: Figure 1 in Salthouse, T. A. (2009). Selective review of cognitive aging. Journal of International Neuropsychological Society, 16, 754‐760.


A finer‐grained look

21

DSM tasks require “fluid intelligence”

Specific cognitive processes that are vulnerable to the effects of aging

Processing Speed

Long Term Memory

Sensory Perception

Inhibitory Control

Working Memory*

General control processes“executive functions”

*

22

Executive function—the brain’s “command & control” system

It refers to specific mental processes that enable us to: • Plan • Focus attention • Remember instructions • Juggle multiple tasks successfully

These mental processes include: • Working Memory (how much information the mind can hold &

work on at the same time)• Attention (keep focusing on what is relevant)• Inhibition (suppress irrelevant & impulsive thoughts)

The brain uses these processes to: • Filter distractions • Prioritize tasks • Set and achieve goals• Control impulses

It is like:• An air traffic control system at a busy airport, which safely

manages the arrivals and departures of many aircraft on multiple runways

All are important in diabetes self‐management

23

“Crystallized” intelligence [past learning]• Breadth/depth of general knowledge

(e.g., language) • Accrued over lifetime based on fluid

intelligence, education, interests

“Fluid” intelligence [current ability to learn & reason]• Aptness in processing information (e.g., learning,

reasoning, abstract thinking, problem solving) • Includes executive function (e.g., working memory)• Reflects overall integrity of brain (speed,

connectedness, etc.)

Growing gap – past learning is faulty guide to current cognitive capacity


A finer‐grained look

Source: Figure 1 in Salthouse, T. A. (2009). Selective review of cognitive aging. Journal of International Neuropsychological Society, 16, 754‐760. 24

Example: Your patient is an elderly professor starting a new meter and/or insulin device

She may be highly literate and well‐read (crystallized intelligence), but that does not guarantee she grasped your instructions for how and when to use the new device (fluid intelligence).

25

0

10

20

30

40

50

60

70

80

90

100

Prose Document

% of age group

Age

% with low or very low functional literacy*

16‐59 60‐69 70‐79 80 and older

To summarize: Most older adults have very weak learning skills. Their brain’s “command & control” centers not working as wellSo, most older adults need lots of cognitive help

*Level 1 or 2 on NALS adult literacy survey’s 5‐level scale. Source of data: Tables 1.2 and 1.3 of Literacy of Older Adults in America, 1996. Retrieved from http://nces.ed.gov/pubs97/97576.pdf

Most have very weak

learning skills

26

Specific cognitive processes that are vulnerable to the effects of aging

—and diabetes

Processing Speed

Long Term Memory

Sensory Perception

Inhibitory Control

Working Memory*

General control processes“executive functions”

*

27

Cognitive challenge of an ever‐changing, increasingly complex world

28

Outline


2. Abilities for diabetes self‐care—decline with age (and diabetes)






29

“Older adults with diabetes are at higher risk of cognitive decline and institutionalization.”

“People with diabetes have higher incidence of all‐cause dementia, Alzheimer disease and vascular dementia than people with normal

glucose tolerance.”

2017 ADA Standards of Medical Care in Diabetes

30

Source: Takahiko Kawamura, T., Umemura, T., & Hotta, N. (2012). Cognitive impairment in diabetic patients: Can diabetic control prevent cognitive decline? Journal of Diabetes Investigation, 3(5), 413‐423.

Diabetes and cognitive impairment:a bi‐directional effect

31

“The presence of cognitive impairment can make it difficult for cliniciansto help their patients to reach individualized glycemic…targets.”

“Older adults tend to have higher rates of unidentified cognitive deficits…”

“Cognitive dysfunction makes it difficult for patients to perform complex self‐care tasks, such as glucose monitoring and adjusting insulin doses….and appropriately maintain the timing and content of diet .”

2017 ADA Diabetes Standards of Care

32

Stroh, K., & Gottfredson, L. S. Beyond health literacy: Cognitive demands of diabetes self‐management. Presented at the annual meeting of the American Association of Diabetes Educators, Indianapolis, August 2, 2012.

Patient’s‐eye view of diabetes self‐management

33

Outline








34



by recognizing the cognitive demands of DSM

35

What makes individual tasks more difficult? Complexity of information processing required

Elements of “process complexity”

level of inference abstractness of info

distracting information

Not reading per se, but “problem solving”

number of features to match

Examples

36

Cognitive demands that increase the complexity of quantitative* tasks

Elements of “process complexity”

level of inference abstractness of info

distracting information

Not reading per se, but “problem solving”

number of features to match

37

*Source: P. 11 in Kirsch, I. S., Jungeblut, A., Jenkins, L., and Kolstad, A. (1993/2002). Adult literacy in America: A first look at the findings of the National Adult Literacy Survey. U.S. Department of Education, National Center for Education Statistics, Washington, DC. Retrieved from http://nces.ed.gov/pubs93/93275.pdf **The 3 NALS scales—prose, document, & quantitation—correlate >.9. They all measure mostly same latent construct (Rock & Yamamoto, 2001, p. 273).

Task #1—Underline sentence saying how often to give the medicine

•One piece of info •Simple match•But lots of irrelevant info

Caution!Can train people to do this task, butnot all possible tasks like it

38

Task #1—Underline sentence saying how often to give medicine

LITERACY SCORES: 100 200 250 300 350 400 500

Mean = 272

•One piece of info •Simple match•But lots of irrelevant info

#1

239

39HALS LEVELS: Below Level 1 Level 1 Level 2 Level 3 Level 4 Level 5

HALS SCORES: 175 225 275 325 375 500

239

Mean = 272

#1

•Multiple featuresto match•Two‐step task•Infer proper mathoperation•Select propernumbers to use•Ignore the mostobvious butincorrect number•Calculate theresult

#3—Your child is 11 years old and weighs 85 pounds. How many 80 mg tablets can you give in 24‐hr period?

40

•Multiple featuresto match•Two‐step task•Infer proper mathoperation•Select propernumbers to use•Ignore the mostobvious butincorrect number•Calculate theresult

#3—Your child is 11 years old and weighs 85 pounds. How many 80 mg tablets can you give in 24‐hr period?

41HALS LEVELS: Below Level 1 Level 1 Level 2 Level 3 Level 4 Level 5

HALS SCORES: 175 225 275 325 375 500

239

Mean = 272

#1378#3

Objective: Keep blood glucose within safe limits & avoid complications

• Learn about diabetes in general (Ongoing)• Physiological process• Interdependence of diet, exercise, meds• Symptoms & corrective action• Consequences of poor control

• Apply knowledge to own case (Daily, Hourly)• Implement appropriate regimen • Continuously monitor physical signs • Diagnose problems in timely manner• Adjust food, exercise, meds in timely and appropriate manner

• Coordinate with relevant parties (Frequently)• Negotiate changes in activities with family, friends, job • Enlist/capitalize on social support• Communicate status and needs to practitioners

• Update knowledge & adjust regimen (Occasionally)• When other chronic conditions or disabilities develop• When new treatments are ordered• When life circumstances change

• Conditions of work—24/7, no days off, no retirement

Job description for diabetes self‐management (DSM)

42

DSM job performance (adherence) depends on cognitive ability

IT IS NOTmechanically following a recipe

IT IS keeping a complex metabolic system under control in often unpredictable circumstances (like the accident prevention process) Coordinate a regimen having multiple interacting elements

Adjust parts as needed to maintain good control of system buffeted by many other factors

Anticipate lag time between (in)action and system response Monitor advance “hidden” indicators (blood glucose) to prevent system veering

badly out of control Decide appropriate type and timing of corrective action if system veering off‐

track Monitor/control other shocks to system (infection, emotional stress) Coordinate regimen with other daily activities

Plan ahead (meals, meds, etc.) For the expected

For the unexpected and unpredictable

Prioritize conflicting demands on time and behavior

43

Learn and recall relevant information

Reason and make judgments

Deal with unexpected situations

Identify problem situations quickly

React swiftly when unexpected problems occur

Apply common sense to solve problems

Learn new procedures quickly

Be alert & quick to understand things

Heavy cognitive burdens

Cognitive demands of DSM are like all complex jobs

that pile up

Job analysis of job demands that best distinguish higher‐ from lower‐level jobs.

Arvey, R. D. (1986). General ability in employment: A discussion. Journal of Vocational Behavior, 29, 415‐420.

44

Age‐related functional declines also increase complexity of DSM

• Functional declineo Must recognize and compensate for progressive declines in sight, hearing, taste, touch, proprioception, memory, and

thinking that might impair self‐care

o Less mobile inside & outside the home, so more “captive to environments” imposed by others (prepared meals/Meals on Wheels)

o Must increasingly rely on (uncertain?) availability and competence of caregivers

• More co‐morbidities & complicationso More treatment regimens (and changes in them) to manage & coordinate

o More medications & side‐effects to manage

o More tradeoffs in treatment goals, finances, and

o Larger, more diverse set of health care providers

• More socially disconnected • Increasingly thrown back on own (waning) abilities and resources

• Increasingly captive to unfamiliar or alien environments (senior housing, assisted living )

• Less able to assert or act on own preferences

• Geriatric syndromes o Common patient and caregiver errors more dangerous because physiology increasingly dysregulated

45

Outline








46



by recognizing DSM tasks that invite preventable error

47

Prevention is key. Prevention is a cognitive process.

Source: Reason, J. (1990). Human error. Cambridge: Cambridge University Press.48

Cognitive challenges of DSM for patient

Diabetes self‐management is inherently complex

Relentless, evolving cognitive demands

Frequent cognitive overload

High‐risk of errors

Non‐adherence

Decline in patient outcomes

Prevent critical errors among older patients

• Avoid cognitively overloading the patient

• Minimize opportunities for patient error

• Be alert for patient error

49

Functional Literacy of American adults, by ageNational Adult Literacy Survey (NALS), 1993

Adults dwelling in communities and prisons

Literacy Level = Most Difficult Level of Tasks Person Can Perform**

Examples

50

Column1 1

200 20

1

3

5 (hardest)

0

20

40

60

80

100

200 250 300 350 400

NALS task level

45

32

111 2

Error rate (%)

at mean score

Mean score:

23% 28%31% 15% 3%

% adults peaking in this range:

2Literacy level:

3 4 5

Older adults are at much greater risk of making cognitive errors

% of 60+ year‐olds:33%

4%16%

˜0%

47%

20% error rate (>80% correct = “mastery”)

51

Column1 1

200 20

1

3

5 (hardest)

0

20

40

60

80

100

200 250 300 350 400

NALS task level

45

32

111 2

Error rate (%)

at mean score

Mean score:2

Literacy level:3 4 5

% of 60+ year-olds:33%

4%16%

˜0%

47%

Matrix of cognitive risk

Cognitive burden

Cognitive resources

52

Opportunities for patient error when giving insulin injection

Retrieved from https://medlineplus.gov/ency/patientinstructions/000660.htm

Hazards—errors waiting to happen

53

Giving an insulin injection – cont.

https://medlineplus.gov/ency/patientinstructions/000660.htm 54

Functional status

Cognitive ability

Cognitive complexity of DSM

Patient Errors

55

To summarize……

Patients will:

• often have complex medical problems

• experience heavy burdens in diabetes self‐care

• but have fewer physical and cognitive reserves for

effective self‐care.

Patients’ physical and cognitive health trajectories—

and self‐care needs—will differ widely

56

Outline








57



by bringing diabetes self‐management

within cognitive reach

58

Does easy readability reduce the

inherent cognitive demands of educational

materials—or the tasks they describe?

59

Using insulin: Version 1

60

HANDOUT

Using insulin: Version 2

61

HANDOUT Injecting insulin: Version 1

62

HANDOUT

Injecting insulin: Version 2

63

HANDOUT Using insulin: Version 1 (very low literacy)

64

65

Using insulin: Version 2 (low literacy) Injecting insulin: Version 1 (low literacy)

66

Injecting insulin: Version 2 (very low literacy)

67

Improving the readability of educational materials

does not guarantee comprehension and adherence

because

it does not eliminate a task’s inherent cognitive demands.

68

Beyond health literacy…

69

Bloom’s taxonomy of educational objectives: cognitive domain(Anderson & Krathwohl, 2001)

Simplest tasks1. Remember

recognize, recall,Identify, retrieve

2. Understandparaphrase, summarize, compare, predict, infer,

3. Applyexecute familiar task, apply procedure to unfamiliar task

4. Analyzedistinguish, focus, select, integrate, coordinate

5. Evaluatecheck, monitor, detect inconsistencies, judge effectiveness

6. Createhypothesize, plan, invent,devise, design

Most complex tasks

© Stroh, K., & Gottfredson, L. S. Beyond health literacy: Cognitive demands of diabetes self‐management. Presented at the annual meeting of the American Association of Diabetes Educators, Indianapolis, August 2, 2012. 70

Anticipate effect of various exercises on blood glucose

Coordinate meds, diet, and exercise

Determine when & why blood glucose is out of

control

Monitor symptoms; assess whether action is needed;, evaluate effectiveness

of actions.

Create daily plans and contingency plans that control blood glucose.

Remember to take Rx

Recall effects of exercise on blood

glucose

DSM Goals• Keep BG

under control• Deal with

unexpected events• Prevent and

managecomplications

© Stroh, K., & Gottfredson, L. S. Beyond health literacy: Cognitive demands of diabetes self‐management. Presented at the annual meeting of the American Association of Diabetes Educators, Indianapolis, August 2, 2012. 71









Most complex tasks

Calculate Check

Classify Coordinate

DesignDetect problems

Find pattern Hypothesize

Identify

ImplementIntegrate

Interpret

Judge effectivenessMeasure

Memorize Plan

Predict effectsRecognize

72

What are we asking the patient to learn and do?

72

HANDOUT

© Stroh, K., & Gottfredson, L. S., 2017

What are we asking the patient to learn and do?

73

IdentifyMemorizeRecognize

DesignHypothesizePlan

CheckDetect problemsJudge effectiveness

CoordinateFind pattern Integrate

Calculate ImplementMeasure

ClassifyInterpretPredict effects

Remember

Understand

Apply

Analyze

Evaluate

Create

Higher level thinking skills

73Adapted from Anderson, L. W., & Krathwohl, D. R. (2001.) A taxonomy for learning, teaching, and assessing: A revision of Bloom's taxonomy of educational objectives.NY: Addison Wesley Longman.

© Stroh, K., & Gottfredson, L. S., 2017

Outline








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by reducing risk of DSM errors

Examples

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National trends in US hospital admissions

for hyperglycemia and hypoglycemia among

Medicare beneficiaries, 1999 to 2011

Lipska, K.J., Ross, J. S., Wang, Y., et al. (2014). National trends in US hospital admissions for hyperglycemia and hypoglycemia among Medicare beneficiaries, 1999 to 2011. JAMA Internal Medicine, 174(17), 1116‐1124.

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Source: Figure 1 and eTable 2 in Lipska, K.J., Ross, J. S., Wang, Y., et al. (2014). National trends in US hospital admissions for hyperglycemia and hypoglycemia among Medicare beneficiaries, 1999 to 2011. JAMA Internal Medicine, 174(17), 1116‐1124. Note: To provide consistent axes for all relevant subgroups, the y‐axis is on a logarithmic scale. The circles and diamonds indicateobserved values; the lines represent the smoothed trend over time.

Hospitalizations for hyperglycemia fell in Medicare population, 1999‐2011Rate per 100,000 patient years among 34 million fee‐for‐service beneficiaries

Ages 1999 2005 2011 % down

65‐74 97 69 67 ‐ 31%

75‐84 132 81 75 ‐ 43%

85+ 136 76 68 ‐ 50%

All 65+ 114 74 70 ‐ 39%

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Ages 1999 2005 2011 % up

65‐74 70 90 72 + 3%

75‐84 121 169 141 + 17%

85+ 126 177 152 + 21%

All 65+ 94 128 105 + 12%

Hospitalizations for hypoglycemia rose in Medicare population, 1999‐2011Rate per 100,000 patient years among 34 million fee‐for‐service beneficiaries

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Source: Figure 1 and eTable 2 in Lipska, K.J., Ross, J. S., Wang, Y., et al. (2014). National trends in US hospital admissions for hyperglycemia and hypoglycemia among Medicare beneficiaries, 1999 to 2011. JAMA Internal Medicine, 174(17), 1116‐1124. Note: To provide consistent axes for all relevant subgroups, the y‐axis is on a logarithmic scale. The circles and diamonds indicateobserved values; the lines represent the smoothed trend over time.

Source: Figure 1 (top half) in Lipska, K.J., Ross, J. S., Wang, Y., et al. (2014). National trends in US hospital admissions for hyperglycemia and hypoglycemia among Medicare beneficiaries, 1999 to 2011. JAMA Internal Medicine, 174(17), 1116‐1124. Note: To provide consistent axes for all relevant subgroups, the y‐axis is on a logarithmic scale. The circles and diamonds indicateobserved values; the lines represent the smoothed trend over time.

79 80

Source: Figure 1 (bottom half) in Lipska, K.J., Ross, J. S., Wang, Y., et al. (2014). National trends in US hospital admissions for hyperglycemia and hypoglycemia among Medicare beneficiaries, 1999 to 2011. JAMA Internal Medicine, 174(17), 1116‐1124. Note: To provide consistent axes for all relevant subgroups, the y‐axis is on a logarithmic scale. The circles and diamonds indicateobserved values; the lines represent the smoothed trend over time.

Munshi M. N., Slyne, C., Segal, A. R., Saul, N., Lyons, C., & Weinger, K. (2016). Simplification of insulin regimen in older adults and risk of hypoglycemia. JAMA Internal Medicine, 176(7), 1023‐1025.

National estimates of insulin‐related hypoglycemiaand errors leading to emergency department

visits and hospitalizations, 2007‐2011

Geller, K. I., Shehab, N., Lovegrove, M.C., Kegler, S. R., Weidenbach, K. N., Ryan, G. J., & Budnitz, D. S. (2014). National estimates of insulin‐related hypoglycemia and errors leading to emergency department visits and hospitalizations. JAMA Internal Medicine, 174(5), 678‐686.

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IHE = Insulin-relatedHypoglycemia and errors

Source: Geller, K. I., Shehab, N., Lovegrove, M.C., Kegler, S. R., Weidenbach, K. N., Ryan, G. J., & Budnitz, D. S. (2014). National estimates of insulin‐related hypoglycemia and errors leading to emergency department visits and hospitalizations. JAMA Internal Medicine, 174(5), 678‐686. 83

“Perhaps the most important finding from these analyses is that over half of hypoglycemic episodes were preceded by a decrease in carbohydrate intake.”

“With proactive planning by patients with diabetes, this behavior could be changed with a potentially large impact on the risk of severe hypoglycemia.”

Source: Table 2 in Bonds, D. E., Miller, M. E., Dudl, J., Feinglos, M., Ismail‐Beigi, F., Malozowski, S., et al. (2012). Severe hypoglycemia symptoms, antecedent behaviors, immediate consequences and association with glycemiamedication usage: Secondary analysis of the ACCORD clinical trial data. BMC Endocrine Disorders, 12(5). Retrieved from http://www.biomedcentral.com/1472‐6823/12/5

Secondary analysis of the ACCORD clinical trial data:Major cause of severe hypoglycemia was food related

Immediate antecedent Intensive glycemia control

Standard glycemia control

Delayed or missed meal 31% 44%

Ate less carb than prescribed or usual at preceding meal or snack

26% 25%

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Source: Geller, K. I., Shehab, N., Lovegrove, M.C., Kegler, S. R., Weidenbach, K. N., Ryan, G. J., & Budnitz, D. S. (2014). National estimates of insulin‐related hypoglycemia and errors leading to emergency department visits and hospitalizations. JAMA Internal Medicine, 174(5), 678‐686.


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86



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1. What was the patient’s error of omission or commission?

2. What are the cognitive demands of the task(s)?

3. Does the patient have any functional limitations that increase risk of error?

4. How can the mis‐performed task be simplified (e.g., fewer steps)?

5. How would you use Bloom’s cognitive taxonomy of learning objectives to reduce the patient’s risk of making such errors?

Identifying sources of DSM error to improve patient adherence

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HANDOUT

Meal‐related misadventures

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• Analyze the amount of other nutrients to be limited (e.g., fat, sodium).

• Know that Total CHO gms = relevant number

• Know “Sugars” gms ≠ total CHO gms• Know ” Gms” after “Serving Size” ≠ Total CHO

gms• Know % Daily Value CHO ≠ Total CHO gms

• Judge whether the intended serving contains too much CHO, fat, sodium.

• Locate “Serving size” on label• Locate “Total CHO gms” on label

• Based on serving size, calculate number of “servings” to be consumed

• Calculate Total CHO gms in servings consumed (multiply number of intended servings by Total CHO gms in one serving)

• Plan a meal and or snack with recommended amount of CHOs.

• Coordinate CHO gms with non‐labeled foods & drinks

Using Bloom’s taxonomy to identify cognitive demands on nutrition labels.

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Most complex tasks

Patients need to be able to read food labels and know portion sizes in order to dose insulin correctly.

After reviewing a patient's food log and insulin dosing, he was questioned about the amount of carbohydrate he had used for a particular food item, as it seemed high. The patient was actually looking at the weight of the food in grams, instead of looking at Total Carbohydrate grams on the food label.

The patient had erroneously calculated a higher insulin dose based on total weight grams, not carb grams. This error can result in hypoglycemia.

Excerpted from Diabetes Disasters Averted, “#11: Label Literacy.” http://www.diabetesincontrol.com/label‐literacy/

Meal‐related misadventure #1

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HANDOUT

A long‐term patient could not figure out what was happening with her post‐breakfast glucose readings. She counted carbs and would typically have a 2 hour PPBG of no more than 145 mg/dl. Even though her pre‐breakfast BG was around 110 mg/dl, she was now experiencing PPBGs near 200 mg/dl.

She kept a food diary for 7 days and identified 3 days she was eating French toast when her PPBGs were over 200 mg/dl. The breakfast meal had never been a problem in the past. We went over the ingredients and found the problem.

For the past 3 years, she had been using a sugar‐free low carb brand name syrup that contained 10 grams carbohydrate in the serving she used.

On her last trip to the grocery store, she had bought the regular syrup and was actually putting 60 grams of carbs on her French toast.

Excerpted from “Is It Sugar‐Free or Isn’t It?” http://www.diabetesincontrol.com/is‐it‐sugar‐free‐or‐isnt‐it/


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• An 85‐year‐old female was diagnosed with type 2 diabetes 3 years ago.

• Some other diagnoses are CHF, Afib, HTN, hyperlipidemia.

• Her “barriers to communication” are eyeglasses.

• She reports that she is “extremely” confident filling out medical forms by herself.

• She exercises regularly, biking, line dancing as well as tai chi.

• She sometimes feels “shaky and thinks it can be from her Afib.”

• She takes 10 mg. glipizide twice day and 8u basal insulin at night.

• She listed FBGs of e.g. 57, 63, 72, 71.

• She keeps a daily food and BG log.

• When reviewed, her BG/food log listed low/no carb dinners, e.g. fish, sugar‐free pudding, salad, cheese, egg, tomato juice.

• She eats frozen dinners 3‐4x week.

• She returned with WNL FBGs, but elevated (>300mg/dl) PPBGs after dinner.

• Her BG/food log revealed that she had the elevated BGs on days when her granddaughter brought her muffins, apple crisps.


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HANDOUT

An elderly patient had passed out during her evening meal.

When the recent episode was reviewed, she was asked to confirm that “you ate your dinner and then you passed out…”, at which point she interrupted with, “No, I did not eat my dinner, I HAD it, it was in front of me on the table and then I passed out….”

We concluded that she had a severe hypoglycemic reaction, because she delayed her dinner.

Excerpted from the Diabetes Disaster Averted, “# 51: Careful Listening Saves Lives.” http://www.diabetesincontrol.com/diabetes‐disaster‐averted‐careful‐listening‐saves‐lives/


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Medication misadventures

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Patient‐centered coordinated care for medication adherence

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National Lipid Association, 2013. Clinician’s Toolkit: A Guide to Medication and Lifestyle Adherence.https://www.lipid.org/sites/default/files/adherence_toolkit.pdf

National Lipid Association, 2013. Clinician’s Toolkit: A Guide to Medication and Lifestyle Adherence.Retrieved from https://www.lipid.org/sites/default/files/adherence_toolkit.pdf

An elderly patient was prescribed Glucotrol XL to treat elevated blood sugars.

The pill was too large for the woman to swallow, so she chewed it. She soon complained of feeling dizzy, weak, listless and lethargic.

Chewing the drug caused it to be released all at once, causing dangerously low blood glucose levels.

Excerpted from Diabetes Disasters Averted, “Do not crush, chew, or cut.” http://www.diabetesincontrol.com/resources/disasters‐averted/

Oral medication misadventure #1

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A 67‐year‐old female, recently diagnosed with type 2 diabetes, was prescribed metformin XR. She made dietary and physical changes, but at her return visit, her A1c was 8.5%.

She reported that she did not take the metformin. “I can’t swallow large pills and the bottle said not to crush or break the tablets. They were just too big to swallow, so I just gave up on everything.”

After the patient was offered other forms of metformin as well as other options, she returned in a month with an improved A1c.

Excerpted from Diabetes Disasters Averted, "When Pills Are Hard to Swallow, Find Alternatives." http://www.diabetesincontrol.com/resources/disasters‐averted/


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A recently diagnosed 58‐year‐old female with type 2 diabetes was prescribed metformin XR 500mg daily.

At her return visit, she complained of “stomach upset, with pain and diarrhea”. The patient was changed to Glucotrol XL 5 mg. once a day.

During her first visit with the CDE, she reported that she had crushed the metformin XR, then swallowed it with food. She did not mention this to her PCP.


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An elderly male, living alone, switched from insulin pens to a vial and syringe due to his insurance coverage.

His BGs then started to increase into the 400s and 500s. He was feeling weak and lethargic but was able to pull himself together and make it to his appointment.

He was asked to demonstrate his injection technique. The patient was laying the insulin vial on its side. He was getting high BGs because he was injecting air and no insulin.

He was able to return to using insulin pens and BGs are stable and <180.

Excerpted from “Incorrect Injection Technique Caught in Time.”http://www.diabetesincontrol.com/incorrect‐injection‐technique‐caught‐in‐time/

Insulin‐related misadventure #1

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An 84‐year‐old male was reviewing his insulin usage. In reporting his dosing, he stated that he checked his glucose before each meal.

He took the “first two numbers of the result” and made that his dosage for meal‐time insulin. For example, if his BG reading was 240, he would take 24 units of pre‐meal insulin.

He was asked if this was the instruction from his provider, and he said, “No, but it was the only thing that made sense to me that I could remember.”

Excerpted from “Patient’s Method of Figuring Meal‐time Insulin Doesn’t Quite Work.” http://www.diabetesincontrol.com/patients‐method‐of‐figuring‐meal‐time‐insulin‐doesnt‐quite‐work/


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HANDOUT

A 70‐year‐old male with type 2 diabetes had been on insulin for over 6 months. Family history revealed a son with type 1. The patient was sent for diabetes education from a clinic where he was seen for dizziness and “just not feeling well.” The patient arrived with his granddaughter.

He gave a good history of meals throughout the week, brought a well‐kept log book and had recorded his insulin doses, always around a meal but at different times and different doses.

When he spoke of his insulin, he said “meal time.”

When he demonstrated how he drew the insulin up with his bottle, the bottle was a long‐acting insulin.

Because his son was type 1, the patient thought he understood diabetes.

He was changed to a pre‐meal insulin and his BGs leveled out.

Excerpted from “Family History Creates Insulin Confusion.” http://www.diabetesincontrol.com/family‐history‐creates‐insulin‐confusion/


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A patient was on reasonably high doses of basal bolus insulin, using a pen. He had been using insulin for a few months. He lived some distance away, and used telephonic support for patient‐reported BGs and insulin adjustments.

BGs continued to climb with further increases in insulin. The patient was finally asked to bring all meds and supplies for an office visit.

He demonstrated the use of his insulin pen by removing the outer cap, but did not remove the needle protector when he injected, resulting in no insulin delivery.

This meant that the entire time he was “on insulin” he had not, in fact, been getting any insulin.

Excerpted from “Even Experienced Patients Need Reviews of Insulin Injection Technique.”http://www.diabetesincontrol.com/even‐experienced‐patients‐need‐reviews‐of‐insulin‐injection‐technique/


104

A 69‐year‐old male returned for an office visit after being started on a single bedtime dose of basal insulin by pen and a long‐acting sulfonylurea. He had received education about basal insulin action.

When he returned, his fasting BG was terrible, but the rest of the day his glucose was near goal. Perhaps the addition of basal insulin was helping the sulfonylurea work better, but the worsening overnight rise was puzzling.

I was considering lowering the oral dose and increasing the basal insulin dose when he volunteered a critical piece of information.

He announced that he had been listening to insulin commercials on TV and realized that when you use the pen, you need to eat a meal right afterwards.

Since he was getting his basal insulin (by pen) at bedtime, he decided that he should add a fourth meal to the day. This meal occurred after his bedtime dose and AFTER his BG check.

Excerpted from “The Power and Dangers of Advertising.”http://www.diabetesincontrol.com/the‐power‐and‐dangers‐of‐advertising/


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HANDOUT

Other Errors

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A 68‐year‐old female, newly diagnosed with type 2 diabetes, had her initial visit with her endocrinologist and diabetes educator. Her second visit was scheduled for 2 weeks later.

She was a no‐show and was contacted to reschedule. She said she could not come, because she was not checking her BGs and was confused about what she learned. She was encouraged to return and was reassured that we understood it was a lot of information to remember.

During our visit, she told us she didn’t want to let us down, because she didn’t do everything we asked her to do. She said she was overwhelmed and didn’t really understand, so she just decided to give up.

During the second visit, we focused on one aspect of her diabetes management, the technique of checking her BGs. She left with clear direction of her next step and made a third appointment.

Excerpted from “When newly diagnosed patients can be easily overwhelmed.” http://www.diabetesincontrol.com/newly‐diagnosed‐patients‐can‐be‐easily‐overwhelmed/

Other Error # 1

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“The use of insulin therapy requires that patients or their caregivers have

good visual and motor skills and cognitive ability.”

2017 ADA Diabetes Standards of Care

108

• 63 year old male, diagnosed with type 2 diabetes in 2010.

• The patient is legally blind; his new caregiver is a family member.

• The course has been gradually worsening.

• He does infrequent BGs, with a range of 66 to >200.

• He takes metformin ER 500 mg once a day and 45u 70/30 insulin w/ breakfast and dinner.

• He states he “listens for clicks” to dose insulin.

• A GLP‐1 RA was prescribed in 10/16.

• During office visit, he reported that he often skipped the metformin and AM 70/30, and did not yet start the GLP‐1 RA.

• He did not bring a BG log or meter to the office visit.

• He reported to the RD/CDE that he often skipped meals and would consume excess snacks, at varying times.

Other Error # 2

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Injecting insulin: Version 2 (very low literacy)

110

Commonalities in patient errors

• Treated unlikes as interchangeable (e.g., different insulins)

• Did not grasp relevance of key distinctions

• Performed only one step of multi‐step task

• Performed one or more steps incorrectly

• Did not coordinate timing of essential tasks

• Did not notice when things amiss

• Lacked basic skills and knowledge we often take for granted

These are elemental cognitive errors

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NALS difficulty level

% US adults peaking at this level: Prose scale

Training potentialAge

16‐59 60‐69 70‐79 80+

5 4 1 1 0 Use calculator to determine cost of carpet for a room

Use table of information to compare 2 credit cards

4 20 8 5 1 Use eligibility pamphlet to calculate SSI benefits

Explain difference between 2 types of employee benefits

3 35 27 19 6 Calculate miles per gallon from mileage record chart

Write brief letter explaining error on credit card bill

2 25 33 22 27 Determine difference in price between 2 show tickets

Locate intersection on street map

1 16 30 42 66 Total bank deposit entry

Locate expiration date on driver’s license

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Training potential differs by literacy level

112

• Can gather, infer information on own

• Learns well in college format

• Written materials & experience

• Mastery learning, hands‐on

• Very explicit, structured, hands‐on

• Slow, simple, concrete, one‐on‐one instruction

Source of training potentials by NALS literacy level: Gottfredson, L. S. (2008). How intelligence research can guide interventions to reduce error rates in health self‐management. Presented in the symposium “Causal models that integrate literacy, g, and health outcomes: A practical guide to more effective disease prevention and health promotion?” at the annual convention of the International Society for Intelligence Research, Decatur, GA, December 12, 2008. Retrieved from http://www1.udel.edu/educ/gottfredson/reprints/2008ISIR.pdf ; Wonderlic Personnel Test, Inc. (1992). Wonderlic Personnel Test and Scholastic Level Exam: User’s manual. Libertyville, IL: Author.

Strategies for preventing patient errors

1. Identify cognitive hurdles

Identify what makes the task(s) cognitively complex

Anticipate common patient errors

Identify which errors potentially most serious

2. Lower task complexity

Focus on essentials

Then simplify

3. Tailor education to patient’s ability level to avoid cognitive overload

Narrow (triage) the task domain when necessary

Provide more support for learning & carrying out tasks

Increase supervision (monitor, call‐back)

113

A clinician must recognize

the cognitive

burdens of DSM

AND

know how to

reduce those burdens,

including referrals to CDEs, RNs, RDs, behavioral providers.

114

“The patient who walks through the examination room door

may have gained access to a medical facility,

but access to effective health care will remain elusive

if communication barriers have not been fully addressed.”

115

Roter, D. L., Rudd, R. E., & Comings, J. (1998). Patient literacy: A barrier to quality of care. Journal of General Internal Medicine, 13, 850‐851.

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Contact Info:

[email protected]

[email protected]

References

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