1. Produced by The Alfred Workforce Development Team on behalf of DHS Public Health - Diabetes Prevention and Management Initiative June 2005 About diabetes and guidelines for management of diabetes in the elderly Planning and delivery of best practice care for general nursing staff Module 3.2.1

2. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Presentation purpose Target audience General nurses – with background knowledge of diabetes Aim To provide best practice care for people with diabetes. Objectives Provide an overview of diabetes and how it affects the body Explore what information people with diabetes require in order to understand their condition and appropriate education strategies to provide this information Explore what is best practice care for people with diabetes and present examples Review current practices across the catchment Review the use of PCP service coordination tools and practices in promoting best practice care Discuss strategies for evaluation of care planning.

3. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Diabetes: a definition Diabetes is a chronic disease Characterised by high blood glucose levels High blood glucose levels may result from  The body not producing insulin (Type 1)  Insulin in the body not working effectively (Type 2)

4. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Insulin Insulin is a hormone produced in the pancreas Insulin is needed for glucose to move from the bloodstream into the bodies cells to be used for energy Lack of insulin or ineffective insulin results in high blood glucose levels

5. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Types of diabetes mellitus Impaired Glucose Tolerance  (IGT, Impaired Fasting Glucose) high risk of developing diabetes Type 1: caused by insulin deficiency Type 2: caused by relative lack of insulin and insulin resistance Gestational Diabetes Mellitus (GDM)

6. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Presentation focus Type 2 Diabetes Mellitus particularly elderly people with Type 2 Diabetes.

7. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Diagnosis of diabetes Type 2, IFG, IGT Glucose Tolerance Test (GTT) 11.1 mmol/l 7.0 mmol/l 7.8- 11.0 mmol/l 6.1- 6.9 mmol/l <5.5 mmol/l Venous plasma RandomFasting2hr GTTFastingRandomFasting DiabetesIGT & IFGDiabetes Unlikely Evidence Based Guideline for the case Detection and Diagnosis of Type 2 Diabetes. Australian Government NHMRC www.diabetesaustralia.com.au/education_info/nebg.htmlwww.diabetesaustralia.com.au/education_info/nebg.html

8. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Signs and symptoms of Type 2 Excessive urination Thirst Recurrent infections / Thrush Tiredness / Drowsiness Weight change Blurred vision Hyperglycaemia Dehydration Urinary ketones Glycosuria

9. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Common characteristics of type 1 and 2 Type 1 (10-15%) Type 2 (85-90%) Age of onsetUsually <40 ( can occur in elderly) Usually >45 (but increasing at younger age Body weightLeanUsually obese Prone to ketoacidosisYesNo MedicationInsulin essentialTablets and /or insulin Onset of symptomsAcuteGradual (may be asymptomatic) Risk Factors Genetic Viral/Environmental Family history Obesity/ ↓ activity Cultural background

10. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Prevalence of diabetes Diabetes  7.5% of population aged 25 years and over  17.9% 64-75 years  23.0% 75 years+ IFG or IGT 16.4% AusDiab Study (Dunstan et al, 2002)

11. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Large landmark trials Diabetes Control and Complications Trial Type1DM (DCCT, 1993) Type 2 DM United Kingdom Prospective Diabetes Study (UKPDS, 1998)  Both demonstrated the beneficial effects of maintaining good glycemic control on the development & progression of DM complications  UKPDS also highlighted need for blood pressure control

12. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Treatment goals for diabetes Symptom free Prevent short term complications Prevent long term complications Quality of life =Lifestyle focus

13. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Why do we need guidelines for the elderly? Australian population is ageing Diabetes has a higher prevalence in ageing people Sub-optimal management in many settings Diabetes guidelines rarely address specific care issues and the elderly National Diabetes Strategy & Implementation Plan (1998) cites special considerations required for the elderly

14. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Who is considered elderly? “Young old” 65-75 years “Old, old” >75 years Popplewell P. Diabetes and the Elderly in Phillips P et all Diabetes and You – The essential Guide. Canberra: Diabetes Australia 1999

15. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Guidelines for the management and care of diabetes in the elderly The Australian Diabetes Educators Association (ADEA) 2003 www.adea.com.au www.adea.com.au Guidelines are a consensus statement following:  Extensive literature review  Consultation process involving: Relevant professional organisation Commonwealth/State/Territory Health Depts. Geriatric Services Content experts

16. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Guidelines focus Guidelines focus on “healthy” person with diabetes over the age of 65 years Needs of frail elderly should be considered on individual basis with special consideration of physical and mental status

17. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Purpose of guidelines Provide accessible information on diabetes prevention, diagnosis, treatment and long term management options for elderly people Guidance on what is broadly appropriate rather than prescriptive Important application relies on individual assessment of health status, self care beliefs and physical environment.

18. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 1. Case detection and diagnosis Asymptomatic elderly people should be screened for undiagnosed diabetes by measurement of fasting plasma glucose as recommended for the general population

19. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 2. Assessments and targets Elderly people with diabetes should have regular comprehensive clinical and laboratory evaluation of metabolic control and screening for complications as follows…………………….

20. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 2. Assessments and targets Glycaemic control  Glycaemic control (HbA1c 7%, adjustment for hypoglycaemia) Assess twice a year - 4x year if unstable  Target BGLs (not included in guidelines) 4-8 mmol/L ideal 5-10 mmol/L safer for elderly (many live alone) 6-12 mmol/L in hospital < 4 mmol/L= risk of hypoglycaemia >15 mmol/L = symptoms of hyperglycaemia, increased risk of complications

21. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 2. Assessments and targets Controlling blood sugar levels  Exercise / Activity Increased insulin sensitivity Decreased insulin requirements Weight reduction Lipid control Blood pressure control

22. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 2. Assessments and targets Controlling blood glucose levels  Healthy Eating Regular carbohydrate High in fibre Low in fat (particularly saturated fat) Low in added sugar Adequate energy /protein/fluids/vits and mins

23. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 2. Assessments and targets Monitoring BGLs

24. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 Blood pressure and lipids  Blood pressure (140/90 mm/Hg)  Lipid profile (LDL <2.5, trig <2.0 mmol/L)  Assessment 3 monthly / 6 monthly if normotensive 2. Assessments and targets

25. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 2. Assessments and targets Eyes, kidneys and feet  Renal function Assess annually 3-6/12 if positive (microalbuminuria/protein) Creatinine annually  Eye examination Assess at diagnosis and every 2 years If retinopathy present then annually  Foot assessment Assess annually 3-6/12 for high risk feet

26. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 2. Assessments and targets Cognitive capacity  Capacity/desire to learn  Capacity for self care  Eyesight/hearing  Literacy level  Poor memory Assess with Mini Mental State Exam (MMSE) ( score = 30, 18-26 suggests dementia, <10 severe dementia) Gregg EW. Complications of diabetes in elderly people. Underestimated problems include cognitive decline and physical disability. BMJ 2002b; 325,916-7

27. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 3. Special treatments Nutrition assessment  Distribution and intake of carbohydrate important  Weight loss not recommended unless > 20% above weight range Encouraged to follow National Physical Activity Guidelines: 30 minutes of physical activity each day (tailored for frail elderly)

28. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 3. Special treatments Alcohol (1/day women 2/day men) No smoking Hypoglycaemic agents  Need to consider comorbidities, contraindications and side effects especially hypoglycemia Antihypertensive therapy Lipid lowering therapy

29. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 4. Addressing barriers to health care and education Special attention should be given to ensuring elderly and their carers have access to diabetes education and specialist services Use of care plans based on recognised standards of diabetes care  Comprehensive assessment  Identification of problems and actions to address problems  Documentation  Regular evaluation of care plan  Active involvement of individual in care plan if practical

30. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 4. Addressing barriers to health care and education Actively involve individuals in their own care  Knowledge is required.  Understanding the problem as seen by the person with diabetes.  Finding out what their fears and hopes for the future are.  Helping them to identify the problems and work through solutions to fulfill their hopes for the future.

31. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 4. Addressing barriers to health care and education Education considerations  Information provided is consistent with individual’s capacity to comprehend  Communication is consistent with adult learning principles  Language and culture, interpreter  Assess individual needs  Include significant others  Provide written information  Review knowledge and skills regularly  Consistent information

32. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 5. Hypoglycemia Greater awareness of risk Specific education to the elderly and carers re hypos/changes in OHA/other Increase BG testing Caution with prescribing diabetes tablets /insulin treatment

33. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 6. Hyperglycemia The possibility of Hyperosmolar Hyperglycemic Nonketotic state (HONK) should be considered in elderly people with extremely high blood glucose levels

34. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 6. Hyperglycemia Hyperosmolar non-ketotic coma (HONK) Extreme hyperglycemia  Symptoms/confusion  NO ketones  Significant dehydration  50% have non diagnosed Type 2 Diabetes  Can be fatal, mortality 10-63%  Treated with IV fluids, some insulin

35. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 7. Primary Prevention Elderly people should be encouraged to exercise regularly and to lose excess weight in order to reduce their risk of developing Type 2 diabetes

36. DPMI Workforce Development – The Alfred Workforce Development Team June 2005 In conclusion the aim in elderly people with diabetes is to… Relieve symptoms of high glucose levels Avoid low glucose levels Achieve agreed blood glucose levels Monitor diabetes complications Encourage health and fitness habits Ensure older people are actively involved in setting goals for their diabetes management