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NOT TOO HIGH… NOT TOO LOW… Quality of Life Matters A PLAN FOR OPTIMIZING DIABETES MANAGEMENT IN NURSING HOMES 4. Glycemic Variability.

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Presentation on theme: "NOT TOO HIGH… NOT TOO LOW… Quality of Life Matters A PLAN FOR OPTIMIZING DIABETES MANAGEMENT IN NURSING HOMES 4. Glycemic Variability."— Presentation transcript:

1 NOT TOO HIGH… NOT TOO LOW… Quality of Life Matters A PLAN FOR OPTIMIZING DIABETES MANAGEMENT IN NURSING HOMES 4. Glycemic Variability

2 UNDERSTANDING GLYCEMIC VARIABILITY Carol Nicholson, RN BN CDE

3 Blood sugar… High, Low… What to consider Overview: 1.Reality 2.Food 3.Activity 4.Oral Medications 5.Insulin & Injection Technique 6.Illness, Stress 7.Sick Day Management 8.Hyperglycemia 9.Hypoglycemia 10.Summary

4 1. Reality: Blood sugar control… Accept that some things you have some control over; some things you don’t. Confidence comes from understanding the difference. Knowledge empowers advocacy for your residents. Individualize targets.

5 Diabetes management in LTC: Avoid Hypoglycemia Avoid Excessive Hyperglycemia Avoid the roller coaster of highs and lows Bottom line  Reasonable Balance Contributes to Quality of life

6 2. Food

7 guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Diabetes in Nursing Homes Under nutrition is a problem in people with diabetes living in nursing homes “Regular diets” may be used in nursing homes instead of “diabetic diets” or “diabetic nutritional formulas” Mooradian AD et al. J Am Geriatr Soc 1988;36:391-396 Coulston AM et al. Am J Clin Nutr 1990;51:67-71. 2013

8 guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendations 2013 Individuals with diabetes should be encouraged to follow Eating Well with Canada’s Food Guide in order to meet their nutritional needs [Grade D, Consensus] People with type 2 diabetes should maintain regularity in timing and spacing of meals to optimize glycemic control [Grade D, Level 4]

9 What does that look like on a plate?

10 Here’s another…

11 This is a handy tool  The Diabetes Food Guide to Healthy Eating. Centretown Community Health Centre; Community Diabetes Education Program of Ottawa. April 2011

12 3. Activity Guidelines.diabetes.ca 1-800-banting (226-8464)- diabetes.ca Copyright ©2013. Canadian Diabetes Association

13 4. Medications Unlikely to cause hypoglycemia Metformin** Acarbose (alpha-glucoside inhibitor) DPP-4 Inhibitors Sitagliptin = Januvia Linagliptin = Trajenta Saxagliptin = Onglyza GLP-1 receptor agonists Exenatide = Byetta Liraglutide = Victoza TZD’s (Thiazolidinediones = Avandia, Actos) Weight loss agent Orlistat SGLT2 inhibitors Can cause hypoglycemia Insulin secretagogues: – Glyburide NOT RECOMMENDED FOR ELDERLY – Gliclazide = Diamicron – Glimiperide = Amaryl – Repaglinide = Gluconorm Insulin – Basal = long or intermediate acting – Bolus (meal) = short or rapid acting

14 5. Insulin Not all created equal!! Onset of action varies from 15 minutes to 3 hours!! Basal (background) = long or intermediate acting Onset of action: 1 – 3 hours Duration of action  18 – 24 hours Bolus (meal) = short or rapid acting Short acting  Humulin R; Toronto Onset 30 – 60 min Duration  5 – 8 hours Rapid acting  Novo Rapid; Humalog Onset 15 min Duration of action  3.5 – 5 hours

15 Injection Technique FORUM FOR INJECTION TECHNIQUE (FIT) Best Practices for Injection Technique Evidence Based recommendations Recently updated with second edition published on-line fit4diabetes.com fit4diabetes.com

16

17 Injection Technique: Main concerns Storage of insulin Proper mixing of cloudy insulin Correct technique of Insulin syringe & pens Subcutaneous injection versus IM – Site choice – Needle length Injection into healthy tissue – Appropriate site assessment – Planned site rotation – Avoid lipohypertrophic areas – 50 – 66 % of individuals on insulin therapy have been shown to have lipohypertrophy.

18 Lipodystrophy is umbrella term ‘disorder of fat tissue’ Pictures courtesy of Nurse Ruth Gaspar, Madrid, Spain Lipoatrophy: scarring and indention of fat tissue Lipohypertrophy: swelling and induration (hard or rubbery texture) of fat tissue Forum for Injection Technique Canada; Recommendations for Best Practice in Injection Technique 2 nd edition; 2014

19 Why is lipohypertrophy (LH) a problem? Unexplained hypoglycemia Unexplained hypoglycemia Glycemic variability 49% 39% 39% of patients with LH have unexplained hypoglycemia, compared to only 6% of patients without LH 49% of patients with LH have glycemic variation, compared to only 7% of patients without LH Delayed uptake 25% reduction in insulin absorption 25% reduction in insulin absorption Blanco M, et al. Diabetes Metabolism. 2013;39:445-453. Forum for Injection Technique Canada; Recommendations for Best Practice in Injection Technique 2nd edition; 2014

20 6. Illness & Stress “Illness or stress can trigger high blood sugars because hormones produced to combat illness or stress can also cause your blood sugar to rise” Examples: – Illness or infection (cold, urinary tract infection, heart attack) – Injury or surgery – Infected wounds – Pain – Positive stress (wedding or vacation) – Negative stress (a death in the family) – Emotional upset – Any change in your normal daily routine – Certain medications http://www.mayoclinic.org/diseases-conditions/diabetes/expert-blog/diabetes-blog/BGP-20056560

21 7. Sick Day Management Think about : -Ability to maintain adequate fluid intake? -Potential decline in renal function (e.g. due to gastrointestinal upset or dehydration) vomiting/diarrhea

22 Consider holding medications which will: Increase risk for a decline in kidney function If kidney function is reduced… can build up and cause side effects

23 Layman’s terms… Instructions for Patients When you are ill, particularly if you become dehydrated (e.g. vomiting or diarrhea), some medicines could cause your kidney function to worsen or result in side effects. If you become sick and are unable to drink enough fluid to keep hydrated, you should STOP the following medications:

24 Sick day management Blood pressure pills Water pills Metformin Diabetes pills Pain medications Non-steroidal anti-inflammatory drugs Seek medical attention!! Guidelines.diabetes.ca 1-800-banting (226-8464)- diabetes.ca Copyright ©2013. Canadian Diabetes Association

25 S – sulfonylureas A – ACE-inhibitors D – diuretics, direct renin-inhibitors M – metformin A – angiotension receptor blockers N – non-steroidal anti-inflammatory agents S – SGLT2 inhibitors Guidelines.diabetes.ca 1-800-banting (226-8464)- diabetes.ca Copyright ©2013. Canadian Diabetes Association Consider holding these medications:

26 All trademarks owned by Novo Nordisk A/S and used by Novo Nordisk Canada Inc. (Novo Nordisk Canada Inc. 300-2680 Skymark Ace. Mississauga, ON, L4W 5L6 TEL: (906-629-4222) www.novonordisk.ca www.novonordisk.ca

27 8. Hyperglycemia Fatigue, drowsiness Sleeping a lot Confusion Thirst (polydipsia) Polyuria Dry mouth Paleness Blurred vision As with Hypoglycemia, Elderly may not be aware of symptoms!!

28 9. Hypoglycemia Risk of death increases in elderly More difficult to detect in the elderly – Inability to communicate to caregivers or self treat – Hypoglycemia unawareness – Liver impairment – Renal impairment – Beta blockers

29 Causes of hypoglycemia Less food Medications…which ones? Increased activity

30 Hypoglycemia Symptoms: Sweating Fatigue Mood changes Hunger Shaking Pale…..but….

31 May presents as: Fall Stroke Cardiac ischemia Is associated with morbidity and mortality!!! Hypoglycemia

32 Controlled Glycemia not too high; not too low Less infections Less risk of wounds Improved wound healing Less UTI’s Improved Cognition & Sense of well being

33 Blood Glucose Balance Blood sugar Food Medications Activity These factors you may have some control over!

34 These we have less control over Declined Appetite Ability to be active Medication absorption Medication action in the body Declined renal function Hypoglycemia unawareness More Food Less activity Illness Infection Stress Depression Other medications Steroids HypoglycemiaHyperglycemia

35 Education and Awareness… let’s you be like a detective Help you troubleshoot what may seem unexplainable Help you ask the right questions Better advocacy better for residents Finding the balance to achieve glycemic control is often like a puzzle… The more pieces that you can clearly see, the easier it is to solve the puzzle!

36 Do these make any sense?

37

38 Questions

39 References Sources Building Competency in Diabetes Education: Advancing Practice http://www.diabetes.ca/membership/professional-membership/diabetes-educator-section-membership#sthash.TLjsNWPq.dpufhttp://www.diabetes.ca/membership/professional-membership/diabetes-educator-section-membership#sthash.TLjsNWPq.dpuf Building Competency in Diabetes Education: The Essentials http://www.diabetes.ca/membership/professional-membership/diabetes-educator-section-membership#sthash.TLjsNWPq.dpufhttp://www.diabetes.ca/membership/professional-membership/diabetes-educator-section-membership#sthash.TLjsNWPq.dpuf Calgary Zone Long Term Care Formulary. Alberta Health Services, 2013. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes 2013;37 (suppl 1):S1-S212. Cook, B., Mallery, L., Harrigan, L. & Ranson, T. Diabetes Guidelines for Elderly Residents in Long-Term Care (LTC) Facilities. Diabetes Care Program of Nova Scotia, 2010. Diabetes Guidelines for Elderly Residents in Long-Term Care (LTC) Facilities Pocket Reference. Diabetes Care Program of Nova Scotia, 2010. Diabetes Guidelines for Elderly Residents in Long-Term Care (LTC) Facilities, Diabetes Care Program of Nova Scotia Supporting Document – Background. Diabetes Care Program of Nova Scotia, 2010. Diabetes Management in the Long Term Care Setting. U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, 2014. Herzig Mallery, L.,Ransom, T.,Steeves, B. et al (2013). Evidence-Informed Guidelines for Treating Frail Older Adults With Type 2 Diabetes: From the Diabetes Care Program of Nova Scotia (DCPNS) and the Palliative and Therapeutic Harmonization (PATH) Program. Journal of the American Medical Directors Association, 14, 801-808. Individualizing Diabetes Care for Long Term Care Residents: A Guidebook. Long Term Care Working Group of Health Care Professionals working in the Central Local Health Integration Network (Ontario), 2013. Kirkman, M., Briscoe, V., Clark, N. et al (2012). Diabetes in Older Adults : A Consensus Report. Journal of the American Geriatrics Society, 60, 2342-2356. Managing Older People With Type 2 Diabetes Global Guideline. International Diabetes Federation, 2013. Management of Diabetes in the Long-Term Care Population: A Review of Guidelines. Canadian Agency for Drugs and Technology in Health, 2013. Self-monitoring of Blood Glucose in People with Type 2 Diabetes: Canadian Diabetes Association Briefing Document for Healthcare Providers. Canadian Journal of Diabetes, Vol. 35, Issue 4, p317– 319, 2011 Sinclair, A., Paolisso, G., & Castro, M. (2011). European Diabetes Working Party for Older People 2011 Clinical Guidelines for Type 2 Diabetes Mellitus. Executive Summary.. Diabetes & Metabolism, 37, S27-S38. Retrieved from http://www.sciencedirectcom. Standards of Medical Care in Diabetes 2013. American Diabetes Association, 2013.


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