care of the elderly diabetic client

Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved

CARE OF THE ELDERLY DIABETIC CLIENTStephanie Postma

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Introduction

Awarded Whitney Young Gerontological Nursing Scholarship for a second year

Last year’s internship and project

Employed at Clark as an aide in assisted living specialized in dementia

What should I do with the internship this semester?

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The Idea

A meeting with Prof. Flikkema, Clark’s DON, the educator, and myself

Ideas:Something independentUse adult med-surgical knowledgeCreate something that would benefit Clark

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The projectDiabetes was chose by

the DON as the education topic.

I will work with the educator and DON.

I will create a PowerPoint teaching module on the care of the elderly diabetic client.

Use information from the Geriatric Nursing Education Consortium, funded by the John A. Hartford Foundation.

RNs and LPNs from Clark will complete the module and test and receive one contact hour credit.

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Available Resources

From GNECDesigned to be used by nursing professors to teach

students about older adults and their complex care needs

Research paper100 slide PowerPointCase Study PowerPoint

What I liked about the resources and provided information

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Assessment and Management of Type 2

Diabetes in Older Adults with Complex Care Needs

Author: Kathleen McDonald, MSN, APRN, BC-ADM, CDEDeanna Gray-Miceli, DNSc, RN, GNP-BC, FAANP

Copyright, American Association of Colleges of Nursing and the JAHFIGN. All Rights Reserved 7

Learner Objectives

The Geriatric Nursing Education Consortium (GNEC) is a national initiative of the American Association of Colleges of Nursing (AACN) to enhance geriatric content in senior-level undergraduate nursing courses. This project is generously funded by the John A. Hartford Foundation.


Pre-Test

True or False: Diagnosis of diabetes is often made when the long-term effects of poor glucose control lead to an acute or long-term complication such as a stroke or myocardial infarction.

True or false: Neuropathy in a client with type 2 diabetes has been linked to the development of oral-mandibular problems.

Because diabetes has an insidious onset, the disease is slowly recognized. Older adults often present with complications of the disease before it is formally diagnosed. Some of these complications include all of the following except Urinary tract infection Peripheral neuropathy Hypothyroidism Cognitive impairment

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Diabetes Statistics and Background

Worldwide by 2025, adults over age 60 will comprise two-thirds of the population with diabetes. With an aging population projected to be 70 million individuals over age 65 years by 2030, the impact of type 2 diabetes will only intensify. For those with type 2 diabetes, the greatest prevalence will be seen in those over age 80.

Because diabetes has an insidious onset, the disease is slowly recognized. As such, older adults often present with the complications of the disease before it is formally diagnosed. Evident in the medical history of these individuals are various problems ranging from infections to peripheral neuoropathy.


Information in the PowerPoint

• Prevalence of diabetes in older adults

• Diagnostic Criteria for Type 1 and Type 2 Diabetes

• Atypical presentation of diabetes in older adults

• Impact of Co-Morbidities

• Geriatric Syndromes

• Other age related changes that complicate management of diabetes

• Nursing Responsibilities

• Nutrition

• Physical activity

• Medications

• Educational Considerations

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Age-Related Changes Influencing the Diagnosis of Type 2 Diabetes

The classic symptoms of diabetes are often absent or misdiagnosed in older adults. Polyuria can be attributed to urinary tract infection in women and

benign prostatic hypertrophy in males. Polydyspia is often missed due to decreased sensation of thirst in

the elderly individual. Polyphagia is an atypical presentation in the elderly who

experience decreases in appetite secondary to GI dysmotilities and depression.

Diagnosis is often made when the long-term effects of poor glucose control lead to an acute or long-term complication such as a stroke or myocardial infarction.

Check


Impact of Comorbidities

All individuals with diabetes have higher rates of premature functional disability and coexisting illnesses such as:Hypertension (HTN)Coronary artery disease (CAD)Stroke

80% die due to cardiovascular

disease: combination of hypertension, heart disease, and stroke

2-3x risk of myocardial infraction or

stroke

2x risk of death

1 of 5 unaware they have CAD


Impact of Geriatric Syndromes

Because type 2 diabetes is an all-inclusive, multi-system disease, its presence sets the stage for increased risk of several geriatric syndromes among older adults.

When present, each of these geriatric syndromes can influence the older adult’s ability to safely and accurately manage their disease in order to achieve or maintain normal glycemic levels.

PolypharmacyDepressionCognitive

impairmentUrinary

incontinence Injurious fallPersistent pain

Geriatric Syndromes


Depression

Because depression is a treatable condition, its recognition as part of a thorough nursing assessment is paramount in the early detection and management of the older adult with type 2 diabetes.

Not all older adults with type 2 diabetes and depressive symptoms will readily reveal these symptoms.

Impacts self-management of diabetes and achieve euglycemia.

Depression contributed as much to mortality

as did myocardial infarction or diabetes

1.6x higher risk than in older adults without

diabetes

Case Study


Falls

Chronic hyperglycemia causes cellular damage and its effect on the neuro-sensory system include symptoms of peripheral loss of sensation in the extremities (peripheral neuropathy).orthostatic hypotension as a result of autonomic

neuropathy decreased cognition

Neuropathy of the lower limbs results in reduced sensation of one’s feetWhen walking, there is deceased sensation of foot

placement on the floor


Age Changes That Further Complicate Management of Type 2 Diabetes

in Older Adults

Type 2 diabetes effects the vascularture of the kidney (nephropathy) by decreasing the glomerular filtration rate (GFR)

Physiological reasons: Reduced renal blood flow reduced number of functioning nephrons ultimately decreased GFR

Diabetic nephropathy compounded with the renal changes associated with aging and other causes of renal insufficiency can precipitate kidney failure

For those taking potentially nephrotoxic drugs, on-going dosage considerations and regular surveillance of lab data is vital.

Chronic kidney disease from Stage 1 through 5 based on GFR determinations


Macrovascular Damage

Other large vessel changes Elevated blood pressure Hypertension which co-contributes to

> Stroke> Renal failure > Myocardial infarction

Additional noted complications stem from congestive heart failure

Also, use of diuretics can result in noxious side effects including orthostatic hypotension, a condition predisposing older adults to falls.

Check


Nursing Assessment of the Older Adult with Type 2 Diabetes

Keen and timely assessment by the professional nurse is critical to quality management


Management: Management Principles for Older Adults with Complex Illness/Frailty

What influences overall management? The mechanism for multiple

comorbiditiesFunctional disability Presence of geriatric syndromes

Nursing care requires critical analysis of all confounding factors influencing glycemic control.

Benefits of early, tight glucose control in the prevention of cardiovascular disease have been demonstrated.

Approximately 8 years needed before benefits of

glycemic control are reflected in reduction in

microvascular complications, such as

retinopathy, renal disease, and neuropathy

2-3 years required to see the benefits from better

control of blood pressure and lipids

Case Study


Management: Management Principles for Older Adults with Complex Illness/Frailty

Mainstays of diabetes management medical nutrition therapyphysical activitymedications self-monitoring of blood glucose


Management: Physical Activity

Co-morbid medical problems such as coronary artery disease, arthritis, balance problems, and decreased mobility may prevent some types of physical exercise.

Overweight older men and women with Type 2 Diabetes in high intensity progressive resistance training combine with moderate weight loss

significantly improved glycemic control

Case Study

Exercise has been shown to Prevent and reverse some micro vascular/muscle changes in

older individuals Means to achieve improved hemoglobin A1c values


Management: Medications

Medication therapy goal Achieve and maintain a physiological balance that includes

the reduction of insulin resistance and promotion of insulin secretion.

Understanding where the individual is along the disease progression/treatment continuum can be a challenge.

The older adult and/or caregiver must understand the progressive nature of diabetes and the ongoing need for periodic changes in the treatment plan that could include the use of insulin to avoid hyperglycemia and prevent complications.

Ensure


Management:Self-Management Education

Older adults with diabetes have special educational needs secondary to sensory and other deficits related to the aging process.

Educational plan: Include an assessment of the individual’s priorities Use easily read or heard messages and proceed at a slower

pace utilizing significant others and caregivers in instruction Elderly persons with diabetes need assistance with

organization of information so they can slowly adapt it to their activities of daily living

Constant reinforcement of content needs to occur during each individual session especially when hyperglycemia or sensory or cognitive deficits are present.


Post-Test

What problem are older adults with type 2 diabetes at an increased for because of the high prevalence of peripheral neuropathy? Daytime sleepiness Liver damage Chronic pain syndromes Excessive hair growth

What measurement of HbA1c is reasonable for frail older adults with a life expectancy of less than 5 years? 6% 7% 8% 9%

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Now What?

Nurse educator “test ran” the PowerPoint and quizzes.

Prof. Flikkema will work with Calvin and Clark regarding the contact hour credits.

We submitted our article to the Journal of Gerontological Nursing and were notified last week that it was accepted for publication!

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Conclusion

Grateful to Clark and their kindness shown to me.

Felt good to create something beneficial for Clark using the internship/scholarship.

Publication is the perfect way to wrap-up this 2 year project and my experience.

Thanks to Prof. Flikkema for all her help and fun!

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care of the elderly diabetic client

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