Article Archive
July/August 2014

Diabetes Self-Management Improves Outcomes
By Angela Ginn, RDN, LDN, CDE
Today’s Geriatric Medicine
Vol. 7 No. 4 P. 24

Covered by Medicare, diabetes self-management programs help patients learn how to manage their disease through appropriate monitoring, medication adherence, diet modifications, and beneficial activity.

More than one-fifth of all patients with diabetes are over the age of 60,1 and the aging population is considered a significant driver of the growing diabetes epidemic. Diabetes in this population can be linked to a higher risk of mortality, decreased functional status, and increased chances of institutionalization.2 Peripheral neuropathy occurs in 50% to 70% of older patients with diabetes, intensifying the risk of balance problems, instability, and muscle atrophy, all of which increase the risk of falls and activity limitations.3

Older adults present unique challenges in managing diabetes. Health care providers should perform evaluations to determine patients’ knowledge and understanding of the disease and assess their ability to learn and apply new self-care skills.

Diabetes requires daily problem solving to meet overall clinical outcomes. Patients may have vision or dexterity problems that interfere with monitoring blood glucose or taking medication. Many have lost spouses and friends and live on their own, which may contribute to developing depression, and untreated depression can lead to difficulty with self-care and the ability to adopt lifestyle behavior modifications.4

Diabetes self-management education (DSME) is an integral part of care for all individuals with diabetes who want to achieve successful outcomes.5 It should be individualized and should involve multiple disciplines, including patients’ care team members.

Initiating a Program
Typically, a primary care physician or health care provider who writes a referral for diabetes education prescribes DSME. Diabetes education programs are offered in a variety of environments, including outpatient facilities, clinics, and physicians’ offices staffed by diabetes educators. When it’s provided through an accredited program, diabetes education is covered by Medicare.

DSME can assist individuals with diabetes with learning how to manage their chronic disease and remain as healthy as possible. The education focuses on seven self-care behaviors: healthful eating, being active, monitoring blood sugar, taking medications, problem solving, healthy coping, and reducing the risk of complications. Diabetes educators often are nurses, dietitians, or pharmacists who address all aspects of diabetes care.

The planning of self-care for older adults must consider the duration of the disease, medical comorbidities, and life expectancy. Within this patient population, it is important to assess treatment goals and self-management skills. Over time, physical, cognitive, and psychological changes as well as changes in social status can impact older adults’ self-care capabilities.

DSME requires patients to learn complex skills, so assessing for indications of cognitive impairment is important before providing education. Treatment regimens and self-care guidelines should be simple and easy to learn. For example, the diabetes educator should choose monitoring equipment that is easy to use and should conduct education sessions at a slower pace, if necessary, to help patients to remember newly learned skills.

Positive Outcomes
Research has shown that older adults with diabetes can benefit from nutrition education designed to improve the knowledge and skills necessary for diabetes self-care.6 A registered dietitian (RD) or certified diabetes educator (CDE) can provide an individualized meal plan and exercise regimen that fall within a patient’s capabilities. A careful assessment can evaluate barriers to adequate nutrition, a vital part of diabetes care. Older adults become at risk of poor nutrition resulting from altered taste or smell, dental issues, and difficulty swallowing. Overly restrictive meal plans also can contribute to anorexia and nutrient deficits.7

Every effort should be made to limit the complexity of meal plans and to engage a patient’s care team to achieve dietary modifications. Understanding individuals’ personal food preferences empowers them and creates a healthier environment. The goals of nutrition education are to avoid hypoglycemia, consume a healthful diet for blood pressure and lipid management, and maintain a reasonable weight.

The involvement of care partners is essential in managing chronic conditions such as diabetes. The proper care related to diabetes requires day-to-day responsibilities. An older adult may be unable to take on the full responsibility of monitoring blood glucose, taking medications, eating healthfully, and engaging in physical activity. If necessary, caregivers and family should be involved in DSME goal planning. 

Physical Limitations or Cognitive Dysfunction
Diabetes educators should provide patients with blood glucose monitors that are easy to hold, have large display windows, and, ideally, do not require any coding. When patients must use insulin, educators should simplify patient regimens by avoiding complex doses and having them use insulin pens or prefilled syringes. For patients who experience vision deficits, a caregiver should be involved in insulin administration, and a syringe magnifier should be used.

When considering hyperglycemia, diabetes educators should explain the importance of regular hydration and increased blood glucose monitoring when patients are sick. Educators also should provide instructions on when to call a health care provider. Additionally, it is important to review the signs and symptoms of hypoglycemia, provide examples of treatment options for it, and encourage patients to wear special medical identification (eg, bracelet, necklace).

With respect to educational materials, diabetes educators should use low-literacy materials with pictures when appropriate, invite family members to educational sessions, and evaluate the benefits and drawbacks of individual education vs. group sessions.

Case Study
The following example illustrates the application of general DSME principles with an older adult: Charles is an 86-year-old black man newly diagnosed with diabetes. His blood glucose level was randomly checked at his primary care physician’s office. He started taking an oral diabetes medication (sulfonylurea) upon diagnosis. In addition to diabetes, Charles has a history of hypertension for which he takes two medications.

His usual body weight has ranged from 136 to 140 lbs over most of his adult life; he lost between 9 and 11 lbs prior to his diabetes diagnosis. His current BMI is 21.

A widower who lives alone in an apartment, but who attends church and has a supportive family, Charles still drives his car and is physically active every day. He recently made an appointment with his physician because of urination frequency during the night.

His primary care physician referred Charles to an endocrinologist and an RD/CDE. He presented to the diabetes educator with a hemoglobin A1c of 12.2%, blood pressure of 150/100 mm Hg, and LDL cholesterol of 102. Several issues of significance were identified:

• elevated A1c;

• uncontrolled hypertension;

• hypoglycemia (at midday);

• weight loss/fear of eating; and

• lack of knowledge about diabetes and monitoring it.

 The initial diabetes education visit focused on healthful eating, monitoring blood sugar levels, remaining active, and taking medication appropriately. Suggestions for healthful eating emphasized the importance of consuming three meals per day; ensuring a daily intake of lean protein, such as meat, fish, poultry, and legumes; using low-fat dairy alternatives such as soymilk and almond milk; enjoying one-half of a plate of vegetables and small portions of fruit at least twice per day; drinking water and sugar-free beverages; and including healthful oils and fats to increase weight to baseline.

During the discussion on remaining active, the diabetes educator learned that Charles enjoyed walking. He also expressed his fears related to his hypoglycemia. The activity considerations included a discussion of the benefits, type, frequency, and duration of physical activity, and the conversation reviewed hypoglycemia prevention and treatment and the diabetes educator offered the suggestion to carry an extra snack during exercise or activity.

To clarify monitoring instructions, Charles was provided with instructions and a demonstration of using a blood glucose monitor and performed a trial to show his understanding of the information. The diabetes educator also discussed blood glucose goals and the appropriate testing regimen and demonstrated how to keep a logbook. The two worked cooperatively to identify personal goals for his disease management.

In a review of proper medication adherence with sulfonylurea and dipeptidyl peptidase-4 inhibitors, the educator reviewed dose, timing, action, and possible side effects. She also notified the endocrinologist and primary care physician of Charles’ hypoglycemia.

Three weeks later, Charles brought his granddaughter with him to the meeting with the diabetes educator. He was more confident and reported monitoring his blood glucose two or three times per day, eating on time, and experiencing hypoglycemia in the morning. He also was walking 3 to 4 miles every day. The endocrinologist lowered Charles’ sulfonylurea dose in the morning.

The education focus extended to problem solving, meal planning, and activity. Problem solving included recommendations on pattern management (reviewing blood glucose values and understanding patient patterns), prevention, causes and treatment of hypo- and hyperglycemia, a review of Charles’ blood glucose log and A1c at diagnosis, and guidance on when to contact his physician. Suggestions for meal planning focused on reviewing sources of carbohydrates, consistency of carbohydrates (maintaining a level intake of carbohydrates over the course of each day and from one day to the next), weight goals, grocery shopping, heart health guidelines, food preparation, and using spices instead of salt.

The educator also reviewed Charles’ exercise regimen, outlining the benefits and blood glucose effects achieved through activity. She also reviewed his personal goals for diabetes management and notified the endocrinologist and primary care physician regarding his fasting hypoglycemia.

At his third visit four weeks later, Charles was feeling better about his diabetes diagnosis and achieving his personal goals. The educator reviewed his blood work, which included the following: A1c of 6.7%, blood pressure of 134/80 mm Hg, weight of 130 lbs. He reported no hypoglycemia, so his medication dosage was decreased.

The educational session focused on healthy coping, reducing risk, and personal goals. With respect to healthy coping, the educator reviewed Charles’ social support network and ways to manage stress. For reducing risk, the educator reviewed the ABCs of diabetes care (A1c, blood pressure, and cholesterol) and the importance of foot care, health care follow-ups, and avoiding risky behaviors.

Charles shared that his personal goal was to live to 100 even with his diabetes. He increased his knowledge of the disease, improved his outlook on life, and improved his clinical outcomes. He was scheduled for a three-month follow-up to reassess his A1c and functional status.

Integral Role
When managing older adults with diabetes, it is essential to understand the unique needs of this patient population. DSME can play an integral role in improving self-care and clinical outcomes. An RD/CDE can provide diabetes education in collaboration with the health care team, assess barriers, and create a simplified plan for improved blood glucose control.

— Angela Ginn, RDN, LDN, CDE, is a senior education coordinator at the University of Maryland Center for Diabetes and Endocrinology in Baltimore.

What to Tell Patients Newly Diagnosed With Diabetes
Learning about diabetes management is a process. Patients need to understand the basics, including what causes diabetes and its various complications, treatment options, proper nutrition, and monitoring blood glucose. But to ensure that they really hear and understand that diabetes can be well managed, the American Association of Diabetes Educators recommends the following six items to tell patients:

It’s not your fault. Emphasize that diabetes can be caused by many factors, including genetics. Specific conditions can trigger the onset of diabetes, including stress, lack of activity, and weight gain, but patients can take steps to improve the condition and live more healthfully.

Don’t panic. Patients may recall an uncle with diabetes who had his leg amputated or a neighbor who died of a heart attack. Explain that there are steps patients can take to decrease their risk of diabetes-related complications. Ask what they know about diabetes, which will provide an opportunity to correct their misperceptions.

You don’t need special foods. Patients may want to know what they may eat and worry about never again being able to consume anything sweet. Let them know that they should eat the same way everyone should eat: controlling portion size and carbohydrate, fat, and salt intake but also enjoying an occasional sweet treat. Use diabetes as a motivator for patients (and their families) to live healthful lives.

Being active helps. This doesn’t mean patients need to run a marathon, though. Whatever their activity levels, encourage patients to think of ways they can become more active. If they aren’t active, little changes can help get them started, from taking the stairs rather than the elevator or parking the car at the far end of the parking lot. Emphasize that being active results in big payoffs, helping to lower glucose levels; strengthen the heart, bones, and muscles; lose weight; and feel better.

Learn to master your diabetes. Diabetes educators are licensed health care professionals who work with patients to design individualized healthful living plans that include the necessary tools and support. Diabetes education has been proven to help patients manage their weight and reduce cholesterol levels and blood pressure, and it can be incorporated to help manage care in a way that makes sense to each patient.

You’re not alone. It’s important to remember that a diabetes diagnosis is frightening and can be overwhelming, so reassure patients that although they must make changes, you and their other health care providers will help them. Encourage patients to discuss experiences, ask questions, and even become involved with support groups in person or online. Most insurance programs cover diabetes education.

— Source: American Association of Diabetes Educators

1. Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2014. Atlanta, GA: US Department of Health and Human Services; 2014.

2. Brown AF, Mangione CM, Saliba D, Sarkisian CA; California Healthcare Foundation/American Geriatrics Society Panel on Improving Care for Elders With Diabetes. Guidelines for improving care of the older person with diabetes mellitus. J Am Geriatr Soc. 2003;51 (Suppl Guidelines): S265-S280.

3. Richardson JK, Thies SB, DeMott TK, Ashton-Miller JA. Gait analysis in a challenging environment differentiates between fallers and nonfallers among patients with peripheral neuropathy. Arch Phys Med Rehabil. 2005;86(8):1539-1544.

4. Lin EH, Katon W, Von Korff M, et al. Relationship of depression and diabetes self-care, medication adherence, and preventive care. Diabetes Care. 2004;27(9):2154-2160.

5. Haas L, Maryniuk M, Beck J, et al. National standards for diabetes self-management education and support. Diabetes Educ. 2012;38(5):619-629.

6. Miller CK, Edwards L, Kissling G, Sanville L. Evaluation of the theory-based nutrition intervention for older adults with diabetes mellitus. J Am Diet Assoc. 2002;102(8):1069-1074.

7. Sue Kirkman M, Briscoe VJ, Clark N, et al. Diabetes in older adults: a consensus report. J Am Geriatr Soc. 2012;60(12):2342-2356.