Diabetes in Assisted Living: What YOU Need to Know

Diabetes in Assisted Living: What YOU Need to Know

Diabetes in Assisted Living: What YOU Need to Know Sandra Petersen, DNP, APRN, FNP-BC, GNP-BC, PMHNP-BE, FAANP Type 1 Type 2 HbA1C Diabetes: Its more than just blood sugar. This Photo by Unknown Author is licensed under CC BY

Aging in America Average life expectancy 72-79 At age 65, average life expectancy 82! At age 85, average life expectancy 90 Fasting growing segment: over 85 1.5% population Almost 5% of population by 2050 Prevalence of Diabetes Over 20% those over 65 (NHANES 1994) Framingham Data: Diabetes or impaired glucose tolerance (fasting glucose 120-139) in nearly 40% those over 65 Over 65 account for over 40% diabetic population

Cardiovascular Disease Heart disease and stroke: Leading causes of death 60% deaths in those over 85 due to CVD Morbidity: stroke and CHF CHF: 6% new diagnoses/per year in age over 85 Prevalence of Dementia 6-10% those over 65 30-50% those over 85 Nearly 70% in those over 95 By 2025, expected 2 million centenarians in US! Leading public health concern as the new chronic disease

Diabetes Types 1 & 2: The Pathophysiology Type 1 Diabetes Type 1 diabetes signs and symptoms can appear relatively suddenly and may include: Increased thirst. Frequent urination. Extreme hunger. Unintended weight loss. Irritability and other mood changes. Fatigue and weakness. Blurred vision.

Type 1 Diabetes Insulin-dependent/Juvenile onset (usually, but 1 in 3 with Type 2 dont know they have it!) 20 to 30% develop microalbuminuria after 15 years Of the ones who develop this less than half progress to diabetic nephropathy Associated with microvascular disease retina and kidney. The increased sugar is neurotoxic hence neuropathy 2.2 percent will develop end stage renal disease in 20 years and 7.8 percent in 30 years Type 1 Diabetes (Continued)

The microalbuminuria can regress and it is not the risk of developing kidney failure after 20 to 25 years in patients who have no proteinuria is low Labile swings in blood sugar because of autonomic insufficiency Always requires insulin If diabetic nephropathy develops, the patient will develop insulin resistance metabolic syndrome due to kidney disease. Atherosclerosis and hypertension are not primary but secondary events Type 2 Diabetes

Common in Hispanics, Native Americans, African Americans, but also prevalent in those with history of obesity and poor cholesterol and hypertensive control. Incidence of End stage kidney disease is lower, but the disease is more frequent thus it is the most common cause of renal failure Incidence of microalbuminuria 25% but incidence of end stage renal disease only 0.8% Microlbuminuria patients spent an average of 11 years before progressing to overt proteinuria Only 2.3% progress from macroalbuminuria to ESRD QUADRUPLED OVER NEXT 3 DECADES!

Type 2 Diabetes (Continued) Disease progresses slowly over many years and is associated with proteinuria. The urine should show more than just red cells. In the elderly, it is impossible to clinically distinguish the hypertensive and atherosclerotic effects from the diabetic effects without a kidney biopsy. Not associated with labile blood sugar swings Insulin resistance Incidence of Type 2 Diabetes Doubled in past 20 years

Related to Lifestyle Change and Obesity BMI Increase confirmed by NHANES Dataset Source: American Heart Association Prevalence of Diagnosed and Undiagnosed Diabetes in the United States, All Ages, 2007 Total: 23.6 million people 7.8 percent of the populationhave diabetes. Diagnosed: 17.9 million people Undiagnosed: 5.7 million people Source: NIDDK

Diet Plays a Major Role The Sugar Fix High fructose corn syrup Decreases the ATP in cells this decreases cell respiration and causes hypoxia in cells Releases cytokines that impair nitrous oxide synthesis Releases uric acid which increases blood pressure Causes leptin resistance (Leptin turns off the appetite) continue to be hungry Supersized HFCS is in many soft drinks and other products Americans eat more sugar, now have an epidemic of obesity, the metabolic syndrome, heart disease

and diabetes Sugar Consumption For a 2,000-calorie diet, 5% would be 25 grams. Limit daily sugar to 6 tsps (25 g) for women, 9 tsps (38 g) for men. Yet, the average American consumes 17 teaspoons (71.14 grams) every day. That translates into about 57 pounds of added sugar consumed each year, per person!!!! Metabolic Syndrome Metabolic Syndrome Characterized by insulin resistance 50 to 75 million Americans

High blood pressure High blood sugars High levels of triglycerides Low levels of HDL Increased waist line It is associated with Diabetes, Hypertension, stroke, cardiovascular disease

Dominant Features Obesity, lack of exercise WHAT CAN YOU DO? This Photo by Unknown Author is licensed under CC BY-NC-ND What slows progression? Proven interventions Control blood sugar in diabetics Strict blood pressure control Certain meds: ACES (Angiotensin-converting enzyme

inhibition) and ARBS (angiotensin-2-receptor blockade) Studied and has strong evidence Dietary protein and carb balance Lipid lowering therapy (except after age 85) Partial correction of anemia Vitamin D administration Management Objectives: OFFER A

COMPREHENSIVE REVIEW Lifestyle An aspirin a day Smoking and Exercise Weight/cholesterol Blood Pressure ACE and ARB Vitamin D

Diabetes Control (Logs) Lifestyle - An aspirin a day Stop Smoking and START Exercising CONTROL Weight/cholesterol Can be a rewarding way to keep diabetes under control. Requires a lifelong strategy Diet: Avoid fructose, excess salt, trans fats and excess carbohydrates Two alcoholic beverages at most/day 25% incident diabetics are smokers Potentiates kidney disease Increases inflammation

Gentle aerobic exercise Aspirin a day to reduce cardiovascular risk IDEAS FOR MARKETING/WELLNESS for AL RESIDENTS! BLOOD PRESSURE CONTROL CRITICAL AT ALL AGES! Blood pressure goal

< 150/90 or less in some cases Any person with abnormal kidneys is at risk for heart disease Most patients will require two or more medications to control their blood pressure Lowering the systolic blood pressure to <130 mm Hg is usually associated with a reduction in diastolic blood pressure to <80 mm Hg

Adapted from American Journal of Kidney Diseases, Vol 43, No 5, Suppl Suppl 1 (May), 2004: pp S14-S15 ACES & ARBS are the two major classes of medications used to treat high blood pressure Common Generic and Brand Names for ACE Inhibitors and ARBs Common ACEs and ARBs ACE Inhibitors benazepril (Lotensin) captopril (Capoten)

enalapril (Vasotec) fosinopril (Monopril) lisinopril (Prinivil, Zestril) perindopril (Aceon) quinapril (Accupril) ramipril (Altace) trandolapril (Mavik) Angiotensin II Receptor Blockers (ARBs) candesartan (Atacand) eprosartan (Tevetan) irbesartan (Avapro) losartan (Cozaar) olmesartan (Benicar)

telmisartan (Micardis) valsartan (Diovan) Vitamin D Makes the News Vitamin D to the Rescue! Vitamin D is believed to help improve the body's sensitivity to insulin the hormone responsible for regulating blood sugar levels and thus reduce the risk of insulin resistance, which is often a precursor to type

2 diabetes!!! Diabetes Control Sulfonylureas Biguanides Thiazolidinediones Glitazones Meglitinides DPP-4 Inhibitors Incretin Memetics Insulin ADA Guidelines

Medications for Diabetes TYPE Sulfonylureas Biguanides NAME Glimepiride Glipizide Glyburide Metformin (Glucophage) Thiazolidinedio

nes Glitazones Meglitinides Rosiglitazone (Avandia) Pioglitazone (Actos) Repaglinide (Prandin) Nateglinide (Starlix) DPP-4 Inhibitors Sitagliptin (Januvia)

Incretin Memetics Exenatide (Byetta) MECHANISM Increases insulin production through K channels of beta cells Reduce hepatic glucose output and increase its muscle uptake PPAR gamma ligand

improves glucose utilization Close K channel and open Ca channel in Beta cell increasing insulin Blocks, DPP-4 which catalyzes enzyme breaking down insulin Stimulates beta cells and slows digestion ROUTE, TIME Po qd or bid Po bid tid

XR po qd Po qd Po 5 30 min AC 100 mg po qd 10 mcg sc 60 min AC AM and PM meal SULFONYUREAS First category of oral agents for diabetes now in third generation Mainly for type 2 diabetes work on existing beta cells Increase secretion of insulin by

binding to potassium channels and opening calcium channels Can cause hypoglycemia and weight gain BIGUANIDES Metformin used in obese type 2 diabetics Maximum reduction in HgbA1c after 6 months Action lasts additional 9 months with thiazolidinedione With sulfonureas HgbA1C tends to increase Reduced cardiovascular risks Pharmacotherapy. 2007 Aug;27(8):1102-10.Loss of glycemic

control in patients with type 2 diabetes mellitus who werereceiving initial metformin, sulfonylurea, or thiazolidinedione monotherapy.Riedel AA, Heien H, Wogen J, Plauschinat CA. ROSIGLITAZONE Controversy regarding risk of causing MI Odds ratio 1.43

ADOPT increased fractures Associated with macular edema Stimulates the PPAR receptor Not to be used in heart failure Nissen SE, Wolski K. Effect of Rosiglitazone on the Risk of Myocardial Infarction and Death from Cardiovascular Causes. N Engl J Med. 2007;356(24):2457-2471. INCRETIN MIMETICS

Exenatide (Byetta) From the saliva of the gila monster Incretin mimetic Enhances beta cell insulin Blocks glucagon Delays gastric emptying Injection sub cutaneously 30 to 60 minutes before first and last meal adjunctive therapy Side effects Gastrointestinal symptoms FDA warning pancreatitis may be fatal WHEN TO START INSULIN Start with oral agents (metformin) and

proceed to insulin if goal is not achieved May be able to manage for up to 6 years HgbA1C use a target In kidney patients because of the risk of hypoglycemia may want to have a higher goal Mono-duo-triple therapy disease has advanced HgbA1C American Diabetic Association 7.0% American Society of Clinical Endocrinologist 6.5% Many local endocrinologist 6.0%

CONTROVERSY: The lower the HgbA1C the lower the risk of microvascular disease, but the higher the risk of hypoglycemia < 8.0 for over age 65 seems to work best. INSULIN INSULIN PREPARATION RAPID ACTING

Lispro (Humalog) Aspart (Novolog) ONSET PEAK DURATION MAX DURATION 5 15 min

.5-1.5 hr 5 hr 4-6 hr Glulisine (Apidra) SHORT Regular .5 1 hr 2 3 hr

5 8 hr 6 10 hr INTERMEDIATE NPH (isophane) 2 4 hr 4-10 hr 10-16 hr

14-18 hr Lente (zinc) 2 4 hr 4-12 hr 12-18 hr 16-20 hr LONG

Ultralente 6 10 hr 10-16 hr 18-24 hr 20-14 hr LONG ANALOGUE

Glargine (Lantus) Levemir 2 4 hr No Peak 20-24 hr 24 hr COMBINATIONS 70/30 NPH/Reg

.5 to 1 hr Dual 10 -16 hr 14-18 hr 5 15 min Dual

10 -16 hr 14-18 hr 50/50 NPH/Reg CONBINATION ANALOGUES 75/25 NPL/lispro 70/30 NPL/aspart Adapted from Hirsch IB, Edelman SV Practical Management of Type 1 Diabetes, PCI Book,, West Islip Ny (2005) INSULIN

Glucose homeostasis declines Loss of post prandial glycemic control Decline in control around breakfast Nocturnal Hyperglycemia is often seen. Basal insulin typically started in type 2 Diabetes-the eyes & the kidneys Type 1 Almost always have retinopathy and

neuropathy-then, they develop nephropathy Detected clinically by the doctor or opthalmologist Type 2 Retinopathy will likely be accompanied by nephropathy If no retinopathy is present, they may have something other than diabetic nephropathy Background Diabetic Retinopathy

NORMAL BDR Common Medications to avoid in kidney disease NSAIDS Ibuprofen (Motrin) Indomethacin (Indocin) Naproxen (Aleve, Anaprox, Naprosyn) (Celecoxib) Celebrex _ METFORMIN Glucophage (metformin) Diabetes Complications

Vascular Disease Peripheral vascular disease Amputations Autonomic insufficiency Gastroparesis Postural hypotension Bladder dysfunction Neuropathy Charcot Joints Burning Neuropathy

How are we doing? Elderly diabetic patients Medical insurance claims through the roof! 65 years and older 30,750 patients studied (58.7% also had high blood pressure and/or protein in the urine) Of these only 50.7% (CI 50.0-51.4) received an ACE or ARB Am J Kidney Dis. 2005 Dec;46(6):1080-7. Summary of prevention

Lifestyle Modification ACE/ARB inhibitor therapy ARB therapy Control Blood sugar Control Blood pressure

Vitamin D Detect proteinuria Intervene for falls secondary to neuropathy. Service Planning for Diabetes Develop a comprehensive approach Planning ahead is everything! *Review meds & work closely with providers to optimize *Ensure labs happen quarterly *Ensure blood pressure is controlled *Involve therapy and encourage exercise *Address neuropathy * Smoking cessation

*Dietary plans that satisfy but maximize control *Diabetes support groupsshared medical goals work! Service Planning for Diabetes Reminders for annual eye exams/more frequent with problems or changes in vision. Provision for residents with poor vision. Podiatry on a regular basis Skin checks with personal care Plan for insulin: delegation of staff plan for high/low blood sugars What STAFF need to KNOW!

Develop a TEAM approach Empower your team with knowledge Insulin injctions Provide quick start guides to staff for symptoms Provide quick start guides for residents who have diabetes; talk about these residents with staff, so they

know what to expect and what to look for. Role play to ready staff for crises with residents. Teach staff how to encourage positive/healthy behaviors. This Photo by Unknown Author is licensed under CC BY HYPO/HYPERGLYCEMIA Teach the symptoms ROLE PLAY can help staff respond appropriately This Photo by Unknown Author is licensed under CC BY

This Photo by Unknown Author is licensed under CC BY-SA Do all diabetic residents have working glucometers? Check monthly to ensure glucometers are working correctly. Easy to add to monthly medication checks when residents are self-med. Make a plan for crisis for each resident. Decide on a place to keep it to ensure its handy for ALL staff to access. Decide as a team what the response will be and add it as an addendum to the service plan. Have a Diabetic of the month resident to discuss at inservices to keep the level of awareness high.

Incentivize staff who are able to state the plan for residents. Skin and Feet: The Achilles Heel for diabetics Teach staff how to carefull look at all skin when they are assisting with personal care. Foot checks should be part of daily routine as residents don shoes. Help Residents Help Staff

Group training has evidence support success Teach residents how to report high/low blood sugar symptoms Adherence to diet Report skin issues Pay attention to feet/footwear Exercise clubs In house vision screening Blood pressure checks Insulin

Pre-planning is everything Review blood sugar logs prior to admission Individualized care is important; resident habits are critical Involve others in training. Pharmacy and home health partners can help. Take advantage of new initiatives to train staff. QUESTIONS

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