Diabetes self-management education(DSME) can easily be used in place of self-monitoring of bloodglucose (SMBG) to confuse the unknowing public. They both involveeducation of the patient in management of blood glucose; however,DSME is then taken a few steps further to expand the issue. Both areequally valuable and can be used together. Many of us stop whentalking about SMBG at the end of managing blood glucose.
This is where we make the mistake anddo not carry the topic as far as DSME does. DSME continues on toinclude the whole process of diabetes management and takes intoconsideration the entire patient. For that reason, there has beensome separation legitimately in the titles. Sometimes certain groupsuse the term DSMT (diabetes self-management training). It is a shamethat the group that developed this only uses it in writing andself-promotion. This group seldom uses DSME or DSMT in actualpractice.
This article is about older adults, butshould apply across all ages with modifications. Older patients (age60 and older) with diabetes do account for more than one-fifth of allpatients with diabetes. One statement made in the study that I mayrepeat is this, and I quote, “Medical carein the absence of adequate self-care is rarely effective for chronicillnesses.” This is an important point and worthemphasizing repeatedly.
DSME is the supposed goal of certifieddiabetes educators. If they would follow and use it, we could allbenefit. Instead, they muddy it up with mantras and do not educatemany type 2 diabetes patients. This is their weakness and theimportance of DSME should not be diminished. DSME was originallydesigned for all types of diabetes – again the one-size-fits-all;however, I will be talking about type 2 diabetes for the oldergeneration in this blog and maybe for the younger generations in afuture blog.
DSME for those age 60 and olderrequires, and I mean requires that it be on an individualbasis. There is no place for a one-size-fits-all application for theelderly. Where possible it should involve care partners whenpatients are not able to assume full responsibility for their ownself-care. DSME should also consider the potential effects ofdiabetes treatments on quality of life, but at the same time,encourage all individuals who want to achieve successfulhealth-related care.
Studies of self-managementinterventions clearly indicate that health behaviors, health status,and health care utilization improve with patient education indiabetes daily care. If only Medicare would stop taking away testingsupplies, it might improve even more. One study compared patientsthat had received some diabetes self-management education withpatients not receiving any DSME. Those not receiving any DSME had afourfold increased risk for major diabetes complications. This alonepoints out the importance of diabetes education, and the moreeducation the better. This also explains the importance of follow upreinforcement of what they have learned, and asking how they aredoing with what they have learned. Be specific and do not acceptbrush-offs of the questions.
Now the one fault of DSME for the over60 age group is they are very under-represented in DSME researchstudies. Therefore, what we have is a set of expert consensusformulated guidelines developed by the American Association ofDiabetes Educators (AADE) and the American Geriatric Society. Thisalso highlights the need for other groups that can step forward andfill the need for those with type 2 diabetes. Since the AADE isobviously ignoring the needs of the elderly, this opens opportunitiesfor peer mentors, and peer-to-peer people. With the increasingnumber of people with type 2 diabetes, and the lack of growth in theAADE, these people will assume roles that are even more important inthe near future.
First, we have discussed making surethat the diabetes self-management education is created for theindividual and not a one-size-fits-all situation. This shouldconsider how long the individual has had type 2 diabetes. Next, adetermination needs to be made of existence of any complications,other medical conditions, and life expectancy. Lastly, is theindividual limited in English proficiency, frail, or cognitivelyimpaired as these must be part of the education process and made partof the care partner concerns.
Older adults should be carefullyevaluated do determine their knowledge of diabetes and their abilityto learn and apply new self-care skills. Social support,transportation availability, financial problems, and functionalstatus must be assessed. Treatment goals and management skills mayneed to be evaluated frequently to keep pace with changes infunctional and cognitive abilities, which can occur relativelyquickly.
For the elder generations, nutrition isimportant. Be sure that the proper nutrition authority is inattendance as problems with the Academy of Nutrition and Dietetics insome states is now the only people that can give nutrition adviceunless you are certified by them. Nutrition education is importantand older adults must be evaluated to determine if there needs to bechanges and to what degree these changes will be followed.
When assessing elder patients'understanding of diabetes and nutrition, a thorough assessment mustinclude individual food preferences, meal preparation capabilities,and potential misunderstandings of adequate nutrition. This shouldinclude, but not be limited to dental health, swallowingdifficulties, gastrointestinal complaints, decreased appetite,decreased thirst, taste-altering medications, limited finances, andsocial isolation. Because the diabetes patients are elderly, pushinga fixed number of carbohydrates must be forbidden. Registereddietitians that will not work to the needs and nutrition of elderlypatients should not be allowed on a team.
The above is an area of importance forthose doing DSME and sometimes they forget about unintentional weightloss as this increases mortality in elderly patients with diabetes. The problem of destructive metabolism is sometimes ignored for thesepeople because acute illness or recent hospitalization is overlooked. Diet moderation, and if medically able, increased physical activityshould be considered instead of severe caloric restriction, andshould be encouraged in older adults who sincerely wish to loseweight. The goal for individualized planning needs to minimizeproblems in nutrition management and facilitate changes in eatingbehaviors. This should be part of the goal to improve clinicaloutcomes, improved function, and enhance quality of life.
Inthe elderly, physical activity assessment can be very difficult andshould be done in coordination with their doctor. The elderly canoften be at increased risk for sedentary lifestyle. This may becaused by recent acute illnesses, coexisting medical conditions suchas chronic pain, no safe environment for physical activity, historyof falls, and fear of falling. There are many benefits if theelderly diabetes patients are able to exercise, but they should neverbe forced to exercise. Limited activity exercises need to beinvestigated when needed and done with their doctor's knowledge.
Other chronic diseases and the numberof medications the diabetes patient is taking are important inevaluating potential limitations for the patient. Polypharmacy isthe use of several or many medications at the same time. Polypharmacy is always difficult to assess in older patients as manywill not tell you what supplements they are taking because they thinknatural cannot be dangerous. With the conflicts between prescriptionmedications and some supplements, it is important to draw thisinformation out and get them to talk about them. If nothing more,list the supplements that can conflict with the medications you learnthey are using.
The fact finding with the elderly canbe problematic. Even if the elderly patient is coming to an officeand has been instructed to bring all medications and supplements,there is often the doubt that you are seeing all of them. Even forhome visits, medications are often hidden and not brought out. Therefore, some detective work must be done. Look for medicationsfrom more than one doctor or more than one pharmacy, as this may be aclue to more medications. Always record all information that is onthe prescription container, Rx number, date filled, directions,medication name and dosage size, quantity, physician name, refillsremaining, and prescription expiration date. Whether you are aneducator, peer-to-peer worker, or a peer mentor, dealing with someelderly patients can be a delicate situation where even the bestdiplomacy may not yield the discovery of all prescriptions andsupplements in use.
All conflicts in medication must bereported to the doctor as well as discrepancies like out of datemedications, medications not refilled, especially other doctors andpharmacies discovered. Always be on the lookout for duplication ofmedications and medications that may conflict with other medications.
An additional assessment needs to bedone to evaluate patients and their cognitive abilities to understandwhen medications need to be taken. Look for signs of depression andphysical disabilities that may interfere with medication adherence. This can be very important for the elderly with diabetes and usinginsulin. Pens may become more important than syringes in many casesand in some instances, it may be necessary to suggest or recommendfull care facilities.
Based on the discussion above,consider the following practical pointers for DSME in older adultsfound to have functional limitations: 1. Choose equipment that is easy to hold and easy to use.
2. When possible, simplify the self-care regimen.
3. Conduct education sessions at a slow pace, with instructionoccurring in steps. Use educational material that is easy to followand excludes extraneous information. Schedule multiplesessions, if necessary, to prevent information overload.
4. Provide individual rather than group education.
5. Recommend further evaluation and treatment of depression andcognitive dysfunction before making any diabetes treatment regimenchanges.
6. Use memory aids (e.g., personalized handouts) to reinforcepoints made during face-to-face sessions.
7. Make sure patients understand how to identify hypoglycemia andwhen to call the provider.
8. Make every effort to minimize the complexity of meal planningand to engage the patient's spouse or others living with the patientin creating a home environment that supports positive dietary change.
9. Prescribe weight loss diets with great caution.
To be continued in part 2.
Hiç yorum yok:
Yorum Gönder