Diabetes Self-management Education – Part 2

In part 1 of this blog, I discussedmuch of the importance of diabetes self-management education (DSME)and mentioned diabetes self-management training (DSMT) in mainly thecontext of use by certified diabetes educators. The article fromthis link provides much information. There are a few more points tobe discussed and emphasized before I discuss more about peer mentorsand peer-to-peer workers using this (DSME) to supplementself-monitoring of blood glucose (SMBG).
The topics of depression, physicaldisability, personal preferences, and quality of life were mentionedand need more emphasis. It is also important to considerhypoglycemia, life expectancy, and the incorporation of otherprofessionals in the care of the elderly. These topics are importantfor professionals and need to be learned by peer mentors andpeer-to-peer workers.
Mild depression for people with type 2diabetes is about two-thirds of them and less than one-fifth may havesevere depression. The article states that the rate of depression inpatients is at least two times higher than the general population. It then continues to say the risk of an older person with diabetesexperiencing a major depressive episode is 1.6 times higher. I thinkthey mean the general population, but this is not said. The key ofwhy this is important is this statement “Functionaldisability (difficulties performing activities of daily living andsocial activities) is significantly increased in the presence of bothdiabetes and depression, and it negatively affects self-care.” Therefore, screening for depression in the elderpopulation is necessary. If depression if suspected, the depressionneeds to be resolved before any changes are made to the diabetesself-management plan.
In the previous blog, recent illness oran operation were mentioned, but physical disabilities also needs tobe evaluated. The people over the age of 60 may have other physicallimitations in performing the activities of daily living (eating,dressing, and toileting). They may also have problems in other areasof daily living such as using the telephone, preparing meals,traveling, and managing finances. Additionally, older adults are athigher risk of hearing loss, vision problems, decreased mobility,falls, fear of falls, and chronic pain.
Patients who are experiencingdifficulties with daily tasks will need mandatory individual ratherthan group DSME. Treatment regimens will need to be relativelysimple rather than normal or complex regimens. Learning new skillswill take longer and may require referral to a visiting nurse to makesure the task is fully integrated into the patient's self-careregimen. A check back program to evaluate the learning progress maybe necessary as well. A physical therapy or local elder servicesreferral may be needed to assess the home environment and preventpotential injury from falls or accidents.
In elderly patients with type 2diabetes, it is very important to find out what the personalpreferences are with respect to care. It is well known that whenpatients' preferences can be incorporated into care plans, adherenceincreases, patient satisfaction increases, and the likelihood ofimproved patient outcomes goes up. Some patients will not needadjustments to their treatment plan, but others with physical orcognitive challenges, may need many adaptive changes.
For the elder type 2 diabetes patients,concern for hypoglycemia is a must if they are on insulin or acombination of oral medications and sulfonylurea is among thecombinations. The elderly are more likely to be vulnerable withhypoglycemia occurring at lower blood glucose levels, be harder torecognize, and have poorer outcomes. In the elderly, hypoglycemiamay show up in terms of neuroglycopenic symptoms like dizziness,weakness, confusion, and even delirium. This is unlike the symptomsof the younger generations called adrenergic such as tachycardia,palpitation, and sweating. In the elderly, hypoglycemia mayaggravate common diseases such as coronary artery disease andcerebrovascular disease. The frail elderly may have outcomes such asinjurious falls, even with mild hypoglycemia.
Taking the two diseases mentioned inthe last paragraph and adding the two other pathological conditionsof hypertension and dyslipidemia to the list and these often dominatethe overall health of older patients. Functional status of olderpeople with type 2 diabetes and cognitive decline changes the focusof care treatments from optimizing goals for diabetes to optimizingfunction and quality of life. The best treatment goals then becomeachieving the best possible glycemic management allowable, whilemaintaining independence and optimizing quality of life.
Factoring in that for some elderly withtype 2 diabetes, life expectancy may be shorter than the time neededto obtain benefits from an intervention. Before recommending orimplementing complicated, costly, or uncomfortable treatment regimensthat may result in harmful side effects, it is necessary to realizethat there will be reduced adherence to recommended therapies, andreduced general well-being. In other words, the time frame needed torealize benefits should be carefully considered relative to lifeexpectancy.
Two other areas for discussion mustinclude the use of multiple disciplines and care partners in thetreatment of the elderly diabetes population. Because older patientswith diabetes are clinically and functionally even more diverse thantheir younger counterparts, therefore they have even greater need forthe services of specialists, including nurses, dietitians, exercisephysiologists, behavioral medicine specialists, social workers,pharmacists, and rehabilitation professionals.
In chronic diseases such as diabetes,day-to-day care responsibilities fall mostly on patients. However,when patients are unable to assume full responsibility for theirself-care, family members, friends, or other care partners may needto be involved. In older adults in particular, care partners can playa critical role in managing chronic illness, tipping the balancetoward effective rather than failed self-care. If needed, familymembers or other caregivers should be included in DSME.
Because of the shortage of certifieddiabetes educators and even the absence of in many rural areas, thisis an opportunity for peer mentors, and peer-to-peer workers to filla need. For the ages about 60, the educators seem to vacate theirresponsibility and this creates a vacuum that needs filling. This isa reason to become educated in this area and work with theprofessionals that do care about the health status of the elderly. They, in my limited experience, are willing to share knowledge andgive some training.
It is necessary for us to learn what weare able from these caring professional and undertake with theirguidance the task of using DSME to assist the elderly diabetespatients. Communication is a must especially back to the doctor bythe peer mentor and peer-to-peer worker. Because of HIPAA rules,unless a patient specifically asks the doctor to alert us of his/hermedical health conditions, our participation will be severelylimited.
Limitations aside, there are someelderly patients being served by peer mentors and peer-to-peerworkers and the patients are sometimes filling in the informationneeded.  Never let the lack of informationcompletely stop you as a peer mentor or peer-to-peer worker as theneed for us is there and by learning about DSME and SMBG and othercare areas, we will be useful.
Build a network of specialists,including nurses, dietitians or nutritionists, exercisephysiologists, behavioral medicine specialists, social workers,pharmacists, and rehabilitation professionals, so that if the patientyou are working with is in need of their services, you are able torecommend to the doctor, people that are available in that community. The doctor is the only one able to make the determination call andmake the referral after evaluating your report and talking to thepatient or their caregiver.
Always make a report to the doctor eachtime you visit a patient you are assigned and make the report asdetailed as possible. What you leave out, may make a difference, soinclude any item even if you prioritize the list. This blog and theprevious blog lists many of the areas of concern; however, it is notall-inclusive.