Module 3.2.1
About diabetes and guidelines
for management of diabetes in
the elderly
Planning and delivery of best
practice care for general
nursing staff
Produced by The Alfred Workforce Development Team
on behalf of DHS Public Health Diabetes Prevention and Management Initiative
June 2005
Presentation purpose
Target audience
 General nurses – with background knowledge of diabetes
Aim
 To provide best practice care for people with diabetes.
Objectives
 Provide an overview of diabetes and how it affects the body
 Explore what information people with diabetes require in order to
understand their condition and appropriate education strategies to
provide this information
 Explore what is best practice care for people with diabetes and present
examples
 Review current practices across the catchment
 Review the use of PCP service coordination tools and practices in
promoting best practice care
 Discuss strategies for evaluation of care planning.
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Diabetes: a definition
Diabetes is a chronic disease
 Characterised by high blood glucose
levels
 High blood glucose levels may result
from

The body not producing insulin (Type 1)
 Insulin in the body not working effectively
(Type 2)

DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Insulin
Insulin is a hormone produced in the
pancreas
 Insulin is needed for glucose to move
from the bloodstream into the bodies
cells to be used for energy
 Lack of insulin or ineffective insulin
results in high blood glucose levels

DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Types of diabetes mellitus

Impaired Glucose Tolerance

(IGT, Impaired Fasting
developing diabetes
Glucose)
high
risk
of
Type 1: caused by insulin deficiency
 Type 2: caused by relative lack of insulin

and insulin resistance

Gestational Diabetes Mellitus (GDM)
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Presentation focus

Type 2 Diabetes Mellitus
particularly elderly
people with Type 2
Diabetes.
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Diagnosis of diabetes
Type 2, IFG, IGT
 Glucose Tolerance Test (GTT)

Diabetes
Unlikely
Venous Fasting
plasma <5.5
mmol/l
IGT & IFG
Diabetes
Random
Fasting
2hr GTT
Fasting
Random
<5.5
6.16.9
7.811.0
7.0
11.1
mmol/l
mmol/l
mmol/l
mmol/l
mmol/l
Evidence Based Guideline for the case Detection and Diagnosis of Type 2 Diabetes.
Australian Government NHMRC www.diabetesaustralia.com.au/education_info/nebg.html
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Signs and symptoms of Type 2
Excessive urination
 Thirst
 Recurrent infections / Thrush
 Tiredness / Drowsiness
 Weight change
 Blurred vision
 Hyperglycaemia
 Dehydration
 Urinary ketones
 Glycosuria

DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Common characteristics of type 1 and 2
Age of onset
Body weight
Type 1 (10-15%)
Type 2 (85-90%)
Usually <40 (can occur in
Usually >45 (but
elderly)
increasing at younger
age
Lean
Usually obese
Prone to ketoacidosis Yes
No
Medication
Insulin essential
Tablets and /or insulin
Onset of symptoms
Acute
Gradual (may be
asymptomatic)
Family history
Risk Factors
Genetic
Viral/Environmental Obesity/↓ activity
Cultural background
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Prevalence of diabetes

Diabetes
7.5% of population aged 25 years and over
 17.9% 64-75 years
 23.0% 75 years+


IFG or IGT 16.4%
AusDiab Study (Dunstan et al, 2002)
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Large landmark trials
Diabetes Control and Complications Trial
Type1DM (DCCT, 1993)
 Type 2 DM United Kingdom Prospective
Diabetes Study (UKPDS, 1998)

Both demonstrated the beneficial effects of
maintaining good glycemic control on the
development & progression of DM
complications
 UKPDS also highlighted need for blood
pressure control

DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Treatment goals for diabetes
Symptom free
 Prevent short term
complications
 Prevent long term
complications
 Quality of life =Lifestyle focus

DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Why do we need guidelines for the
elderly?





Australian population is ageing
Diabetes has a higher prevalence in ageing
people
Sub-optimal management in many settings
Diabetes guidelines rarely address specific care
issues and the elderly
National Diabetes Strategy & Implementation
Plan (1998) cites special considerations
required for the elderly
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Who is considered elderly?
“Young old” 65-75 years
 “Old, old” >75 years

Popplewell P. Diabetes and the Elderly in Phillips P et all Diabetes and You – The essential Guide.
Canberra: Diabetes Australia 1999
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Guidelines for the management and care of
diabetes in the elderly
The Australian Diabetes Educators Association
(ADEA) 2003 www.adea.com.au

Guidelines are a consensus statement
following:


Extensive literature review
Consultation process involving:




Relevant professional organisation
Commonwealth/State/Territory Health Depts.
Geriatric Services
Content experts
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Guidelines focus

Guidelines focus on “healthy” person
with diabetes over the age of 65 years

Needs of frail elderly should be
considered on individual basis with
special consideration of physical and
mental status
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
Purpose of guidelines

Provide accessible information on diabetes
prevention, diagnosis, treatment and long term
management options for elderly people

Guidance on what is broadly appropriate rather
than prescriptive

Important application relies on individual
assessment of health status, self care beliefs
and physical environment.
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
1. Case detection and diagnosis

Asymptomatic elderly people should be
screened for undiagnosed diabetes by
measurement of fasting plasma glucose
as recommended for the general
population
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
2. Assessments and targets

Elderly people with diabetes should have
regular comprehensive clinical and
laboratory evaluation of metabolic
control and screening for complications
as follows…………………….
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
2. Assessments and targets

Glycaemic control

Glycaemic control (HbA1c 7%, adjustment for
hypoglycaemia)


Assess twice a year - 4x year if unstable
Target BGLs (not included in guidelines)





4-8 mmol/L ideal
5-10 mmol/L safer for elderly (many live alone)
6-12 mmol/L in hospital
< 4 mmol/L= risk of hypoglycaemia
>15 mmol/L = symptoms of hyperglycaemia,
increased risk of complications
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
2. Assessments and targets

Controlling blood sugar levels

Exercise / Activity
Increased insulin sensitivity
 Decreased insulin requirements
 Weight reduction
 Lipid control
 Blood pressure control

DPMI Workforce Development – The Alfred Workforce Development Team June 2005
2. Assessments and targets

Controlling blood
glucose levels

Healthy Eating



Regular carbohydrate
High in fibre
Low in fat (particularly
saturated fat)


Low in added sugar
Adequate energy
/protein/fluids/vits and
mins
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
2. Assessments and targets
Monitoring BGLs
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
2. Assessments and targets

Blood pressure and lipids
Blood pressure (140/90 mm/Hg)
 Lipid profile (LDL <2.5, trig <2.0 mmol/L)
 Assessment


3 monthly / 6 monthly if normotensive
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
2. Assessments and targets

Eyes, kidneys and feet

Renal function




Eye examination



Assess annually
3-6/12 if positive (microalbuminuria/protein)
Creatinine annually
Assess at diagnosis and every 2 years
If retinopathy present then annually
Foot assessment


Assess annually
3-6/12 for high risk feet
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
2. Assessments and targets

Cognitive capacity
Capacity/desire
to learn
Capacity for self care
Eyesight/hearing
Literacy level
Poor memory
Assess with Mini Mental State Exam (MMSE)
(score = 30, 18-26 suggests dementia, <10 severe dementia)
Gregg EW. Complications of diabetes in elderly people. Underestimated problems include cognitive
decline and physical disability. BMJ 2002b; 325,916-7
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
3. Special treatments

Nutrition assessment
Distribution and intake of carbohydrate
important
 Weight loss not recommended unless > 20%
above weight range


Encouraged to follow National Physical
Activity Guidelines: 30 minutes of
physical activity each day (tailored for
frail elderly)
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
3. Special treatments
Alcohol (1/day women 2/day men)
 No smoking
 Hypoglycaemic agents


Need to consider comorbidities,
contraindications and side effects especially
hypoglycemia
Antihypertensive therapy
 Lipid lowering therapy

DPMI Workforce Development – The Alfred Workforce Development Team June 2005
4. Addressing barriers to health care
and education


Special attention should be given to ensuring elderly
and their carers have access to diabetes education
and specialist services
Use of care plans based on recognised standards of
diabetes care





Comprehensive assessment
Identification of problems and actions to address problems
Documentation
Regular evaluation of care plan
Active involvement of individual in care plan if practical
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
4. Addressing barriers to health care
and education

Actively involve individuals in their own care




Knowledge is required.
Understanding the problem as seen by the person with
diabetes.
Finding out what their fears and hopes for the future
are.
Helping them to identify the problems and work
through solutions to fulfill their hopes for the future.
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
4. Addressing barriers to health care
and education

Education considerations








Information provided is consistent with individual’s
capacity to comprehend
Communication is consistent with adult learning
principles
Language and culture, interpreter
Assess individual needs
Include significant others
Provide written information
Review knowledge and skills regularly
Consistent information
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
5. Hypoglycemia
Greater awareness of risk
 Specific education to the elderly and
carers re hypos/changes in OHA/other
 Increase BG testing
 Caution with prescribing diabetes tablets
/insulin treatment

DPMI Workforce Development – The Alfred Workforce Development Team June 2005
6. Hyperglycemia

The possibility of Hyperosmolar
Hyperglycemic Nonketotic state (HONK)
should be considered in elderly people
with extremely high blood glucose levels
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
6. Hyperglycemia

Hyperosmolar non-ketotic coma (HONK)
Extreme hyperglycemia
Symptoms/confusion
 NO ketones
 Significant dehydration
 50% have non diagnosed Type 2 Diabetes
 Can be fatal, mortality 10-63%
 Treated with IV fluids, some insulin

DPMI Workforce Development – The Alfred Workforce Development Team June 2005
7. Primary Prevention
Elderly people should be encouraged to
exercise regularly and to lose excess
weight in order to reduce their risk of
developing Type 2 diabetes
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
In conclusion the aim in elderly
people with diabetes is to…






Relieve symptoms of high glucose levels
Avoid low glucose levels
Achieve agreed blood glucose levels
Monitor diabetes complications
Encourage health and fitness habits
Ensure older people are actively involved in
setting goals for their diabetes management
DPMI Workforce Development – The Alfred Workforce Development Team June 2005