A diabetic battle plan: strategies for the front line of the primary care setting to support elderly type 2 diabetic patients manage their health” Chad.

A diabetic battle plan: A diabetic battle plan: strategies for the front line of the strategies for the front line of the

primary care setting primary care setting to support elderly type 2 diabetic to support elderly type 2 diabetic

patients manage their health”patients manage their health”

Chad LaRoche, PA-SChad LaRoche, PA-SAdvisor: Dr. Carrie JohnsonAdvisor: Dr. Carrie Johnson

The purpose of this event was to direct attention to the global epidemic of diabetes, now killing more people annually than AIDS and malaria combined (UN Radio 2007).

It was estimated that during 2007:•every 10 seconds one life prematurely ended from diabetes-related causes•every 10 seconds somewhere in the world two new people developed diabetes

(IDF 2007).

Martin Silink, president of the International Diabetes Federation , defined diabetes as “the largest epidemic the world has ever seen (UN Radio 2007).”

The United Nations declares diabetes a “potential threat to society… as it threatens to subvert the gains of economic advancement globally.”

Prevalence of Diagnosed Diabetes

by Age, United States, 1980–2005

Diabetes is prevalent.

In 2005, among Americans 60 years of age or older, 10.3 million or 20.9% had diabetes. Of this group, only 65% were aware of their condition, leaving at least 35% of the 10.3 million elders untreated and very vulnerable to diabetes’ devastating complications (NDEP 2007).

By the year 2050, this already high prevalence is expected to increase by 220% among those aged 65–74 years and 449% among those aged ≥75 years (Narayan 2006).

This means that in 40 years, every second person over the age of 65 would have diabetes.

Diabetes is prevalent.

Adding to this number will be the percentage of people with pre-diabetes, which in 2005 was already over 40% for those over 65 years of age (NDEP 2007). A diagnosis of pre-diabetes is clinically significant because it marks an increase risk for heart disease and approximately 50% of cases eventually progress to diabetes (McCulloch 2007).

Diabetes’ effects are severe.

If you are diagnosed with diabetes, you are approximately 2 to 4

times more likely to die from heart disease or suffer from a stroke

than adults without diabetes.

Diabetes is the leading cause of new cases of blindness among

adults 20-74 years of age. In 2002, it was the leading cause of

new cases of kidney failure, accounting for 44%.

Out of all non-traumatic lower-limb amputations more than 60%

occur in people with diabetes.

Additionally, it is estimated that 60% to 70% of people with

diabetes have mild to severe forms of nervous system damage

(CDC 2005).

Diabetes’ effects are severe.

Longitudinal analysis of Medicare data ,1994-2004

six years past a new diagnosis of diabetes 90% of patients

experienced at least one complication.

Compared to cohorts without a diagnosis of diabetes:

•rates of cerebrovascular, renal, and lower extremity

complications actually increased

•rates of cardiovascular complications remained stable

•only ophthalmic disease rates fell

(Sloan 2008)

Diabetes’ effects are expensive.

After adjusting for differences in age, sex, and ethnicity, Hogan and colleges found that individuals diagnosed with diabetes had medical expenditures during 2002 that were approximately 2.4 times higher than those incurred by the same group without diabetes (Hogan 2003).

Frank Vinicor, of the Centers for Disease Control and Prevention in Atlanta, stated that “we do not seem to be making great progress in preventing complications in these elderly diabetes cohorts… Taken to the extreme, there will soon be too many patients with diabetes to be individually treated and not enough money to pay for it all (Vinicor 2008)”

In the United States, the immense and yet needless suffering and financial loss many elderly patients incur from type 2 diabetes mellitus can be significantly minimized by improving the quality of care in the primary care setting.

How can care improve?

1. There are many things about the disease that are yet to be understood.

2. Lack of adherence to already documented evidence-based practices

Copyright restrictions may apply.

Saydah, S. H. et al. JAMA 2004;291:335-342.

Percentages of Adults With Recommended Levels of Vascular Disease Risk Factors in NHANES III (1988-1994) and NHANES 1999-2000

Copyright restrictions may apply.

Shojania, K. G. et al. JAMA 2006;296:427-440.

Postintervention Differences in Serum HbA1c Values After Adjustment for Study Bias and Baseline HbA1c Values

In 2005 only 53% of adults in the U.S. (42% of those over 65 in Kentucky) had even taken a class in how to manage their diabetes (KCHFS 2007)

What is known?

American Diabetes Association states that screening should be considered in all individuals over 45 years of age. If results are normal, repeat testing should be carried out at minimum 3-year intervals

Medicare has determined it cost effective to pay for two diabetic screening tests per 12 month period if two of the following risk factors are met: high blood pressure, dyslipidemia, obesity, impaired glucose tolerance, or a high fasting glucose level (CMS 2007)

Regular glucose screening in elderly patients is especially important because the usual signs and symptoms of diabetes are different in an older population: •As one ages the renal threshold for glucose increases, thus older patients do not typically develop glucosuria until the plasma glucose is profoundly elevated. •Also because of an impaired thirst mechanism, older people often do not develop the presenting sign of polydipsia. •To make a swift diagnosis more difficult other presenting symptoms often tend to be nonspecific: like fatigue, slight cognitive impairment, and general pain. These lead to a large set of differential diagnoses in the elderly. Often these general symptoms are understood by the elderly person as inherent to the aging process and thus are seldom reported (Meneilly 2006).

What is known?

A is for aspirin. • All adults with diabetes and additional

cardiovascular risk factors or over the age 40 should be taking between 75 and 162 mg daily of enteric-coated aspirin, unless there are contraindications. (Sherman 2004).

• A meta-analysis of a large number of secondary prevention trials found that the absolute benefit of aspirin was greatest in those over age 65 years with diabetes and/or diastolic hypertension (McCulloch 2007).

What is known?

A is for Hemoglobin A1c (HbA1c) HbA1c twice/yr in patients with stable glycemic control; quarterly, if poor control (AGS 2007).

For Pts that are healthy the general goal of 7% is appropriate

For Pts that are frail; life expectancy <5 yr; or high risk of hypoglycemia, polypharmacy, or drug interaction consider a higher goal like <8%

What is known?

A is for Hemoglobin A1c (HbA1c)

However, patients with poorly controlled diabetes may be subject to acute complications of diabetes, including dehydration, poor wound healing, and hyperglycemic hyperosmolar coma

What is known?

Drugs should be started at the lowest dose and titrated up gradually until targets are reached or side effects develop

•Metformin is often contraindicated because of renal insufficiency or significant heart failure.

•TZDs can cause fluid retention, which may exacerbate or lead to heart failure. They are contraindicated in patients with CHF (New York Heart Association class III and IV),

•Sulfonylureas, other insulin secretagogues, and insulin can cause hypoglycemia. (ADA 2008).

What is known?

B is for blood pressure • All adults with diabetes the blood pressure

goal should be <130/80 mm Hg, if safely achieved. This can be accomplished by behavior changes and with various hypertensive drugs.

What is known?

C is for cholesterol. Lipid profiles q 1–2 yr depending on whether

values are in normal range. (AGS 2007)

Keeping the low-density-lipoprotein (LDL) to less than 100 should be the goal

Lowering blood pressure with a variety of antihypertensives and LDL cholesterol with statins results in decreased morbidity and mortality within 2 to 3 years (Sherman 2004).

What is known?

C is for cognitive impairment. • It is important to remember to do the Mini-

Mental State examination on older adult diabetic patients. There is a link between decreased memory, learning and verbal skills with type 2 diabetes.

What is known?

D is for diet A diet rich in fruits, vegetables, whole grains,

and healthy sources of protein (poultry and fish), and containing unsaturated vegetable fats as the main source of fat, but that is low in red and processed meats, refined grains, and sugar-sweetened beverages.

What is known?

D is for depression• Depression is more prevalent in adults with diabetes than

those without.

• Among the elderly this can be exacerbated by isolation and lack of family or peer support.

• The prevalence of depression among older diabetics ranges from approximately 15 to 40%.

• Depression has been associated with an approximately five-fold increase in health care expenditures for diabetes significantly these are medically related and not mental health related (DeRekeneier 2003).

What is known?

D is for Drugs interactions. Older adults are highly susceptible to adverse drug reactions as well as drug

interactions and drug-disease/disability interactions.

Common syndromes among the elderly, such as falling, confusion, and incontinence can be reduced through simple evaluation of the patient’s daily medication during each visit. This is when a team approach is much more effective.

Patients with renal dysfunction have a significantly higher probability of adverse drug reactions. Renal dysfunction increases with age and is present in many older diabetics. With the use of a nomogram to calculate glomerular filtration rate, it was found that concealed renal dysfunction was present in nearly 20% of older patients with diabetes that had acceptable serum creatinine levels.

What is known?

D is for diabetes education. Older adults however may be limited in either one-

on-one or group sessions due to physical, visual, or even cognitive impairments. The need for this education in self-management skills and nutritional therapy is vital in order for the patient to continue care at home through lifestyle changes that are significant in their overall health. Providers must be sensitive to the method of education and make accommodations for impairments common in geriatrics

What is known?

E is for eye care. Annual comprehensive dilated eye and visual

examinations by an ophthalmologist or optometrist who is experienced in management of diabetic retinopathy (AGS 2007).

Cataracts are over twice as common in people over age 65 years with diabetes compared with normal subjects (38.4% versus 16.6%) while glaucoma is almost three times more common (11.2% versus 3.8%).

What is known?

E is for abnormal urinary Excretions • Incontinence and electrolytes indicative of

renal failure and microalbuminuria.• Older women are especially at risk for urinary

incontinence.• Testing for excretion of certain electrolytes

must be done soon after diagnosis and continue annually given the added risk of renal failure and microalbuminuria. This also should lead to treatment using ACE inhibitors

What is known?

E is also for exercise Older adults benefit significantly from exercise,

even 20 minutes 3 times a weekAdding resistance training to aerobic training

enhanced glucose disposal in postmenopausal women with type 2 diabetes. The improved insulin sensitivity is related to loss of abdominal subcutaneous and visceral adipose tissue and to increased muscle density. (Cuff 2003)

What is known?

F is for Foot careFoot examination, including monofilament

testing at 4 plantar sites (great toe and base of first, third, and fifth metatarsals), palpation, and inspection, each visit; insensate feet should be inspected q 3–6 mo; well-fitted walking or athletic shoes my be of benefit (AGS 2007)

What is known?

F is for Falls. Older patients with diabetes have a higher rate of injurious falls, possibly related to visual impairment, peripheral neuropathy, hypoglycemia, polypharmacy, or any combination thereof.

Falls by older adults are associated with high rates of morbidity, mortality, and functional decline.

Confirming one or more falls in the past year and performing tests of dynamic (tandem gait) and static (tandem stance) balance can help you find the older adult with diabetes who is at risk of falling (Sherman 2004).

What is known?

F is for flu and pneumonia vaccine: All geriatric patients with diabetes are at risk for both of these infections. Administering a yearly influenza vaccination and a one-time pneumococcal vaccination will decrease the incidence of influenza and pneumonia in your practice (Sherman 2004).

What is known?

S is for stopping smoking.

Approximately 12% of adults over age 65 smoke cigarettes.

www.bridgestoexcellence.org• Number of Recognized Physicians:• 40

• Rewards Paid to Date:• $340,475 since 2003

• BTE Programs Implemented:• Diabetes Care Link

• Geographic Scope of Market: • Louisville area

• Number of Covered Lives in Market:• 52,000

• Participating Employers: General Electric , UPS

• Licensed Health Plan Administrators: Aetna , Anthem-Wellpoint , United Healthcare

• Performance Assessment Organizations and Measures:• National Committee for Quality Assurance (NCQA)

• American Association of Diabetes Educators (AADE)* - http://www.diabeteseducator.org

• American Diabetes Association (ADA)* - http://www.diabetes.org

• American Dietetic Association (ADietA)* - http://www.eatright.org

• American Geriatric Society (AGS). - www.geriatricsatyourfingertips.org.

• The Better Diabetes Care website - http://www.betterdiabetescare.nih.gov/

• International Diabetes Federation* - http://www.idf.org/home/

• National Diabetes Education Program (NDEP). - www.ndep.nih.gov/diabetes

• World Health Organization* - http://www.who.int/

• References:

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Figures 2: Plasma glucose multihormonal regulation of glucose