Helping Senior Patients Better Manage Type 2 Diabetes

August 21st, 2014

A diagnosis of type 2 diabetes can be life changing. From significant dietary alterations to lifelong medication management, type 2 diabetes requires seniors to make many lifestyle adjustments, and often leads to a different relationship with food altogether. For older adults especially, the disease can lead to serious complications, many of which have to do with a condition called hyperglycemia: a state of elevated blood sugar levels that can persist in seniors who are not properly controlling their diabetes or receiving adequate diabetes care. And the disease is on the rise in the elderly population: according to the Centers for Disease Control and Prevention, “The prevalence of diabetes among adults aged 65 and over increased by more than 50 percent between 1997 and 2006.”

We know that diabetes is not simply a metabolic disease that changes the body’s ability to make and utilize insulin. It’s also a disease of the vascular system, as excess glucose (sugar) in the blood damages blood vessels. Complicating matters further, older adults with diabetes have a higher risk of heart attack, stroke, renal disease, eye disease, and death than their younger counterparts. Undoubtedly for these seniors, the disease exacerbates the physical and emotional difficulties they already face as they age.

Successful diabetes control is due, in part, to the small everyday choices senior patients and their caregivers make. You have the unique opportunity to educate them on what it takes to live well with the disease, as well as what to do when they are feeling ill in order to head off a crisis. Here’s how to help your elderly patients stay on top of their diabetes care, no matter where they are in their disease progression.

Medical Care and Diabetes Education

Studies show that well-educated diabetes patients often fare better with the disease, and have better-controlled blood glucose levels, than those who don’t receive diabetes education.

Primary care physicians play an important role, as they are often at the helm of care coordination and can address patient questions and concerns about medications. Primary doctors can not only allay fears about issues like taking insulin injections for the first time, but they can also refer seniors to other healthcare providers who can further educate them about the disease. While it’s important to assess the cognitive and physical abilities of your senior patient to utilize education services, seniors with diabetes are eligible to receive 10 hours of diabetes self-management training in a 12-month period under Medicare, if their doctors prescribe it. This added help can make a world of difference in their quality of life.

When Nancy Ryan, MS, RD, BC-ADM, CDE, registered dietitian and certified diabetes educator who is board certified in advanced diabetes management, first meets with a senior, she makes sure to ask what information is most important to them. “I ask them what their concerns are and what they would like to achieve during our visit,” says Ryan. “They may be coming to an appointment with information they heard about the disease, some of which is spot-on and some of which is not, so it’s important to see what their health beliefs are.”

Through this training, either with an independent certified diabetes educator or at a hospital that offers an outpatient diabetes self-management program, seniors can learn how to monitor their own blood glucose levels to make sure they’re reaching their targets. They are also shown what to do in the event of a hypoglycemic episode, how to emotionally cope with the disease, and strategies for remembering to take their medications.

Since many certified diabetes educators are also registered dietitians, you could recommend that your senior patient receive diabetes education and medical nutrition therapy with the same provider, if possible, in his area. This can save him time and transportation costs. Seniors can find certified diabetes educators by logging on to the National Certification Board for Diabetes Educators website.

Nutrition Therapy

As many healthcare professionals know, medical nutrition therapy is a core component of diabetes treatment as outlined by the American Diabetes Association (ADA). But because the willingness and ability to make dietary changes will vary from patient to patient, and because many patients may have other diseases that affect their dietary needs, it’s not enough to simply suggest that they watch their carbohydrate intake. A registered dietitian can provide individualized nutrition therapy to your senior patient — and this treatment is a covered benefit under Medicare for older adults with diabetes, if they have referrals from their doctors.

Aside from teaching correct portion sizing and how to read food labels, a registered dietitian can address individual nutritional needs, taking personal preferences into account, and help with everything from meal planning to carbohydrate counting (the person with diabetes will need to limit themselves to 45-60 grams of carbohydrate per meal, according to the ADA guidelines).

“A lot of this is a negotiation with the senior,” says Ryan. “If they have a favorite food that will raise their blood sugar, like chocolate cake, we’ll work to make an accommodation for it.”

Registered dietitians can also address obstacles to adequate food intake that might fly under the radar during a routine doctor’s visit and impact blood sugar levels, such as lack of access to food or low appetite as a drug side effect.

Debra Brown-Grossman, RD, CDE, who has a private practice in Montclair, NJ, cautions her senior patients with diabetes not to skip meals. This can be even more harmful than eating too many carbohydrates in one sitting as it raises their risk of hypoglycemia (low blood sugar).

“The first order of business is making sure [patients] have enough to eat,” Brown-Grossman says. “Meal replacement shakes formulated for people with diabetes can be helpful here. If patients or their family members can purchase a case, they can choose that instead of not eating.”

For day-to-day meal planning, there are several rules of thumb your senior patients can follow: protein will slow sugar absorption, so have a lean cut of meat, an egg, or a handful of nuts to accompany carbohydrate-rich foods. Also, look at the total carbohydrate value on food labels at mealtime — there may be multiple servings in a food that comes in a single container. Help your senior patient find a dietitian by pointing her or her caregiver to the Academy of Nutrition and Dietetics website.

Preventing and Treating Complications

Because seniors are at high risk of developing hypoglycemia due to altered kidney function, other medications that interact with their diabetes drugs, and even the diabetes drugs themselves, it is important that they know the signs and symptoms of a hypoglycemic episode.

“If they have blurry vision, the shakes, and nausea, we want to make sure they have emergency skills to treat that,” says Therese Franzese, MS, RD, CBE, CDN and clinical nutrition manager for Hebrew Hospital Home Care. “They should immediately have four ounces of fast-acting glucose, such as a half of a glass of juice or milk, wait 15 to 20 minutes, and then check their blood sugar levels.”

Ask your senior patient if she has experienced hypoglycemia since her last visit. If you notice that these episodes are becoming more frequent, she may require a change in medication. (For example, sulfonylureas, a class of oral diabetes medications, have been associated with a higher frequency of hypoglycemia.)

Once diagnosed, seniors should also be screened for conditions common among those with diabetes, such as heart and renal disease, and depression. (People with diabetes are twice as likely to suffer from depression as people without the disease, and this often leads them to stop receiving adequate diabetes care.) A referral to a cardiologist, ophthalmologist or optometrist, podiatrist, dentist, mental health professional, and an endocrinologist at the outset can help prevent complications.

It may also be beneficial to remind your senior patient to take note of his cholesterol levels and blood pressure readings so that he can inform other members of his healthcare team of those numbers. High blood pressure and high blood cholesterol are two common coexisting illnesses among people with diabetes.

“We have to look at all the parts of the puzzle,” Ryan says. “If we only look at blood sugar and not blood lipids or blood pressure, we’re missing two thirds of the issue.”

Lastly, encouraging your senior patients to check their feet every day for sores, cuts, blisters, bruises, and ingrown toenails can help them find and treat wounds right away. According to the National Institutes of Health (NIH), between 60 to 70 percent of people with diabetes develop neuropathy, or nerve damage, which can decrease sensation in their legs and feet. A daily foot check can help decrease the risk of complications such as infections, gangrene, or tissue death.

Exercise and Weight Management

Regular physical activity has been consistently shown to improve glycemic control and prevent cardiovascular disease in people with diabetes. Its importance in diabetes management cannot be overemphasized to the senior or her caregiver. Many seniors with diabetes will have impediments to some forms of exercise because of retinopathy, nerve damage, or other medical conditions such as arthritis, so they should be assessed for these conditions prior to starting an exercise program. Beyond that, referring your senior patients to a clinical exercise physiologist can help them boost their own safety during exercise, reduce their risk of injury and fear of falling, and learn techniques to help their balance and coordination.

The American Diabetes Association’s current guidelines suggest 30 minutes of aerobic exercise at least five days per week (for a total of 150 minutes per week) along with strength training twice per week.

Edy McClure, MS, RD, CDE, CDN, works with senior patients in Southbury, CT, and suggests that they take a daily walk with a loved one or friend and use any weight machines available to them in their housing complex or long-term care facility. “If they don’t have access to machines, they could use canned goods or water bottles as weights and do arm exercises with them,” McClure adds.

Many seniors are eligible for a program called SilverSneakers, a nationwide health program that that provides gym membership and wellness counseling through their Medicare Advantage or Medicare Supplement Health plan. They or their caregivers can check their eligibility by visiting the SilverSneakers Fitness website.

Above all, seniors should know that people are living longer with type 2 diabetes, despite the fact that it does pose a great number of physical, mental, and emotional challenges. If a senior patient is finding diabetes self-management difficult, they may be able to receive in-home diabetes care from a home health clinician to make living with the disease more manageable.