Meeting the challenge of caring for older adults living with diabetes
In this issue, Susan Weiner, MS, RDN, CDN, CDCES, FADCES, talks with Kathy W. Warwick, RD, CDCES, about special considerations when working with older adults with diabetes.
Why is the topic of caring for older adults with diabetes so important today?
Warwick: Estimates are that 1 in 5 Americans will be older than 65 years by the year 2030, and diabetes currently affects more than 25% of those in this age group. Prediabetes is also present in about half of those over age 65 and is likely to progress to type 2 diabetes if no lifestyle changes are made. In addition, a substantial number of those diagnosed with type 1 diabetes early in life are surviving longer. The sheer numbers are staggering for the health care system, providers and payers. In 2016, Medicare spent $42 billion more to care for those with diabetes than those without the diagnosis. Statistics show that diabetes alone is responsible for half of hospital admissions and over half of long-term care admissions. Diabetes self-management education and support training has never been more relevant, and yet only 5% of those eligible take advantage of this Medicare benefit. Looking at older adults with diabetes through the lens of COVID-19 certainly amplifies the need for optimum diabetes management and holistic care.
What makes the older adult population challenging to care for?
Warwick: This is a very diverse group. On any given day in clinic, you may encounter an 86-year-old asking for help adjusting the timing of meals and insulin dosing for a trip across several time zones and then a frail 68-year-old needing a referral for home care services. Most carry several chronic illness diagnoses, and polypharmacy is common. Many are living on fixed incomes, and approximately 1 in 3 live alone, which can put them at greater risk for malnutrition, food insecurity, depression and hypoglycemia. In contrast, others may still be working, enjoying great family and community support, and feeling the desire and motivation to fully participate in self-care for optimal quality of life.
This group has a wealth of knowledge, insight and life experience, but may be overwhelmed by the burden of daily care associated with a new diagnosis of diabetes. Newer diabetes technologies, such as continuous glucose monitors and integrated insulin delivery devices, may offer flexibility and improved glucose management but can be daunting to master for some older adults.
What do you see as priorities for care providers working with older adults?
Warwick: Performing an accurate initial assessment of cognitive ability, financial situation, social support, barriers to medication adherence, and the client’s beliefs and goals for care is critical. This takes time and patience from a dedicated interdisciplinary care team. The key to developing a successful treatment plan is the practice of patient-centered and patient-driven decision-making.
Older adults have likely experienced many losses in their lives: the death of parents, siblings, a life partner or perhaps a child; retirement from a career; and declining physical health with limitations on activities they once enjoyed, increasing dependence on others and a loss of control. Care providers should avoid making treatment choices for older adults, allowing them as much control over decisions as is practical. Involving family members or caregivers in these discussions can be essential. Ongoing support and follow-up assessments can help avoid medication errors and the need for emergent care.
Several professional associations suggest individualization of HbA1c goals based on this assessment and other criteria, such as the presence and severity of complications or physical impairments, and life expectancy at the time of diagnosis. Prevention of hypoglycemia and reducing the risk for falls and serious injury should have a high priority. In terms of medication adherence, cost and complexity of the prescribed regimen must be regularly evaluated to ensure safety, efficacy and affordability. Simplification of medication regimens can be achieved without sacrificing glycemic stability.
Referrals for psychiatric care, physical therapy, occupational therapy and social services are often warranted initially and then as medical complications develop or living situations evolve. There are four critical times when older adults should see a diabetes care and education specialist: at the time of diagnosis; annually to assess education, nutrition and emotional needs; when new complicating factors influence self-management; and when transitions in care occur.
How is the post-acute or long-term care environment changing, and what are providers focused on?
Warwick: The trend toward creating a home-like environment with flexible mealtimes, liberalized regular diets and relaxed HbA1c goals is becoming more common. There is increased concern for undernutrition with restrictive diets. Self-selected meals offered in family or restaurant style may help maintain adequate food and fluid intake.
As the baby boomers move into this phase of life, there will be more demand for autonomy and flexibility around medical management. Older adults in these care settings have greater risks for unrecognized hypoglycemia and hyperglycemia for many reasons. Care providers in these settings have been challenged to eliminate the use of sliding scale insulin for long-term management of diabetes. Minimizing the risk for hypoglycemia is the primary consideration along with improved quality of life. Transitioning to a once-daily dose of basal insulin given in the morning to provide prandial action and to reduce the incidence of nocturnal hypoglycemia is a good first step. In adults with dementia who may have great variability in meal intake, rapid-acting insulin can be given after meals so that care staff can evaluate the actual amount of carbohydrate ingested.
Polypharmacy is extremely common as medications have been added through the years and multiple specialists have been consulted. As kidney and liver function decline, health care providers are encouraged to reduce dosages or eliminate medications whenever possible.
Transitions in care can be exceptionally difficult when residents require acute care. Accurate interfacility communication and a dedicated interdisciplinary team focused on quality diabetes care can reduce serious complications and hospital readmissions.
Caring for older adults with diabetes is as rewarding as it is challenging, and this group deserves respectful, compassionate care.
- American Diabetes Association. Diabetes Care. 2020;doi:10.2337/dc20-S012.
- LeRoith D, et al. J Clin Endocrinol Metab. 2019;doi:10.1210/jc.2019-00198.
- Munshi MN, et al. Diabetes Care. 2016;doi:10.2337/dc15-2512.
- Power MA, et al. Clin Diabetes. 2016;doi:10.2337/diaclin.34.2.70.
For more information:
Kathy W. Warwick, RDN, CDCES, is owner of Professional Nutrition Consultants LLC in Madison, Mississippi. She can be reached at firstname.lastname@example.org; Twitter: @RD_KWarwick.
Susan Weiner, MS, RDN, CDN, CDCES, FADCES, is co-author of The Complete Diabetes Organizer and Diabetes: 365 Tips for Living Well. She is the owner of Susan Weiner Nutrition PLLC and is the Endocrine Today Diabetes in Real Life column editor. She can be reached at email@example.com; Twitter: @susangweiner.