Matteson and McConnell suggested that the issue of self care is of special concern for older individuals and their families since the later years are often a time when this capacity becomes limited. l Diabetes, a chronic illness affecting 14% of the elderly population, is an example of a condition that threatens the ability of older persons to care for themselves. In addition to an increased likelihood of contracting diabetes with advancing age, an elderly client who develops the disease will be challenged by a self-care regimen that may be rendered more difficult by normal physiologic changes of aging.
Ninety percent of older diabetics suffer from Type II or noninsulin dependent diabetes.2 This type of diabetes often does not become apparent until the middle or later years, at which time obese or overweight persons with a family history of the disorder are primary candidates. Since signs and symptoms of diabetes may be altered or absent in elderly persons, diabetes is often not diagnosed until the onset of some other type of physiologic stress, such as infection or surgery.3 Often by this time, complications such as retinopathy or renal disease have already set in (Case I).4
Because blood sugar levels tend to rise in the later years,5 it is important mat screening efforts take into account age-related changes in renal and pancreatic function. Carotenuto and Bullock have suggested that the use of ageadjusted nomograms are particularly relevant for elderly persons.6 Beebe believes that the oral glucose tolerance test is the preferred means for detecting diabetes.7
Once a diagnosis is established, the diabetic regimen for older individuals consists of basically the same components as the regimen younger persons follow. Depending on the particular primary care provider's philosophy, these components can be adhered to with varying degrees of strictness (tight versus loose control).8 Regardless of me measure of control prescribed, however, it should be stressed to the client that diabetes is a chronic disease that requires a large measure of responsibility for carrying out individualized routines on a daily basis. Whereas nurses, dietitians, and other health-care providers can teach a patient necessary measures for self care, it is ultimately the individual who decides whether to implement and comply with them.
Richardson asserts that noncompliance with regimens for chronic illnesses such as diabetes occurs in half of all patients.9 Koltun and Stone have identified three variables most frequently named in relation to compliance: those related to the patient, those related to the provider or prescribed treatment, and those related to the environment where the treatment was prescribed.10 Yurick, Robb, and Spier suggest that elderly persons can fail to comply with specific therapeutic prescriptions either intentionally or unintentionally for a variety of reasons.11 In the case of diabetes, it is especially important to examine physiological and psychological factors that may inhibit the elderly person's capacity for self care. It is the role of nurses working with elderly diabetic patients to diligently assess a client's ability and intention to carry out a prescribed regimen prior to implementing nursing interventions that can help achieve a client goal of maximal function. In this manner, nursing is a primary force for helping older persons comply with programs designed to enhance their health status.
Health promotion efforts often focus on the young or middle-aged segments of society with the rationale that early intervention may offset later problems . ,2 Yet, for older persons who have an increased risk for many chronic illnesses, health promotion and prevention strategies are equally as important. A healthy, nutritional lifestyle consisting of a balanced diet and maintenance of ideal body weight can help reduce the risk of diabetes.13 Persons with a family history of the disease should have regular blood sugar screenings to provide a means for the early detection of possible problems. Although an elderly diabetic may initially appear asymptomatic, it is nonetheless a good practice to teach all older persons signs and symptoms that may accompany the disease. Older people who complain of fatigue, weight loss, hunger, thirst, or other alterations in their sense of wellbeing should always be screened for diabetes.
Education about the cause of the disease is the first step in helping older persons adjust their lifestyles to accommodate diabetes. Any sound teaching plan begins with an assessment of the learner's knowledge base, motivation, and communication abilities. This is especially important with older persons because contacts with peers who have diabetes may have lead to misconceptions or fear about the disease. Relying on commercialized pamphlets with small, difficult-to-read print to impart important information is not sufficient. Because older persons come from an era where formal education was often limited to grade school14 or they may suffer from declines in hearing and sight that make communication difficult, teaching strategies must be tailored to meet the individual's needs (Cases). For an older client, presentation of small amounts of material at a slow pace is more likely to be retained.2 Short-term memory loss (common with the aging process) necessitates providing written or verbal cues to remind the client of key points taught previously. Obtaining feedback at the end of each teaching segment and prior to beginning a new session will help focus on topics that may require additional reinforcement.
Regardless of the rigidity of the elderly diabetic's diet, underlying principles of good nutrition should be the basis for teaching. Although calorie counting and weighing of food portions may be encouraged, a well-balanced, consistent diet may be a more realistic goal for an older client. For some elderly persons, especially those with financial constraints, merely achieving a nutritious diet may require drastic changes from their current patterns. Decreased taste sensitivity and the need to eat alone may predispose the older individual to highly sweetened and seasoned convenient foods. Arthritis or other problems with mobility and dexterity may hamper the person's ability to prepare the proper types of food. Two good resources for diabetics are the government subsidized Meals on Wheels or Congregate Feeding programs. Meals on Wheels will deliver a diabetic diet to the home; Congregate Feedings will provide the same in a group setting.
For an older diabetic who is overweight, it is essential to begin gradual weight reduction by establishing a properly balanced diet. Because metabolic declines in older adults may cause them to maintain or gain weight even if they are consuming the same number of calories as in the younger years, the process may need to take more time and focus on short-term, attainable goals.15
Monitoring the urine or blood for glucose levels is an important component of any diabetic's daily routine. Although the frequency and specific type of test to be used may vary between individuals, elderly diabetics should be encouraged to keep a written record of test results to offset difficulties with short-term memory loss. If urine testing is used, the elderly person should be reminded to use a double-voided specimen first thing in the morning. Care should be taken to ensure that older persons are able to see the print and interpret the results of their tests from the side of the urine test bottle or package insert. Although testing blood glucose with either a chemical strip or glucose monitor is more accurate man urine testing, these procedures may be difficult for an older person to master if there exists limited range of motion from degenerative joint disease. Medicare will usually cover the cost of a Glucometer (approximately $150 to $210); however, it is important that patients continue to visit their regular health-care provider for periodic health screenings. Clients should be encouraged to report any sustained elevations of blood sugar readings, especially in the presence of other diabetic symptoms.
If older diabetics are capable of producing some insulin, they may be placed on an oral hypoglycemic agent. It should be stressed that careful regulation of the diet is still indicated even though the client is on medication. Because older persons in general tend to take many medications, possible drug interactions should be monitored. 1 Salicylates, alcohol, anticoagulants, Phenytoin, furosemide, and thiazide diuretics have all been known to interact negatively with oral agents.5 If insulin injections are prescribed, the client's ability to see the medication label and withdraw the correct amount of the drug should be evaluated. If needed, aids such as a magnifying sleeve that fits over insulin syringes can be obtained from the Blind Association or other low-vision groups. Older persons should not be encouraged to depend on someone else for their injections; if at all possible, they should self-administer insulin to maintain their independence. Although degenerative joint disease may limit the areas that can be used for injections, proper rotation methods can provide sufficient sites in the legs and abdomen. Because there tends to be a decrease in subcutaneous fat and increased friability of the skin with age, elderly diabetics should be cautioned against repeatedly injecting insulin in the same spot, which could result in hardened areas where poor absorption of insulin has occurred. New injectors offer promise for elderly persons who are able to master their use.
Due to financial constraints, an older person may question reusing insulin syringes. Although pharmacists may not recommend this practice, in reality it occurs quite frequently. Education about aseptic technique and skin care should be carried out; however, if syringes are kept clean and needles remain sharp, no adverse consequences of reuse have been reported.16
Although the precise mechanism remains unknown, exercise can enhance the body's ability to utilize glucose.1 In addition, older people often suffer from other chronic conditions, such as arthritis and osteoporosis, that respond to exercise programs. Low impact forms of exercise, such as walking and swimming, have been encouraged for older individuals.17 If the person is homebound or has extreme limitations in mobility, a simple program of range of motion exercises can be implemented. It is important that elderly persons, as with any age group, be screened prior to beginning a fitness program and that they start slowly and gradually increase length and difficulty.
PREVENTION OF OTHER CONDITIONS
Elderly persons are generally more prone to other acute and chronic conditions; thus, additional early action should be undertaken to decrease risks in persons with diabetes. Pneumonia and influenza vaccines should be strongly encouraged to prevent potentially life-threatening respiratory infections. Regular visits to an ophthalmologist are critical, since mere vision screening is unlikely to detect retinopathy until extensive damage has occurred. Foot care is another area there teaching should be aggressively implemented. Older people are normally more prone to foot problems due to slowed circulation and skin changes, and they must be vigilant in protecting their skin integrity should diabetes occur. Attention should be paid to obtaining properly fitting shoes and nonconstrictive hosiery. Clients who smoke should be informed of the relationship between smoking and circulatory disease, and methods for cessation efforts explored.18 Sensory changes in the lower extremities increase the vulnerability of older persons to burns from innocent sources such as too-hot bath water or prolonged use of heating pads on extremities that have decreased heat sensitivity. If breakdown occurs, it is important that the client seek the advice of a physician or nurse rather than relying on home remedies to cure the problem. Regular visits to a podiatrist for nail care are also encouraged.
In the event of diabetic coma or insulin shock, it is likely that older persons may not have the "typical" signs and symptoms of these conditions.16 Sometimes confusion is the sole presenting condition of a diabetes-related complication. Older individuals, as well as those in their immediate environment, should be taught the standard interventions for dealing with either shock or coma. In addition, wearing an identification bracelet or necklace and carrying a wallet card may help others detect the cause of changes in the client's condition when communication is impaired.
If elderly persons experience an acute illness, such as a viral infection, and find eating impossible, they should continue testing blood or urine sugar levels and contact their physicians regarding any adjustments in type or amount of insulin that may be indicated. Since elderly persons are very susceptible to dehydration, it is especially important that clients maintain their fluid intake. Sources of carbohydrates, such as toast or crackers, should be encouraged to maintain energy levels.
Elderly diabetics present a special challenge for gerontological nurses. Often, the coping process that accompanies any chronic illness is more difficult for an elderly person who may be struggling to deal with other conditions or who views any efforts at self-care as worthless. In these instances, an opportunity exists for nurses to make a profound difference in the lives of older individuals. By facilitating a client's ability to remain independent despite a disease process, nurses convey the belief that elderly persons deserve the same opportunity for a vital, fulfilling lifestyle as any other age group.
- 1. Matteson M, McConnell E. Gerontological Nursing: Concepts and Practice. Philadelphia: WB Saunders Co; 1988.
- 2. Burggraf V, Stanley M. Nursing the Elderly: A Care Plan Approach. Philadelphia: JB Lippincott; 1989.
- 3. Murray R, Huelshoetter M, O'Driscoll D. The Nursing Process in Later Maturity. Englewood Cliffs, NJ: Prentice-Hall, Ine; 1980.
- 4. Bigos J. The elderly diabetic: Sometimes there are no red flags. Second Season: Clinical Care for Your Aging Parent. 1987; 2(l):4-5.
- 5. Eliopoulos C. Gerontological Nursing, 2nd ed. Philadelphia: JB Lippincott; 1987.
- 6. Carotenuto R, Bullock J. Physical Assessment of the Gerontological Client. Philadelphia: FA Davis Co; 1980.
- 7 . Beebe M; VanDam Anderson S , Bauwens E, eds. Diabetes Mellitus in Chronic Health Problems: Concepts and Application. St. Louis: CV Mosby Co; 1981:201-219.
- 8. Smith D. Outpatient care of the diabetic. Journal of Gerontological Nursing. 1983; 9(8):422-430.
- 9. Richardson J. Perspectives on compliance with drug regimens among the elderly. Journal of Compliance in Health Care. 1986; l(l):33-45.
- 10. Koltun B, Stone G. Past and current trends in patient noncompliance research·. Focus on diseases, regimens, programs and providers - disciplines. Journal of Compliance in Health Care. 1986; l(l):21-32.
- 11 . Yurick A, Robb S, Spier B, et al. The Aged Person and the Nursing Process. New York: Appleton-Century-Crofts; 1980.
- 12. Dychtwald K. Wellness and Health Promotion for the Elderly. Rockwell, MO: Aspen Publications; 1986.
- 13. Department of Health and Human Services. Dietary guidelines for Americans. Home and Garden Bulletin. 1985; 232.
- 14. National Institute on Aging. Established Populations for Epidemiologic Studies of the Elderly. Washington, DC: Department of Health and Human Services; 1986. National Institutes of Health publication NIH 86-2443.
- 15. Mezey M, Rauckhorst L, Stokes S. Health Assessment of the Older Individual. New York: Springer Publishing Co; 1980.
- 16. Cameveli D, Patrick M. Nursing Management for the Elderly. Philadelphia: JB Lippincott; 1986.
- 17. Ebersole P, Hess P. Toward Healthy Aging: Human Needs and Nursing Response, 2nd ed. St. Louis: CV Mosby;. 1985.
- 18. Swearington P, ed. Manual of Nursing Therapeutics: Applying Nursing Diagnoses to Medical Disorders. Menlo Park, Calif: Addison Wesley Publishing Co; 1986.