The purpose of this pilot study was to identify elderly patients' technique errors in self-monitoring of blood glucose (SMBG) in nie home setting. Twenty-two patients aged 65 and older were observed using the One Touch II® meter in their homes 3 to 4 weeks after the initial meter instruction. A 25-item behavioral skills checklist was used to determine how much of what the patient initially learned was accurately demonstrated over time. Overall, the elderly patients were able to perform the Wood glucose test correctly. However, performing the Duality control checks proved more ifficult. The need for follow-up instruction regarding quality control measures and the blood glucose test procedure is documented. Results from this investigation will expand existing knowledge of elderly patients' self-care skills in the home setting.
Diabetes management is a complex issue in an increasing number of elderly patients. Noninsulin dependent diabetes mellitus (NIDDM) rates of diagnosis increase proportionally with patient age. The number of US residents over age 65 with diabetes mellitus is projected to increase from 3.3 million in 1990 to 4.1 million in 2010 - and to 6.8 million by the year 2030 (American Diabetes Association, 1989).
Diabetes educators instruct the elderly on the aspects of self-care necessary for daily management. Widely accepted as a standard practice in diabetes management, SMBG provides the elderly patient the ability to check glucose levels in his or her home. The 1986 Consensus Statement on SMBG concluded that all SMBG systems tested were sufficiently accurate; however, technique was the main source of erroneous results (American Diabetes Association, 1987). This article addresses the following question: What technique errors in SMBG do elderly patients make at home after attending a diabetes education program?
Even though many meters are easier to operate than those available in the past, quality control measures still are necessary. SMBG quality control consists of meter maintenance, calibration, verification, and control solution checks (Gadsden, 1988). The American Association of Diabetes Educators (1989) recommended assessing test procedures, checking equipment, and conducting quality control tests at regular intervals.
Because medication and daily schedule changes may be based on the recorded blood glucose readings, it is imperative that the results are accurate. A diabetes education program includes instruction in performing a blood glucose test and quality control checks on the meter system.
Numerous studies have examined user technique in the younger population; (Delamater, 1989; Wing, 1986) however, the elderly patient's technique in SMBG has not been fully addressed. Along with the increased possibility of developing diabetes with advancing age, an elderly client who develops the disease will be faced with a self-care regimen that may be rendered more difficult by the normal physiologic changes of aging (Dellasega, 1990). Changes in hearing, vision, memory, manual dexterity, and comprehension have an impact on effective patient teaching of the elderly (Casserly, 1988). All the above are necessary components in learning the self-care of SMBG.
The importance of summarizing education to the elderly and evaluating self-care skills immediately after instruction is documented in the literature (Picariello, 1986). However, evaluating the performance of the SMBG skill several weeks after instruction has not been addressed. Also, there is minimal documentation in the literature on research that specifically addresses elders' SMBG technique errors in the home setting.
Criteria for participant inclusion in the study were the following:
* Age 65 years or older;
* Confirmed diagnosis of NIDDM;
* Completed diabetes education program at study site hospital as either an inpatient or outpatient; and
* Use of One Touch II meter
Twenty-two subjects (17 women and 5 men) were included in the study (Mean Age = 72.6, SD = 5.8). Fifty percent of subjects received inpatient instruction and 50% were trained in an outpatient setting. The participants had attended the diabetes education program at Methodist Hospital in Minneapolis, where they were instructed in the use of the One Touch II meter by a certified diabetes educator. Each patient was able to perform all the One Touch II technique steps correctly at the completion of the diabetes education program.
The hospital's human subjects committees reviewed the research proposal. All subjects were required to sign a consent form if they chose to participate. Subjects were given one box of One Touch test strips for participating in the study.
The One Touch II behavioral skills checklist was developed specifically for this study. The instrument has 25 behavioral skills divided into four subgroups, which are necessary for operation of the One Touch ? meter. The specific skills on the checklist were derived from the operating manual of the One Touch II.
To establish content validity and face validity, the instrument was analyzed by three certified diabetes educators familiar with the One Touch ? meter and one company representative from the manufacturer of the meter. The three certified diabetes educators were nurses employed by the hospital's diabetes education program. The four experts rated each of the 25 skills on the checklist as to their appropriateness. Interrater reliability was established by having a second diabetes educator complete a checklist while the primary investigator filled one out. Checklist scores for both observers were identical on the pretests done on three inpatients.
The elderly patients' homes were the sites for this research study. Each patient's SMBG technique was observed in the room where testing usually was done. The researcher set up a time and date (3 to 4 weeks following the initial meter instruction) to go to the participant's home.
On the day prior to the scheduled visit, a reminder phone call was made. When the investigator arrived at the home, she asked the participant to do a blood glucose test, followed by a check strip test, a glucose control test, and a cleaning of the One Touch ? meter. Through observation, the investigator rated each of the behavioral skills on the checklist as pass or fail.
The data obtained from the checklist was quantified for analysis. The limitations of the instrument were that it indicated only whether the elderly patient passed or failed each objective. The reason why the behavior was not acceptable was not documented.
The investigator documented blood glucose results at the time of the study to determine if each patient was hypo- or hyperglycemic, which could have affected skill performance. The mean blood glucose level was 178 ±68 mg/dL (9.8 ± 3.8 rnmol/L). All blood glucose tests were taken postprandially.
Because normal distribution was not assumed with the sample size of 22, nonparametric tests were used on the data. Using 2x2 tables, the pass /fail responses were compared with the patient's age, sex, and inpatient/ outpatient status. Because of the smaller sample, the Fisher exact test was applied. No significant differences in the frequency of pass/ fail rates were identified for any of the above variables.
Frequency distributions were used to determine what technique errors in SMBG elderly patients make at home after attending a diabetes education program. The Table gives the percentage of patients who failed the individual skills on the checklist. The three most frequent errors included the following:
* Failure to check control solution expiration dates (86%);
* Not shaking the vials of control solution (82%); and
* Not verifying glucose control solution results (68%).
This study demonstrated that many elderly patients were able to operate a One Touch II meter in their home setting after proper initial instruction. This finding is important for health professionals who previously may not have done SMBG with elderly clients, thinking the skill was too difficult for the clients to learn. It was also a positive sign that the majority of patients were able to clean the meter; a clean meter is vital for continued accurate results.
However, the elderly patient does need to review quality control measures. The execution of SMBG quality control measures are important procedures for the proper operation of any blood glucose meter. The results from this study support the American Association of Diabetes Educator's (1989) recommendation of periodic evaluation of SMBG use. Inservice programs to home care and public health nurses regarding the importance of quality control measures to check meter operation are recommended; these nurses have the advantage of evaluating SMBG in the home setting of their patients.
Self 'Monitoring of Blood Glucose Evaluation Instrument
Location of the testing (eg, kitchen, bedroom, bathroom) and room lighting may be factors in obtaining accurate results. Eight of the 12 kitchen tables used in this study had food debris on the surface (many patients set their blood glucose strip down on the table before putting it in the meter). Seven participants had placed small lamps directly next to the meter to aid them in applying the blood to the correct spot on the test strip.
Having two types of quality control checks (ie, check strip and glucose control solution test) appeared to be ovenvhelrning for some of the participants. Participants often were able to perform only one of the quality control checks. It would be beneficial, especially for the elderly patient, if meter manufacturers devised one simple method for checking the SMBG system's accuracy.
Development of a noninvasive blood glucose meter using laser technology is presently being investigated. However, the issues of correctly performing the test and quality control measures will still be important for meters of the future.
Further studies using larger samples and various populations are needed to further assess and document SMBG by the elderly patient. As the numbers of elders using SMBG increase, so does the need for research to promote the most appropriate and cost-effective education and evaluation of this self-care.
- American Association of Diabetes Educators. Position statement: Effective utilization of blood glucose monitoring. Diabetes Educator 1989; 15(5):461.
- American Diabetes Association. Conference summary: Financing the care of diabetes mellitus in the 1990s. Diabetes Care 1989; 13:1021.
- American Diabetes Association. Consensus statement: Self-monitoring of blood glucose. Diabetes Care 1987; 10:95-99.
- Casserly, D.M., Shock, E. Educating the older patient. Caring 1988; 7(ll):60-64.
- Delamater, A.M., Davis, S.G., Bubb, J., Santiago, J. V, White, N.H. Self-monitoring of blood glucose by adolescents with diabetes: Technical skills and utilization of data. Diabetes Educator 1989; 15(1)56-61.
- Dellasega, C. Self-care for the elderly diabetic. Journal of Gerontological Nursing 1990; 16(l):16-20.
- Gadsden, R.H. Challenges in diabetes management/milestone in monitoring. New York: Health Education Technologies, 1988, pp. 63-66.
- Picariello, G. A guide for teaching elderly. Geriatric Nursing 1986; 7(l):38-39.
- Wing, R., Koeske, R., New, A., Lamparski, D., Becker, D. Behavioral skills and selfmonitoring of blood glucose. Relationship to accuracy. Diabetes Care 1986; 9:330-333.
Self 'Monitoring of Blood Glucose Evaluation Instrument