Perspectives on Diabetes Care

Meds, Tech and Behavior Change in Care of Older Persons with Diabetes

Jun 28, 2021, 10:24 AM

By Sara (Mandy) Reece, PHARMD, CDCES, BC-ADM, BCACP, FADCES

MM, a 72-year-old female, comes to see you for diabetes self-management education and support along with her husband. She has successfully managed her diabetes for the last 10 years through her collaboration with you, strong support system and utilizing tools in her self-management tool kit. During today’s visit, she shares that she has new onset memory loss, recent hypoglycemia and is simply burned out pricking her finger and managing her diabetes. You empathize with her new challenges and want to help her work through them. So how can the recently updated ADCES Special Considerations in Management and Education of Older Persons with Diabetes provide valuable insight to help you?

At the foundation of the updated older persons recommendations is the ADCES7 Self-Care Behaviors™, providing a comprehensive approach in addressing healthy coping, healthy eating, being active, taking medication, monitoring, problem solving and reducing risks. Additionally, the American Diabetes Association provides a framework in considering treatment goals for older adults with diabetes in terms of glycemia, blood pressure and dyslipidemia. Within this framework, health status is determined by the number of comorbid conditions, presence and severity of cognitive impairment and presence of impairment of activities in daily living.

Here are a few ways you can use the ADCES7 in older adult care:  

• Healthy coping. Assessment of psychological well-being is critical, specifically assessing for diabetes distress, depression, stress and cognitive mental status as this directly impacts ability to self-manage diabetes. A variety of screening tools are available with baseline and follow up assessments.
• Healthy eating. Key for preventing hypo- and hyperglycemia and maintaining a healthy body weight in older adults. Assessment of healthy eating must be comprehensive considering risk for dehydration, changes in eating due to dentition, and undernutrition, which is particularly important in older adults.
• Being active. Collaboration with the care team is essential as well as considerations of comorbidities, cardiovascular status, fall risk and possibility of hypoglycemia when developing a physical activity plan. Monitoring of diabetes and possible complications goes beyond glucose and incorporates a variety of tools to assess cardiovascular risks; diabetes-related kidney, eye and nerve disease; periodontal disease; sleep apnea; etc. When we consider glucose monitoring, continuous glucose monitoring is an alternative to finger pricking, providing a deep dive into glucose trends and valuable insight for collaborative management of diabetes for older person with diabetes and their care team.
• Medication taking. Factor in cardiovascular and diabetes-related kidney disease benefits, simplifying the plan and deprescribing when appropriate, overcoming financial barriers and reducing risk for hypoglycemia.
• Problem solving. This encompasses social determinants of health, addressing financial barriers, evaluating the unique needs of older adults and caregivers, living environment, and screening and monitoring for cognitive decline.
• Reducing risk. This area addresses hypoglycemia identification, prevention and contributing factors (i.e. polypharmacy, inadequate nutritional intake).

Back to MM, she is in the complex/intermediate category due to her mild cognitive impairment which allows for slightly higher A1C and glucose targets which will help resolve her hypoglycemia. The burnout that MM is experiencing indicates possible diabetes distress and need for collaborative discussion with her and her husband on healthy coping and problem solving. Exploring continuous glucose monitoring and deprescribing of medications may contribute to resolution of both burnout and hypoglycemia. Additionally, assessment of her current eating and physical activity habits will provide insight into her hypoglycemia and possible nutritional deficiencies. Lastly, monitoring beyond glucose for complications from diabetes such as heart disease, diabetes related kidney disease and neuropathy would be appropriate for MM.

After you finish working collaboratively with MM and her husband in the most appropriate plan, she leaves the visit relieved that she is not alone and has a great support team to help her along her journey with diabetes.

Learn more about older adult care in recently updated guidance from ADCES.