Sandra Petersen DNP APRN FNPBC GNPBC PMHNPBE FAANP This Photo by Unknown Author is licensed under CC BYSANC Type 1 Type 2 HbA1C Diabetes Its more than just blood sugar ID: 775373
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Slide1
Diabetes in Assisted Living: What YOU Need to Know
Sandra Petersen, DNP, APRN, FNP-BC, GNP-BC, PMHNP-BE, FAANP
This Photo
by Unknown Author is licensed under CC BY-SA-NC
Type 1
Type 2
HbA1C
Slide2Diabetes: It’s more than just blood sugar…….
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by Unknown Author is licensed under
CC BY
Slide3Aging in America
Average life expectancy 72-79
At age 65, average life expectancy 82!
At age 85, average life expectancy 90
Fasting growing segment: over 85
1.5% population
Almost 5% of population by 2050
Slide4Prevalence of Diabetes
Over 20% those over 65 (NHANES 1994)
Framingham Data: Diabetes or impaired glucose tolerance (fasting glucose 120-139) in nearly 40% those over 65
Over 65 account for over 40% diabetic population
Slide5Cardiovascular Disease
Heart disease and stroke: Leading causes of death
60% deaths in those over 85 due to CVD
Morbidity: stroke and CHF
CHF: 6% new diagnoses/per year in age over 85
Slide6Prevalence of Dementia
6-10% those over 65
30-50% those over 85
Nearly 70% in those over 95
By 2025, expected 2 million centenarians in US!
Leading public health concern as the new chronic disease…
Slide7Diabetes Types 1 & 2: The Pathophysiology
Slide8Type 1 Diabetes
Type 1 diabetes signs and symptoms can appear relatively suddenly and may include:Increased thirst.Frequent urination.Extreme hunger.Unintended weight loss.Irritability and other mood changes.Fatigue and weakness.Blurred vision.
Slide9Type 1 Diabetes
Insulin-dependent/Juvenile onset (usually, but 1 in 3 with Type 2 don’t know they have it!)20 to 30% develop microalbuminuria after 15 yearsOf the ones who develop this less than half progress to diabetic nephropathyAssociated with microvascular disease – retina and kidney. The increased sugar is neurotoxic – hence neuropathy2.2 percent will develop end stage renal disease in 20 years and 7.8 percent in 30 years
Slide10Type 1 Diabetes (Continued)
The microalbuminuria can regress – and it is not the risk of developing kidney failure after 20 to 25 years in patients who have no proteinuria is lowLabile swings in blood sugar because of autonomic insufficiencyAlways requires insulinIf diabetic nephropathy develops, the patient will develop insulin resistance – metabolic syndrome due to kidney disease. Atherosclerosis and hypertension are not primary but secondary events
Slide11Slide12Type 2 Diabetes
Common in Hispanics, Native Americans, African Americans, but also prevalent in those with history of obesity and poor cholesterol and hypertensive control.Incidence of End stage kidney disease is lower, but the disease is more frequent – thus it is the most common cause of renal failureIncidence of microalbuminuria 25% but incidence of end stage renal disease only 0.8%Microlbuminuria patients spent an average of 11 years before progressing to overt proteinuriaOnly 2.3% progress from macroalbuminuria to ESRD
Slide13QUADRUPLED OVER NEXT 3 DECADES!
Slide14Type 2 Diabetes (Continued)
Disease progresses slowly over many years and is associated with proteinuria. The urine should show more than just red cells. In the elderly, it is impossible to clinically distinguish the hypertensive and atherosclerotic effects from the diabetic effects without a kidney biopsy.Not associated with labile blood sugar swingsInsulin resistance
Slide15Incidence of Type 2 Diabetes
Doubled in past 20 yearsRelated to Lifestyle Change and ObesityBMI Increase confirmed by NHANES DatasetSource: American Heart AssociationPrevalence of Diagnosed and Undiagnosed Diabetes in the United States, All Ages, 2007Total: 23.6 million people7.8 percent of the population—have diabetes.Diagnosed: 17.9 million peopleUndiagnosed: 5.7 million peopleSource: NIDDK
Slide16Diet Plays a Major Role
The Sugar Fix High fructose corn syrupDecreases the ATP in cells – this decreases cell respiration and causes hypoxia in cellsReleases cytokines that impair nitrous oxide synthesisReleases uric acid which increases blood pressureCauses leptin resistance (Leptin turns off the appetite) continue to be hungrySupersized – HFCS is in many soft drinks and other productsAmericans eat more sugar, now have an epidemic of obesity, the metabolic syndrome, heart disease and diabetes
Slide17Sugar Consumption
For a 2,000-calorie diet, 5% would be 25 grams. Limit daily sugar to 6
tsps
(25 g) for women, 9
tsps
(38 g) for men. Yet, the average American consumes 17 teaspoons (71.14 grams) every day. That translates into about
57 pounds
of added sugar consumed each year, per person!!!!
Slide18Metabolic Syndrome
Slide19Metabolic Syndrome
Characterized by insulin resistance – 50 to 75 million AmericansHigh blood pressureHigh blood sugarsHigh levels of triglyceridesLow levels of HDLIncreased waist lineIt is associated withDiabetes, Hypertension, stroke, cardiovascular diseaseDominant FeaturesObesity, lack of exercise
Slide20WHAT CAN YOU DO?
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by Unknown Author is licensed under
CC BY-NC-ND
Slide21What slows progression?
Proven interventionsControl blood sugar in diabeticsStrict blood pressure controlCertain meds: ACES (Angiotensin-converting enzyme inhibition) and ARBS (angiotensin-2-receptor blockade)Studied and has strong evidenceDietary protein and carb balanceLipid lowering therapy (except after age 85)Partial correction of anemiaVitamin D administration
Slide22Management Objectives: OFFER A COMPREHENSIVE REVIEW
Lifestyle An aspirin a daySmoking and ExerciseWeight/cholesterolBlood PressureACE and ARBVitamin DDiabetes Control (Logs)
Slide23Lifestyle - An aspirin a day – Stop Smoking and START Exercising – CONTROL Weight/cholesterol
Can be a rewarding way to keep diabetes under control.
Requires a lifelong strategy
Diet: Avoid fructose, excess salt, trans fats and excess carbohydrates
Two alcoholic beverages at most/day
25% incident diabetics are smokers
Potentiates kidney disease
Increases inflammation
Gentle aerobic exercise
Aspirin a day to reduce cardiovascular risk
IDEAS FOR MARKETING/WELLNESS for AL RESIDENTS!
Slide24BLOOD PRESSURE CONTROL
CRITICAL AT ALL AGES!
Slide25Slide26Blood pressure goal < 150/90 or less in some cases
Any person with abnormal kidneys is at risk for heart diseaseMost patients will require two or more medications to control their blood pressureLowering the systolic blood pressure to <130 mm Hg is usually associated with a reduction in diastolic blood pressure to <80 mm Hg
Adapted from American Journal of Kidney Diseases, Vol 43, No 5, Suppl Suppl 1 (May), 2004: pp S14-S15
Slide27ACES & ARBS
are the two majorclasses of medicationsused to treathigh blood pressure
Slide28Common ACEs and ARBs
ACE InhibitorsAngiotensin II Receptor Blockers (ARBs)benazepril (Lotensin)candesartan (Atacand)captopril (Capoten)eprosartan (Tevetan)enalapril (Vasotec)irbesartan (Avapro)fosinopril (Monopril)losartan (Cozaar)lisinopril (Prinivil, Zestril)olmesartan (Benicar)perindopril (Aceon)telmisartan (Micardis)quinapril (Accupril)valsartan (Diovan)ramipril (Altace)trandolapril (Mavik)
Common Generic and Brand Names for ACE Inhibitors and ARBs
Slide29Vitamin D Makes the News
Slide30Vitamin D to the Rescue!
Vitamin D
is believed to help improve the body's sensitivity to insulin – the hormone responsible for regulating blood sugar levels – and thus reduce the risk of insulin resistance, which is often a precursor to type 2
diabetes!!!
Slide31Diabetes Control
Sulfonylureas
Biguanides
Thiazolidinediones “Glitazones”
Meglitinides
DPP-4 Inhibitors
Incretin Memetics
Insulin
Slide32ADA Guidelines
Slide33TYPENAMEMECHANISMROUTE, TIMESulfonylureasGlimepirideGlipizideGlyburideIncreases insulin production through K channels of beta cellsPo qd or bidBiguanidesMetformin (Glucophage)Reduce hepatic glucose output and increase its muscle uptakePo bid – tidXR – po qdThiazolidinediones “Glitazones”Rosiglitazone (Avandia)Pioglitazone (Actos)PPAR gamma ligand – improves glucose utilizationPo qdMeglitinidesRepaglinide (Prandin)Nateglinide (Starlix)Close K channel and open Ca channel in Beta cell – increasing insulinPo 5 – 30 min ACDPP-4 InhibitorsSitagliptin (Januvia)Blocks, DPP-4 which catalyzes enzyme breaking down insulin100 mg po qdIncretin MemeticsExenatide (Byetta)Stimulates beta cells and slows digestion10 mcg sc 60 min AC AM and PM meal
Medications for Diabetes
Slide34SULFONYUREAS
First category of oral agents for diabetes – now in third generation
Mainly for type 2 diabetes – work on existing beta cellsIncrease secretion of insulin by binding to potassium channels and opening calcium channelsCan cause hypoglycemia and weight gain
Slide35BIGUANIDES
Metformin used in obese type 2 diabeticsMaximum reduction in HgbA1c after 6 monthsAction lasts additional 9 months with thiazolidinedioneWith sulfonureas HgbA1C tends to increaseReduced cardiovascular risksPharmacotherapy. 2007 Aug;27(8):1102-10.Loss of glycemic control in patients with type 2 diabetes mellitus who werereceiving initial metformin, sulfonylurea, or thiazolidinedione monotherapy.Riedel AA, Heien H, Wogen J, Plauschinat CA.
Slide36ROSIGLITAZONE
Controversy regarding risk of causing MI
Odds ratio 1.43ADOPT – increased fracturesAssociated with macular edemaStimulates the PPARγ receptorNot to be used in heart failureNissen SE, Wolski K. Effect of Rosiglitazone on the Risk of Myocardial Infarction and Death from Cardiovascular Causes. N Engl J Med. 2007;356(24):2457-2471.
Slide37INCRETIN MIMETICS
Exenatide (Byetta)From the saliva of the gila monsterIncretin – mimeticEnhances beta cell insulinBlocks glucagonDelays gastric emptyingInjection sub cutaneously 30 to 60 minutes before first and last meal – adjunctive therapySide effects – Gastrointestinal symptomsFDA warning – pancreatitis – may be fatal
Slide38WHEN TO START INSULIN
Start with oral agents (metformin) and proceed to insulin if goal is not achievedMay be able to manage for up to 6 yearsHgbA1C – use a targetIn kidney patients– because of the risk of hypoglycemia – may want to have a higher goalMono-duo-triple therapy – disease has advanced
Slide39HgbA1C
American Diabetic Association 7.0%American Society of Clinical Endocrinologist 6.5%Many local endocrinologist 6.0%CONTROVERSY: The lower the HgbA1C the lower the risk of microvascular disease, but the higher the risk of hypoglycemia< 8.0 for over age 65 seems to work best.
Slide40INSULIN
Slide41INSULIN
PREPARATIONONSETPEAKDURATIONMAX DURATIONRAPIDACTINGLispro (Humalog)5 – 15 min.5-1.5 hr5 hr4-6 hrAspart (Novolog)Glulisine (Apidra)SHORTRegular.5 – 1 hr2 – 3 hr5 – 8 hr6 – 10 hrINTERMEDIATENPH (isophane)2 – 4 hr4-10 hr10-16 hr14-18 hrLente (zinc)2 – 4 hr4-12 hr12-18 hr16-20 hrLONGUltralente6 – 10 hr10-16 hr18-24 hr20-14 hrLONG ANALOGUEGlargine (Lantus)Levemir2 – 4 hrNo Peak20-24 hr24 hrCOMBINATIONS70/30 NPH/Reg.5 to 1 hrDual10 -16 hr14-18 hr50/50 NPH/RegCONBINATIONANALOGUES 75/25 NPL/lispro5 – 15 minDual10 -16 hr14-18 hr70/30 NPL/aspart
Adapted from Hirsch IB, Edelman SV Practical Management of Type 1 Diabetes, PCI Book,, West Islip Ny (2005)
Slide42INSULIN
Glucose homeostasis declines – Loss of post prandial glycemic controlDecline in control around breakfastNocturnal Hyperglycemia is often seen.Basal insulin typically started in type 2
Slide43Diabetes-the eyes & the kidneys
Type 1Almost always have retinopathy and neuropathy-then, they develop nephropathyDetected clinically by the doctor or opthalmologistType 2Retinopathy will likely be accompanied by nephropathyIf no retinopathy is present, they may have something other than diabetic nephropathy
Slide44Background Diabetic Retinopathy
NORMAL
BDR
Slide45Common Medications to avoid in kidney disease
NSAIDSIbuprofen (Motrin)Indomethacin (Indocin)Naproxen (Aleve, Anaprox, Naprosyn)(Celecoxib) Celebrex_ METFORMINGlucophage (metformin)
Slide46Diabetes Complications
Vascular DiseasePeripheral vascular diseaseAmputationsAutonomic insufficiencyGastroparesisPostural hypotensionBladder dysfunctionNeuropathy Charcot JointsBurning Neuropathy
Slide47How are we doing?
Elderly diabetic patientsMedical insurance claims through the roof!65 years and older30,750 patients studied (58.7% also had high blood pressure and/or protein in the urine)Of these only 50.7% (CI 50.0-51.4) received an ACE or ARB
Am J Kidney Dis. 2005 Dec;46(6):1080-7.
Slide48Summary of prevention
Lifestyle ModificationACE/ARB inhibitor therapyARB therapyControl Blood sugarControl Blood pressureVitamin DDetect proteinuriaIntervene for falls secondary to neuropathy.
Slide49Service Planning for Diabetes
Develop a comprehensive approach – Planning ahead is everything!
*Review meds & work closely with providers to optimize
*Ensure labs happen quarterly
*Ensure blood pressure is controlled
*Involve therapy and encourage exercise
*Address neuropathy
* Smoking cessation
*Dietary plans that satisfy but maximize control
*Diabetes support groups—shared medical goals work!
Slide50Service Planning for Diabetes
Reminders for annual eye exams/more frequent with problems or changes in vision. Provision for residents with poor vision.
Podiatry on a regular basis
Skin checks with personal care
Plan for insulin: delegation of staff – plan for high/low blood sugars
Slide51What STAFF need to KNOW!
Develop a TEAM approachEmpower your team with knowledgeInsulin injctionsProvide quick start guides to staff for symptomsProvide quick start guides for residents who have diabetes; talk about these residents with staff, so they know what to expect and what to look for.Role play to ready staff for crises with residents.Teach staff how to encourage positive/healthy behaviors.
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by Unknown Author is licensed under
CC BY
Slide52HYPO/HYPERGLYCEMIA – Teach the symptoms
ROLE PLAY can help staff respond appropriately
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by Unknown Author is licensed under
CC BY
This Photo
by Unknown Author is licensed under
CC BY-SA
Slide53Do all diabetic residents have working glucometers?
Check monthly to ensure glucometers are working correctly.
Easy to add to monthly medication checks when residents are self-med.
Make a plan for crisis for each resident. Decide on a place to keep it to ensure it’s handy for ALL staff to access.
Decide as a team what the response will be and add it as an addendum to the service plan.
Have a “Diabetic of the month” resident to discuss at
inservices
to keep the level of awareness high.
Incentivize staff who are able to state the plan for residents.
Slide54Skin and Feet: The “Achilles Heel” for diabetics
Teach staff how to
carefull
look at all skin when they are assisting with personal care.
Foot checks should be part of daily routine as residents don shoes.
Slide55Help Residents Help Staff
Group training has evidence support success
Teach residents how to report high/low blood sugar symptoms
Adherence to diet
Report skin issues
Pay attention to feet/footwear
Exercise clubs
In house vision screening
Blood pressure checks
Slide56Insulin
Pre-planning is everything
Review blood sugar logs prior to admission
Individualized care is important; resident habits are critical
Involve others in training. Pharmacy and home health partners can help. Take advantage of new initiatives to train staff.
Slide57QUESTIONS