A diabetic battle plan:
strategies for the front line of the
primary care setting
to support elderly type 2 diabetic
patients manage their health”
Chad LaRoche, PA-S
Advisor: Dr. Carrie Johnson
The purpose of this event was to direct
attention to the global epidemic of diabetes,
now killing more people annually than AIDS
and malaria combined (UN Radio 2007).
It was estimated that during 2007:
• every 10 seconds one life prematurely
ended from diabetes-related causes
• every 10 seconds somewhere in the world
two new people developed diabetes
(IDF 2007).
The United Nations declares
diabetes a “potential threat to
society… as it threatens to
subvert the gains of economic
advancement globally.”
Martin Silink, president of the International
Diabetes Federation , defined diabetes as
“the largest epidemic the world has ever
seen (UN Radio 2007).”
Prevalence of Diagnosed Diabetes
by Age, United States, 1980–2005
Diabetes is prevalent.
In 2005, among Americans 60 years of age or older, 10.3
million or 20.9% had diabetes. Of this group, only 65%
were aware of their condition, leaving at least 35% of the
10.3 million elders untreated and very vulnerable to
diabetes’ devastating complications (NDEP 2007).
By the year 2050, this already high prevalence is
expected to increase by 220% among those aged 65–74
years and 449% among those aged ≥75 years (Narayan
2006).
This means that in 40 years, every second person over
the age of 65 would have diabetes.
Diabetes is prevalent.
Adding to this number will be the percentage
of people with pre-diabetes, which in 2005
was already over 40% for those over 65
years of age (NDEP 2007). A diagnosis of
pre-diabetes is clinically significant because
it marks an increase risk for heart disease
and approximately 50% of cases eventually
progress to diabetes (McCulloch 2007).
Diabetes’ effects are severe.
If you are diagnosed with diabetes, you are approximately 2 to 4
times more likely to die from heart disease or suffer from a
stroke than adults without diabetes.
Diabetes is the leading cause of new cases of blindness among
adults 20-74 years of age. In 2002, it was the leading cause of
new cases of kidney failure, accounting for 44%.
Out of all non-traumatic lower-limb amputations more than 60%
occur in people with diabetes.
Additionally, it is estimated that 60% to 70% of people with
diabetes have mild to severe forms of nervous system damage
(CDC 2005).
Diabetes’ effects are severe.
Longitudinal analysis of Medicare data ,1994-2004
six years past a new diagnosis of diabetes 90% of patients
experienced at least one complication.
Compared to cohorts without a diagnosis of diabetes:
• rates of cerebrovascular, renal, and lower extremity
complications actually increased
• rates of cardiovascular complications remained stable
• only ophthalmic disease rates fell
(Sloan 2008)
Diabetes’ effects are expensive.
After adjusting for differences in age, sex,
and ethnicity, Hogan and colleges found that
individuals diagnosed with diabetes had
medical expenditures during 2002 that were
approximately 2.4 times higher than those
incurred by the same group without diabetes
(Hogan 2003).
Frank Vinicor, of the Centers for Disease Control
and Prevention in Atlanta, stated that “we do not
seem to be making great progress in
preventing complications in these elderly
diabetes cohorts… Taken to the extreme,
there will soon be too many patients with
diabetes to be individually treated and not
enough money to pay for it all (Vinicor
2008)”
In the United States, the immense and
yet needless suffering and financial
loss many elderly patients incur from
type 2 diabetes mellitus can be
significantly minimized by improving the
quality of care in the primary care
setting.
How can care improve?
1. There are many things about the
disease that are yet to be understood.
2. Lack of adherence to already
documented evidence-based practices
Percentages of Adults With Recommended Levels of Vascular Disease
Risk Factors in NHANES III (1988-1994) and NHANES 1999-2000
Saydah, S. H. et al. JAMA 2004;291:335-342.
Copyright restrictions may apply.
Postintervention Differences in Serum HbA1c Values
After Adjustment for Study Bias and Baseline HbA1c Values
Shojania, K. G. et al. JAMA 2006;296:427-440.
In 2005 only 53% of adults in the U.S. (42% of those over 65
in Kentucky) had even taken a class in how to manage their
diabetes (KCHFS 2007)
Copyright restrictions may apply.
What is known?
American Diabetes Association states that screening
should be considered in all individuals over 45
years of age. If results are normal, repeat testing
should be carried out at minimum 3-year intervals
Medicare has determined it cost effective to pay for
two diabetic screening tests per 12 month period if
two of the following risk factors are met: high blood
pressure, dyslipidemia, obesity, impaired glucose
tolerance, or a high fasting glucose level (CMS
2007)
Regular glucose screening in elderly patients is
especially important because the usual signs and
symptoms of diabetes are different in an older population:
•As one ages the renal threshold for glucose increases,
thus older patients do not typically develop glucosuria until
the plasma glucose is profoundly elevated.
•Also because of an impaired thirst mechanism, older
people often do not develop the presenting sign of
polydipsia.
•To make a swift diagnosis more difficult other presenting
symptoms often tend to be nonspecific: like fatigue, slight
cognitive impairment, and general pain. These lead to a
large set of differential diagnoses in the elderly. Often
these general symptoms are understood by the elderly
person as inherent to the aging process and thus are
seldom reported (Meneilly 2006).
What is known?
A is for aspirin.
• All adults with diabetes and additional
cardiovascular risk factors or over the age 40
should be taking between 75 and 162 mg
daily of enteric-coated aspirin, unless there
are contraindications. (Sherman 2004).
• A meta-analysis of a large number of
secondary prevention trials found that the
absolute benefit of aspirin was greatest in
those over age 65 years with diabetes and/or
diastolic hypertension (McCulloch 2007).
What is known?
A is for Hemoglobin A1c (HbA1c)
HbA1c twice/yr in patients with stable glycemic
control; quarterly, if poor control (AGS 2007).
For Pts that are healthy the general goal of 7%
is appropriate
For Pts that are frail; life expectancy <5 yr; or
high risk of hypoglycemia, polypharmacy, or
drug interaction consider a higher goal like <8%
What is known?
A is for Hemoglobin A1c (HbA1c)
However, patients with poorly controlled
diabetes may be subject to acute
complications of diabetes, including
dehydration, poor wound healing, and
hyperglycemic hyperosmolar coma
What is known?
Drugs should be started at the lowest dose and
titrated up gradually until targets are reached or
side effects develop
• Metformin is often contraindicated because of renal
insufficiency or significant heart failure.
• TZDs can cause fluid retention, which may exacerbate or
lead to heart failure. They are contraindicated in patients
with CHF (New York Heart Association class III and IV),
• Sulfonylureas, other insulin secretagogues, and insulin
can cause hypoglycemia. (ADA 2008).
What is known?
B is for blood pressure
• All adults with diabetes the blood pressure
goal should be <130/80 mm Hg, if safely
achieved. This can be accomplished by
behavior changes and with various
hypertensive drugs.
What is known?
C is for cholesterol.
Lipid profiles q 1–2 yr depending on whether
values are in normal range. (AGS 2007)
Keeping the low-density-lipoprotein (LDL) to
less than 100 should be the goal
Lowering blood pressure with a variety of
antihypertensives and LDL cholesterol with
statins results in decreased morbidity and
mortality within 2 to 3 years (Sherman 2004).
What is known?
C is for cognitive impairment.
• It is important to remember to do the MiniMental State examination on older adult
diabetic patients. There is a link between
decreased memory, learning and verbal
skills with type 2 diabetes.
What is known?
D is for diet
A diet rich in fruits, vegetables, whole grains,
and healthy sources of protein (poultry and
fish), and containing unsaturated vegetable
fats as the main source of fat, but that is low
in red and processed meats, refined grains,
and sugar-sweetened beverages.
What is known?
D is for depression
• Depression is more prevalent in adults with diabetes than
those without.
• Among the elderly this can be exacerbated by isolation and
lack of family or peer support.
• The prevalence of depression among older diabetics ranges
from approximately 15 to 40%.
• Depression has been associated with an approximately fivefold increase in health care expenditures for diabetes
significantly these are medically related and not mental health
related (DeRekeneier 2003).
What is known?
D is for Drugs interactions.
Older adults are highly susceptible to adverse drug reactions as well as drug
interactions and drug-disease/disability interactions.
Common syndromes among the elderly, such as falling, confusion, and
incontinence can be reduced through simple evaluation of the patient’s daily
medication during each visit. This is when a team approach is much more
effective.
Patients with renal dysfunction have a significantly higher probability of adverse
drug reactions. Renal dysfunction increases with age and is present in
many older diabetics. With the use of a nomogram to calculate glomerular
filtration rate, it was found that concealed renal dysfunction was present in
nearly 20% of older patients with diabetes that had acceptable serum
creatinine levels.
What is known?
D is for diabetes education.
Older adults however may be limited in either oneon-one or group sessions due to physical, visual,
or even cognitive impairments. The need for this
education in self-management skills and nutritional
therapy is vital in order for the patient to continue
care at home through lifestyle changes that are
significant in their overall health. Providers must
be sensitive to the method of education and make
accommodations for impairments common in
geriatrics
What is known?
E is for eye care.
Annual comprehensive dilated eye and visual
examinations by an ophthalmologist or
optometrist who is experienced in
management of diabetic retinopathy (AGS
2007).
Cataracts are over twice as common in people
over age 65 years with diabetes compared
with normal subjects (38.4% versus 16.6%)
while glaucoma is almost three times more
common (11.2% versus 3.8%).
What is known?
E is for abnormal urinary Excretions
• Incontinence and electrolytes indicative of
renal failure and microalbuminuria.
• Older women are especially at risk for urinary
incontinence.
• Testing for excretion of certain electrolytes
must be done soon after diagnosis and
continue annually given the added risk of
renal failure and microalbuminuria. This also
should lead to treatment using ACE inhibitors
What is known?
E is also for exercise
Older adults benefit significantly from exercise,
even 20 minutes 3 times a week
Adding resistance training to aerobic training
enhanced glucose disposal in
postmenopausal women with type 2 diabetes.
The improved insulin sensitivity is related to
loss of abdominal subcutaneous and visceral
adipose tissue and to increased muscle
density. (Cuff 2003)
What is known?
F is for Foot care
Foot examination, including monofilament
testing at 4 plantar sites (great toe and
base of first, third, and fifth metatarsals),
palpation, and inspection, each visit;
insensate feet should be inspected q 3–6
mo; well-fitted walking or athletic shoes my
be of benefit (AGS 2007)
What is known?
F is for Falls.
Older patients with diabetes have a higher rate of injurious falls,
possibly related to visual impairment, peripheral
neuropathy, hypoglycemia, polypharmacy, or any
combination thereof.
Falls by older adults are associated with high rates of
morbidity, mortality, and functional decline.
Confirming one or more falls in the past year and
performing tests of dynamic (tandem gait) and static
(tandem stance) balance can help you find the older adult
with diabetes who is at risk of falling (Sherman 2004).
What is known?
F is for flu and pneumonia vaccine: All
geriatric patients with diabetes are at
risk for both of these infections.
Administering a yearly influenza
vaccination and a one-time
pneumococcal vaccination will
decrease the incidence of influenza
and pneumonia in your practice
(Sherman 2004).
What is known?
S is for stopping smoking.
Approximately 12% of adults over
age 65 smoke cigarettes.
www.bridgestoexcellence.org
•
•
Number of Recognized Physicians:
40
•
•
Rewards Paid to Date:
$340,475 since 2003
•
•
BTE Programs Implemented:
Diabetes Care Link
•
•
Geographic Scope of Market:
Louisville area
•
•
Number of Covered Lives in Market:
52,000
•
Participating Employers: General Electric , UPS
•
Licensed Health Plan Administrators: Aetna , Anthem-Wellpoint , United Healthcare
•
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Performance Assessment Organizations and Measures:
National Committee for Quality Assurance (NCQA)
• American Association of Diabetes Educators (AADE)*
- http://www.diabeteseducator.org
• American Diabetes Association (ADA)*
- http://www.diabetes.org
• American Dietetic Association (ADietA)*
- http://www.eatright.org
• American Geriatric Society (AGS).
- www.geriatricsatyourfingertips.org.
• The Better Diabetes Care website
- http://www.betterdiabetescare.nih.gov/
• International Diabetes Federation*
- http://www.idf.org/home/
• National Diabetes Education Program (NDEP).
- www.ndep.nih.gov/diabetes
• World Health Organization*
- http://www.who.int/
•
References:
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Blonde L. State of diabetes care in the United States. Am J Manag Care. 2007;13:S36-S40
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Figures 2: Plasma glucose multihormonal regulation of glucose