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Diabetes in Assisted Living: What YOU Need to Know

Diabetes in Assisted Living: What YOU Need to Know. Sandra Petersen, DNP, APRN, FNP-BC, GNP-BC, PMHNP-BE, FAANP. Type 1 Type 2 HbA1C. This Photo by Unknown Author is licensed under CC BY-SA-NC. Diabetes: It’s more than just blood sugar…….

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Diabetes in Assisted Living: What YOU Need to Know

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  1. Diabetes in Assisted Living: What YOU Need to Know Sandra Petersen, DNP, APRN, FNP-BC, GNP-BC, PMHNP-BE, FAANP Type 1 Type 2 HbA1C This Photo by Unknown Author is licensed under CC BY-SA-NC

  2. Diabetes: It’s more than just blood sugar……. This Photo by Unknown Author is licensed under CC BY

  3. Aging 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

  4. Prevalence 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

  5. Cardiovascular 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

  6. Prevalence 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…

  7. Diabetes Types 1 & 2: The Pathophysiology

  8. Type 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.

  9. Type 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 years • Of the ones who develop this less than half progress to diabetic nephropathy • Associated with microvascular disease – retina and kidney. The increased sugar is neurotoxic – hence neuropathy • 2.2 percent will develop end stage renal disease in 20 years and 7.8 percent in 30 years

  10. Type 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 low • Labile swings in blood sugar because of autonomic insufficiency • Always requires insulin • If diabetic nephropathy develops, the patient will develop insulin resistance – metabolic syndrome due to kidney disease. Atherosclerosis and hypertension are not primary but secondary events

  11. Type 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 failure • Incidence 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 proteinuria • Only 2.3% progress from macroalbuminuria to ESRD

  12. QUADRUPLED OVER NEXT 3 DECADES!

  13. Type 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 swings • Insulin resistance

  14. Incidence of Type 2 Diabetes • Doubled in past 20 years • Related to Lifestyle Change and Obesity • BMI Increase confirmed by NHANES Dataset • Source: American Heart Association • Prevalence of Diagnosed and Undiagnosed Diabetes in the United States, All Ages, 2007 • Total: 23.6 million people • 7.8 percent of the population—have diabetes. • Diagnosed: 17.9 million people • Undiagnosed: 5.7 million people • Source: NIDDK

  15. Diet Plays a Major Role • The Sugar Fix • High fructose corn syrup • Decreases the ATP in cells – this decreases cell respiration and causes hypoxia in cells • Releases cytokines that impair nitrous oxide synthesis • Releases uric acid which increases blood pressure • Causes leptin resistance (Leptin turns off the appetite) continue to be hungry • Supersized – HFCS is in many soft drinks and other products • Americans eat more sugar, now have an epidemic of obesity, the metabolic syndrome, heart disease and diabetes

  16. Sugar 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!!!!

  17. Metabolic Syndrome

  18. Metabolic Syndrome • Characterized by insulin resistance – 50 to 75 million Americans • High blood pressure • High blood sugars • High levels of triglycerides • Low levels of HDL • Increased waist line • It is associated with • Diabetes, Hypertension, stroke, cardiovascular disease • Dominant Features • Obesity, lack of exercise

  19. WHAT CAN YOU DO? This Photo by Unknown Author is licensed under CC BY-NC-ND

  20. What slows progression? • Proven interventions • Control blood sugar in diabetics • Strict blood pressure control • Certain meds: ACES (Angiotensin-converting enzyme inhibition) and ARBS (angiotensin-2-receptor blockade) • Studied and has strong evidence • Dietary protein and carb balance • Lipid lowering therapy (except after age 85) • Partial correction of anemia • Vitamin D administration

  21. Management Objectives: OFFER A COMPREHENSIVE REVIEW • Lifestyle • An aspirin a day • Smoking and Exercise • Weight/cholesterol • Blood Pressure • ACE and ARB • Vitamin D • Diabetes Control (Logs)

  22. Lifestyle - 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!

  23. BLOOD PRESSURE CONTROL CRITICAL AT ALL AGES!

  24. Blood pressure goal < 150/90 or less in some cases • Any person with abnormal kidneys is at risk for heart disease • Most patients will require two or more medications to control their blood pressure • Lowering 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

  25. ACES & ARBS are the two majorclasses of medicationsused to treathigh blood pressure

  26. Common Generic and Brand Names for ACE Inhibitors and ARBs Common ACEs and ARBs

  27. Vitamin D Makes the News

  28. Vitamin 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!!!

  29. Diabetes Control • Sulfonylureas • Biguanides • Thiazolidinediones “Glitazones” • Meglitinides • DPP-4 Inhibitors • Incretin Memetics • Insulin

  30. ADA Guidelines

  31. Medications for Diabetes

  32. SULFONYUREAS • First category of oral agents for diabetes – now in third generation • Mainly for type 2 diabetes – work on existing beta cells • Increase secretion of insulin by binding to potassium channels and opening calcium channels • Can cause hypoglycemia and weight gain

  33. BIGUANIDES • Metformin used in obese type 2 diabetics • Maximum reduction in HgbA1c after 6 months • Action lasts additional 9 months with thiazolidinedione • With sulfonureas HgbA1C tends to increase • Reduced cardiovascular risks • Pharmacotherapy. 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.

  34. ROSIGLITAZONE • Controversy regarding risk of causing MI • Odds ratio 1.43 • ADOPT – increased fractures • Associated with macular edema • Stimulates the PPARγ receptor • Not to be used in heart failure • Nissen 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.

  35. INCRETIN MIMETICS • Exenatide (Byetta) • From the saliva of the gila monster • Incretin – mimetic • Enhances beta cell insulin • Blocks glucagon • Delays gastric emptying • Injection sub cutaneously 30 to 60 minutes before first and last meal – adjunctive therapy • Side effects – Gastrointestinal symptoms • FDA warning – pancreatitis – may be fatal

  36. WHEN TO START INSULIN • Start with oral agents (metformin) and proceed to insulin if goal is not achieved • May be able to manage for up to 6 years • HgbA1C – use a target • In kidney patients– because of the risk of hypoglycemia – may want to have a higher goal • Mono-duo-triple therapy – disease has advanced

  37. HgbA1C • 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.

  38. INSULIN

  39. INSULIN Adapted from Hirsch IB, Edelman SV Practical Management of Type 1 Diabetes, PCI Book,, West Islip Ny (2005)

  40. INSULIN • Glucose homeostasis declines – • Loss of post prandial glycemic control • Decline in control around breakfast • Nocturnal Hyperglycemia is often seen. • Basal insulin typically started in type 2

  41. Diabetes-the eyes & the kidneys • Type 1 • Almost always have retinopathy and neuropathy-then, they develop nephropathy • Detected clinically by the doctor or opthalmologist • Type 2 • Retinopathy will likely be accompanied by nephropathy • If no retinopathy is present, they may have something other than diabetic nephropathy

  42. Background Diabetic Retinopathy NORMAL BDR

  43. Common Medications to avoid in kidney disease • NSAIDS • Ibuprofen (Motrin) • Indomethacin (Indocin) • Naproxen (Aleve, Anaprox, Naprosyn) • (Celecoxib) Celebrex _ METFORMIN • Glucophage (metformin)

  44. Diabetes Complications • Vascular Disease • Peripheral vascular disease • Amputations • Autonomic insufficiency • Gastroparesis • Postural hypotension • Bladder dysfunction • Neuropathy • Charcot Joints • Burning Neuropathy

  45. How are we doing? Am J Kidney Dis. 2005 Dec;46(6):1080-7. Elderly diabetic patients Medical insurance claims through the roof! 65 years and older 30,750 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

  46. Summary of prevention • Lifestyle Modification • ACE/ARB inhibitor therapy • ARB therapy • Control Blood sugar • Control Blood pressure • Vitamin D • Detect proteinuria • Intervene for falls secondary to neuropathy.

  47. Service 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!

  48. Service 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

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