A Guide for Hospital Discharge Planning

I could not have ended this year with a better topic. Hospital discharge planning is not something to be ignored, but often it is, much to the detriment of the patient and their safety after being discharged. Therefore, if you are expecting to have this happen to you, or you are a caregiver for someone being discharged from a hospital, take time to read this and I mean really digest the contents. Then you can print out a copy to have with you to remind you of important points.

Not all hospitals are equal and some do very good at discharging patients. It is the hospitals that are not doing things properly that need to be challenged. The high points of this guide are:

1. What is discharge planning?

2. Why is good discharge planning so important?

3. The caregiver's role in the discharge process

4. Getting help at home

5. Discharge to a facility

6. Paying for care after discharge

7. What if you feel it's too early for discharge?

8. Improving the system

9. Conclusion

Below the conclusion is some information for caregivers. Some may seem overkill, but to make this adaptable for many people, this section needs to be large.

The other website that is so important is this one - http://www.nextstepincare.org./

Do not allow hospitals to discharge you without knowing your rights and procedures that hospitals need to follow to see that you receive the proper care after discharge.

Nutrients - Vitamin B12

Vitamin B12

Overview

All B vitamins are water-soluble, meaning that the body does not store them. Vitamin B12, also called cobalamin, is one of 8 B vitamins. It is important to know that all B vitamins help the body convert food (carbohydrates) into fuel (glucose), which is used to produce energy. These B vitamins, commonly referred to as B complex vitamins, also help the body use fats and protein. B complex vitamins are also used for healthy skin, hair, eyes, and liver. They help the nervous system function properly.

Vitamin B12 is an especially important vitamin for maintaining healthy nerve cells, and it helps in the production of DNA and RNA, the body's genetic material. Vitamin B12 also works closely with vitamin B9, also called folate or folic acid, to help make red blood cells and to help iron work better in the body. Folate and B12 work together to produce S-adenosylmethionine (SAMe), a compound involved in immune function and mood.

Vitamins B12, B6, and B9 work together to control blood levels of the amino acid homocysteine. High levels of homocysteine are associated with heart disease. However, researchers aren't sure whether homocysteine is a cause of heart disease or just a marker that indicates someone may have heart disease.

It' s rare for young people to be deficient in vitamin B12, but it' s not uncommon for older people to be mildly deficient. That may be because their diets are not as healthy or because they have less stomach acid, which the body needs to absorb B12. Low levels of B12 can cause a range of symptoms including fatigue, shortness of breath, diarrhea, nervousness, numbness, or tingling sensation in the fingers and toes. Severe deficiency of B12 causes nerve damage.

Others at risk for B12 deficiency include:

1. Vegans, vegetarians who also don't eat dairy or eggs -- vitamin B12 is found only in animal products

2. People with problems absorbing nutrients, due to conditions such as Crohn's disease, pancreatic disease, and people who have had weight loss surgery

3. People who are infected with Helicobacter pylori, an organism in the intestines that can cause an ulcer. H. pylori damages stomach cells that make intrinsic factor, a substance the body needs to absorb B12

4. People with an eating disorder

5. People with HIV

6. The elderly

Folic acid (vitamin B9), especially when taken in high doses, can mask the symptoms of a vitamin B12 deficiency. The danger is that without symptoms, someone with a vitamin B12 deficiency may not know it, and could run the risk of developing nerve damage. Anyone planning to take more than 800 mcg of folic acid should talk to their doctor first, to make sure they do not have a B12 deficiency.

Vitamin B12
Vitamin B12 is bound to protein in food. The activity of hydrochloric acid and gastric protease in the stomach releases vitamin B12 from its protein.  Once it is released, vitamin B12 begins to work quickly. It is important for the formation of red blood cells, neurological function, and DNA synthesis. It also supports the digestive system in keeping glucose levels stable.

A simple blood test can determine the level of B12 in the body. Adults who have a value below 170 to 250 pg/ml are considered deficient in the vitamin. An elevated blood homocysteine level or elevated methylmalconic acid level may also suggest a B12 deficiency.

Tests

Vitamin B12 and folate are ordered to detect deficiencies and to help diagnose the cause of certain anemias. One type of associated anemia is pernicious anemia, an autoimmune disease that affects the absorption of B12. This megaloblastic anemia occurs when the body produces antibodies against the gastric parietal cells or the intrinsic factor, resulting in B12 malabsorption.

Folate, B12, and an assortment of other tests may be ordered to help evaluate the general health and nutritional status of a person with signs of significant malnutrition or dietary malabsorption. This may include people with alcoholism, other liver diseases, gastric cancer, and those with malabsorption conditions such as celiac disease, tropical sprue, Crohn’s disease, inflammatory bowel disease, and cystic fibrosis.

B12 and folate may also be ordered to aid in diagnosis when an individual presents with an altered mental state or other behavioral changes, especially in the elderly. B12 may be ordered with folate, by itself, or with other screening laboratory tests (antinuclear antibody, CRP, rheumatoid factor, CBC and chemistry blood tests) to help establish reasons why a person shows symptoms of neuropathy.

In those treated for known B12 and folate deficiencies, these tests will be ordered occasionally to monitor the effectiveness of treatment. This is especially true in those who cannot properly absorb B12 and/or folate and must have lifelong treatment.

Recommended Daily Allowance

If you are considering taking a B12 supplement, ask your health care provider to help you determine the right dose for you.

Daily recommendations for dietary vitamin B12 are listed below.

Pediatric

 Newborns - 6 months: 0.4 mcg (adequate intake)

 Infants 6 months - 1 year: 0.5 mcg (adequate intake)

 Children 1 - 3 years: 0.9 mcg (RDA)

 Children 4 - 8 years: 1.2 mcg (RDA)

 Children 9 - 13 years: 1.8 mcg (RDA)

 Teens 14 - 18 years: 2.4 mcg (RDA)

Adult

 19 years and older: 2.4 mcg (RDA)*

 Pregnant women: 2.6 mcg (RDA)

 Breastfeeding women: 2.8 mcg (RDA)

*Because 10 - 30% of older people may not absorb B12 from food very well, people over 50 should meet their daily requirement through either foods fortified with vitamin B12 or a supplement containing B12.

Cautions

If the B12 deficiency is not remedied, permanent nerve damage can occur. Neuropathy is a common problem for people with diabetes, who experience pain, tingling, and numbness in their arms, hands, legs, and feet, resulting in sores.

Vitamin B12 is an especially important vitamin for maintaining healthy nerve cells, and it helps in the production of DNA and RNA, the body's genetic material. Vitamin B12 also works closely with vitamin B9, also called folate or folic acid, to help make red blood cells and to help iron work better in the body.

Food Sources

Vitamin B12 is found only in animal foods. Liver, sardines, and salmon rank highest, with liver running away with it. Kidney, eggs, beef, and pork are also good sources. There are no vegetarian sources. Supplements include - Methylcobalamin is probably the best.

Precautions

One large study found that women who took 1,000 mcg of vitamin B12 along with 2500 mcg of folic acid and 500 mg of vitamin B6 daily reduced their risk of developing AMD, an eye disease that can cause loss of vision.

Fatigue is one of the symptoms of a vitamin B12 deficiency. One preliminary study indicated that people with chronic fatigue syndrome might benefit from B12 injections, although more research is needed to know for sure.

Although there is no evidence that vitamin B12 alone reduces the risk of breast cancer, population studies have shown that women who get more folate in their diet have lower risk of breast cancer. Vitamin B12 works with folate in the body, so it may help contribute to a lesser risk. Another preliminary study suggested that postmenopausal women who had the lowest amounts of B12 in their diet had an increased risk for breast cancer.

Studies suggest that vitamin B12 supplements may improve sperm counts and sperm mobility. However, the studies were of poor quality. Better studies are needed to see whether B12 has any real effect.

Possible Interactions

If you are currently being treated with any of the following medications, you should not use vitamin B12 supplements without first talking to your health care provider.

Medications that reduce levels of B12 in the body include:

Anti-seizure medications -- including phenytoin (Dilantin), phenobarbital, primidone (Mysoline)

Chemotherapy medications -- particularly methotrexate

Colchicine -- used to treat gout

Bile acid sequestrants -- used to lower cholesterol; include colestipol (Colestid), cholestyramine (Questran), and colsevelam (Welchol)

H2 blockers -- used to reduce stomach acid; include cimetidine (Tagamet), famotidine (Pepcid AC), ranitidine (Zantac)

Metformin (Glucophage) -- medication taken for diabetes

Proton pump inhibitors -- used to reduce stomach acid; include esomeprazole (Nexium), lansprazole (Prevacid), omeprazole (Prilosec), and rabeprazole (Aciphex)

Antibiotics, Tetracycline -- Vitamin B12 should not be taken at the same time as tetracycline because it interferes with the absorption and effectiveness of this medication. Vitamin B12 should be taken at different times of the day from tetracycline. All vitamin B complex supplements act in this way and should be taken at different times from tetracycline. In addition, long-term use of antibiotics can lower vitamin B levels in the body, particularly B2, B9, B12, and vitamin H (biotin), which is considered part of the B complex vitamins.

Do You Have Happy or Unhappy Feet?

Most articles about shoes are written for women, by women, and I do not totally understand why. Is it because women own more pairs of shoes and require a pair for every dress they wear and others for when they hike, or get out in the country? Men often wear shoes that do not fit properly and then they wonder why they have sore feet and areas on their feet that are hard because of calluses that aren't taken care of until sores develop.

Why is that people with diabetes refuse to take care of their feet until forced to because of a possible amputation looming. Yes, I am being anything but understanding or sympathetic toward people who have diabetes and insist on abusing their feet. When they start complaining about feet that hurt, they know that I will not feel any sympathy and may be very difficult to get along with. Yes, I am aware of this being the wrong way to make friends and influence people. Even in the diabetes clinic, I see people wearing shoes that are wrong – spike heels, flip-flops, sandals with poor heal support and other improper shoes.

I have finally met two doctors that are very strong advocates for proper footwear. I could not believe it when I heard it, but one doctor will not treat patients for foot problems, men or women, wearing improper footwear. The type 2 patient, a man wearing flip-flops had cut his foot at home after dropping a glass container, which broke in many pieces. The doctor told him he would need to go the emergency room for treatment. The ER doctor did treat him, but said he would need to purchase a proper set of house slippers or shoes to continue being treated if he had problems healing.

Both doctors are very set on people with diabetes wearing proper footwear. The doctor that has his own practice does have a foot measuring device to show people the correct size and posters showing the incorrect footwear for both men and women. If you don't want to be embarrassed when he insists on measuring your foot and tells you your shoes are too small, you will want to avoid this doctor. His advice is correct though as many people insist on wearing shoes that are too small for them. A few people do wear shoes that are too large. This is an invitation for developing blisters and calluses.

This article from WebMD has some excellent pointers and even if the United Kingdom is the setting, the information is still valid. The information given shows that only 25 to 40 percent of people with diabetes wear shoes that are the correct size. Because the information given is great, I will quote it. “When people with diabetes start experiencing nerve damage or numbness, they often gravitate toward shoes that are too small because tight shoes make it easier for them to feel the snugness on their feet. They mistake that tightness for good support. Instead, they need to wear shoes with comfortable -- not tight – support.”

“Once you know your correct size, here are nine guidelines for choosing shoes when you have diabetes:

1. Look for shoes that don't come to a point at the toe. Instead, choose shoes with a spacious "toe box" -- the forward tip of the shoe where the toes are. That way your toes won't be crushed together. When your toes have space, it lessens the chance of corns, calluses, and blisters that can turn into ulcers and eventually infections.

2. If the shoe's insole is removable, take it out and step on it. Your foot should fit comfortably on top of it with no overlap. If your foot is bigger than the insole, then your foot will be crammed inside the shoe when you wear it. Choose a different shoe.

3. Avoid high-heeled shoes because they put unnatural pressure on the ball of your foot. If you have neuropathy, you may not realize that you are sore there or even getting calluses. High heels also can cause balance issues and ligament damage.

4. Steer clear of sandals, flip flops, or other open-toe shoes. Straps can put pressure on parts of your foot, leading to sores and blisters. In addition, open shoes can leave you susceptible to injury like cuts. They also can allow gravel and small stones to get inside the shoe. These can rub against your feet, causing sores and blisters.

5. Consider laced shoes instead of slip-ons. They often provide better support and a better fit.

6. Try on shoes at the end of the day. That's when your feet are more likely to be a little swollen. If shoes are comfortable when your feet are swollen, they should feel fine the rest of the time, too.

7. Don't buy shoes if they are uncomfortable, planning to break them in as you wear them. Shoes should feel good when you first try them on. If you take off new shoes after wearing them a couple hours and find red, sensitive spots, don't wear them again.

8. Buy at least two pairs of supportive, comfortable shoes. Each pair will likely have different pressure points on your feet, so it will relieve the pressure when you alternate wearing different shoes. It will also allow your shoes to dry and air out when you don't wear them every day.

9. In some cases, the cost of special shoes is covered by Medicare for people with diabetes. You must meet certain criteria -- such as foot deformities, past foot ulcers, or calluses that can lead to nerve damage -- and must have a doctor's prescription. Talk to your podiatrist or primary care doctor for more information.”

The above is a reason everyone with diabetes should see a podiatrist at least yearly, if not quarterly to have their feet examined and problems found early and corrected.

If you find shoes that fit correctly, wear them at all times – except when sleeping. Do not go barefoot, even around your own house. This is where most problems start for people that have neuropathy or other foot numbness, as they don't feel anything when they step on something sharp and injure themselves. Then the area becomes infected and problems start.

Now one final word of advice, before you opt for the overly uncomfortable shoes on special occasions, talk with a podiatrist first. Let the podiatrist tell you if these shoes can be worn for short periods of time like that special party. If the podiatrist advises against this, do follow the directions as it is your feet and you don't want to see the doctor later to correct the damage you could have prevented.

Joslin Advocates for SMBG

This is an interesting turn of events. Normally I am the one complaining about the lack of self-monitoring of blood glucose, but now Joslin Diabetes Center is asking in their book Joslin's Diabetes Deskbook, 2nd Ed, Excerpt #4: Do Your Patients Self-Monitor Their Blood Glucose Enough? For this, I have to ask if they will appeal to the Centers for Medicare and Medicaid Services (CMS) to up the number of test strips that diabetes patients can be reimbursed.

I complain because people do not test enough and use the results to help manage their diabetes in as more informed manner. I appreciate Joslin's statement, “It is imperative that people who are self-monitoring know what to do with the results of their glucose checking so that they can take active steps to improve their control. They should be given instructions on how to interpret their results, what they can do themselves in response to the results, and when they should call for help.” At least the authors know and understand the importance of education and that it should be part of every diabetes treatment plan.

Too many doctors do not even prescribe a meter and test strips for patients on oral medications, meaning patients with type 2 diabetes. This excerpt should be required reading for these self-important doctors. All doctors do either give out meters and prescribe test strips or inform their patients where to obtain testing supplies for people with type 1 diabetes and for people with type 2 diabetes on insulin.

I like what is covered in chapter 3. They state that, “Goals of diabetes treatment need to be defined in terms of self-monitoring results.” This is a great statement, which patients with diabetes need to understand. This brings both patients and physicians into the picture and makes each a participant. The patients are responsible for gathering the information, doing this diligently, and providing this information to the physicians. Then the physicians are responsible for taking this information and helping the patients set goals (whether new or revised) to help then manage their diabetes more effectively.

In summary, here are a few reasons why SMBG should be performed:

1. To provide data about glucose patterns that can be used by the healthcare team, working with the patient, to make treatment manageable.

2. To provide data with which patients themselves can make daily decisions on treatment adjustments.

3. To provide feedback on how effectively the individual is managing daily self-care routines, including medical nutrition therapy, physical activity, and medication use.

These are by no means the only reasons and the tables uses are adapted from the American Diabetes Association and are therefore not ideal, but can only be interpreted as suggestive for patients that are elderly or have other diseases, which affect their ability to manage their diabetes more effectively. Those patients that are younger and fully able to manage their diabetes need to consider using these tables.

Another area of concern is a few of the “diabetes coaches” that tell their people not to give the information to their doctors. Granted some doctors do not know what to do with the information, but they are on their way out of practice as patients become more empowered. I have crossed paths with a few of these “coaches” and know they are attempting to hide what they are doing. Not that they are giving out advice that is out of line, but too often these “coaches” are practicing medicine without a license. They may not have intended to, but they do cross the line time after time.

Happy Holidays!

Happy Holidays

Wishing you and your family a Merry Christmas and a Happy New Year!

Note: No blog will be posted on 25 December 2012

Have You Been Evaluated for Patient Adherence?

This is the first in an on going series from Joslin's Diabetes Deskbook. The book is interesting as a patient and I will write blogs about the excerpts from Diabetesin Control dot com. There is much available for good discussion.

The first two paragraphs are a key to this discussion. “The gap in meeting clinical targets is in large part due to the gap that presently exists between actual and optimal treatment goals and strategies for patients and physicians.

Even when patients have an ongoing relationship with their primary physician, they often fall short of the recommended treatment goals due to gaps between actual and ideal treatment strategies. Collaboration is the key to closing this gap. Your patients are the most underused resource in your clinical practice. If you and your patients are able to jointly establish aligned goals, they will improve their health, and you will improve the efficiency of your practice and outcomes that you can achieve.”

Often there is a difference of opinion about optimal treatment goals between patients and physicians. Sometimes this is on purpose and at other times, it is difficult to determine why they are different. In reading the deskbook, it is easy to discern some of the reasons for the differences in goals. Younger patients may want to manage their diabetes very stringently and the physician does not want the goals to be so tight.

Then when it comes to the elderly, some are still capable of tight management and the physicians are demanding that they loosen up their management. This is when the physician needs to step back and reassess the patient to determine if they are indeed capable of this maintenance and if encouragement is in order rather that changing goals.

The five steps outlined in this excerpt are enlightening, if only more physicians would see them as valuable. The patient and physician may have a long history, but this does not mean that the physician is in command. The steps include:

First Step - When you enter the room where the patient is, start with a simple open-ended question like "What brings you in today?" Other questions are also useful and the doctor needs to listen to the patient. Most patients take about 32 seconds to create the answer and finish their statement. Most physicians make the mistake of interrupting at about 23 seconds to ask another question or redirect the discussion. This may make it seem to the patient that the doctor is in autopilot and not listening to them.

Second Step – Be sure to help the patient focus on their risk factors, and to appreciate their clinical importance. Many doctors fail here by not explaining carefully the risk factors and working with the patient to help them understand them. The discussion of all the risk factors at once does not work... ”This unfocused shotgun approach often leads to inaction, or to the wrong action.”

Third Step - If you and the patient have succeeded in reaching an agreement about a general goal such as A1c, then ask the patient how they would like to get there. Letting the patient set a goal can be guided to a point, to make the patient desire to take the action to obtain a better A1c. However, the doctor cannot set the goal and expect the patient to meet it. When the patient sets a goal that is attainable and does, this is the positive reinforcement that the patient needs and will work for other goals knowing that the doctor is there with him/her to make sure the goal is attainable. If the patient falls short and the doctor has the daily data – blood glucose readings, food log, and other records the patient has maintained, the doctor should be able to offer guidance to help the patient achieve the goal by the next visit.

Fourth Step - Having chosen a goal and a treatment strategy, it is important to encourage the patient not to lose momentum. “Remember that there are different paths to achieving the same result, with different combinations of lifestyle changes and medications. If their strategy doesn't seem optimal, you can then suggest: "I have some information on what strategies have worked for other patients similar to you. Would you like to hear some of these possibilities?"” Different techniques work for different patients and doctors need to work with patients to assist them and thereby increase their value and help the patient keep the desire to do more to meet the goal.

Fifth Step - Keep Cycling - The hardest work involves the first four steps described above. Often physicians and patients come up short of reaching their goals because they lose momentum. Encouragement is important. Because the patient is the person managing their diabetes on a daily basis, knowing that the doctor is helping them set reasonable goals and assisting them in achieving these goals, makes the doctor more appreciated.

This statement from the excerpt is important, and I quote, “This is a great time to be treating people with diabetes, and those without diabetes who are at risk for cardiovascular disease. Clinical results are improving dramatically; and while clinical gaps continue to exist, they are responsive to a number of different approaches. This provides an opportunity for the physician, but an opportunity that is best addressed through collaboration with your patient. The physician's role is to evaluate the patient's disease state, listen carefully to their concerns, and then provide the needed information that will help to inform and form the patient's choices. The patient controls their disease, whether they want to or not. You need to be the best guide possible in their journey toward health.”

Wheat Belly Review

I have now finished reading Wheat Belly by William Davis MD. Yes, I am late to the reporting. Therefore, this will be a review that is different than what many write. I knew that David Mendosa and Tom Naughton had written reviews and I sought out their blogs. After recording them, I went to the search engine and typed in “wheat belly by william davis review” and pressed the enter key. I received 147,000 results. At first glance, not all entries are book reviews and of course, many items are repeated several times with some different wording.

Before going further, I will say that taking so long to read the book helped me understand many of the points Dr. Davis put forth. I have greatly reduced the amount of wheat I consume by about 90%, and the weight is declining. I have enjoyed reading many of the reviews that were written even before I purchased the book. I am happy to report that many of the reviews are positive and the one review that disputes some of the studies Dr. Davis uses is not negative either.

The Grain Foods Foundation is naturally sticking out against Dr. Davis because he is a threat to their business. Most of the time they quote the same unproven points about grains, especially whole grains, are healthy for us. They have their experts and very few studies that conclusively support this, but both sides of this issue have “experts.”  You may read several blogs on the Grain Foods Foundation blog site here (link is broken now as they removed the blog and comments). Sometimes the comments are better than the blog. There are several blogs following this in the month of September 2011.

I would urge everyone to read a blog by Peter Bronski, who with his wife, have the blog, “No Gluten, No Problem” blog site. I think he does raise some good issues. I will admit that in Chapter 7, Dr. Davis is a bit glib in his discussion of diabetes. Eliminating wheat for many people with type 2 diabetes, do have good results and some are able to eliminate medications totally – at least until they revert to old habits. Diabetes is not curable yet, but people reading chapter may think they are cured.

David Mendosa wrote his review here. Tom Naughton had a two-part interview here and here. Tom also had two very good articles about the reactions of the grain producers here and here. Tom makes valid points and I enjoy reading his blogs. Then go to BalancedBites and read the review by Diane Sanfilippo, BS, Certified Nutrition Consultant, one of four women writing for the blog site. After completing that blog, take time to read the review by Dana Carpender on “Hold the Toast” blog site, and author of “500 Low Carb Recipes.”

If you haven't read Wheat Belly by William Davis MD, it is worth the time and there is much to be said for the fact that wheat is not the wheat of biblical times or even 100 years ago. It has been so perverted with genetics engineering that is does not resemble the wheat of old. It can cause diabetes and other health problems and is a real problem similar to high fructose corn syrup. Our modern agriculture is trying to feed the world, but in doing so has created health problems that are spreading around the world. We need someone to point this out, like Dr. Davis.

Holiday Gifts for Person with Diabetes

At this time of year and before birthdays, people are always looking for gifts that people with diabetes will appreciate. Joslin Diabetes has a list and some suggestions that could be appropriate. I will say that the books listed in the blog should be considered with care as the American Diabetes Association is not known for low carbohydrate cookbooks, but some may appreciate them.

Books of any kind should be purchased with care because a book about type 1 diabetes may be very appropriate for a person with type 1 diabetes, but not appreciated by a person with type 2 diabetes. Another consideration should be about the subject matter covered in the book. Also, consider if the person is likes to read. A book that I received as a combination birthday and Christmas present is much appreciated – Joslin's Diabetes Deskbook, Updated Second Edition. Read my review here. You may read a little about it here and there are some other books as well. Yes, they are advertised for healthcare professionals, but sometimes these can benefit patients as well. I will be asking for the Educating Your Patient with Diabetes but only after I have a chance to see the book and preview the table of contents and look at a few chapters.

These books and many other excellent books may be found at Amazon and I will provide this link. There are several pages of diabetes books. Most are excellent to good, but there are a few I would not want in my library.

One suggestion from the Joslin blog is the possible purchase of an electronic food scale that calculates the carb counts of food. This may be on the expensive side for many people, but could be of value if you have the funds. One the less expensive side is items like a pedometer or resistance bands. Read the entire Joslin blog as ideas are presented to the end of the blog.

Even at this late date, do not forget that a printout of books can be given and specify the amount that you are willing to pay for the book or books. I have had people do this for me, I always enjoyed looking at the selection they were offering, and I made it a point always to choose the best book I was interested in and could stay below what they were willing to spend. One time, I did ask for one book over the amount offered, but I made sure that I paid the excess. The book had just been published and I had planned to buy it myself, but had hints about books so I had held off. He also wanted the book so I told him that we could split the cost, he would let me use it for six months until his birthday, and then he could own it.

Therapeutic Goals for Older Adults with Diabetes

When I wrote these two blogs, here and here, I did not realize I would be revisiting the topic for the elderly so quickly. However, a blog by Joslin Communications brought some good points back into the discussion and need to be considered, especially for elderly patients with diabetes. Since I have to classify myself as elderly, I have a special interest in these discussions. Wishing it was easier doesn't solve any problems and makes these articles and blogs that much more valuable. More doctors specializing in geriatrics are also learning about diabetes and diabetes management for the elderly. This can definitely be a step forward in assisting the elderly to maintain excellent management of diabetes. The Joslin blog starts with the over 70 elderly and my two blogs were for the elderly of age 60 and over.

Yes, I am concerned about the age many decide to consider elderly. This 10-year difference can mean many things to different people. I cannot tell if this is because the people doing the writing are nearing one age and want to not be classified in the elderly, or if this is done for another reason. Since I fit in either group, I have nothing to keep me from writing about the elderly as being age 60 and over. Health problems are still problems regardless of a person's age. Often many healthcare providers do not assess the elderly correctly and therefore do not prescribe the correct medication levels. Other doctors feel these people are a burden to society and will not properly treat them. Still other doctors and especially some healthcare providers believe that anyone over 80 should be euthanized and are an expense to society. This is not right as many of these people are still productive and contributors to society.

This article about the elderly just approaches the topic as a one-size-fits-all subject and degrades people that are capable of managing their diabetes. I know that for some people, the guidelines are reasonable, but not for everyone. I'll be darned if I will accept A1c targets of between 7.0 and 7.5 mg/dl, but this is what this article says and it states that this should be individualized for co-morbidities, cognitive and functional status. This means they will encourage higher A1c levels for many people. I take to mean that because we are classified as over the age of 70, they want diabetes complications to take over and end our life sooner, rather than later. Even though they say individualized, nothing is mentioned about those that are capable and able to manage their diabetes with no problems. Everything is aimed at the elderly that have problems and difficulty managing life.

“The International Association of Gerontology and Geriatrics, the European Diabetes Working Party for Older People, and the International Task Force of Experts in Diabetes combined resources to tackle the problem of addressing the needs of older adults with diabetes. The group addressed eight categories of concern: hypoglycemia, therapy, diabetes in the nursing home, influence of co morbidities, glucose targets, family/caretaker perspectives, diabetes education, and patient safety.”

These are great topics to be discussed and some of the elderly are affected by these areas and the need for concern for these people is well placed. I am happy to see that 'diabetes in the nursing home' is one of the areas for concern. Too often, people with diabetes in nursing homes are barely cared for and what little care they do receive is done by care providers that do not care and do not understand diabetes. It would be interesting to know what A1c's these people have. But forget that, most nursing homes are not even required to have these records for people incarcerated in their facilities. Even if states have regulations about safety and patient abuse, diabetes is not even mentioned and this goes unmanaged in many states.

Even though I find much to be concerned about in this blog, I will quote much of the last part of the blog as these tips are valid for anyone having these problems. “In addition to the medical establishment loosening their guidelines for acceptable control in the elderly, you can do things for yourself that can make your diabetes self-management easier.

If memory is an issue

1. Use your meter to set alarms to remind you to take your medicine or check your blood glucose. Even though I did not believe this – many meters do have alarms. Get help if necessary from someone that is tech savvy.

2. Get a pill dispenser—if you take a lot of pills this can help you keep track of which medications you need to take and which you have already taken.

If vision is a problem

1. Have a bright task light available—you will see better with direct lighting for reading such things as drug labels

2. Contrast helps! Put light objects against a dark background and vice-versa to make them stand out.

3. Ask your educator about syringe magnifiers that can help you see the markings on the insulin vial. If an educator is not available, please talk to your pharmacist.

4. Ask your educator for a meter that talks or has large print. This may be of help for some, but if privacy is an issue, the meter that talks may not be for you.

If dexterity is an issue

 Ask your educator about meters and supplies that are easy to handle. If an educator is not available, please talk to your pharmacist.

Joslin’s Geriatric Diabetes Clinic is apparently different from many diabetes clinics and worth reading about here and here. The only objection I can find is the one-size-fits-all discussion, but why should I be surprised, this is the stance of the American Diabetes Association, the American Association of Clinical Endocrinologists, and supporting groups.

Supplements – Does the Elderly Need Them?

This debate has been around for some time and just does not go away. Do elderly people need to take supplements? Some “experts” say no, other “experts” say yes. Many of these “experts” are assuming that the elderly have unlimited funds, can prepare meals that are nutritionally complete, and reside in areas that are safe and easy to move around within. Most of the “experts” have never had to spend a day in the shoes of some of the elderly.

I wish some of these “experts” would have to do a field study of the elderly and really get out and spend a few weeks seeing how they live, how safe it is for them to even walk around the neighborhood they live in, and how little money has to last for a month for food, shelter, and medications. This says nothing about transportation and some of the other necessities of life. Most of these elderly have no money left for supplements.

To ridicule the elderly like Donald B. McCormick, PhD, an Emory professor emeritus of biochemistry and the graduate program in nutrition and health sciences at Emory, takes ridicule to new levels. He says, “A lot of money is wasted in providing unnecessary supplements to millions of people who don't need them.” It is one thing to sit in the towers of academia and make statements like this, but I would have to ask if he has even seen where some of the elderly live. Then he continues, “We know too little to suggest there is a greater need in the elderly for most of these vitamins and minerals. A supplement does not cure the aging process.”

He thinks that the elderly believe they need vitamins and mineral supplements to blunt the aging process and the older they get the more supplements they need. He seems determined to take these supplements away from the elderly. One statement that McCormick makes I have to agree with and it is this - “At very high levels, some vitamins and minerals can be toxic.” This is especially true for many of the fat-soluble vitamins and minerals that the body can't readily flush.

Yes, McCormick does soften his rhetoric further into the article. He almost allows for obtaining most of them from foods, but with dietary changes. While I agree that it is best to obtain your nutrients from food, not all the elderly do well at cooking and balancing their nutritional needs. Not everyone can make use of nutrition experts and others capable of helping them.

Andrea Giancoli, RD, MPH, a spokeswoman for The Academy of Nutrition and Dietetics does carefully say that when counseling older adults, it is first necessary to determine what nutrients are lacking in the diet. I can believe it when she says it is often vitamin D, calcium, and vitamin B12. She does say she tries to fix it with food. I will give her positive marks for saying, “I don't think we should be recommending supplements blindly without assessing their food intake.”

Does the elderly need supplements? This debate will continue and probably never be resolved. I do think many of the elderly need some of the supplements because they do not eat a large variety of foods and are often short of some nutrients. Having seen some of my friends have anemia and be short of Vitamin D and Vitamin B12, I know what can happen. Another area of concern is those supplements that may cause extreme and even deadly side effects when taken with some prescriptions. Therefore, I have to urge caution for any supplements and urge all patients to make sure their physician knows what supplements are being taken.

Poor Glucose Control Impacts on Cognition

Now they want to add another complication to the list of diabetes complications. Cognition decline is now the result of poor blood glucose management. Cognition is the mental act or process by which knowledge is acquired, including perception, intuition, and reasoning. I can understand this happening, but how do they classify other people with cognition decline. Are they people with undiagnosed diabetes? I would be guessing, but I do believe some may have undiagnosed diabetes, but not a large number.

The study in Archives of Neurology says that, “poor glucose control in older, well-functioning adults with no dementia are linked to reduced cognitive function and higher cognitive decline.” The researchers conclude: "This study supports the hypothesis that older adults with DM have reduced cognitive function and that poor glycemic control may contribute to this association. Future studies should determine if early diagnosis and treatment of DM lessen the risk of developing cognitive impairment and if maintaining optimal glucose control helps mitigate the effect of DM on cognition."

Therefore, they are not saying type 2 only, but all with diabetes mellitus. The researchers from the University of California, San Francisco and the San Francisco VA Medical Center assessed 3069 patients and administered two tests. The two tests were the Modified Mini-Mental State Examination (3MS) and Digit Symbol Substitution Test (DSST). These tests were done at the beginning of the study and repeated at selected intervals over the 10-year period of the study. The average age of the patients was 74.2 years. Of the participants, 42% were black and 52% were female.

Of the participants, 717 had diabetes at the beginning of the study and 2352 has no diabetes. During the study, 159 participants developed diabetes. At the start of the study, those with diabetes had lower 3MS and DSST test scores than those without diabetes. At the 9-year mark, participants without diabetes had a similar pattern of decline. Those with diabetes and that developed diabetes, showed a marked decline in both the 3MS and DSST tests compared to those not having diabetes.

This points out how important good blood glucose management is for our brain health and the fact that poor management can bring on not only many complications, but cognitive decline as well.

FDA Creates Group to Speed Medical Devices to Market

Will this be the answer for many people, to accelerate medical devices to market, or just another stepping-stone to slow the process? I hope for many people that the first is true. Yes, the FDA has created a group – nonprofit, public-private partnership. The object of this partnership is to speed safe medical devices to market. The underlying aim is to encourage competing manufacturers to pool their knowledge about product testing. This last part may be the death of many medical devices as some manufacturers do not want to share information and may leave the market rather than be forced to share information.

Sounds great for patients if products do make it to market sooner, but in telephone conversations with a couple of manufacturers, there is little enthusiasm for the idea. Many are concerned about the procedures and who will have control of the testing. If the FDA is the only one doing the testing with only people from the company's device present during testing, then maybe this will work. If any company can be present during testing, it is doubtful some companies will participate. Both agreed that it is still too early in the process to know how this will work.

One spokesperson did say that this will make acquiring some of the good ideas from cash strapped start-ups a lot more difficult. He also said that the value added from FDA approval will be great for the smaller companies, some will be able to find the funds for manufacturing, and others will still sell the product to larger manufacturers.

Both admitted that if this group, called the Medical Device Innovation Consortium (MDIC), was actually able to make it easier to bring products to FDA approval, then everyone would gain, including the patients.

Nurse Practitioner Groups Unite

Primary care physicians move over, the new American Association of Nurse Practitioners (AANP) is now united (as of January 1, 2013) and looking to expand their role in healthcare. As of this date, the American Academy of Nurse Practitioners and the American College of Nurse Practitioners will be the above AANP and have a combined membership of 41,000. The merger will strengthen NPs' influence; the growth of the specialty has already amplified its voice. NP numbers have risen nearly 80% in just more than a decade, from 87,000 in 2001 to 155,000 in 2012, with 11,000 graduating from NP programs this year alone.

There are many reasons for the two groups to merge, but the largest is the Patient Protection and Affordable Care Act (ACA) which will mean about 30 million more patients will enter the healthcare system through 2019. Then according to a recent study in the Nov/Dec issue of Annals of Family Medicine, the shortage of primary care physicians is expected to exceed 52,000 by 2025. Then factor in the fact that the medical groups are coming out in favor of limiting the functions of NPs, makes it even more important that they present a united position.

NPs have been doing the right thing and working to present a consistent front in the establishment of national guidelines for scope of practice. Currently this varies from state to state. Some states require NPs to practice under the supervision of doctors, and in other states, they can practice independent of doctors. One objective that may be required under the ACA rules is the ability to order home healthcare for patients. Presently, to be reimbursed by Medicare, NPs can order home care only through physicians.

There are many other areas that NP can work in as well. I don't care the arguments raised by the American Academy of Family Physicians (AAFP) and other professional medical organizations, we are headed for a primary healthcare dilemma of great seriousness and the professional medical organizations are thumbing their noses at those that can help. If you are ready to accept long delays in seeing your doctor and even longer delays between appointments then support the physicians. Read my blog here to understand that NPs are on a par with doctors and may actually help reduce the cost of healthcare. Doctors are not really working to reduce healthcare costs because they continue to order more and more costly tests because they can.

Review this map for the states that are welcoming NPs and those that doctors have presently under their control. The map shows the states still allowing NPs to practice very much like primary care physicians.