August 30, 2012

Diabetes Self-management Education – Part 1

Diabetes self-management education (DSME) can easily be used in place of self-monitoring of blood glucose (SMBG) to confuse the unknowing public. They both involve education of the patient in management of blood glucose; however, DSME is then taken a few steps further to expand the issue. Both are equally valuable and can be used together. Many of us stop when talking about SMBG at the end of managing blood glucose.

This is where we make the mistake and do not carry the topic as far as DSME does. DSME continues on to include the whole process of diabetes management and takes into consideration the entire patient. For that reason, there has been some separation legitimately in the titles. Sometimes certain groups use the term DSMT (diabetes self-management training). It is a shame that the group that developed this only uses it in writing and self-promotion. This group seldom uses DSME or DSMT in actual practice.

This article is about older adults, but should apply across all ages with modifications. Older patients (age 60 and older) with diabetes do account for more than one-fifth of all patients with diabetes. One statement made in the study that I may repeat is this, and I quote, “Medical care in the absence of adequate self-care is rarely effective for chronic illnesses.” This is an important point and worth emphasizing repeatedly.

DSME is the supposed goal of certified diabetes educators. If they would follow and use it, we could all benefit. Instead, they muddy it up with mantras and do not educate many type 2 diabetes patients. This is their weakness and the importance of DSME should not be diminished. DSME was originally designed for all types of diabetes – again the one-size-fits-all; however, I will be talking about type 2 diabetes for the older generation in this blog and maybe for the younger generations in a future blog.

DSME for those age 60 and older requires, and I mean requires that it be on an individual basis. There is no place for a one-size-fits-all application for the elderly. Where possible it should involve care partners when patients are not able to assume full responsibility for their own self-care. DSME should also consider the potential effects of diabetes treatments on quality of life, but at the same time, encourage all individuals who want to achieve successful health-related care.

Studies of self-management interventions clearly indicate that health behaviors, health status, and health care utilization improve with patient education in diabetes daily care. If only Medicare would stop taking away testing supplies, it might improve even more. One study compared patients that had received some diabetes self-management education with patients not receiving any DSME. Those not receiving any DSME had a fourfold increased risk for major diabetes complications. This alone points out the importance of diabetes education, and the more education the better. This also explains the importance of follow up reinforcement of what they have learned, and asking how they are doing with what they have learned. Be specific and do not accept brush-offs of the questions.

Now the one fault of DSME for the over 60 age group is they are very under-represented in DSME research studies. Therefore, what we have is a set of expert consensus formulated guidelines developed by the American Association of Diabetes Educators (AADE) and the American Geriatric Society. This also highlights the need for other groups that can step forward and fill the need for those with type 2 diabetes. Since the AADE is obviously ignoring the needs of the elderly, this opens opportunities for peer mentors, and peer-to-peer people. With the increasing number of people with type 2 diabetes, and the lack of growth in the AADE, these people will assume roles that are even more important in the near future.

First, we have discussed making sure that the diabetes self-management education is created for the individual and not a one-size-fits-all situation. This should consider how long the individual has had type 2 diabetes. Next, a determination needs to be made of existence of any complications, other medical conditions, and life expectancy. Lastly, is the individual limited in English proficiency, frail, or cognitively impaired as these must be part of the education process and made part of the care partner concerns.

Older adults should be carefully evaluated do determine their knowledge of diabetes and their ability to learn and apply new self-care skills. Social support, transportation availability, financial problems, and functional status must be assessed. Treatment goals and management skills may need to be evaluated frequently to keep pace with changes in functional and cognitive abilities, which can occur relatively quickly.

For the elder generations, nutrition is important. Be sure that the proper nutrition authority is in attendance as problems with the Academy of Nutrition and Dietetics in some states is now the only people that can give nutrition advice unless you are certified by them. Nutrition education is important and older adults must be evaluated to determine if there needs to be changes and to what degree these changes will be followed.

When assessing elder patients' understanding of diabetes and nutrition, a thorough assessment must include individual food preferences, meal preparation capabilities, and potential misunderstandings of adequate nutrition. This should include, but not be limited to dental health, swallowing difficulties, gastrointestinal complaints, decreased appetite, decreased thirst, taste-altering medications, limited finances, and social isolation. Because the diabetes patients are elderly, pushing a fixed number of carbohydrates must be forbidden. Registered dietitians that will not work to the needs and nutrition of elderly patients should not be allowed on a team.

The above is an area of importance for those doing DSME and sometimes they forget about unintentional weight loss as this increases mortality in elderly patients with diabetes. The problem of destructive metabolism is sometimes ignored for these people because acute illness or recent hospitalization is overlooked. Diet moderation, and if medically able, increased physical activity should be considered instead of severe caloric restriction, and should be encouraged in older adults who sincerely wish to lose weight. The goal for individualized planning needs to minimize problems in nutrition management and facilitate changes in eating behaviors. This should be part of the goal to improve clinical outcomes, improved function, and enhance quality of life.

In the elderly, physical activity assessment can be very difficult and should be done in coordination with their doctor. The elderly can often be at increased risk for sedentary lifestyle. This may be caused by recent acute illnesses, coexisting medical conditions such as chronic pain, no safe environment for physical activity, history of falls, and fear of falling. There are many benefits if the elderly diabetes patients are able to exercise, but they should never be forced to exercise. Limited activity exercises need to be investigated when needed and done with their doctor's knowledge.

Other chronic diseases and the number of medications the diabetes patient is taking are important in evaluating potential limitations for the patient. Polypharmacy is the use of several or many medications at the same time. Polypharmacy is always difficult to assess in older patients as many will not tell you what supplements they are taking because they think natural cannot be dangerous. With the conflicts between prescription medications and some supplements, it is important to draw this information out and get them to talk about them. If nothing more, list the supplements that can conflict with the medications you learn they are using.

The fact finding with the elderly can be problematic. Even if the elderly patient is coming to an office and has been instructed to bring all medications and supplements, there is often the doubt that you are seeing all of them. Even for home visits, medications are often hidden and not brought out. Therefore, some detective work must be done. Look for medications from more than one doctor or more than one pharmacy, as this may be a clue to more medications. Always record all information that is on the prescription container, Rx number, date filled, directions, medication name and dosage size, quantity, physician name, refills remaining, and prescription expiration date. Whether you are an educator, peer-to-peer worker, or a peer mentor, dealing with some elderly patients can be a delicate situation where even the best diplomacy may not yield the discovery of all prescriptions and supplements in use.

All conflicts in medication must be reported to the doctor as well as discrepancies like out of date medications, medications not refilled, especially other doctors and pharmacies discovered. Always be on the lookout for duplication of medications and medications that may conflict with other medications.

An additional assessment needs to be done to evaluate patients and their cognitive abilities to understand when medications need to be taken. Look for signs of depression and physical disabilities that may interfere with medication adherence. This can be very important for the elderly with diabetes and using insulin. Pens may become more important than syringes in many cases and in some instances, it may be necessary to suggest or recommend full care facilities.

Based on the discussion above, consider the following practical pointers for DSME in older adults found to have functional limitations:
1. Choose equipment that is easy to hold and easy to use.

2. When possible, simplify the self-care regimen.

3. Conduct education sessions at a slow pace, with instruction occurring in steps. Use educational material that is easy to follow and excludes extraneous information. Schedule multiple sessions, if necessary, to prevent information overload.

4. Provide individual rather than group education.

5. Recommend further evaluation and treatment of depression and cognitive dysfunction before making any diabetes treatment regimen changes.

6. Use memory aids (e.g., personalized handouts) to reinforce points made during face-to-face sessions.

7. Make sure patients understand how to identify hypoglycemia and when to call the provider.

8. Make every effort to minimize the complexity of meal planning and to engage the patient's spouse or others living with the patient in creating a home environment that supports positive dietary change.

9. Prescribe weight loss diets with great caution.

To be continued in part 2.

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