Diabetes & The Body

Diabetes management in the frail elderly

Because diabetes is a prevalent and costly disease in the elderly, both economically and physically, it has become a popular target for disease-management programs among payers.

Diabetes has a number of long-term complications, including damage to the nerves or blood vessels in a person's lower legs and feet, which can necessitate amputation, and damage to the eyes, which can result in blindness.

A disease-management program for Medicare beneficiaries could try to ensure that enrollees receive recommended foot and eye exams annually. In addition, since diabetes is associated with increased risk of heart disease, better monitoring of a diabetic's cholesterol level could be part of a disease-management program.

Many physicians and medical directors have already embraced the use of evidence-based medicine to better manage diabetes. A large number of elderly diabetics could be found with comorbidities that include cardiovascular disease, stroke, kidney disease, skin integrity problems, and neuropathy.

Lifestyle management & more

The pre-diabetics--those whose glucose levels are just above normal should be recommended to do exercise five times per week, better nutrition and hydration, and reducing body weight by 7%. When glucose levels cross the line and the patient becomes diabetic, the patients should take oral insulin as long as possible.

Hydration can be particularly difficult for caregivers when a resident has a poor appetite or is anorexic. They need water to control the diabetes but a milk shake for nutrition. He also recommends exercise--even for those confined to bed or chair--as a way to reduce complications. Cognitively impaired diabetics require special vigilance on the caregiver's part, he notes.

Failure to diagnose and manage diabetes in the frail elderly leads to poor outcomes when a patient is hospitalized. In a study of more than 2,000 elderly patients reported in the Journal of Clinical Endocrinology and Metabolism. Hyperglycemia was present in 38% of patients admitted to the hospital.

However, only 26% had a known history of diabetes and 12% had no history of diabetes before admission. Newly discovered diabetes was linked to higher in-hospital mortality rates--16%, compared with 3% for those previously diagnosed with diabetes. Such patients also had longer hospital stays, higher ICU admission rates, and were more likely to go to a nursing home rather than home post-discharge.

Can't Afford Medication?

There is the lack of prescription drug coverage for the elderly, which makes the patients worried about choosing between paying for food and medication. At minimum, diabetics require insulin and glucose-monitoring test strips. If they are hypertensive and require lipid-controlling drugs, their monthly drug costs can easily climb to 400 dollar or more.

This is not just a problem of the indigent. Even affluent patients struggle with medication costs necessary to comply with their disease management programs.

However, many of the patients need control nephropathy and arthritis, as well. The physicians use a number of strategies to make medications more affordable, including prescribing cost-effective generic substitutes, when appropriate; larger doses and pill splitting; purchasing medication.

Need of consistent effort

Because diabetes is so taxing to the health care system, implementing disease management on a large scale can be a cost-effective strategy. Evidence-based management of diabetes requires a large commitment, and it can be done.

Working through consensus, medical directors and other practitioners should adopt a uniform standard of care based on national standards, building in extensive monitoring and measurement of clinical indicators. The core clinical care teams should be hospital-based, and be deployed to the community as indicated. With its primary goal of reducing HbA1c to levels as close to normal as possible, the IHS program incorporates education, nutrition, and lifestyle management in addition to medication and monitoring features.

Controlling HbA1c has led to a reduction of further complications of diabetes by 30%-60%, compared with such complications before the program was initiated. According to experts, multiple, locally controlled diabetes education programs can be unified into one consistent, effective program to make a measurable difference in care and quality.

The patient or caregiver must be able to accurately measure and record blood glucose, urine ketones, insulin dosage administered, temperature, respiratory and pulse rate, and body weight, and relay this information to a health care professional.