Diabetes mellitus is a common metabolic disorder that affects carbohydrate, lipid, and protein metabolism. It is estimated that about 4.4 to 17.4% percent of adults in the United States have diabetes mellitus (Cory , Ussery-Hall, Griffin-Blake et al., 2010). It is estimated that 11.5 million women and 12.0 million men over the age of 60 have diabetes, but many do not know it. The Indian Health Service reported via the National Diabetes Survey of 2007 that of the 1.4 million Native Americans and Alaska Natives in the United States, 14.2% age 20 years or older have diagnosed diabetes. Rates vary by region, from 6.0% of Alaska Natives to 29.3% of the Native Americans in southern Arizona (CDC, 2007). There are two major types of diabetes, type 1 (T1DM) and type 2 ( T2DM). T1DM is characterized by autoimmune destruction of the insulin-producing beta cells of the pancreas, leading to a deficiency of insulin. New-onset of adult T1DM in older adults rarely happens; however, due to better treatment of T1DM, older adults who have been diagnosed at an earlier age are living longer. About 90% of older adults with diabetes have T2DM, which is often related to obesity. T2DM is characterized by hyperglycemia and insulin resistance; however, impaired insulin secretion may also be present. Diabetes mellitus is a major cause of disability and death in the United States, and is the seventh leading cause of death among older adults.
The risk of diabetes increases with age (45 years and older). Other risk factors include family history, obesity, race (African Americans, Hispanics, Native Americans, Asian Americans, Pacific Islanders), hypertension, less “good” cholesterol (less than 35 mg/dl), lack of exercise, having a history of delivering large babies (≥9 pounds), personal history of gestational diabetes, and pre-diabetes in men and women (Laberge, Edgren, & Frey, 2011). Type 2 is the most common type in older women (CDC, 2007). The risk of death from DM is significantly higher among older ¬Mexican American, African American, and Native American women when compared to Whites. The Centers for Disease Control CDC (2005) names obesity, weight gain, and physical inactivity as the major risk factors for DM among women.
The most common presentation for older adults with T1DM is hyperglycemia (high blood sugar). Older adults may not have the classical symptoms such as polydipsia, polyuria, polyphagia, and weight loss. Instead, they may have an atypical presentation (Halter Chang & Halter, et al., 2009). They may first present with falls, urinary incontinence, fatigue, or confusion. Because older adults may have T2DM for years before it is diagnosed, they often have macrovascualar and microvascular complications at the time of diagnosis, so evaluation of these should be considered at that time.
Prevention is the best approach to care, which involves identifying those at risk and encouraging lifestyle change. Older adults with diabetes mellitus have a high risk for complications related to macrovascular disease, microvascular disease, and neuropathy. Macrovascular diseases include coronary heart disease, stroke, and peripheral vascular disease, which can lead to amputation. Microvascular diseases are chronic kidney disease, which is the most common cause of end-stage renal disease, and diabetic retinopathy, that which can lead to blindness. Peripheral neuropathy presents as uncomfortable, painful sensations in the legs and feet that are difficult to treat. A lack of sensation may also be present and contribute to the risk of falls. There is no cure for peripheral neuropathy, and it tends to be a complication for which patients experience daily challenges trying to manage the symptoms. A combination of medication to address pain and interventions by a physical therapist seems to be the best current treatment.
Treatment is aimed at helping patients to achieve and maintain glycemic control to decrease risk of complications. The initial treatment approach is to work with the older adult to establish treatment goals aimed at reducing long-term complications. This often requires working within an interprofessional team. Aggressive treatment may be appropriate for most older adults; however the risk of hypoglycemia (low blood sugar) is higher in older adults. Older adults with hypoglycemia may have an atypical presentation with acute onset of confusion, dizziness, and weakness instead of tremors or sweating. The best measure of good blood glucose management and controlled blood sugars is HgbA1c levels (glycosylated hemoglobin). This measure of hemoglobin provides insight into the previous 3 months of blood sugar control. If HgbA1c is elevated, it indicates that the blood sugar has been high over time. For most people, a HgbA1c ≤ 7% indicates optimal glycemic control; however, due to poor health outcomes, for frail older adults or those with a life expectancy ≤ 5 years this may not be the best, and a Hgb A1c of 8% might be more appropriate.
Management is successful when a balance is achieved among exercise, diet, and medications. Medications may be oral hypoglycemics or insulin injection. Insulin injection is used in T1DM and may be prescribed for T2DM because as the person ages, beta-cell function declines. If insulin is needed, it is important to consider if there are visual problems and or hand arthritis that limits the dexterity that is necessary to prepare and inject the medication. For some, a simple regimen, such as premeasured doses and easier injection systems (e.g.,insulin pens with easy-to-set dosages) is the best.
Thorough evaluation of readiness to learn and of the ability of an older person to manage his or her medications must be done. Older adults who need to give themselves insulin injections may experience anxiety about learning this task. Demonstration, repetition, and practice are good techniques for the older age group. Adaptive devices such as magnifiers may help if the syringes are hard to read. A family member should also be taught to give the insulin to provide support and encouragement, although the older adult should be encouraged to remain independent in this skill if possible. Williams and Bond’s (2002) research suggested that programs that promote confidence in self-care abilities are likely to be effective for those with diabetes. A plan for times of sickness and the use of a glucometer to monitor blood sugars will also need to be addressed. Additionally, the dietician may be consulted to provide education for the patient and family on meal planning, calorie counting, carbohydrate counting, and nutrition. Many patients benefit from weight loss, so the nutritionist can assist with dietary planning in this regard also.
Due to the increased risk of infection and slow healing that result from diabetes, foot care is an essential component in teaching older adults to manage DM. Some experts believe that good preventive foot care would significantly reduce the incidence of amputation in the elderly. Older persons with DM should never go barefoot outside. Extremes in temperature should be avoided. Shoes should be well fitting and not rub. Socks should be changed regularly. Elders should be taught to inspect their feet daily, with a mirror if needed. Corns and ingrown toenails should be inspected and treated by a podiatrist, not by the patient. Older persons should see their podiatrist for a foot inspection at least yearly. Patients should be cautioned that even the smallest foot injury, such as a thorn or blister, can go unnoticed and unfelt—and often results in partial amputations that lead to a cascade of lower extremity problems.
Adapted from Mauk, K. L., Hanson, P., & Hain, D. (2014). Review of the management of common illnesses, diseases, or health conditions. In K. L.
Mauk’s (Ed.) Gerontological Nursing: Competencies for Care. Sudbury, MA: Jones and Bartlett Publishers. Used with permission.
The human survival instinct is strong and our spirits are made to embrace life. But what happens when your loved one is diagnosed with a terminal illness that has no cure? How do you reconcile the certain death of your spouse, parent, or child? Where can you turn when death is close or imminent?
We are fortunate to live in a society that supports excellent care for those who are coming towards the end of their life. As difficult as this journey is for persons and their family members, the appropriate level of service can provide the needed care and comfort to make the end of life a time of peace and reflection rather than pain and suffering.
Two major services are readily available to bring comfort and promote quality of life even until the end of life. These are palliative care and hospice.
Palliative care is a consultative service for those with life-limiting illnesses who may not yet meet the criteria for hospice or who do not wish to enter hospice yet. The focus of palliative care is comfort and symptom management, but patients may still continue treatments such as radiation, chemotherapy, dialysis, home health, or other therapy. Palliative services can be provided in the acute hospital setting, in the home, or in a long-term care facility. A new program called PRIME (Progressive Illness Management Expertise) by AseraCare, focuses on symptom management, goals of care planning, medication management, and transition management. PRIME provides palliative care through nurse practitioners and social workers who coordinate care with your regular medical providers. For persons with serious chronic illnesses who experience recurring rehospitalizations, palliative care management can provide care coordination and smooth transitions to other settings, including hospice, at the appropriate time.
Hospice is a supportive and comprehensive service for those who are dying. The National Hospice and Palliative Care Organization states that the foundation of hospice and palliative care is the belief that “each of us has the right to die pain-free and with dignity, and that our families will receive the necessary support to allow us to do so”. Generally, to qualify for hospice a patient is expected to live 6 months or less. Hospice uses an interdisciplinary team of physicians, nurses, social workers, home health aides, chaplains, bereavement counselors, trained volunteers and others to provide comfort and support to the dying patient and family. These services are covered by Medicare, Medicaid, and most private and commercial insurances. Hospice care can be provided wherever a patient lives, with 24-hour on-call availability.
End of life decisions are often difficult for families to discuss, but palliative care and hospice programs provide the help that is needed to have these conversations. Their aim is to help provide quality of life until death, helping people “live until they die”. If your loved one may qualify for assistance, don’t delay in seeking this support. It may be the best way you can help your family member have a peaceful end of life.
In the wake of the sad news about the suicide death of beloved actor Robin Williams, discussions about depression, its recognition and treatment seem appropriate. Depression is common in American society, with 10% of men and 18% of women over the age of 65 in the United States reporting current symptoms associated with clinically significant depression. These statistics have been relatively stable since about 1998. Severe depression is one of the major causes for suicide attempts.
Sometimes it is hard to understand why a person would become so depressed that suicide seems like the only option. There are many reasons that depression occurs. These may include losses of various types such as outliving a spouse, friends, or loved ones. There may have been loss of health, financial difficulties, loss of a job, or a drastic unwanted change in living situation. Maybe the person has experienced a trauma that was life-changing. For some people, these losses can be overwhelmingly painful and persons may lack the support or coping mechanisms to successfully deal with their extreme feelings.
Men and women may display depression differently. Men express depression in the form of irritability, anger, agitation, controlling behavior, blaming others, or expressions of despair. In contrast, women may appear anxious, scared, apathetic, and express feelings of worthlessness.
Other common signs of depression include:
• No interest or pleasure in enjoyable activities
• No interest in sexual activities
• Feeling sad or numb
• Crying easily or for no reason
• Feeling slowed down
• Feeling worthless or guilty
• Change in appetite; unintended change in weight
• Trouble recalling things, concentrating, or making decisions
• Problems sleeping, or wanting to sleep all of the time
• Feeling tired all of the time
• Thoughts about death or suicide
While depression can be associated with suicide, persons with depression may not actually want to die. They simply feel they cannot live with the pain they feel and may express wanting that pain to end. This pain can be physical or emotional or both. In the United States, the highest rate of suicide is among white males over the age of 85. These men often visit their doctors within the month prior to their suicide, and give few other signs of their suicidal thoughts. They most often use lethal means to carry out suicide such as hanging or firearms. In women, suicide attempts are more often by nonlethal means such as taking pills, and should be considered a cry for help. If you have a loved who is at high risk for depression or suicide, be sure to take special note of the warning signs listed here.
The good news is that depression can be successfully managed and treated with the right help. Early recognition and treatment of depression is important and generally includes medication therapy and counseling. Talk to your doctor if you or your loved one is feeling depressed. Your primary care provider can assist you in diagnosing depression and can refer you to a reliable mental health professional to help address your symptoms and promote a better quality of life.
Tips for helping your loved one who is experiencing depression are provided on SCC’s care page that can be found at http://senior-care-central.com/category/dr-mauks-boomer-blog/
With the birth of my daughter’s second child, I began to reflect on the important role that grandparents can play in the lives of their grandchildren. Here are five essential tips for older adults who want to have a lasting influence in the lives of their children and grandchildren.
Visit often. For those of us fortunate enough to live near our children and grandchildren, it is easy to see them often. Grandparents may even be the caregivers while parents are working. Visits don’t always have to be planned. Sometimes the best family time is a spontaneous invitation to dinner and a movie. However, sometimes distance can prevent regular visits. Some grandparents make it a goal to see their distant grandchildren once every 6 weeks or every few months. Be sure to take advantage of technology for your time together. Set a regular time to Skype or do Face-time. Don’t miss out on the subtle changes in those early years while babies are growing. Exchanging pictures may help, but they don’t replace the in-person experience. You may even think of relocating to be closer to family. For older grandchildren, be sure to have their cellphone number. Text them often and exchange pictures to stay involved in their lives and let them know you are available to them. Even small connections throughout the week (but without being annoying to teenagers of course) can make a difference in your relationship with your grandchildren.
Offer to help in practical ways. Working parents with young children will need a break at times. Ask how you can best help. Offer to keep the children for an overnight while mom and dad have a special dinner or weekend getaway. Many grandparents like to take their grandchildren on trips without the parents. Places like amusement parks, the zoo, or day trips to the water park or national forest all provide good diversion and quality time with Grandma and Grandpa while giving parents a rest. For even more quality time, take the older grandchildren on a cruise, camping in the mountains, or to a resort without their parents. For the mom with a newborn, take meals to the house (if you live close), do her grocery shopping or laundry, or send her a new bathrobe to show you are thinking of her. A favorite role model of mine sends the grandchildren a “baby shower in a box” with all sorts of goodies when she can’t be present due to distance or health concerns.
Plan special activities. Special activities need not be expensive. This could mean a trip to the park with Grandma or a special morning walk each week with Grandpa. My father used to take every grandson on a bow-hunting trip when they turned 12 years old. This was a rite of passage for every boy in the family. Grandpa would mount their first deer head for them and buy them a special hunting knife to commemorate the occasion. The girls in the family would take a trip to a Disney resort while the men were hunting. Grandchildren remember these events forever.
Attend special events. How fortunate are the kids whose grandparents are able to attend basketball and volleyball games, swimming tournaments, and Grandparent’s Day at school! Take advantage of being able to attend those dance recitals and school plays. If you live far, plan your visits to be able to attend some significant events like graduations, wedding showers, or school performances. This makes lasting memories with your family.
Be a constant in their lives. My parents divorced when I was 9 years old, and my paternal grandparents were the one constant in my life at that time. When a child’s world is jolted by change, grandparents can be that steadying influence that doesn’t change. They provide stability and security in an unsteady world for a child. The most important thing to remember is to be there. You don’t have to be the all-star parent or grandparent, but your children will remember that you were there for them when it counted the most.
Today’s technology is not only for the young. The digital age has brought with it innovations which aim to benefit seniors. A new age of Internet of Things (IoT) devices has made senior care better, more efficient and less costly. It aims to eliminate isolation, which has been a major concern for many years. It has provided caregivers in the healthcare industry a tool to allow seniors to be more independent and remain connected with friends and family.
When it comes to senior care, the IoT is revolutionizing the way seniors are living their lives. Assisted living communities are using the internet to connect and humanize senior care. Communities such as the K4Community leverage technology to make seniors’ life simpler, healthier and happier. These communities integrate IoT wearables such as watches or belt clips. They also have floor sensors that provide real-time monitoring to prevent falls and other injuries. Other types of sensors monitor heart rate, blood pressure and oxygen levels to immediately alert caregivers when there’s an emergency.
To lead a healthy, active lifestyle, IoT devices go beyond the standard activity trackers. Devices are more targeted towards the individual’s needs, alerting them when to rest, whether they’re standing up or down too fast and when to give their knees a break. Food and hydration is also considered, with wearables reminding seniors when it’s time to eat and how often to drink to maintain proper hydration. When it comes to sleep, sensors can also alert caregivers whether a senior needs help getting in and out of bed. With the internet being all about connection, keeping seniors in contact with friends and family is one of the best things the IoT can provide to improve senior health. Seniors are spending more time online, using social networks and other platforms to connect with loved ones.
This trend is only going to get more prevalent. Research shows that using the internet makes people happier and increases life satisfaction, especially for seniors. A study published in the Journal of Computers in Human Behavior shows that life satisfaction was much higher among seniors who use the internet than those who don’t. The ability to keep in touch and prevent the cycle of loneliness and isolation in an advanced age has done more for senior health than any medication. It is no wonder then that internet use among seniors rose from 8% to 34% between 2003 and 2012, as cited by the Journalist’s Resource. The empowerment that the internet and technology have given seniors is invaluable to their health. Such developments revolutionized the way society and healthcare providers care for the elderly.
With Baby Boomers contributing to an increasingly aging population, the need for caregivers and connected assisted living communities is becoming greater than ever. In order to provide quality healthcare to seniors, healthcare is not just about technology but also about the people who provide it. Maryville University details how general healthcare workers can specialize in senior services to provide care for an aging population. Healthcare and senior care are becoming two of the fastest-growing industries. Boosted with the aid of technology and IoT devices, they provide a way to create a better quality of life for seniors, while reducing the costs of healthcare at the same time.
Article submitted by Tanya Olivers
There are three major types of skin cancer: basal cell, squamous cell, and malignant melanoma (MM). Basal cell carcinoma is the most common skin cancer, accounting for 65–85% of cases (Kennedy-Malone et al., 2000). According to the American Cancer Society (2013), more than 3.5 million cases of basal cell and squamous cell skin cancer are diagnosed every year. Squamous cell carcinoma is more common in African Americans and is also less serious than malignant melanoma. Malignant melanoma accounts for only 3% of all skin cancers, but it is responsible for the majority of deaths from skin cancer. Older adults are 10 times more likely to get MM than adults under age 40 (Johnson & Taylor, 2012). About 8,420 people were estimated to die from malignant melanoma in 2008. The American Cancer Society (2013) estimated that in 2013 there would be over 76,000 new cases of malignant melanoma in the United States.
Older adults are more susceptible to skin cancers because of a variety of factors. These include exposure to carcinogens over time (such as through sunburn or tanning booths) and immunosenescence, or a decline in immune function. Family history of skin cancers, multiple moles (more than 100), and pale skin also put a person at higher risk. The major risk factor for all types of skin cancer is sun exposure.
The ABCDE method can help people remember the warning signs of skin cancer:
A = Asymmetry (if a line is drawn down the middle of the lesion, the two sides do not match)
B = Border (the borders of the lesion tend to be irregular)
C = Color (a variety of colors is present; the lesion is not uniform in color)
D = Diameter (MM lesions are usually larger)
E = Evolving (note any changes in shape or size, or any bleeding)
Annual physical examinations should include inspection of the skin for lesions. Older adults should be taught to report any suspicious areas on their skin to the physician. Persons should particularly look for changes in shape, color, and whether a lesion is raised or bleeds.
Basal Cell Carcinoma
Basal cell carcinoma (BCC) is the most common kind of skin cancer. It is often found on the head or face, or other areas exposed to the sun. Although there are different forms of BCC, the nodular type is most common, and appears as a raised, firm, papule that is pearly or shiny with a rolled edge. (Johnson & Taylor, 2012). Patients often complain that these lesions bleed and scab easily. When treated early, it is easily removed through surgery and is not life threatening, though it is often recurring.
Squamous Cell Carcinoma
Squamous cell carcinoma (SCC) also appears as lesion on areas of the body exposed to the sun, or from other trauma such as radiation. HPV is a risk factor of SCC, and metastasis is more common than with BCC. The lesions of SCC appear scaly, pink, and thicker than BCC. Their borders may be more irregular and the lesions may look more like an ulceration.
Malignant melanoma MM has a more distinctive appearance than other types of skin cancer. The areas appear asymmetric with irregular borders, a variety of colors (including black, purplish, and pink), and size greater than 6 mm. Malignant melanoma MM is often identified with the ABCDE method and MM accounts for the vast majority of deaths from skin cancer. The good news is that MM is almost always curable when found early. A skin check should be part of an older person’s yearly physical.
The best treatment for skin cancer in the elderly is prevention. All older persons, especially those with fair skin who are prone to sunburn, should wear sunblock and protective clothing. Most skin cancers, when treated early, have a good prognosis.
All skin lesions larger than 6 mm, or those with any of the ABCDE signs, should be referred for biopsy. There are many nonsurgical interventions. These include cryotherapy, radiotherapy (for superficial BCC or SCC), electrodessication and curettage, and topical treatments. Topical treatments are generally not as effective as more aggressive interventions, but research is ongoing in this area.
The prognosis for MM depends on the extent and staging of the tumor, but when caught very early, the cure rate is nearly 100%. Malignant melanoma MM presenting in older adults is often more advanced and aggressive. Malignant melanoma MM metastases sites are typically the lymph nodes, liver, lung, and brain (Johnson & Taylor, 2012). Surgical treatment is required in malignant melanoma, with chemotherapy and radiation. Adjuvant treatments for MM are also often used.