Diabetes Risk Factors and Treatments
Background
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.
Risk Factors
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.
Diagnosis
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.
Treatment
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.
http://www.diabetes.org
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.
Stroke Warning Signs and Risk Factors
Background
Stroke, also known as cerebrovascular accident (CVA) or brain attack, is an interruption of the blood supply to the brain that may result in devastating neurological damage, disability, or death. Approximately 795,000 people in the United States have a new or recurrent stroke each year (American Stroke Association [ASA], 2012a). Stroke accounts for 1 in 18 deaths, making it the fourth leading cause of death in the United States. A death from stroke occurs every 4 minutes and the cost of stroke treatment and disability was over $73 billion dollars in 2010. Death from stroke is generally higher among females, with higher rates in Black males (67.7/100,000) and females (57.0/100,000) than in Caucasians (ASA, 2012a). In Canada, stroke is the fourth leading cause of death, affecting 50,000 people each year (Heart and Stroke Foundation of Canada, 20059).
There are two major types of stroke: ischemic and hemorrhagic. The vast majority of strokes are caused by ischemia (87%), usually from a thrombus or embolus (ASA, 2012a). The symptoms and damage seen depend on which vessels in the brain are blocked. Carotid artery occlusion is also a common cause of stroke related to stenosis
Risk Factors
Some risk factors for stroke are controllable and others are not. The most significant risk factor for stroke is hypertension. Controlling high blood pressure is an important way to reduce stroke risk. Those with a blood pressure of less than 120/80 have half the lifetime risk of stroke as those with hypertension (ASA, 2012a). Smoking 40 or more cigarettes per day (heavy smoking) increases the stroke risk to twice that of light smokers. If a person quits smoking, their risk after 5 years mirrors that of a nonsmoker, so older adults should be particularly encouraged to stop smoking.
Warning Signs
Several warning signs are common. These include:
SUDDEN numbness or weakness of face, arm or leg – especially on one side of the body.
SUDDEN confusion, trouble speaking or understanding.
SUDDEN trouble seeing in one or both eyes.
SUDDEN trouble walking, dizziness, loss of balance or coordination.
SUDDEN severe headache with no known cause (National Stroke Association, 2013)
Diagnosis
There are several tools for assessing for signs and symptoms of stroke. One easy acronym is FAST:
F stands for facial droop. Ask the person to smile and see if drooping is present.
A stands for arm. Have the person lift both arms straight out in front of him. If one is arm is drifting lower than the other, it is a sign that weakness is present.
S stands for speech. Ask the person to say a short phrase such as “light, tight, dynamite” and check for slurring or other abnormal speech.
T stands for time. If the first F-A-S checks are not normal, then one is to remember F-A-S-T that Time is important and the emergency medical system should be activated (National Stroke Association, 2012).
Older adults experiencing the warning signs of stroke should note the time on the clock and seek immediate treatment by activating the emergency response system in their area calling 911 (American Stroke Association, 2012). Transport to an emergency medical facility for evaluation is essential for the best array of treatment options. A history and neurological exam, vital signs, as well as diagnostic tests including electrocardiogram (ECG), chest Xx-ray, platelets, prothrombin time (PT), partial thromboplastin time (PTT), electrolytes, and glucose are routinely ordered. Diagnostic testing imaging may include computed tomography (CT) without contrast, magnetic resonance imaging (MRI), arteriography, or ultrasonography to determine the type and location of the stroke. The CT or MRI should ideally be done within 90 minutes so that appropriate emergency measures may be initiated to prevent further brain damage.
Treatment
The first step in treatment is to determine the cause or type of stroke. A CT scan or MRI must first be done to rule out hemorrhagic stroke. Hemorrhagic stroke treatment often requires surgery to evacuate blood and stop the bleeding.
The gold standard at present for treatment of ischemic stroke is t-PA (tissue plasminogen activator). At this time, t-PA must be given within 3 hours after the onset of stroke symptoms. This is why it is essential that older adults seek treatment immediately when symptoms begin. Only about 3 – 5% of people reach the hospital in time to be considered for this treatment (ASA, 2012d). t-PA may be effective for a select group of patients after the 3-hour window (up to 4.5 ½ hours), and this treatment window has been approved in Canada (Heart and Stroke Foundation of Canada, 2009). The major side effect of t-PA is bleeding. t-PA is not effective for all patients, but may reduce or eliminate symptoms in over 40% of those who receive it at the appropriate time (Higashida, 2005). Other, much less common procedures such as angioplasty, laser emulsification, and mechanical clot retrieval may be options for treatment of acute ischemic stroke.
To prevent recurrence of thromboembolic stroke, medications such as aspirin, ticlopidine (Ticlid), clopidogrel (Plavix), dipyridamole (Persantine), heparin, warfarin (Coumadin), and enoxaparin (Lovenox) may be used to prevent clot formation. Once the stroke survivor has stabilized, the long process of rehabilitation begins. Each stroke is different depending on location and severity, so persons may recover with little or no residual deficits or an entire array of devastating consequences.
The effects of stroke vary, and some persons may recover with no residual effects. But more often, stroke survivors may have problems that include hemiplegia or hemiparesis (paralysis or weakness on one side of the body), visual and perceptual deficits, language deficits, emotional changes, swallowing dysfunction, and bowel and bladder problems. Ninety percent of all dysphagia (swallowing problems) results from stroke (White, O’Rourke, Ong, Cordato, & Chan, 2008).
Poststroke Rehabilitation
Rehabilitation after a stroke focuses on several key principles. These include maximizing functional ability, preventing complications, promoting quality of life, encouraging adaptation, and enhancing independence. Rehabilitation emphasizes the survivor’s abilities, not disabilities, and helps him or her to work with what he or she has while acknowledging what was lost.
Stroke survivors go through a unique recovery process. This model shows the process of stroke recovery where forward progress after stroke lead to acceptance and adaptation:
If significant functional impairments are present, evaluation for transfer to an intensive acute inpatient rehabilitation program is recommended. Inpatient rehabilitation units offer the survivor the best opportunity to maximize recovery, including functional return. An interdisciplinary team of experienced experts, including nurses, therapists, physicians, social workers, and psychologists, will help the survivor and the family to adapt to the changes resulting from the stroke. Outcomes for geriatric stroke survivors are enhanced by intensive rehabilitation programs, whether offered in rehabilitation units or in skilled nursing facilities (Duraski, Denby, Danzy & Sullivan, 2012; Jett, Warren, & Wirtalla, 2005).
A large amount of teaching is often done by stroke rehabilitation nurses who work with older survivors and their families. These include knowing the warning signs of stroke and how to activate the emergency response system in their neighborhood, managing high blood pressure, understanding what medications are ordered as well as how often to take them and why, the importance of regular doctor visits, preventing falls and making the home environment safe, available community education and support groups, and the necessity of maintaining a therapeutic regimen and lifestyle to decrease the risk of complications and recurrent stroke. All survivors will need assistance in re-integrating into the community. This is generally begun in the rehabilitation setting.
http://www.strokeassociation.org/
Guest Blog: 5 Smart Senior Hacks for Independent Living
Getting older doesn’t have to mean losing your independence. If you’re looking forward to spending your golden years at home, you can make the experience safer and more comfortable with these life hacks.
1. Try Meal Prep
It can become harder to lead an active lifestyle, and still, pay time and attention to cooking at eating healthy. You may choose to arrange help in the kitchen or check out some quick and easy recipes for seniors. Cooking groups are another great way to meal prep, and can also help you build a network.
2. Update Home Security
There are plenty of reasons to consider home security. In addition to a new system, get familiar with your community. Arrange for friends, family members, or neighbors to pick up any mail, or keep an eye on your home when you’re not there.
Motion activated lights can also discourage intruders. Connecting a smartphone to your home security can make life more accessible. Try wireless doorbells, which will allow you to see, hear and talk to whoever is at the door.
3. Keep Your Contacts List Updated
Any senior living alone should keep an up-to-date list of emergency contacts and medical needs. Keep it in one place and up-to-date. Set up your smartphone so it takes simple voice commands. This way you can contact someone quickly when you can’t reach your phone.
4. Keep Your Home In Good Shape
Scheduling regular maintenance means you’ll spot any tears in carpets, loose fixtures, or anything else that may cause accidents. Ensure that you have regular maintenance done on the home. Setting alerts can help you keep your home updates on a schedule.
5. Smart Apps & Wearable Technology
We’ve already mentioned setting alarms to keep your home in good shape. But what about you? There are simple assistant apps that can help you stay healthy. For instance, an app to remind you to take your medicine, to drink water, or work out.
Apart from apps you install on your phone or tablet, there are health trackers that will ensure your health stays, well, on track. Fitness trackers can measure your heart rate and activity level. Medical alert accessories contain your health information, which can be important in emergencies.
There are many changes that make living independently complicated for seniors. But complicated doesn’t have to mean difficult. Try these tips and make living alone easier on yourself.
Guest Blog: When Should Seniors Stop Driving?
On a list of the greatest fears many seniors have, failing health, hearing loss, and falling often rise to the top. One major fear that few actually talk to their families and doctors about though is losing the ability to drive. In fact, a new AAA study found that over 80 percent of older drivers never discuss their safe driving ability at all with their care networks or medical professionals.
For many seniors, driving is the hallmark characteristic that defines independence. Being able to drive allows seniors to travel, to run their own errands, to get out of their house and socialize. Losing that ability to drive doesn’t just strip those things away, but it also requires seniors to ask for help and coordinate transportation, all of which can leave them feeling like a burden on their caregivers.
What is the danger then? Well not only do older drivers who have outlived their ability to safely drive a vehicle endanger their passengers and other drivers on the road, they put themselves at increased risk for injury and even death. Because older adults typically have more fragile bones and higher rates of chronic illness that can complicate an injury recovery, they are more likely to get hurt or even die in a car crash than younger adults.
Talking About Driving with Your Aging Parent
The bottom line is that simply conducting a dialogue about driving doesn’t mean a senior will lose their license or be held back from driving. In fact, it is quite the opposite. Just as using a cane for walking empowers a senior with mobility limitations to keep moving, talking about safe driving can empower seniors to take helpful steps that keep them safe on the road.
For example, the Senior Driving division of AAA offers loads of helpful resources, tools, and information that connect seniors with local refresher courses on defensive road wise driving, help them understand how medicine can affect safe driving, and much more.
If you need to have a conversation with your aging parent about safe driving, experts recommend approaching it from a place of compassion and empathy. Instead of accusing them of being an unsafe driver, confess the concerns you feel about their safety on the road and ask them about their own perspective. Discuss helpful driving tools, safe driving refresher classes, and even consider attending a senior driving expo together.