Linda B. Haas

Diabetes in Older Adults

More than 25% of the U.S. population aged ≥65 years has diabetes (1), and the aging of the overall population is a significant driver of the diabetes epidemic. Although the burden of diabetes is often described in terms of its impact on working-age adults, diabetes in older adults is linked to higher mortality, reduced functional status, and increased risk of institutionalization (2). Older adults with diabetes are at substantial risk for both acute and chronic microvascular and cardiovascular complications of the disease. Despite having the highest prevalence of diabetes of any age-group, older persons and/or those with multiple comorbidities have often been excluded from randomized controlled trials of treatments—and treatment targets—for diabetes and its associated conditions. Heterogeneity of health status of older adults (even within an age range) and the dearth of evidence from clinical trials present challenges to determining standard intervention strategies that fit all older adults. To address these issues, the American Diabetes Association (ADA) convened a Consensus Development Conference on Diabetes and Older Adults (defined as those aged ≥65 years) in February 2012. Following a series of scientific presentations by experts in the field, the writing group independently developed this consensus report to address the following questions: 1. What is the epidemiology and pathogenesis of diabetes in older adults? 2. What is the evidence for preventing and treating diabetes and its common comorbidities in older adults? 3. What current guidelines exist for treating diabetes in older adults? 4. What issues need to be considered in individualizing treatment recommendations for older adults? 5. What are consensus recommendations for treating older adults with or at risk for diabetes? 6. How can gaps in the evidence best be filled? According to the most recent surveillance data, the prevalence of diabetes among U.S. adults aged ≥65 years varies from 22 to 33%, depending on the diagnostic criteria …

National Standards for Diabetes Self-Management Education and Support

By the most recent estimates, 18.8 million people in the U.S. have been diagnosed with diabetes and an additional 7 million are believed to be living with undiagnosed diabetes. At the same time, 79 million people are estimated to have blood glucose levels in the range of prediabetes or categories of increased risk for diabetes. Thus, more than 100 million Americans are at risk for developing the devastating complications of diabetes (1). Diabetes self-management education (DSME) is a critical element of care for all people with diabetes and those at risk for developing the disease. It is necessary in order to prevent or delay the complications of diabetes (2–6) and has elements related to lifestyle changes that are also essential for individuals with prediabetes as part of efforts to prevent the disease (7,8). The National Standards for Diabetes Self-Management Education are designed to define quality DSME and support and to assist diabetes educators in providing evidence-based education and self-management support. The Standards are applicable to educators in solo practice as well as those in large multicenter programs—and everyone in between. There are many good models for the provision of diabetes education and support. The Standards do not endorse any one approach, but rather seek to delineate the commonalities among effective and excellent self-management education strategies. These are the standards used in the field for recognition and accreditation. They also serve as a guide for nonaccredited and nonrecognized providers and programs. Because of the dynamic nature of health care and diabetes-related research, the Standards are reviewed and revised approximately every 5 years by key stakeholders and experts within the diabetes education community. In the fall of 2011, a Task Force was jointly convened by the American Association of Diabetes Educators (AADE) and the American Diabetes Association …

Diabetes in Older Adults: A Consensus Report

More than 25% of the U.S. population aged 65 years has diabetes mellitus (hereafter referred to as diabetes), 1 and the aging of the overall population is a significant driver of the diabetes epidemic. Although the burden of diabetes is often described in terms of its impact on working-age adults, diabetes in older adults is linked to higher mortality, reduced functional status, and increased risk of institutionalization. 2 Older adults with diabetes are at substantial risk for both acute and chronic microvascular and cardiovascular complications of the disease. Despite having the highest prevalence of diabetes of any age-group, older persons and/or those with multiple comorbidities have often been excluded from randomized controlled trials of treatments—and treatment targets— for diabetes and its associated conditions. Heterogeneity of health status of older adults (even within an age range) and the dearth of evidence from clinical trials present challenges to determining standard intervention strategies that fit all older adults. To address these issues, the American Diabetes Association (ADA) convened a Consensus Development Conference on Diabetes and Older Adults (defined as those aged 65 years) in February 2012. Following a series of scientific presentations by experts in the field, the writing group independently developed this consensus report to address the following questions:

Professional practice committee for the 2014 clinical practice recommendations

LINDA HAAS, PHC, RN, CDE (CHAIR) MELINDA MARYNIUK, MED, RD, CDE (CHAIR) JONI BECK, PHARMD, CDE, BC-ADM CARLA E. COX, PHD, RD, CDE, CSSD PAULINA DUKER, MPH, RN, BC-ADM, CDE LAURA EDWARDS, RN, MPA EDWIN B. FISHER, PHD LENITA HANSON, MD, CDE, FACE, FACP DANIEL KENT, PHARMD, BS, CDE LESLIE KOLB, RN, BSN, MBA SUE MCLAUGHLIN, BS, RD, CDE, CPT ERIC ORZECK, MD, FACE, CDE JOHN D. PIETTE, PHD ANDREW S. RHINEHART, MD, FACP, CDE RUSSELL ROTHMAN, MD, MPP SARA SKLAROFF DONNA TOMKY, MSN, RN, C-NP, CDE, FAADE GRETCHEN YOUSSEF, MS, RD, CDE ON BEHALF OF THE 2012 STANDARDS REVISION TASK FORCE

Translation of the diabetes nutrition recommendations for health care institutions.

The Nutrition Recommendations and Principles for People With Diabetes Mellitus (1,2) reflect current scientific nutrition and diabetes knowledge and consensus. The recommendations apply primarily to individuals receiving diabetes medical nutrition therapy on an outpatient basis and living in a home setting and not to hospitalized patients or residents of long-term care facilities with diabetes. This population takes on added importance when one considers that adults with diabetes are hospitalized three times more often than adults without diabetes and tend to have longer hospital stays. In addition, ~18% of all long-term care residents have diabetes (3). To provide guidance on implementation of the nutrition recommendations in acute and long-term health care facilities (e.g., hospitals, nursing homes), a task force was formed by the American Diabetes Association. The task force began by gathering data on how, and if, health care facilities were implementing the nutrition recommendations as well as on other nutrition issues related to the recommendations that should be addressed. This technical review summarizes the survey; reviews the role of diabetes medical nutrition therapy in acute and long-term health care settings; summarizes the advantages and disadvantages of meal planning systems used; reviews the role of patient selfmanagement education in acute-care settings; examines nutrition issues such as liquid and surgical diets, catabolic illness, and nutrition support; and suggests areas for future research. The technical review summarizes published research and recommendations, as well as traditional and usual acute and long-term nutrition care and food service. However, for many of the issues, few studies were available. This area requires additional research to determine if current nutrition therapy practices for diabetes lead to desired nutrition, medical, and clinical outcomes.

Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association

Diabetes is more common in older adults, has a high prevalence in long-term care (LTC) facilities, and is associated with significant disease burden and higher cost. The heterogeneity of this population with regard to comorbidities and overall health status is critical to establishing personalized goals and treatments for diabetes. The risk of hypoglycemia is the most important factor in determining glycemic goals due to the catastrophic consequences in this population. Simplified treatment regimens are preferred, and the sole use of sliding scale insulin (SSI) should be avoided. This position statement provides a classification system for older adults in LTC settings, describes how diabetes goals and management should be tailored based on comorbidities, delineates key issues to consider when using glucose-lowering agents in this population, and provides recommendations on how to replace SSI in LTC facilities. As these patients transition from one setting to another, or from one provider to another, their risk for adverse events increases. Strategies are presented to reduce these risks and ensure safe transitions. This article addresses diabetes management at end of life and in those receiving palliative and hospice care. The integration of diabetes management into LTC facilities is important and requires an interprofessional team approach. To facilitate this approach, acceptance by administrative personnel is needed, as are protocols and possibly system changes. It is important for clinicians to understand the characteristics, challenges, and barriers related to the older population living in LTC facilities as well as the proper functioning of the facilities themselves. Once these challenges are identified, individualized approaches can be designed to improve diabetes management while lowering the risk of hypoglycemia and ultimately improving quality of life.

Healthy Coping: Issues and Implications in Diabetes Education and Care

Psychological, emotional, and social factors not only impact quality of life, but also often play a role in chronic illness outcomes. Diabetes care, in particular, is greatly influenced by psychosocial factors when they hinder a persons ability to manage the disease and achieve metabolic control. Healthy coping, defined as responding to a psychological and physical challenge by recruiting available resources to increase the probability of favorable outcomes in the future, is essential to effective self-management by people with diabetes. In June 2009, the American Association of Diabetes Educators convened a multidisciplinary expert panel to discuss healthy coping in diabetes. The panel included diabetes educators and behavioral science and mental health professionals. Drawing on their knowledge and experiences, as well as information presented at the symposium, the panel probed several aspects of healthy coping including what it entails, common barriers, assessment, population diversity, and clinical applications. A team approach to addressing the patients coping is critical. Team involvement relieves the diabetes educator of the entire burden of supporting the patient in this regard. The team should be broadly defined and include those who are formally and informally involved. Healthy coping is a complex, qualitative behavior that cannot be easily quantified. Future efforts to address the issue of healthy coping should add to the body of literature regarding diabetes self-management at the individual and population-based levels.

Insights and trends in diabetes education: results of the 2008 AADE National Diabetes Education Practice Survey.

Purpose The purpose of this study is to describe current diabetes education practice and specific interventions and responsibilities of diabetes educators in the United States. Methods The 2008 National Practice Survey (NPS) instrument consisted of 53 items addressing diabetes education program structure, processes and interventions, outcomes and quality improvement activities, and the chronic care model. The survey was hosted online for American Association of Diabetes Educators (AADE) members. Participants totaled 2447 members, constituting a 25% return rate. Data from the 2008 NPS were analyzed and compared with results from previous surveys. Results Nearly two-thirds of respondents in 2008 provided diabetes education in a single location, most commonly in a clinical outpatient/managed care setting (39%). Most programs provided comprehensive services. Managers noted that 42% of their programs were either cost/revenue neutral or profitable. Programs varied in types of services, number of patient visits, team member functions, time spent on services, and instructional methods used. At least 50% of managers said their programs report outcome data, and 88% participate in quality/performance improvement activities. Nearly two-thirds of respondents were unfamiliar with the AADE-adopted chronic care model. Conclusions Many 2008 NPS results concur with those obtained in 2005 through 2007. Areas of variability among programs suggest a need for standardized interventions and prac- tice guidelines. Educators are encouraged to report out- comes to elucidate the contributions of their programs to patient care. AADE can use the results and comparative data obtained from the 2008 survey when developing practice, research, and advocacy activities

Financing the care of diabetes mellitus in the 1990s.

treatment regimen does exist, such as in pregnancy, only 25 % of the targeted consumers use the service. Why is this’? Is it due to lack of knowledge about the importance of this service, or to the inability to pay for it? Answers are needed to these and similar questions. Another important issue that emerged was the lack of a common language regarding services and reimbursement among payers, providers, and patients. In addition, these services should include preventive, early, and effective treatments as well as education. Man-

Assuming responsibility for communicating safe practices.

Earlier this year, two major medical journals published correspondence describing some very disturbing situations. A letter published in the New England Journal of Medicine reported an outbreak of hepatitis B in an endocrinology unit in a French hospital. Apparently the outbreak was caused by unsafe practices in the use of a capillary blood-sampling device-specifically, by not changing the platform between patients. The result was an epidemic of hepatitis B, an epidemic being more than the expected number of cases. At this writing, a similar scenario in the United States is being investigated by the Centers for Disease Control. In the US facility, 9 of 12 inpatients who developed hepatitis had diabetes. The actual vector (vehicle of transmission) of this hepatitis outbreak is not known but is the subject of intense investigation. Meanwhile, multiple use of finger-sticking devices has been banned in this large national health care system. The second letter, which appeared in the Journal of the American Medical Association,1 reported that a woman who had diabetes, and who also had HIV infection, was &dquo;screening&dquo; her friends for diabetes at social functions.