Multi-Specialty Teams Help Seniors Manage Diabetes (Part 1 of 2)

A multi-disciplinary medical team of pharmacists, podiatrists, optometrists, ophthalmologists, dentists and dental hygienists best assist seniors in managing their diabetes by addressing medication, foot health, vision impairments, dental loss, and heart conditions, researchers at the U.S. Centers for the Disease Control (CDC) and Prevention and the U.S. National Institutes of Health (NIH) say.

While most of the aforementioned categories of physicians may not have time to take on these different aspects of diabetes outside of their specialties, they may be able to ask questions and provide their senior patients with advice during regular visits, check-ups and exams, the National Diabetes Education Program’s (NDEP) Pharmacy, Podiatry, Optometry and Dental Professionals Work Group of CDC and NIH say.

The joint-federal agency working group releases their annual reference guide titled Working Together To Manage Diabetes: A Guide for Pharmacists, Podiatrists, Optometrists and Dental Professionals to train medical professionals to converse with aging diabetics about treating their condition with insulin, drugs, proper diet, exercise and sleep.

The booklet’s recommendations on how to diagnose and manage pre-diabetes and diabetes are based on clinical work and research by the medical professional trade organization American Diabetes Association (ADA). It and other specialty-based literature and materials are available at ndep.nih.gov.

Affected professionals also include primary care, family practice or internal medicine physicians, physician assistants, endocrinologists, certified diabetes educators, nurses, nurse practitioners, registered dietitians, cardiovascular specialists, renologists, neurologists, psychologists, psychiatrists and social workers.

Certified diabetes educators are trained healthcare providers who can counsel and train diabetics about their condition by setting behavioral goals and discussing health issues. A diabetes educator is usually a nurse, dietitian or pharmacist certified to guide and instruct patients about diabetes and self-care.

Diabetes Prevalence and Impact

Deemed severe, common, expensive but able to be controlled, diabetes is considered the sixth leading cause of death in the country and impacts at least 21 million individuals with at least 6.2 million undiagnosed. It costs the nation nearly $200 billion in direct and indirect expenses.

Nationally, diabetes ranks first among all long-term, deadly diseases as the cause of lower limb amputation that is not connected to trauma, first as the cause of acquired blindness and first as the cause of kidney disease ending up in dialysis.

The condition also contributes significantly to heart disease, being its number one cause of death in the country. At least 65 percent of senior diabetics die from heart failure.

Meanwhile, the prevalence of diabetes increases. Federal research shows it has more than tripled in the last 25 years from 5.8 million to the current 21 million, and in some states, over 25 percent of adults are diabetic. Projections will continue to be high. By the year 2050, the number of diabetics is expected to reach 39 million.

With current trends, one out of every three individuals nationwide will contract diabetes in his or his adulthood and may find his or her life span reduced by 10 to 15 years.

There are three forms of diabetes, type 1, type 2 and gestational diabetes. Federal research shows that, as of 2005, about two-thirds of adults nationwide were obese with the body mass index (BMI) of over 25, contributing to the onset of diabetes in this segment of the population.

In fact, the incidence of obesity has jumped by 61 percent since 1991, leaving more than 60 percent of adults overweight. A high body mass index and obesity pose the greatest risks to individuals for developing diabetes.

Type 1 is defined an autoimmune disease that is characterized by the destruction of insulin-producing beta cells. This version of diabetes can take place at any age but most especially in childhood or young adulthood.

Type 1 diabetes patients can develop ketoacidosis, a diabetic complication in which the body releases excess blood acids also known as ketones. Diabetics must take insulin daily whether by injection, insulin pump or inhalation.

Additionally, type 1 diabetics must test their blood sugar several times every day, follow a customized meal plan and take part in physical exercise.

Type 2 diabetes is connected to insulin resistance. The pancreas produces insulin but it is not recognized or used by other body tissues. Patients of this form of diabetes are treated with insulin, drugs or both. Otherwise, the condition can be controlled with an individualized food plan and physical exercise.

The development of type 2 diabetes is multifactorial, with insulin resistance, sedentary lifestyle, advancing age and obesity contributing to this increase.

This version of diabetes hits nearly 10 percent of the country’s population of young adults and double of the senior segment with a high incidence among those who are obese and physically inactive.

Still, the number of type 2 diabetics among children and teens is increasing, a n important concern as the number and intensity of complications grow with age.

Type 2 diabetes affects African Americans, Hispanics, Native Americans, Alaska Natives, Hawaiians or other Pacific Islanders and they are all two times as likely to have the condition as whites of the same age group. Some sectors of the Native American population suffer the highest rates of diabetes in the world.

The third form, gestational diabetes, involves glucose intolerance in women at the time of pregnancy. Gestational diabetes is most likely to take place among African Americans, Hispanics and Native Americans. It also occurs in obese women with a family history of diabetes.

At the time of pregnancy, mothers are treated to have their blood glucose levels stabilized so as to not affect their infants. Afterward, five to 10 percent of gestational diabetics are discovered to have type 2 diabetes. Indeed, women with gestational diabetes harbor a 20 percent to 50 percent risk of contracting diabetes over the next five to 10 years.

Other forms diabetes stem from genetics such as “maturity-onset diabetes of youth,” surgery, drugs, malnourishment, infections and other illnesses. They make up 1 percent to 5 percent of such cases.

Prevention Tools

About 54 million individuals aged 40 to 74 years of age — an age group that makes up 40.1 percent of the country’s population — suffer from pre-diabetes, which endangers them into developing type 2 diabetes.

Without action, pre-diabetics can advance to type 2 by a rate of 10 percent higher every year. They also have a higher risk of heart disease and stroke.

Pre-diabetes, “a condition in which blood glucose levels are higher than” what is considered healthy “but not in the diabetes range,” is described as “impaired fasting glucose (IFG) of 100 to 125 mg/dL or impaired glucose tolerance (IGT) diagnosed by a post 75-gram glucose challenge of 140 to 200 mg/DL.”

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of NIH can assist patients and providers in determining whether they are at risk for pre-diabetes. Federal research identifies three types of prevention: primary prevention to keep diabetes from occurring and secondary prevention to prevent complications in those who are already stricken with diabetes (e.g., prevention of foot disease).

Still, a third version, called tertiary prevention, means avoiding worsening complications such as an amputation from injury to a diseased foot or death.

These three levels of prevention occur because of the high financial and non-financial costs of diabetes. Federal research shows that more than 4,100 individuals per day are diagnosed with diabetes. As a result, 55 lose their sight, 120 undergo renal failure and 230 lose a limb to amputation — daily.

To test for diabetes, medical professionals will perform finger sticks or forms of laboratory testing. To qualify to conduct laboratory testing, professionals must be registered with the Centers for Medicare and Medicaid Services (CMS) under the Clinical Laboratory Improvement Amendment (CLIA) of the law governing the policy and procedures of the federal agency.

The amendment sets quality standards for accuracy, reliability and timeliness of test results no matter what types of tests are performed. Three classes of tests and certification have been set and the categories depend on the level of difficulty and effort of the method used.

It has set up rules for each category of testing calling for quality control and documentation processes. Some states have added more requirements for different laboratory sites or medical professionals. For more information, professionals are asked to consult their state agency and the CMS website at http://www.cms.gov/clia/.

To help those who already have diabetes, the guide, Working Together To Manage Diabetes: A Guide for Pharmacists, Podiatrists, Optometrists and Dental Professionals, provides detail on the type of drugs that best manage blood sugar, including insulin, as well as blood pressure and cholesterol.

The booklet concentrates on diabetes-related complications affecting foot health, vision, oral care and medication therapy issues. Using clinical graphics, including patient education posters to be hung in a medical office, and four specialty-based prevention brochures, it aims to encourage interdisciplinary medical team work to treat diabetes and make appropriate patient referrals.

Additionally, another booklet, the Working Together Medications Supplement, instructs on how to understand and properly use medications meant to control diabetes and can be used to organize team care. Package inserts or another guide titled the Physicians’ Desk Reference include prescribing information.

The Working Together Medications Supplement guide provides insights for professionals and senior patients on such issues as:

–The different types of insulin and the appropriate times to administer them so as to not conflict with a scheduled procedure;

–The most common symptoms of medication use to help a medical specialist to pinpoint a problem and make an appropriate referral to another specialist;

–Reduction of adverse interactions of drugs prescribed by different specialists;

–Avoidance of accidental overdosing or underdosing by generating awareness of medication names, strengths and dosages, and;

–Making the most of each visit, check-up or exam to teach patients about how to correctly use prescribed drugs and to receive drug use counseling from a primary care physician or pharmacist.

Physicians, specialists and other medical professionals can access the reference guides, which are all free, at the Centers for Disease Control and Prevention’s continuing education website, http://www2a.cdc.gov/TCEOnline/ and fill out an evaluation form and post-test.

Taken together, the guides are meant to help professionals identify the different type of diabetes and to prevent complications; to practice key messages to senior patients about diabetes; to articulate the most pressing concerns about drug therapy, foot health, vision and oral care for diabetics, and; to interpret the outcomes of the Diabetes Prevention Program (DPP).

According to the American Diabetes Association Standards of Medical Care, Diabetes Care reference guide, professionals are required to train senior patients to pay attention to their hemoglobin A1C, a test that shows their average blood glucose over three months (the goal is an A1C of less than 7 or 150 mg/dL), a blood pressure reading at less than 130/80 mm Hg, and a cholesterol count of less than 100 mg/dL.

With such training, senior patients are expected to practice sound self-management habits. They can maintain a customized, healthy meal plan with the help of the dietitian, participate in physical exercise, avoid cigarette smoking with guidance from a certified diabetes educator, and take prescribed drugs properly with counseling from a pharmacist.

Social workers can help coordinate government services for patients, especially seniors, and mental health professionals can assist them with depression and other mental illness issues as they pertain to diabetes.

Resources geared at assisting them can be found at the NDEP’s Better Diabetes Care Web site at http://www.betterdiabetescare.nih.gov/WHATpatientcentereddimensions.htm.

Finding the Time

Pharmacists, podiatrists, optometrists, dentists and dental hygienists may not find time to look at a senior patient’s medications, feet, eyes or teeth, especially if each category of physician feels entrenched in his or her specialty, members of the joint CDC-NIH work group say.

However, specialists are capable of sending direct messages to their senior patients about health problems or issues they have noticed. Instead of opening a statement with wording such as, “You should see someone about that … ,“ a specialist could tell his or her patient that, “I recommend that you … “

For example, a pharmacist does not need to be a podiatrist, an optometrist or ophthalmologist or a dentist or dental hygienist or perform an exam to determine when a senior patient presents with a problem that warrants the attention of another category of specialist, the workgroup members say.

A minute is all that is needed, for example for a pharmacist, to view a senior patient’s foot, mouth or eye to ask some questions about medications, supplies or cigarette use, they say.

By merely mentioning the problem a pharmacist, for instance, may have identified, he or she reinforces the need for prevention once he or she examines the issue before referring the patient to another specialist-colleague, goes the argument of the workgroup.

A pharmacist, podiatrist, optometrist, ophthalmologist, dentist or dental hygienist can support comprehensive diabetic care by going beyond his or her specialty to point out potential issues and then make a referral with an “I recommend … “ statement.

CDC-NIH workgroup members say patients will be grateful to specialists for taking their health and well-being into consideration, setting up a referral system and adopting a comprehensive team-care approach with their professional peers.

Foot Health

Besides podiatrists and as part of a comprehensive diabetes care team, pharmacists, optometrists, ophthalmologists, dentists and dental hygienists and other specialists ought to watch their senior patients for the most common diabetes-related foot issues: neuropathy, vasculopathy, dermatological conditions and musculoskeletal problems.

To assess for peripheral sensory neuropathy or the loss of sensation in the feet, specialists should check for the senior patient’s experience of tingling, burning, numbness or sensation of bugs, crawling on the skin of the feet. Podiatrists seek to detect this foot condition by using an instrument known as the Semmes-Weinstein 5.07 (10 gram) monofilament.

Senior diabetics with neuropathy are nearly two times more likely to suffer from ulcers in the feet than their peers without this condition. For senior diabetics with both neuropathy and foot deformity, the danger of cultivating ulcers is 12 times greater. Still, furthermore, senior diabetics with a history of foot disease, including previous amputations or ulcers, face a worsening risk of up to at least 36 times greater.

The demographics most at risk for lower-extremity ulcers and amputations are members of the male gender, non-Hispanics, African Americans, seniors and diabetics of at least 10 years, having past cigarette use and having a history of poor blood sugar control or heart, eye and kidney complications.

A comprehensive foot exam for diabetics includes evaluating “pulses, sensation, foot biomechanics,” which is defined as foot structure and function, and nails. NDEP medical literature titled Feet Can Last A Lifetime describes how to use this monofilament to conduct a complete foot exam and can be accessed at ndep.nih.gov.

Vasculopathy represents the cramping of calf muscles when walking, also known as “charley horse”, which leads to several rest periods bet. The cramping stems from insufficient blood in the area below the knee, caused by the blocking of the arteries, which commonly happens in the lower extremities of senior diabetics.

Nighttime severe cramping and toe aches are known as rest pain and is treated by walking or allowing the feet to hang over the side of the bed. This particular symptom means there is an end-stage blood vessel disorder and tissue ischemia, all of which comes before the onset of diabetic gangrene.

Neuropathy is cited by clinical research as being most responsible for ulceration and related foot complications. However, an inadequate blood supply can also lead to bad ulcer healing and, thus, amputation. Both neuropathy and not enough blood should be factored into a complete diabetic foot exam and care.

Dermatological conditions are exemplified by feet corns and callouses, also hyperkeratotic lesions, which are the result of “elevated mechanical pressure and shearing of the skin.” These conditions come before the “breakdown of skin” and cause “blisters or ulcers.”

Additionally, “surface lacerations and heel fissures or maceration (softening by wetness)” can all result in infection. “Corns, callouses, toenail deformity and bleeding under the nail” may be symptoms of neuropathy. “Fungus infections of skin or nails” become secondary infections that must be treated immediately.

“Musculoskeletal symptoms” in diabetic feet may emerge with “muscle-tendon imbalances” because of motor neuropathy. Such deformities include the hammertoes, bunions, high-arched foot or flatfoot, which raises the possibility for irritation of the foot in the shoe.

A patient’s style of life and his or her family history can determine the status of foot health. Senior diabetics who smoke are four times more likely than smokers without diabetes to acquire lower-extremity vascular disease.

Consuming foods high in fat and sodium and remaining physically inactive can lead to insufficient long-term control of blood glucose and place the patient at risk for diseases of the peripheral nervous system and blood vessels.

Additionally, a family history of illnesses of the blood vessels in the brain and coronary artery disease may mean a greater risk of lower-extremity arterial complications. Foot types or shapes may make a patient more vulnerable to biomechanical deformities that could end in skin breakdown.

Senior patients with neuropathy are highly likely to acquire degenerative arthropathy, also known as Charcot foot, that targets the joints and results in a red, swollen and deformed foot that can be taken for cellulitis. A Charcot foot usually means little to no pain and may progress over weeks to months before a specialist discovers it in a patient.

Radiological imagery may reveal a collapse of joint structure and can be taken for osteomyelitis. Therapy for Charcot foot is a light cast, in the absence of any swelling, and special shoes to correct changed biomechanics. If Charcot foot is not treated, the senior patient’s feet can degenerate into greater deformity, ulcers and, in the end, amputation.

Podiatrists and specialists in general should watch for senior patients who complain that their shoes don’t fit or wear slippers or shoes with portions cut out to adapt to changes in foot shape or limping.

The American Diabetes Association (ADA) and the American Podiatric Medical Association (APMA) take into consideration two forms of risk for developing diabetic foot complications: high risk and low risk.

The symptoms of high risk for developing foot disease include a “loss of protective sensation, absent pedal pulses, foot deformity, a history of foot ulcers and prior amputation.” By sharp contrast, for low risk, none of these symptoms exist.

To prevent low-risk senior patients from advancing to high risk, both professional trade associations, the ADA and the APMA, ask specialists to urge them to control their A1C, or hemoglobin blood sugar levels, blood pressure readings and cholesterol count and to quit smoking for those using cigarettes.

To assist high-risk senior patients, both organizations ask specialists to help patients guard against developing ulcers through self-management training, foot care and using the proper footwear. Light trauma “such as stubbing a toe or stepping on a sharp object” is the event most likely to lead to acquiring ulcers.

As a result, specialists are asked to stress to senior patients and their families the need to take the initiative to clear out walking areas, especially near the bed and the route to the bathroom, and to use night lights to enable a senior patient to see in the dark.

Additionally, high-risk senior patients must know who and when to call about their foot health issues. Same-day emergency calls to a primary care physician or podiatrist will likely be about a puncture wound, ulcer, redness or new foot pain. For less urgent issues such as patients with callouses or thick or ingrown nails, a podiatrist should be phoned and visited within a matter of days.

Nearly 20 percent of senior diabetics who visit their primary care physicians or specialists for check-ups or exams will present a foot health issue. With each visit, their doctors must ask their senior patients to take off their socks and shoes and check both feet for problems.

The likelihood of developing foot ulcers among diabetics is 15 percent. Worse still, the probability of diabetics with kidney complications and undergoing dialysis at risk for foot complications is higher but is treatable.

A podiatrist or other specialists are asked to pose senior diabetics the following questions when probing for foot care problems:

Whether they know how diabetes affects their feet, that diabetes puts them at risk for ulcers, which can result in amputations, and that foot care can prevent this;

Whether they have had a comprehensive foot exam in the past year and, in particular, one by a podiatrist, and a foot inspection by a primary care doctor, and;

How do they care for their feet daily and if their care regimen includes looking and touching for cuts, bruises, puncture wounds, corns or callouses, redness or pus; cleaning the feet’s skin and nails daily; drying in between toes; checking the insides of shoes for materials before wearing them and avoiding walking barefoot at all times.

Specialists can also refer senior diabetic patients to foot care literature from NDEP in English and Spanish at ndep.nih.gov.

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Vladimire Herard, M.S.

A print journalist for 23 years, Vladimire Herard wrote for the National Senior Living Providers Network, (nslpn.com), the Guidance Channel and Longtermcare.com. Under CD Publications, Ms. Herard wrote about senior health, substance abuse prevention, and elderly housing. Under Inside Washington Publishers, she covered health care financing for Inside HCFA and food and product safety issues for FDAWeek. Ms. Herard also covered education, crime, and county affairs for daily newspapers such as the Chicago Defender. She currently serves as Chief Communications Officer for several companies, covering senior long-term care, the pharmaceutical industry, regulatory issues and education. Ms. Herard resides in Chicago.

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