Management of type 2 diabetes mellitus in the elderly: role of the pharmacist in a multidisciplinary health care team

Dementia in Diabetes: The Role of Hypoglycemia

Hypoglycemia, a common consequence of diabetes treatment, is associated with severe morbidity and mortality and has become a major barrier to intensifying antidiabetic therapy. Severe hypoglycemia, defined as abnormally low blood glucose requiring the assistance of another person, is associated with seizures and comas, but even mild hypoglycemia can cause troubling symptoms such as anxiety, palpitations, and confusion. Dementia generally refers to the loss of memory, language, problem-solving, and other cognitive functions, which can interfere with daily life, and there is growing evidence that diabetes is associated with an increased risk of both vascular and non-vascular dementia. Neuroglycopenia resulting from a hypoglycemic episode in diabetic patients can lead to the degeneration of brain cells, with a resultant cognitive decline, leading to dementia. In light of new evidence, a deeper understating of the relationship between hypoglycemia and dementia can help to inform and guide preventative strategies. In this review, we discuss the epidemiology of dementia among patients with diabetes, and the emerging mechanisms thought to underlie the association between hypoglycemia and dementia. Furthermore, we discuss the risks of various pharmacological therapies, emerging therapies to combat hypoglycemia-induced dementia, as well as risk minimization strategies.

Pharmacist led intervention towards management of type 2 diabetes mellitus and assessment of patient satisfaction of care - A prospective, randomized controlled study

BACKGROUND

Diabetes mellitus, a metabolic disorder characterized by hyperglycaemia is due to impaired insulin secretion and deficiency. Though effective current drug therapies are available for diabetes, yet glycaemic maintenance remains a challenge without medication adherence. This necessitates a holistic approach to improve clinical outcomes for a better patient health care.

METHODS

A prospective, interventional, randomized controlled study was conducted among 97 type 2 diabetic patients for 6 months. The primary outcome measures included patient satisfaction of care assessment by diabetes treatment satisfaction questionnaire (DTSQ) and medication adherence by medication adherence rating scale (MARS). Secondary outcomes included assessment of knowledge, attitude, and perception and laboratory parameters. The collected data was analyzed using paired and unpaired T-test.

RESULTS

Of 97 patients randomized to group A (n = 49) and group B (n = 48), there were 3 and 1 drop-out in group A and B, respectively. The mean age of patients was found to be 56.82 ± 4.06 years. At the 6^thmonth follow up, significant improvement of glycaemic parameters was observed in group A vs B. Mean MARS and DTSQ scores also improved in group A vs. B (P-value <0.05).

CONCLUSION

Pharmacist-provided counselling improves patient compliance, quality of life and satisfaction of care in diabetic patients.

Long-term training in diabetes-related knowledge, attitudes, and self-reported practice among diabetes liaison nurses

Objective

We aimed to investigate whether long-term regular training of diabetes liaison nurses (DLNs) could improve their diabetes-related knowledge, attitudes, and self-reported practice.

Methods

We enrolled 45 diabetes liaison nurses (DLNs) and 45 non-specialist nurses (controls). DLNs received 11 days of qualifying training, followed by regular theory classes and practice sessions for 4 years. All nurses were administered a questionnaire assessing demographic characteristics, knowledge about diabetes mellitus (DM), attitudes toward DM, and DM management practices, before and after the 4-year DLN training period.

Results

At baseline, there were no significant differences between the DLN and control groups for sex, age, educational level, nurse title/grade, work experience, hospital department, or questionnaire scores. At 4 years, the DLN group had a higher overall questionnaire score and higher scores for knowledge about DM, attitudes toward DM, and DM management practices, as compared with baseline scores.

Conclusion

Long-term regular training provided by a multidisciplinary diabetes care team can improve the knowledge, attitudes, and self-reported practice levels of DLNs.

Adherence to insulin treatment in diabetes: can it be improved?

Insulin is used in all subjects with Type 1 diabetes, and when Type 2 diabetes is not controlled by oral anti-diabetic medicines, insulin is also used in Type 2 diabetes. However, despite this use, there is still increased mortality and morbidity in subjects with diabetes, compared to subjects without diabetes. One of the factors, which may be involved in this increased mortality and morbidity in subjects with diabetes, is nonadherence to insulin. Nonadherence rates to insulin are in the range of 20-38%, and many factors contribute to the nonadherence. The major aim of the review was to determine whether interventions to improve adherence to insulin do actually improve adherence to insulin. Most studies have shown that adherence to insulin was improved by changing from the vial-and-syringe approach to prefilled insulin pens, but not all studies have shown that this translated into better glycemic control and clinical outcomes. The results of studies using automatic telephone messages to improve adherence to insulin to date are inconclusive. There is limited and variable evidence that an intervention by a nurse/educator, which discusses adherence to medicines, does improve adherence to insulin. In contrast, there is little or no evidence that an extra intervention by a doctor or an intervention by a pharmacist, which discusses adherence to insulin, does actually improve the measured adherence to insulin. In conclusion, rather than assuming that an intervention by a health professional discussing adherence to insulin actually improves adherence to insulin, long-term studies investigating this are required.

Do interventions by allied health professionals discussing adherence to insulin improve this adherence?

It is assumed that interventions to improve the adherence to insulin by allied health professionals discussing adherence to insulin will improve this adherence. However, there is little evidence to support this, as interventions by a pharmacist or nurse educator have not been shown conclusively to improve adherence to insulin.

Lack of congruence between patients' and health professionals' perspectives of adherence to imatinib therapy in treatment of chronic myeloid leukemia: A qualitative study

OBJECTIVE

Consistent use of imatinib is critical for treatment success in chronic myeloid leukemia, yet perfect adherence to the prescribed clinical regimen is reported to be as low as 14%. This study aimed to understand patients' experiences of chronic myeloid leukemia with a qualitative approach, including identified facilitators and barriers to adherence, drawing on patients' and health professionals' perspectives, recording comments made by patients and health professionals involved with the same treatment team.

METHOD

We recruited patients with chronic myeloid leukemia prescribed imatinib therapy and health professionals involved in their treatment from a specialized cancer center. Semi-structured qualitative interviews were recorded, transcribed, and manually analyzed using interpretive phenomenological analysis. Recruitment ceased upon saturation, with 16 patients and 10 health professionals (hematologists n = 4, nurses n = 3, pharmacists n = 3).

RESULTS

Twelve patients reported at least one instance of nonadherence. Reasons for unintentional nonadherence included forgetfulness related to variations of routine and doctor-patient communication issues. Reasons for intentional nonadherence included desires to reduce dose-dependent side effects and insufficient support. Patients who reported higher nonadherence rates felt complacent following periods of sustained disease control or had received conflicting advice regarding nonadherence. Health professionals had difficulty in accurately evaluating medication adherence due to a lack of reliable measures, utilizing patient self-report and manifestations of suboptimal disease control to guide assessments.

SIGNIFICANCE OF RESULTS

Adherence issues persist throughout the course of treatment. While high patient-reported nonadherence rates were recorded, health professionals were often unaware of the complex causes, compounded by an inadequacy of adherence assessment tools. Some patients reported nonadherence events because of insufficient education or lack of access to prompt medical guidance. These issues should be addressed to improve clinical practice.

Improving medication adherence among patients with type 2 diabetes

Type 2 diabetes mellitus (T2DM) accounts for the vast majority of diagnosed diabetes cases and is a considerable burden to the US health care system. However, patients with T2DM often fail to adhere to treatment for numerous reasons including concerns about administration, mode, timing, convenience, adverse events, and cost. As the prevalence of T2DM and the complexity of therapeutic regimens increases, the role of pharmacists in educating patients about treatment benefits, administration techniques, dosage flexibility, and avoiding side effects is critical and may optimize care by increasing the likelihood of treatment adherence. In addition, pharmacists are in a unique position to assess which patients are not taking medications as they are prescribed and can therefore determine the most effective methods to promote adherence. This article will examine the causes of nonadherence in T2DM and the integral role that pharmacists can play in improving medication adherence and persistence. Strategies for improving adherence, such as patient education, motivational interviewing, medication therapy management programs, and collaborative management, will also be considered.

A training program for pharmacy students on providing diabetes care

OBJECTIVE

To compare second- and third-year pharmacy students' competence, attitudes, and self-confidence in providing diabetes care before and after completing a hand-on diabetes training program and to determine if the program had an impact on students' attitude and self-confidence based on their year in the curriculum.

DESIGN

The program included classroom lectures and hands-on learning sessions in 5 facets of diabetes care. Pre- and post-test instruments measured students' competence, attitudes, and confidence in diabetes care.

ASSESSMENT

Students' competence and the mean overall confidence score significantly improved after completing the program, while mean overall attitude score did not. Third-year students had significantly higher confidence scores than did second-year students on both pre- and post-program tests. No significant difference was found for attitude scores between second- and third-year students.

CONCLUSION

The hands-on learning program was an effective approach to training pharmacy students in diabetes care, improving both their competence and confidence.

Efficacy and safety of insulin glargine compared to other interventions in younger and older adults: a pooled analysis of nine open-label, randomized controlled trials in patients with type 2 diabetes

OBJECTIVE

Elderly patients with type 2 diabetes mellitus (T2DM) present therapeutic challenges related to co-morbidities, treatment adherence, and safety. This study examines the efficacy and safety of insulin glargine compared to other glucose-lowering interventions in younger and older adults.

METHODS

In this pooled analysis of 24-week data from nine prospective open-label, multicenter, phase 3/4, two-arm, parallel-group, randomized controlled trials, patients with T2DM aged 18-80 years received insulin glargine (used as a basal insulin regimen) or comparators (including rosiglitazone, pioglitazone, insulin lispro, insulin lispro 75/25, NPH insulin, NPH insulin 30/70, and lifestyle/dietary measures). Endpoints included change from baseline to week 24 in: glycated hemoglobin; fasting plasma glucose; body weight; body mass index; insulin dose; incidence of nocturnal, daytime, or any hypoglycemia. Results were stratified by age (<65, ≥65, 65-74, and ≥75 years) and treatment (insulin glargine or comparator).

RESULTS

A total of 2,938 patients were included (2,263 aged <65 years, 675 aged ≥65 years). Similar levels of glycemic control were achieved in both younger (<65 years) and older (≥65 years) patients with T2DM. Insulin glargine was associated with better glycemic control and a reduced incidence of daytime and any hypoglycemia versus comparator interventions in both younger and older T2DM patients.

CONCLUSION

This analysis suggests that insulin glargine may represent a safe option to improve glycemic control in older patients with T2DM.