Multidisciplinary approach for the treatment of diabetes in the elderly

Quality of care to institutionalized patients with diabetes in Italy: a national survey

PURPOSE

To evaluate the epidemiology of diabetes and quality of care of institutionalized patients with diabetes in Italian nursing homes. More specifically, to evaluate the adherence to the national/international guidelines for the management of older people with diabetes.

METHODS

Data related to the epidemiology of diabetes and the quality of care were collected from questionnaires sent to 41 nursing homes. Data were extracted from papers, electronic medical records and validated operating protocols regulating the management of patients with diabetes in various homes. Completed questionnaires were returned in electronic format and centrally processed.

RESULTS

Out of 4692 residents, 906 (19.3%) had diabetes. Among these residents, excluding patients undergoing diet treatment, more than half were on insulin treatment (alone or in combination with oral antidiabetic agents). The critical findings can be summarized as follows: a lack of shared diagnostic-therapeutic protocols, specifically related to evaluation of frailty; the preparation of nutritional and physical activity plans; the clarification of the objectives of the treatment; the timing of insulin administration (frequent use of sliding scale); the frequency and timing of capillary blood glucose; metabolic control methods; hypoglycemia and hyperglycemia treatment; and the scant use of new drugs that do not cause hypoglycemia.

CONCLUSION

Our data revealed substantial heterogeneity in the treatment of nursing home residents with diabetes in Italy with many discrepancies between what is recommended in the guidelines and real-world practice. The implementation of local diagnostic-therapeutic protocols shared by all caregivers should be encouraged and properly funded to overcome communication problems between doctors and nurses and eventually improve the quality of care for institutionalized patients with diabetes.

A qualitative study on why did the poorly-educated Chinese elderly fail to attend nurse-led case manager clinic and how to facilitate their attendance

Objectives

This study explored the views, barriers and facilitators of the poorly-educated elderly who were non-attendee of the nurse-led case manager clinic. The case managers provide assessment for diabetes complication screening and can refer patients to the appropriate multidisciplinary team in public outpatient primary care setting.

Methods

We adopted qualitative research method by individual semi-structured face to face interviews. Nineteen Chinese type 2 diabetes mellitus subjects aged ≥ 60 who failed to attend the nurse-led case manager clinic were interviewed. They all came from a socially deprived urban district in Hong Kong. Content and thematic analysis was performed.

Results

Seven men and twelve women aged 60 to 89 were interviewed. Nine of them received no formal education and ten of them attended up to primary school. The reasons for non-attendance included attitude and poor knowledge towards diabetes complication screening and confusion of the nurse-led clinic as an educational talk. Most respondents could not understand the reason for the screening of diabetic complications, the concept of multidisciplinary care and the procedure and outcomes of nurse assessment. Five respondents were unable to follow multiple appointments because they could not read. Other reasons included physical barriers and comorbidity, family and financial constraint. They either had a tight daily schedule because of the need to take care of family members, or the family members who brought them to clinic had difficulty in attending multiple appointments. Enhanced understanding of the importance and procedure of diabetes multidisciplinary management, a flexible appointment system and a single clear appointment sheet may facilitate their attendance.

Conclusion

Poorly-educated Chinese elderly with DM and their care givers faced physical, social and psychological barriers when attending the nurse-led case manager clinic. Strategies targeting on their low literacy include effective communication and education by health care professionals to arrive a shared understanding of care plan as well as a flexible appointment and schedule system.

Assessment of barriers to improve diabetes management in older adults: a randomized controlled study

OBJECTIVE

To evaluate whether assessment of barriers to self-care and strategies to cope with these barriers in older adults with diabetes is superior to usual care with attention control. The American Diabetes Association guidelines recommend the assessment of age-specific barriers. However, the effect of such strategy on outcomes is unknown.

RESEARCH DESIGN AND METHODS

We randomized 100 subjects aged ≥69 years with poorly controlled diabetes (A1C >8%) in two groups. A geriatric diabetes team assessed barriers and developed strategies to help patients cope with barriers for an intervention group. The control group received equal amounts of attention time. The active intervention was performed for the first 6 months, followed by a "no-contact" period. Outcome measures included A1C, Tinetti test, 6-min walk test (6MWT), self-care frequency, and diabetes-related distress.

RESULTS

We assessed 100 patients (age 75 ± 5 years, duration 21 ± 13 years, 68% type 2 diabetes, 89% on insulin) over 12 months. After the active period, A1C decreased by -0.45% in the intervention group vs. -0.31% in the control group. At 12 months, A1C decreased further in the intervention group by -0.21% vs. 0% in control group (linear mixed-model, P < 0.03). The intervention group showed additional benefits in scores on measures of self-care (Self-Care Inventory-R), gait and balance (Tinetti), and endurance (6MWT) compared with the control group. Diabetes-related distress improved in both groups.

CONCLUSIONS

Only attention between clinic visits lowers diabetes-related distress in older adults. However, communication with an educator cognizant of patients' barriers improves glycemic control and self-care frequency, maintains functionality, and lowers distress in this population.