2

HOURS

Continuing Education

Functional Decline in Older Adults with Diabetes

Self-care for older adults with disabilities related to aging, diabetes and its complications, or both.
By Linda Haas, PhC, RN, CDE
ore than 10 million people 60 years of age and older have been diagnosed with diabetes in the United States, a prevalence of almost 21% in this age group compared with a prevalence of almost 10% in younger adults.1 Approximately 575,000 people age 60 and older are diagnosed with diabetes annually. The elderly are a heterogeneous group. Whether they are young old (between 65 and 75 years of age), old (between ages 75 and 85), or old old (ages 85 and older),2 older adults with diabetes may live independently and be active in their community, or they may be frail and require considerable assistance. Older adults with diabetes may have been diagnosed recently, or they may have had diabetes for many years and experience complications. Thus individualizing nursing care is essential. Diabetes is a predictor of functional decline in older adults and is associated with increased difficulty with activities of daily living (ADLs) and instrumental activities of daily living (IADLs).2,3 This article focuses on older adults with diabetes who have disabilities associated with aging, longterm complications of diabetes such as retinopathy or neuropathy, or other comorbidities, and it outlines appropriate nursing interventions.

MANAGEMENT GOALS
Self-management goals may require continued modification in older adults with diabetes, because of physical changes associated with aging.
Linda Haas is an endocrinology nurse specialist at the Veterans Affairs Puget Sound Health Care System and a clinical assistant professor of nursing at the University of Washington in Seattle. Contact author: linda.haas@med.va.gov. The author of this article has no other significant ties, financial or otherwise, to any company that might have an interest in the publication of this educational activity.

Glycemic goals. The American Diabetes Association recommends glycemic targets in people with diabetes that approach normal blood glucose levels.4 However, there are reasons not to aim for normal levels in older adults: an inability to sense or respond to hypoglycemia delirium or dementia, which could prevent the patient from communicating or reacting to hypoglycemia a compromised cardiovascular system, because low blood sugar causes secretion of catecholamines, which increases the heart rate an inability or unwillingness to follow an intensive diabetes management regimen coexisting illness that decreases life expectancy, because patients with such conditions wont live long enough to experience long-term complications of diabetes In such cases, the target goal might be to prevent the symptoms of hyperglycemia (increased urination, increased thirst, and blurred vision), which can adversely affect quality of life. In addition, blurred vision can lead to medication errors, difficulty performing ADLs, and decreased functionality. On the other hand, the blood glucose level shouldnt be too high. In addition to increasing the risk of complications of diabetes,5 hyperglycemia is associated with decreased cognition in older adults.6, 7 Nutrition. Meal planning for people with diabetes focuses on maintaining consistent carbohydrate intake and adjusting medication, particularly insulin, to this intake. Weight loss or maintenance is often a goal.8 While many older adults with diabetes are overweight, many others, particularly the old old, are underweight,9 in part because of age-related changes such as decreased taste sensation and salivation. National nutrition surveys have reported
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that more than 30% of older adults consume less than two-thirds of the recommended intake of calories, calcium, and vitamin A, and more than 20% have low intake levels of iron and vitamin C.10 Thus, weight gain, rather than weight loss, and adequate nutrition may be management goals for some. In a study of frail nursing home residents, consumption of a greater variety of fruits and vegetables was associated with better nutritional status.11 Whether this finding can be generalized to all older adults has not been determined. Older adults with limited income and mobility limitations often dont have easy access to a large variety of foods. A project in Detroit is setting up produce stands in local community centers to increase older adults access to fresh fruits and vegetables.12 This project may serve as a model for other communities. Because diminished thirst sensation is common in older adults, adequate hydration is important. Dehydration can cause or be caused by hyperglycemia. In addition, dehydration can lead to a hyperosmolar hyperglycemic state, a life-threatening condition that mainly affects the elderly. Increased activity. Programs that improve aerobic capacity, strength, balance, and flexibility may be beneficial for older adults with diabetes. Other benefits of exercise in older adults include an increased sense of well-being, a decreased risk of falls, and increased mobility, according to one review.13 In the Insulin Resistance Atherosclerosis Study, the subgroup of older people with diabetes who participated in moderate to strenuous physical activity, as defined by estimated energy expenditure, had significantly greater insulin sensitivity.14 A 16-week intensive resistance training program in older men with diabetes (mean age, 66) resulted in improved glucose utilization and insulin sensitivity.15 Peripheral neuropathy, a history of stroke, and arthritis can decrease mobility and increase disability, making exercise a challenge for older adults with diabetes. Because of peripheral neuropathy, people with diabetes may lose sensation and be unaware of minor trauma to their feet; left unattended, such trauma can progress to ulceration with infection and lead to amputation. Before starting a new exercise program, people with diabetes should obtain well-fitting and appropriately supportive footwear. They should examine their feet after every exercise session. This can be difficult; a study by Thomson and Masson demonajn@wolterskluwer.com

strated that only 12% of elders could both see the plantar surfaces of their feet and reach far enough to remove 0.5-cm red dots from these surfaces.16 Determining the ability of older patients to see and reach the plantar surfaces of their feet should be a routine part of nursing assessment. A handheld mirror or one on an extended, flexible handle can help people inspect their feet.

Peripheral neuropathy, a history of stroke, and arthritis can decrease mobility and increase disability.

A sudden drop in blood pressure is common after intense exercise. Older adults with diabetes may be more susceptible because of a tendency for volume depletion (dehydration); its important that they remember to drink adequate amounts of fluids before, during, and after exercise. In addition, autonomic neuropathy can damage the nerves that maintain orthostatic blood pressure, causing dizziness when exercise stops. Appropriate cool-down exercises, such as slow walking, can minimize this drop in blood pressure and the resulting dizziness.17,19

DISABILITIES
Visual impairment contributes significantly to decreased functional capacity and mortality in older adults.20,21 Salive and colleagues found that severe visual impairment tripled the risk of limitations in mobility and ADLs.22 The most frequent cause of visual impairment and blindness in whites is age-related macular degeneration; blacks are more likely to become visually impaired or blind as a result of cataracts, glaucoma, or diabetic retinopathy.23 The leading cause of visual impairment in Hispanics is cataracts, followed by age-related macular degeneration and diabetic retinopathy, but the leading cause of blindness in this population is open-angle glaucoma.24 Because most of these causal conditions are treatable, its essenAJN M June 2007 M Vol. 107, No. 6 Supplement

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tial that patients have appropriate visual screenings and treatments. Medicare Part B covers visual screening exams (see www.medicare.gov). People 65 years of age or older who arent covered by a managed care organization or the Department of Veterans Affairs and who meet other criteria may be eligible for free eye examinations offered through EyeCare America (www.eyecareamerica.org), a public service foundation of the American Academy of Ophthalmology. Interested individuals may call (800) 222-EYES (3937) to determine eligibility and find participating local providers.

Older adults with diabetes are coping not only with the frailty that may come with aging, but also with a complex, chronic disease and the short- and long-term complications that often accompany it.

reading, and speak slowly and clearly. Be sure the lighting in the room is not behind the speaker, as this puts the speaker in shadow and makes lip reading more difficult.25 Hearing-impaired patients should watch the display on a glucose-testing meter rather than relying on audible signals. Cognition. Aging is sometimes associated with decreased cognition, which may have a variety of causes. Verbal learning and memory skills are often impaired in people ages 60 years and older with diabetes.26 Assistive devices that may be helpful include pillboxes and watches that sound an alert when medications are to be taken. When educating patients who are cognitively impaired in self-care, use simple, clearly written instructions and handouts to reinforce oral instructions and help with recall. Printed materials should be in dark ink, in 14-point or larger type, and on white or pale yellow nonglare paper.27

FALLS
Aging, decreased functional capacity, and visual impairment can increase the risk of falls, a major cause of morbidity and mortality for older people.13 Older women with diabetes have more falls than older women who dont have diabetes.28 Several interventions have been shown to reduce falls in older adults. These include general exercise, tai chi practiced as a group exercise, home hazard assessment and modifications, withdrawal of psychotropic medications, and risk-factor screening and related intervention programs.29 Not all of these interventions have been studied in older people with diabetes, so this is an important area for nursing research. Exercise decreases the risk of falls in older people. In a random sample of community-dwelling people ages 68 to 85 years who had mild deficits in strength and balance, Buchner and colleagues found that a supervised exercise program resulted in significant decreases in self-reported falls, outpatient clinic visits, and hospital costs.30 Although no randomized controlled trials with fall prevention as a dependent variable have been done in older people with diabetes, this should not preclude their participation in supervised exercise programs.

Diabetes self-care can be challenging for older adults with visual impairment, and assistive devices can be helpful. For example, a weekly pill organizer with tactile markings helps patients know which medications to take on a given day. A syringe-filling device (Count-a-Dose) allows a person who is visually impaired or blind to mix insulin using tactile sensation. Syringe magnifiers help people with visual impairments draw correct insulin doses. Many patients find insulin pens easier to use than syringes. Patients taking regular insulin on a prandial schedule may be able to use inhaled insulin. Self-monitoring of blood glucose levels is also challenging for people with impaired vision, as its difficult to apply the blood to the testing strip correctly. Devices that use voice prompts to guide the patient through the testing procedure and report the results aloud are available. Hearing deficits also can complicate diabetes selfmanagement. Patients who are hearing impaired may be wrongly labeled as noncompliant when they fail to follow instructions that they did not hear. When working with a person who has a hearing impairment, face the patient directly to enable lip
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NURSING INTERVENTIONS
Older adults who have had and managed diabetes for many years may still need self-management education, including updates on the latest approaches to care and education on adaptive skills. And older
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adults with diabetes who have other concomitant, chronic conditions will have increased needs for support systems and community resources.31 A goal of care for all older adults is continued independence and noninstitutional living. Stuck and colleagues showed that an annual comprehensive in-home assessment by a geriatric NP, including assessment of functional status, mental status, gait and balance, medications, vision, hearing, and social support, can delay disability and reduce the likelihood of permanent nursing home placement.32 Older adults with diabetes are coping not only with the frailty that may come with aging, but also with a complex, chronic disease and the short- and longterm complications that often accompany it. Hypoglycemiaa short-term complication that can result from taking too much insulin or secretagogue, medication mistakes, or not eatingcan cause decreased cognition, falls, and loss of consciousness, which can be particularly dangerous in older adults who live alone. Hyperglycemia, another short-term complication, can impair vision, cause fatigue and increased urination (especially at night), and result in dehydration. Because of the loss of thirst sensation that may accompany aging and the failure of some older people to drink enough fluids to counteract osmotic diuresis, nurses need to be sure that older patients with diabetes are hydrated adequately. The long-term complications of diabetes can include visual impairment resulting from retinopathy, cataracts, or glaucoma. Nephropathy may lead to end-stage renal disease, necessitating hemodialysis or peritoneal dialysis. Neuropathy (sensory, motor, and autonomic) is a major nursing concern in elderly patients with diabetes. Sensory neuropathy can lead to lower-extremity ulcers that may eventually necessitate amputation. Thus, prevention of trauma to the insensate foot is a major nursing intervention. Nurses can ensure that older adults with diabetes are able to examine their lower extremities and have adequate protective footwear. Sensory peripheral neuropathy can also cause decreased proprioception, resulting in falls and a fear of walking. Motor neuropathy can cause calluses, hammertoes, and other deformities, which can in turn lead to ulcers or painful walking. Autonomic neuropathy can impair sweating and cause dryness in the feet. In addition, autonomic neuropathy can cause orthostatic hypotension and gastrointestinal problems, including diarrhea and constipation. Neuropathy can also cause severe muscle weakness, leading to permanent disability unless
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muscles are maintained through exercise, which should include passive range-of-motion exercise. Caring for older patients with diabetes presents a raft of challenges: nurses must help these patients manage diabetes-related disabilities and concomitant disorders, prevent further disability, and maintain a satisfying quality of life. In addressing these challenges, nurses should also look to existing community resources and help patients and their families access those that may meet their needs. Where adequate resources or access is lacking, nurses can also work within their communities to develop programs and improve access. M
REFERENCES
1. National Center for Chronic Disease Prevention and Health Promotion. National diabetes fact sheet: general information and national estimates on diabetes in the United States. Centers for Disease Control and Prevention. 2005. http:// www.cdc.gov/diabetes/pubs/factsheet05.htm. 2. Gould E, et al. Attitudes about aging. In: Mariano C, editor. Best nursing practices in care for older adults: incorporating essential gerontologic content into baccalaureate nursing education. 2nd ed. New York: John A. Hartford Foundation Institute for Geriatric Nursing; 1999. p. 1-2. 3. Volpato S, et al. Comorbidities and impairments explaining the association between diabetes and lower extremity disability: The Womens Health and Aging Study. Diabetes Care 2002;25(4):678-83. 4. Standards of medical care in diabetes2006. Diabetes Care 2006;29 Suppl 1:S4-S42. 5. Turner RC, et al. Glycemic control with diet, sulfonylurea, metformin, or insulin in patients with type 2 diabetes mellitus: progressive requirement for multiple therapies (UKPDS 49). UK Prospective Diabetes Study (UKPDS) Group. JAMA 1999;281(21):2005-12. 6. Hewer W, et al. Short-term effects of improved glycemic control on cognitive function in patients with type 2 diabetes. Gerontology 2003;49(2):86-92. 7. Munshi M, et al. Cognitive dysfunction is associated with poor diabetes control in older adults. Diabetes Care 2006;29(8):1794-9. 8. Sheard NF, et al. Dietary carbohydrate (amount and type) in the prevention and management of diabetes: a statement by the American Diabetes Association. Diabetes Care 2004;27(9):2266-71. 9. Gilden JL. Nutrition and the older diabetic. Clin Geriatr Med 1999;15(2):371-90. 10. Bidlack WR, Smith CH. Nutritional requirements of the aged. Crit Rev Food Sci Nutr 1988;27(3):189-218. 11. Bernstein MA, et al. Higher dietary variety is associated with better nutritional status in frail elderly people. J Am Diet Assoc 2002;102(8):1096-104. 12. Schulz AJ, et al. Healthy eating and exercising to reduce diabetes: exploring the potential of social determinants of health frameworks within the context of community-based participatory diabetes prevention. Am J Public Health 2005; 95(4):645-51.

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13. Skelton DA, Beyer N. Exercise and injury prevention in older people. Scand J Med Sci Sports 2003;13(1):77-85. 14. Mayer-Davis EJ, et al. Intensity and amount of physical activity in relation to insulin sensitivity: the Insulin Resistance Atherosclerosis Study. JAMA 1998;279(9):669-74. 15. Zachwieja JJ, et al. Resistance exercise and growth hormone administration in older men: effects on insulin sensitivity and secretion during a stable-label intravenous glucose tolerance test. Metabolism 1996;45(2):254-60. 16. Thomson FJ, Masson EA. Can elderly diabetic patients cooperate with routine foot care? Age Ageing 1992;21(5):333-7. 17. Maughan RJ. Impact of mild dehydration on wellness and on exercise performance. Eur J Clin Nutr 2003;57 Suppl 2:S19-S23. 18. OKeefe JH, et al., editors. Diabetes essentials. Royal Oak, MI: Physicians Press; 2005. 19. Mazzeo RS, Tanaka H. Exercise prescription for the elderly: current recommendations. Sports Med 2001;31(11):809-18. 20. Cacciatore F, et al. Disability and 6-year mortality in elderly population. Role of visual impairment. Aging Clin Exp Res 2004;16(5):382-8. 21. West CG, et al. Is vision function related to physical functional ability in older adults? J Am Geriatr Soc 2002;50(1): 136-45. 22. Salive ME, et al. Association of visual impairment with mobility and physical function. J Am Geriatr Soc 1994; 42(3):287-92. 23. Munoz B, et al. Causes of blindness and visual impairment in a population of older Americans: The Salisbury Eye Evaluation Study. Arch Ophthalmol 2000;118(6):819-25. 24. Rodriguez J, et al. Causes of blindness and visual impairment in a population-based sample of U.S. Hispanics. Ophthalmology 2002;109(4):737-43. 25. Haas L. Education strategies for geriatric populations. Todays Educator 2000(2):1-3. 26. Ryan CM, Geckle M. Why is learning and memory dysfunction in Type 2 diabetes limited to older adults? Diabetes Metab Res Rev 2000;16(5):308-15. 27. Weinrich SP, Boyd M. Education in the elderly. Adapting and evaluating teaching tools. J Gerontol Nurs 1992;18(1): 15-20. 28. Gregg EW, et al. Complications of diabetes in elderly people. BMJ 2002;325(7370):916-7. 29. Province MA, et al. The effects of exercise on falls in elderly patients. A preplanned meta-analysis of the FICSIT Trials. Frailty and Injuries: Cooperative Studies of Intervention Techniques. JAMA 1995;273(17):1341-7. 30. Buchner DM, et al. The effect of strength and endurance training on gait, balance, fall risk, and health services use in community-living older adults. J Gerontol A Biol Sci Med Sci 1997;52(4):M218-24. 31. Maldague S, Leontos C. Diabetes prevention and management: small steps with big rewards. Centers for Disease Control and Prevention. 2005. http://www.asaging.org/ CDC/module7/home.cfm. 32. Stuck AE, et al. A trial of annual in-home comprehensive geriatric assessments for elderly people living in the community. N Engl J Med 1995;333(18):1184-9.

2
TEST

HOURS

Continuing Education

Aging and Disabilities

LEARNING OBJECTIVES: After reading this article and taking this test (answer coupon on page 75), you will be able to describe various health problems that affect older adults, especially those who have diabetes. list the specific interventions that have shown positive effects for older adults who have diabetes.
1. About what percentage of U.S adults ages 60 and older have diabetes? a. 10% c. 21% b. 16% d. 28% 2. Bernstein and colleagues found better nutrition in frail nursing home residents who ate a wide variety of a. types of fish. b. whole grains. c. fruits and vegetables. d. dairy products. 3. Older adults who engage in intense exercise are especially prone to a. hypertension during exercise. b. excessive hunger after exercise. c. headaches during exercise. d. dizziness when exercise stops. 4.The most common cause of visual impairment and blindness in whites is a. cataracts. b. glaucoma. c. macular degeneration. d. diabetic retinopathy. 5.The leading cause of visual impairment in Hispanics is a. cataracts. b. glaucoma. c. macular degeneration. d. diabetic retinopathy. 6. According to Buchner and colleagues, which of the following reduces the risk of falls in older adults? a. exercise b. home assessment c. antidepressants d. social interaction 7. In older adults, hyperglycemia can easily result in a. tremors. c. dizziness. b. dehydration. d. numbness. 8. Autonomic neuropathy contributes to foot problems by causing a. hammertoes. b. gangrene. c. vascular ulcers. d. dryness of the feet. TEST CODE: AJND7

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