Aged care, disability and diabetes

Susan Carbone

Diabetes Educator

Key Learnings

• Principles of diabetes

• Awareness of risk of clients developing diabetes

• Key considerations for clients living with diabetes

• Possible short and long term complications and prevention strategies

Diabetes In Australia

• Diabetes is Australia’s fastest growing chronic disease

• More than 3 million or one in four Australian adults over the age of 25 have either diabetes or impaired glucose tolerance (pre-diabetes)

The Cost of Diabetes

Age Distribution of Diabetes

What is Diabetes?

• Too much glucose (sugar) in the blood due to:

• Pancreas not producing any insulin

or

• Pancreas not producing enough insulin and/or insulin action is blocked

Types of diabetes

• Type 1

• Type 2

• Gestational Diabetes (GDM)

• Impaired fasting glucose (IFG)/impaired glucose

tolerance (IGT)

Type 1 diabetes

Can NOT be prevented or cured

• Pancreas does not produce any insulin

• Insulin producing cells destroyed by the body’s own immune system

• Commonly diagnosed in children and young adults

Type 2 diabetes

May be prevented but not cured

• The pancreas does not produce enough insulin and/or the insulin produced does not work properly (insulin resistance)

• 85-90% of all people with diabetes

Type 1: 15%

Type 2: 85%

10

Eat (any food)

Digest

Glucose levels in

bloodstream rise

Pancreas releases insulin

Cells accept glucose

BGLs fall

Pancreas stops insulin production

Simplified normal process

Body has a complex set of mechanisms and cross checks to maintain BGLs within a very tight tolerance

No diabetes

What would happen if there was no insulin in this picture?

12

Eat (any food)

Digest

Glucose levels in

bloodstream rise

Pancreas releases insulin

Cells accept glucose

BGLs fall

Pancreas stops insulin production

Type 1

• No cure, no

prevention • Auto-immune • Pancreas does

not produce insulin

• Rapid onset • Insulin is the

only therapy • @ 15% of

diagnoses • Growing at 3%

Type 1 diabetes overview

13

Eat (any food)

Digest

Glucose levels in

bloodstream rise

Pancreas releases insulin

Cells accept glucose

BGLs fall

Pancreas stops insulin production

Type 2

• Insulin resistance • Typically older onset • Progressive • Multiple therapies • @ 85% of diagnoses • Growing at 7% p.a • May be prevented or delayed in @ 60%

Type 2 diabetes

Changeable risk factors

What can’t we change?

Risk factors…unchangeable

Age Family history PCOS

GDM Ethnicity

Assessing the risk

• www.health.gov.au/preventionoftype2diabetes

Signs and Symptoms

• Excessive thirst

• Feeling tired

• Frequent urination

• Excessive hunger

• Blurred vision

• Leg cramps

• Headache

• Itching

• Mood swings

• Slow wound healing

• Repeated infections

IFG and IGT

• Previously known as pre-diabetes

• BGLs are not high enough to diagnose diabetes, but higher than normal.

• Healthy lifestyle changes can prevent or delay progression to diabetes

• Higher risk of heart disease

Gestational Diabetes

• Effects 5-8% of Australian pregnancies

• Temporary form of diabetes

• Risk factors = family history, increased maternal

age, overweight, ethnicity,

• Increased risk of Type 2 diabetes to mother and

baby in future

Why worry about diabetes? Chronic Complications

High blood glucose levels over time may cause:

• Cardiovascular disease

• Damage to the eyes (retinopathy)

• Damage to the kidneys (nephropathy)

• Damage to the nerves (neuropathy)

• Problems with the feet

• Infections and slow healing

• Problems with the teeth and gums

• Erectile dysfunction

Complications of diabetes

ACUTE CHRONIC

What are the consequences of these complication?

Symptomatic Hyperglycaemia

BGL > 15mmol/L

• Heart

• Brain

• Nerves

• Eyes

• Kidneys

• Feet

• Teeth and gums

4

10

15

Hypoglycaemia BGL < 4mmol/L

How can I help to manage his/her diabetes?

• Help the person adopt a number of healthy lifestyle behaviours

• Assist in the correct administration of medications and/or insulin

• Assist and encourage the person to attend annual reviews with diabetes team

Help to keep the daily BGL within the target range

Why manage diabetes?

• To reduce the risk of diabetes complications

• To prevent falls or stroke due to hypo or acute

hyperglycaemia

• To improve general health status

• To improve daily quality of life

Acute complications

Acute (Short Term)

• Hypoglycaemia ‘Hypo’ less than 4mmol/L

• Hyperglycaemia ‘Hyper’ more than 15mmol/L

Blood glucose monitoring

• Use different fingers

• Ensure hands are clean and dry

• Don’t prick on tip of finger...more painful!

• Single use lancet needles

(?retractable lancets required)

Is the BGL within resident target range??

Record BGL levels. Notify if any concerns

NDSS

Blood Glucose Monitoring

Lancets & Pen needles are for single use only.

Pain & discomfort Infection risk Lipohypertrophy Scarring & callouses Dose inaccuracy

When to test

Hypoglycaemia Signs and Symptoms

• Dizziness

• Light headedness

• Weakness, trembling or shaking

• Sweaty

• Headache

• Tingling lips, fingers

• Tearful/crying

• Irritability

• Lack of concentration or behaviour change

• Hunger

• Slurred speech

• Unconscious/

fitting

Causes of Hypoglycaemia

• Delaying or missing a meal or snack

• Not eating enough carbohydrate

• Too much insulin or diabetes tablets

• Unplanned physical activity

• More strenuous exercise than usual

• Drinking alcohol

Treating Hypoglycaemia

Step 1: Quickly absorbed carbohydrate (15g carb) • 100mls Lucozade or • ½ can soft drink or • Just Juice popper or • 3 tsp sugar or honey • 6-7 jelly beans

Test blood glucose levels 10-15 mins later

Step 2: Slower absorbed carbohydrate • 1 glass milk or • 1 piece of bread or • 1 piece of fruit • Tub of low fat yoghurt

Severe Hypoglycaemia

• Call an ambulance if the person is unconscious

• Recovery position

• Stay with person

Administer Glucagon if trained

Hypoglycaemia in the elderly or disability

• Increased risk of hypos in the elderly

• Impaired hypo awareness

• Impaired ability of body to respond and recover from a hypo

• Polypharmacy increases risk of hypo’s

• Difficulty communicating

Hyperglycaemia

When a high is too high

• Type 1 – high may be due to insulin deficiency, increasing the risk of DKA – life threatening

• Type 2 - Hyperosmolar Osmotic Non-ketoacidosis (HONK) Treat underlying cause • Refer to sick day management plan: • Do not withhold insulin – may need dose altered • Testing blood glucose levels every 2 – 4 hours • Drinking extra non sweetened fluids to avoid dehydration • If uncertain contact doctor or diabetes educator

May not be able to tell you when they are having chest pain or a heart attack. They may not even feel it due to nerve damage to heart.

Coronary Heart Disease

Cardiovascular Disease

• Cardiovascular disease accounts for >50% of deaths in Type 2 diabetes

• People with diabetes at greater risk of developing cardiovascular disease

• Maintaining blood pressure, cholesterol and BGL levels within target range decreases risk

Care of People with Diabetes, 3rd ed. Dunning, 2009.

• Diabetes is the major cause of kidney disease in Australia

• Uncontrolled or poorly managed diabetes damages the nephrons -filtration units

• Kidney disease can lead to kidney failure requiring dialysis

Insulin is metabolised by kidneys and excreted in urine. As kidneys age and become less efficient they metabolise insulin more slowly – meaning insulin stays in the system for longer. Older people with renal impairment may need a reduction in dose.

Kidney Disease

Vision affected by Retinopathy

Diabetic Retinopathy

Falls risk !!!! Reduced ability to perform ADL including BGL testing

Peripheral Neuropathy High BGLs can damage the nerve transmission affecting the impulse to the brain e.g. if a person walks barefoot and treads on a nail/pin, a healthy nerve would send a signal to the brain ‘telling’ the person to take the foot off the pin and check the affected area. However, in a person with neuropathy the signal to the brain is impaired/lost and the person might not feel any pain. What would happen as a consequence? First symptoms of neuropathy can be pins and needles in the feet or legs (less commonly arms, fingers), tingling, hot and cold feet, cramps and/or numbness. Can also contribute to:

• Impotence in men • Digestion problems • Incontinence

Other complications

• Teeth and gums: gum infections more common in people with diabetes.

• Susceptibility to infection

• Liver: Non Alcoholic Fatty Liver Disease (NAFLD) associated with insulin resistance and increased waist measurement.

• Depression: affects approximately 50% of people with a chronic disease.

Wounds: Feet and Legs

Foot Care

• The daily foot hygiene time is the perfect opportunity to check feet thoroughly and identify any problems

• Self care capabilities:

– Can the resident see their feet

– Can the resident reach their feet

– Can the resident cut toenails & provide care as necessary

– Does the resident want to care for their own feet

What to look for?

High Risk Feet • Had a foot ulcer in the past

• Had an amputation in the past

• An ulcer at present

• Decreased sensation

• Corn and calluses

• Deformed thick toenails or discoloured nails

• Foot deformities such as bunions, hammer toes, bony prominences

• Any resident with diabetes should see a podiatrist immediately if they have a high risk foot and develop problems

Blood Supply

• Inadequate blood supply:

– Cold feet

– Frequent leg cramps

– Infections and ulceration

– Pain and/or aching when walking

– Changes to the skin colour of the feet

– Numbness, burning and/or tingling

Footwear

• Socks

Natural fibre socks such as wool or cotton are best

Fit correctly

If the seams are prominent, wear socks inside out

Ensure top of sock is not too tight around the leg

• Shoes

Natural materials such as canvas and leather are best

Enough room in the shoe

Firm heel grip, holds the foot securely

Fastened with laces, buckles, or velcro

Medications

• Classes of Medications – Biguanides

– Sulphonylureas

– Thiazolidinediones (Glitazones)

– Alpha Glucose Inhibitors

– DPP-4 Inhibitors

– Incretin Mimetics

– SGLT2 Inhibitors

– Combinations

Side Effects of Biguanides

• Nausea, diarrhoea, constipation, metallic taste in the mouth • Must be ceased immediately prior to surgery and

immediately after surgery, or any procedures that require radio-opaque dye

• Always take during or after food • Caution for elderly:

– Reduced appetite – Severe renal, heart, and liver disease – Small risk of hypoglycaemia

Biguanides

• Metformin, Diabex, Diabex XR, Diaformin, Diaformin XR, Glucobete, Formet, Glocomet, Glucophage, Metex

• Help lower the BGL by:

– Reducing the amount of stored glucose released by the liver

– Slowing absorption of glucose from the gut

– Helping the body to become more sensitive to insulin

Sulphonylurea • Gliclazide: Diamicron, Diamicron MR,

Glyade, Glyade MR, Genrx

Glibenclamide: Doanil, Glimel

Glipizide: Melizide, Minidiab

Glimepiride: Amaryl, Dimirel, Aylide

• Helps lower BGL by stimulating the pancreas

to release more insulin

• Take just prior to the meal

Side Effects of Sulphonylurea

• Hypoglycaemia, weight gain, skin rashes, stomach

upset (nausea and diarrhoea), jaundice

• Caution for elderly:

– Some sulphonylureas have a long half-life therefore increasing the risk of Hypoglycaemia,

such as Daonil.

Thiazolidinediones (Glitizones) • Rosiglitizone: Avandia

• Pioglitizone: Actos

• Help to lower BGL’s by increasing the effect of your own insulin especially on muscle and fat cells, they improve insulin resistance

• Low risk of hypoglycaemia

Side effects of Glitizones

• Weight gain, fluid accumulation, not to be taken by people who have liver disease

• Caution in elderly

– Avoid in people with heart failure

– Regular checks of liver function

Alpha Glucosidase Inhibitors

• Acarbose: Glucobay

• Help to slow down the digestion and

absorption of some dietary carbohydrates

in the gut

• Risk of hypoglycaemia low

• Must be taken just before a meal

Side Effects of Alpha Glucosidase Inhibitors

• Flatulence, bloating, diarrhoea

• They need to be started at low doses and increased slowly

• Caution in elderly:

– Diarrhoea and fluid loss

DPP-4 Inhibitors

• Linagliptin: Trajenta

• Saxagliptin: Onglyza

• Sitagliptin: Januvia

• Vildagliptin: Galvus

• Alogliptin: Nesina

• Help to inhibit the enzyme DPP-4 which

enhances the levels of active incretin hormones

• Incretin hormones increase insulin secretion

and decrease glucagon secretion

Side Effects of DPP-4 Inhibitors

• Few side effects

• Low risk of Hypoglycaemia

• Not likely to cause weight gain

• Caution in elderly:

– Consider lower doses if there are

kidney or liver problems

Incretin Mimetics

• Exanatide: Byetta

• Injected medication

• Helps to lower BGL’s by:

– Stimulating the pancreas to release more insulin in response to eating carbohydrates

– Reducing the amount of glucagon released from the pancreas after the meal

– Slow down the passage of food from the stomach to the gut so food is absorbed more slowly

– Increases a feeling of fullness after eating

– Inject twice a day within 1 hour of breakfast & dinner & at least 6 hours apart.

Side Effects of Incretin Mimetics

• Nausea, vomiting, constipation, diarrhoea

effect other medication passing through

the stomach

• Allergic reactions may occur

• Caution in elderly:

– Not recommended for people with severe gastrointestinal disease or severe kidney disease

SGLT2 Inhibitor

• Canagliflozin: Invokana

• Dapagliflozin: Forxiga

• Selectively inhibit SGLT2 in the kidney

• Lowers renal threshold for glucose and

reduces glucose reabsorption

• Increases urinary glucose excretion

Side Effects of SGLT2 Inhibitors

• Hypoglycaemia, thrush, UTI, frequent urination, balanoposthitis (inflammation of the glans and foreskin of the penis), thirst

• Caution in elderly

– All of the above

– Postural hypotension, dehydration, syncope

– Not recommended in people with severe kidney disease

Combination Medications

What is insulin?

• Insulin is a hormone that is produced by the pancreas

• It lowers blood glucose levels

• The insulin you inject works the same way as the insulin made by the body

• Insulin is the key that opens the cells in our body so they

can store glucose and use it for energy

Insulin

How to store insulin

DO

Store unopened insulin at the front of the door shelves of the refrigerator

Store opened insulin at room temperature

(below 25 degrees)

Store insulin in a cooler bag if living in a hot climate or travelling

DO NOT

X Leave insulin in the car or where it will get hot

X Store insulin in the freezer or at the back of the fridge

X Shake insulin too hard

X Use insulin after its expiry date

Where to inject insulin?

Different Insulin • Novonordisk

Levemir

Novorapid

Actrapid

Novomix 30

Mixtard 30/70

Mixtard 50/50

Protaphane

• Lilly

Humalin R

Humalin NPH

Humamix 25

Humamix 50

Humalin 30/70

Sanofi Aventis Lantus Apidra

Summary

• There are a number of considerations when

managing diabetes in the elderly and/or disability

• Individual care plans are essential to provide

accurate treatment on a range of areas

• Target BGLs

• Sick day management plans

• Hypo treatments

• Insulin administration – timing is vital

When in doubt – speak to GP and CDE