As we all know, aged care is a very different specialty area to other areas of dietetics and as such, our practices tend to run by different recommendations and guidelines. The management of residents with diabetes no different.
What is diabetes?
There are two main types of diabetes, in which either of the following occur;
TYPE 1 – The body does not producing any insulin as the beta cells of the pancreas have been attacked by the body’s own immune system. This is often referred to as Insulin Dependent Diabetes Mellitus (IDDM). It can only be treated by insulin and it makes up about 10% of all diabetes cases.
TYPE II – The insulin produced by the pancreas is not enough or the body is not sensitive enough to the effects of the insulin being produced. This can be treated in a number of ways including lifestyle management (diet & exercise), oral hypoglycaemic agents and/or insulin. This is often referred to as Non-Insulin Dependent Diabetes Mellitus (NIDDM). N.B. Once a person with type II requires insulin to manage their diabetes, they do NOT become type I.
One of the main effects of not having any or enough insulin is that our blood glucose levels (BGL) often end up extremely high.
Complications of Diabetes in Aged Care
Longer term elevated BGLs can damage large and small blood vessels. Damage to larger vessels can lead to heart attack, stroke and reduced blood flow to lower limbs. Damage to smaller vessels is often recognised when people present with eye damage and even blindness, kidney damage, nerve damage, dental & gum disease, increased risk of wounds and slow wound healing and decreased blood flow to extremities thus requiring amputation.
For residents in aged care facilities, who quite often will present with a plethora of other medical complications, these issues may present slightly differently. For example;
- Polyuria, glycosuria, incontinence, noctouria (especially in men) which may present as dehydration, cognitive changes, sleep disturbances
- Vision changes may present as increase in falls and near misses, decrease in ability to complete activities of daily living such as dressing, eating etc.
- Vascular & haematological changes resulting in slow wound healing, gangrene, stroke and/or myocardial infarction
- Nutritional deficiencies such as Vitamin B12, D and C deficiencies, anaemia, sarcopenia, lethargy
- Recurrent infections & slow wounding healing
- Cognitive changes and depression
- Reduced pain tolerance and neuropathic pain which may be mistaken for behavioural changes associated with dementia
- Impaired recovery and increased risk of delirium post surgery
What are the aims of diabetes management in aged care?
With a lot of residents in aged care having cognitive issues and complex medical backgrounds as well as limited health literacy financial support, life expectancy and often being solely reliant on the care provided by staff; the way we view diabetes and its management is very different to the rest of the population.
The primary aims of diabetes management in aged care is to manage diabetes so as to prevent discomfort associated with uncontrolled diabetes. As such, the ‘controls’ set for aged care residents tend to be looser than we would expect from the average population;
- HbA1c of 7 – 7.5% for independent & self-caring residents with few health complications
- HbA1c of 7 – 8% for those not independent and/or self-caring
- HbA1c up to 8.5% for frail individuals with life expectancy less than 5 years and requiring insulin
- Acceptable BGL range 6-15mmol/L. Below 6mmol/L is defined as a hypo and greater than 15mmol/L is defined as a hyper.
Recommendations suggest HbA1c should be monitored in all residents with diabetes every 6-12 months and BGLs should be monitored anywhere from once daily to three times daily pre-meals depending on the severity & management technique used for the diabetes and the health status of the resident.
NB these should all be determined on an individual level in consultation with the GP, Endocrinologist, Diabetes Educator and/or other specialist health professional.
What does this mean for me?
- If a resident is referred to you for BGL management, consider the following;
- What their BGL range is?
- Have they changed medications as some medications can elevate BGLs?
- Has their diet/activity level changed recently?
- Have they been unwell?
- How is there kidney function?
- Do they have any nephropathy at present?
- Is their fluctuating BGLs causing them any discomfort or distress?
- Have they lost or gained a significant amount of weight?
There is more to BGL and diabetes management than just the numbers.