[Treatment quality in geriatric patients with diabetes mellitus in various home environments]

OBJECTIVE

The goal of the present study was to systematically assess treatment quality, perceptions, and cognitive function of elderly patients with diabetes admitted to an acute geriatric hospital from different home environments (nursing home residents, home care, assisted living, family caregivers, self-sufficient).

METHODS

Quality of diabetes treatment, metabolic control (HbA(1c)), nutrition, treatment satisfaction, cognition, disability, and level of dependency were assessed in 128 patients with diabetes.

RESULTS

Out of 128 patients, 87 patients (68%) showed an HbA1c≤8% according to the guidelines for aging people with diabetes of the German Diabetes Association (DDG). Compared to patients living independently at home, the metabolic control in nursing home residents and their treatment satisfaction were as good. They had a higher degree of dependency though (Barthel, p<0.001), more strongly impaired mobility (Tinetti, p<0.01), less diabetes knowledge (p<0.001), inferior cognitive performance (MMSE, SPMSQ, p<0.01), and a higher prevalence of depression (GDS) (p<0.01). Better cognitive function correlated with better diabetes knowledge (r=0.49; p<0.001), but not with better metabolic control.

CONCLUSION

The treatment of geriatric patients with diabetes mellitus requires individual considerations and interdisciplinary care. Particularly the continuing education of geriatric nurses could contribute to improved diabetes treatment quality in nursing home residents.

SGS: a structured treatment and teaching programme for older patients with diabetes mellitus--a prospective randomised controlled multi-centre trial

OBJECTIVES

evaluation of the effectiveness of a new structured diabetes teaching and treatment programme (DTTP) with specific didactical approaches and topics for geriatric patients with diabetes mellitus.

DESIGN

a prospective randomised controlled multi-centre trial.

SETTING AND PARTICIPANTS

a total of 155 geriatric patients were randomly admitted to either the new DTTP SGS (n = 83) or the standard DTTP (n = 72) for insulin-treated patients with type 2 diabetes mellitus (HbA1c 8.0 +/- 1.4%, age 76.2 +/- 6.3 years).

MEASUREMENTS

biometrical data, metabolic control, acute complications, diabetes knowledge, self-management.

RESULTS

SGS participants showed improved levels of HbA1c 6 months after the DTTP, and less acute complications than the standard group (P<0.009). Both groups demonstrated a good capacity for diabetes self-management and improvement in diabetes knowledge after the DTTP (P<0.01).

CONCLUSION

the new SGS diabetes education programme, focusing on the learning capabilities and the particular needs of older persons, is effective in improving metabolic control and in maintaining auto-sufficiency in geriatric patients with diabetes mellitus.

Diabetes mellitus

Diabetes mellitus ist mit einer Prävalenz von etwa 25% bei den 75 bis 80-Jährigen eine der größten Alterserkrankungen. Es besteht eine starke Wechselwirkung zwischen dem Vorliegen und der Einstellung eines Diabetes und der Ausprägung geriatrischer Syndrome. Dass ältere Menschen mit Diabetes stärker unter geriatrischen Syndromen leiden als Gleichaltrige ohne Diabetes ist eine Beobachtung, die zunehmend mit den Erkenntnissen der molekularen Basis von «Frailty» erklärt werden kann. So spielen die «advanced glycation end products» (AGEs), entzündliche Zytokine wie IL-6 oder TNF-α oder auch Proteinkatabolismus bei Insulinmangel eine wichtige Rolle. Möglicherweise lässt sich durch eine bessere Diabetesbehandlung, insbesondere durch die anabole Wirkung der Insulintherapie, Frailty aufhalten oder vermeiden.

[Treating diabetes in the very old]

A very old patient cannot be treated strictly in accordance with the general diabetes guidelines. Rather, interactions between the diabetes and such geriatric syndromes as, for example, dementia, depression, incontinence and immobility also need to be taken into account. In the first instance our concern is to improve the patient's well being and his/her quality of life. It is necessary to tailor not only pharmacotherapy, but also general therapeutic measures, to the specific situation of the individual patient. For this purpose, novel forms of treatment that take account of the specific geriatric aspect of the diabetic are required.

Gesunde Senioren zeigen auch bei normalem Ernährungszustand im Mini-Nutritional-Assessment (MNA) Risikobereiche und eingeschränkte Funktionen

Older adults are potentially vulnerable for malnutrition, risk which can be assessed by the Mini-Nutritional Assessment (MNA). To answer the question, whether the MNA can also assess healthy, normal nourished seniors and to check for correlations on functional disabilities and risk factors for functional status decline, 58 independent living, healthy elderly persons with an MNA above 24 points were studied. Different clinical and laboratory exams were performed and a comprehensive geriatric assessment was carried out. There was a non age-dependent correlation for the number of risks in the Lachs' screening, for the number of drugs taken, for the hemoglobin concentration, the level of the g- GT and for mobility assessment tested by the "Timed Up and Go Test" and the "POMA". The MNA can also distinguish in the "normal" range from 24 to 30 points between persons at risk for functional status decline or persons with slightly impaired functions.

[Structured educational programs for geriatric patients with diabetes mellitus]

Two-thirds of all diabetics are older than 60 years. Owing to the presence of multimorbidity and functional impairments, one-half of these diabetics must be considered "geriatric patients". This category of patients in particular requires a special educational program aimed at improving their situation and quality of life on the basis of good diabetic control. Currently, two educational concepts aimed in particular at elderly patients with type II diabetics and cognitive deficits are available and are described in the present paper. Education for diabetics with impairment of cognitive performance is available to such diabetics irrespective of age. The educational program: "Structured Education for Persons with Type II Diabetes in Old Age", newly developed by the Working Group Diabetes and Geriatrics of the German Diabetes Society teaches self-help skills, offers opportunities for empowerment, and has proved successful also in geriatric patients with mild cognitive deficits.

[Specific aspects of diabetes management in the elderly]

More than two-thirds of all diabetics in Germany are older than 60, and a considerable number with multimorbidity and functional disorders must be considered "geriatric patients". Geriatric syndromes (e.g. intellectual decline, immobility, incontinence and instability) appear to be closely interrelated to diabetes in the old patient. By achieving close-to-normal control of blood sugar, geriatric syndromes can also be improved. In the case of geriatric diabetics, certain peculiarities in terms of diet, instruction, pharmacotherapy and compliance must receive consideration. In addition to the reduction of sequelae and concomitant diseases, an improvement in quality of life achieved by prolonging the impairment-free intervals is the main therapeutic aim in the elderly patient.

Pharmacological treatments for persistent non-malignant pain in older persons

Persistent non-malignant pain is common, often neglected and under-treated among older persons. Some older adults do not complain because they consider chronic pain to be a characteristic of normal aging. Physicians have concerns regarding adverse effects of pharmacological treatment. The model of the World Health Organization for treatment of cancer pain is generally accepted and also recommended for persistent non-cancer pain. Furthermore, non-pharmacological treatment should complement drug treatment whenever possible. An initial assessment and possible treatment of underlying causes of pain are pertinent. Modern pharmacological pain management is based on non-opioid and opioid analgesics. NSAIDs are among the most widely prescribed class of drugs in the world. The new cyclo-oxygenase-2 inhibitors such as celecoxib and rofecoxib offer an alternative for the treatment of mild-to-moderate pain in patients with a history of gastric ulcers or bleeding. Paracetamol (acetaminophen) is being used widely for the management of mild pain across all age groups as it has moderate adverse effects at therapeutic dosages. For moderate pain, a combination of non-opioid analgesics and opioid analgesics with moderate pain relief properties (e.g. oxycodone, codeine, tramadol and tilidine/naloxone) is recommended. For severe pain, a combination of non-opioid analgesics and opioid analgesics with strong pain relief properties (e.g. morphine, codeine) is recommended. The least toxic means of achieving systemic pain relief should be used. For continuous pain, sustained-release analgesic preparations are recommended. Drugs should be given on a fixed time schedule, and possible adverse effects and interactions should be carefully monitored. Adjuvant drugs, such as antidepressants or anticonvulsants, can be very effective especially in the treatment of certain types of pain, such as in diabetic neuropathy. Effective pain management should result in decreased pain, increased function and improvement in mood and sleep.