Self-care management programme for older adults with diabetes: An integrative literature review

A machine learning approach to predict foot care self-management in older adults with diabetes

BACKGROUND

Foot care self-management is underutilized in older adults and diabetic foot ulcers are more common in older adults. It is important to identify predictors of foot care self-management in older adults with diabetes in order to identify and support vulnerable groups. This study aimed to identify predictors of foot care self-management in older adults with diabetes using a machine learning approach.

METHOD

This cross-sectional study was conducted between November 2023 and February 2024. The data were collected in the endocrinology and metabolic diseases departments of three hospitals in Turkey. Patient identification form and the Foot Care Scale for Older Diabetics (FCS-OD) were used for data collection. Gradient boosting algorithms were used to predict the variable importance. Three machine learning algorithms were used in the study: XGBoost, LightGBM and Random Forest. The algorithms were used to predict patients with a score below or above the mean FCS-OD score.

RESULTS

XGBoost had the best performance (AUC: 0.7469). The common predictors of the models were age (0.0534), gender (0.0038), perceived health status (0.0218), and treatment regimen (0.0027). The XGBoost model, which had the highest AUC value, also identified income level (0.0055) and A1c (0.0020) as predictors of the FCS-OD score.

CONCLUSION

The study identified age, gender, perceived health status, treatment regimen, income level and A1c as predictors of foot care self-management in older adults with diabetes. Attention should be given to improving foot care self-management among this vulnerable group.

Classifying self-management clusters of patients with mild cognitive impairment associated with diabetes: A cross-sectional study

AIMS AND OBJECTIVES

This study aims to propose a self-management clusters classification method to determine the self-management ability of elderly patients with mild cognitive impairment (MCI) associated with diabetes mellitus (DM).

BACKGROUND

MCI associated with DM is a common chronic disease in old adults. Self-management affects the disease progression of patients to a large extent. However, the comorbidity and patients' self-management ability are heterogeneous.

DESIGN

A cross-sectional study based on cluster analysis is designed in this paper.

METHOD

The study included 235 participants. The diabetes self-management scale is used to evaluate the self-management ability of patients. SPSS 21.0 was used to analyse the data, including descriptive statistics, agglomerative hierarchical clustering with Ward's method before k-means clustering, k-means clustering analysis, analysis of variance and chi-square test.

RESULTS

Three clusters of self-management styles were classified as follows: Disease neglect type, life oriented type and medical dependence type. Among all participants, the percentages of the three clusters above are 9.78%, 32.77% and 57.45%, respectively. The difference between the six dimensions of each cluster is statistically significant.

CONCLUSION(S)

This study classified three groups of self-management styles, and each group has its own self-management characteristics. The characteristics of the three clusters may help to provide personalized self-management strategies and delay the disease progression of MCI associated with DM patients.

RELEVANCE TO CLINICAL PRACTICE

Typological methods can be used to discover the characteristics of patient clusters and provide personalized care to improve the efficiency of patient self-management to delay the progress of the disease.

PATIENT OR PUBLIC CONTRIBUTION

In our study, we invited patients and members of the public to participate in the research survey and conducted data collection.

Intensive, telemedicine-based, self-management program for rural, underserved patients with diabetes mellitus: Re-entry of retired endocrinologists into practice

INTRODUCTION

Endocrinology workforce data demonstrate a substantial gap in the number of practicing endocrinologists, a phenomenon particularly affecting patients with diabetes in rural, financially challenged, underserved areas. We evaluated the concept that retired endocrinologists could re-enter practice part time and utilize telemedicine in collaboration with personnel in Federally Qualified Community Health Center clinics to conduct an intensive self-management program and provide 6-month concurrent care for patients with diabetes.

METHODS

The program involved intensive glucose control measures and education in diabetes, nutrition, and lifestyle changes over a 6-month period. Key elements included comprehensive initial telehealth evaluations, frequent phone calls, and collaboration with certified diabetes care and education specialists, referring providers, referring-clinic staff, and the University of Virginia Telehealth Center.

RESULTS

The mean A1C in the 139 patients completing the 6-month self-management program decreased from 10.3 ± 1.94% to 7.78 ± 1.51% p < 0.0001. The number of treatment modalities per patient ranged from one to five with several different regimens utilized. The majority of patients maintained the reduction in A1C levels without recidivism over a mean follow-up of 16 months after discharge. Strategies using meal replacements are being implemented to facilitate weight loss.

DISCUSSION

This program resulted in improved A1C levels of patients with diabetes in rural, financially challenged, underserved areas; met recidivism goals; and provided a practical template to reduce the workforce gap of endocrinologists in those areas.

Self-Determination Theory and Quality of Life of Adults with Diabetes: A Scoping Review

Background

Diabetes is one of the leading causes of sickness, death, and decreased quality of life globally. The prevalence of diabetes keeps rising globally due to lifestyle changes and urbanization. Therefore, improved quality of life (QoL) and appropriate diabetes self-management practices, including treatment adherence, are crucial to improving and sustaining the health of diabetic patients. Some studies have adopted the self-determination theory (SDT) to study diabetes interventions, but less is known about its effectiveness in improving QoL, treatment adherence, and diabetes self-management. Aim/Objective. This review assessed the effectiveness of SDT in improving self-management practices, treatment adherence, and QoL among adult diabetic patients.

Method

We followed the six-stage framework by Arksey and O'Malley in conducting the review. PubMed, JSTOR, Central, and ScienceDirect databases were searched for published articles from January 2011 to October 2021 using keywords and Boolean logic. Furthermore, we screened a reference list of related articles. Also, Google Scholar, Z-library, and web-based searches were carried out to retrieve other relevant evidence that applied SDT in improving QoL, diabetes self-management, and treatment adherence. Findings. Fifteen studies met the inclusion criteria, from which data were extracted as findings. SDT effectively improved QoL, diabetes treatment adherence, and diabetes self-management among diabetic patients. Of these studies, 11 provided data on SDT and diabetes self-management and affirmed the effectiveness of the theory in improving appropriate diabetes self-management practices. Two studies confirmed the effectiveness of SDT in improving treatment adherence. SDT and QoL were assessed in 4 of the studies, which demonstrated the effectiveness of SDT in enhancing the QoL of diabetic patients.

Conclusion

SDT effectively improved QoL, diabetes treatment adherence, and diabetes self-management. The application of SDT in diabetes management will improve the health and QoL of diabetic patients. Hence, diabetes management interventions could adopt SDT to guide treatment.

Educational programs in type 2 diabetes designed for community-dwelling older adults: A systematic review

AIMS

This systematic review aimed to assess the effectiveness of educational interventions in type 2 diabetes specifically designed for community-dwelling older adults.

METHODS

In accordance with PRISMA guidelines, a systematic search of studies published between 2010 and 2021 was conducted across five electronic databases and manual sources. The study protocol was previously registered in PROSPERO (CRD42021288236).

RESULTS

Twelve papers matched the inclusion criteria and were appraised using MERSQI. The features of the educational programs were heterogeneous, and none complied with the ten suggested standards for diabetes self-management education and support. Comprehensive gerontological assessment was not considered. Outcomes included biomedical, psychosocial, behavioral, and knowledge measures. HbA1c and knowledge showed improvements with a high certainty level according to GRADE.

CONCLUSIONS

Structured DSME programs aimed at older adults have great potential, however there is still room to improve. Applying the principles of a comprehensive gerontological approach and the standards for DSME as continuous monitoring and support could increase their benefits.

Effectiveness of a nurse-led smartphone-based self-management programme for people with poorly controlled type 2 diabetes: A randomized controlled trial

AIM

To evaluate the effectiveness of a nurse-led smartphone-based self-management programme (NSSMP) on improving self-efficacy, promoting diabetes self-care, increasing health-related quality of life (HRQoL) and decreasing HbA1c, acute complications and unplanned medical consultation for people with poorly controlled type 2 diabetes compared with a nurse-led diabetic service (NDS).

DESIGN

A two-arm randomized controlled trial with repeated measures was conducted.

METHODS

Participants were recruited from June 2018 to September 2020. Eligible participants were assigned to either the intervention or control group randomly. Participants assigned to intervention group received the 6-month NSSMP, while those in the control group received existing NDS provided by the study hospital. Outcomes were measured at baseline, and at 3 and 6 months from baseline.

RESULTS

A total of 114 participants were recruited. There were no significant interactions between group and time for all the outcomes except for blood glucose testing activities (F = 4.742, p = .015). Both groups had reduced HbA1c over 6 months. The intervention group had a lower HbA1c than the control group at follow-ups, but the differences were not statistically significant. None of the participants had acute diabetes complications at follow-up. Similarly, the differences in the number of unplanned medical consultation at 6-month follow-up between two groups were statistically insignificant.

CONCLUSION

The NSSMP is as effective as existing NDS provided by the study hospital in improving most of the outcomes. NSSMP can liberate valuable time for nurses to provide care to critically ill patients and supports healthcare resource constraints in the current COVID-19 pandemic.

IMPACT

The existing diabetes service is labour intensive as nurses are required to deliver education, follow-up telephone calls to trace blood sugar monitoring and provide therapeutic consultations and necessary referrals. The outbreak of COVID-19 pandemic has added further strain on the overworked professionals. NSSMP provides an alternative programme that is just as effective, to reduce nurses' workload by delegating them back to the individuals through self-management strategies. This enables nurses to increase contact time with patients, and individuals to take onus of their disease through increased self-efficacy, facilitated by technology.

CLINICAL TRIAL

This study is registered under clinical registration number NCT03088475.

The Aging, Community and Health Research Unit Community Partnership Program (ACHRU-CPP) for older adults with diabetes and multiple chronic conditions: study protocol for a randomized controlled trial

BACKGROUND

Older adults (≥65 years) with diabetes and multiple chronic conditions (MCC) (> 2 chronic conditions) experience reduced function and quality of life, increased health service use, and high mortality. Many community-based self-management interventions have been developed for this group, however the evidence for their effectiveness is limited. This paper presents the protocol for a randomized controlled trial (RCT) comparing the effectiveness and implementation of the Aging, Community and Health Research Unit-Community Partnership Program (ACHRU-CPP) to usual care in older adults with diabetes and MCC and their caregivers.

METHODS

We will conduct a cross-jurisdictional, multi-site implementation-effectiveness type II hybrid RCT. Eligibility criteria are: ≥65 years, diabetes diagnosis (Type 1 or 2) and at least one other chronic condition, and enrolled in a primary care or diabetes education program. Participants will be randomly assigned to the intervention (ACHRU-CPP) or control arm (1:1 ratio). The intervention arm consists of home/telephone visits, monthly group wellness sessions, multidisciplinary case conferences, and system navigation support. It will be delivered by registered nurses and registered dietitians/nutritionists from participating primary care or diabetes education programs and program coordinators from community-based organizations. The control arm consists of usual care provided by the primary care setting or diabetes education program. The primary outcome is the change from baseline to 6 months in mental functioning. Secondary outcomes will include, for example, the change from baseline to 6 months in physical functioning, diabetes self-management, depressive symptoms, and cost of use of healthcare services. Analysis of covariance (ANCOVA) models will be used to analyze all outcomes, with intention-to-treat analysis using multiple imputation to address missing data. Descriptive and qualitative data from older adults, caregivers and intervention teams will be used to examine intervention implementation, site-specific adaptations, and scalability potential.

DISCUSSION

An interprofessional intervention supporting self-management may be effective in improving health outcomes and client/caregiver experience and reducing service use and costs in this complex population. This pragmatic trial includes a scalability assessment which considers a range of effectiveness and implementation criteria to inform the future scale-up of the ACHRU-CPP.

TRIAL REGISTRATION

Clinical Trials.gov Identifier NCT03664583 . Registration date: September 10, 2018.

Factors influencing diabetes self-management in adults: an umbrella review of systematic reviews

OBJECTIVE

The objective of this review was to identify and describe the factors influencing diabetes self-management in adults by summarizing the available evidence concerning their types, categories, and relative importance.

INTRODUCTION

A wide range of factors, acting simultaneously, influence diabetes self-management and interfere with its actual application by patients. There is a variety of systematic reviews of these factors; however, a more thorough examination of their influences was lacking.

INCLUSION CRITERIA

Systematic reviews of qualitative or quantitative literature focusing on factors influencing adult diabetes self-management in general or on individual behaviors (ie, management of oral antidiabetic medication and insulin injections, self-monitoring of blood glucose, foot care, healthy eating, regular exercise, and smoking cessation) will be included.

METHODS

We performed an extensive search of 11 bibliographic databases, including gray literature, up to June 2019. Quantitative and qualitative findings were summarized separately and labeled according to their types (eg, facilitator/barrier, strength and direction of association), categories (eg, demographic, social), and frequency of occurrence.

RESULTS

We identified 51 types of factors within 114 systematic reviews, which mostly addressed medication-taking behavior. Thirty-two (62.7%) factors were reported in both qualitative and quantitative literature. The predominant influences were psychological factors and behavioral attributes/skills factors. The most frequently reported facilitators of diabetes self-management were motivation to diabetes self-management, a favorable attitude to diabetes self-management, knowledge about the disease, medication and behaviors associated with diabetes self-management, skills, and self-efficacy/perceived behavioral control. The predominant barriers were the presence of depression, and polypharmacy or drug regimen complexity. The demographic factor of female sex was frequently reported for its negative influence on diabetes self-management, whereas older age was a positive factor. The social/cultural and physical environment were the least-studied categories. Other factors such as social support from family, friends, or networks; interventions led by health professionals; and a strong community environment with good social services favoring diabetes self-management were reported as major facilitators of diabetes self-management.

CONCLUSIONS

Essential components of interventions to promote effective diabetes self-management should aim to help adults manage the effects of specific factors related to their psychological and practical self-management experience. Screening for depression, in particular, should become an integral part of the support for adult diabetes self-management, as depression is a particular obstacle to the effectiveness of diabetes self-management. Future studies should more deeply examine the influence of factors identified in the sociocultural and physical environment categories. Research should properly consider and invest efforts in strengthening social support and innovative community care approaches, including pharmacist- and nurse-led care models for encouraging and improving adult diabetes self-management. Finally, researchers should examine non-modifiable factors - age, sex, or socioeconomic status - in the light of factors from other categories in order to deepen understanding of their real-world patterns of action on adult diabetes self-management.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42018084665.

The development and testing of a nurse-led smartphone-based self-management programme for diabetes patients with poor glycaemic control

AIMS

To describe a systematic process for the development of a nurse-led smartphone-based self-management programme for type 2 diabetes patients with poor glycaemic control in Singapore.

METHODS

A three-step process involving the application of a theoretical framework, evidence from literature, content validity, and pilot tests were conducted for the content and technical development of the programme. Content experts and lay patients evaluated the appropriateness, relevance, and comprehensibility of the newly developed Care4Diabetes application. A pilot randomized controlled trial was conducted with 40 patients recruited in Singapore. Twenty patients each were randomly allocated to the control and intervention groups. The study outcomes were collected at baseline and at 3 months thereafter.

RESULTS

The nurse-led smartphone-based self-management programme was developed with integration of the Care4Diabetes application and the web-portal system. The pilot results indicated that the effects of this smartphone-based programme on patient's health-related outcomes were comparable with those of the currently available nurse-led diabetes service.

CONCLUSION

The smartphone-based self-management intervention was deemed effective, yet full-scale randomized controlled trials are still ongoing and the results of these may provide strong evidence of the effectiveness of such an approach in improving patient care.

IMPACT

The uniqueness of this study lies in the integrated system used, which offers a clinical platform for diabetes nurses to provide personalized coaching and care to patients remotely, while monitoring patients' progress closely. By adopting such an approach, it would free up more time for nurses to cater to patients who are more critically in need of their direct attention.

Barriers to Self-Management of Type 2 Diabetes During COVID-19 Medical Isolation: A Qualitative Study

PURPOSE

Diabetes self-management behaviors are necessary to obtain optimum glycemic control, reduce the risk of complications, and improve health outcomes. The COVID-19 pandemic imposes an additional struggle for self-management by diabetes patients. Although previous studies have reported socio-demographic, behavioral, psychological, and cultural barriers to diabetes self-management, little is known about perceived barriers to diabetes self-management among patients during isolation following their recovery from COVID-19. The purpose of this study was to explore perceived barriers among type 2 diabetes patients during isolation following their recovery from COVID-19.

PATIENTS AND METHODS

A qualitative, exploratory, and descriptive research design was utilized. Semi-structured telephonic interviews were conducted with 12 patients with diabetes who had been discharged from one COVID-19 designated hospital and underwent isolation in the designated facilities in Wuhan City, Hubei Province, China. Data were analyzed using Colaizzi's seven steps.

RESULTS

Barriers to diabetes self-management identified by patients with diabetes during isolation were categorized into five major themes: inadequate knowledge and behavioral beliefs, shortage of resources, suffering from health problems, negative emotions, and lack of support.

CONCLUSION

Perceived barriers to diabetes self-management described by diabetes patients indicated a lack of environmental resources and support strategies to meet their needs. Efforts to remove barriers are important in assisting patients with diabetes to improve their quality of life and health outcomes.

Perceptions of self-determination and quality of life among Swedish home care recipients - a cross-sectional study

Background

It is acknowledged that preservation of self-determination is very important in order for older adults to experience good quality of life, but to what degree and in what areas people receiving help from home care service experience self-determination is unknown. Few studies have examined the perception of self-determination in relation to quality of life among older adults living at home with help from home care services. Thus, the aim of this study was to explore perceptions of self-determination among older adults living at home with the support of home care services, and to test whether older adults who perceive a higher degree of self-determination also feel they have a better quality of life.

Methods

This cross-sectional study was conducted in one municipality in northern Sweden. A total of 134 older adults (≥ 65 years) were included. Data were collected by means of a survey including questionnaires about background characteristics, self-determination, and health-related quality of life. Descriptive statistics regarding background characteristics for groups with high and low self-determination respectively were presented and the differences between the groups were analyzed using the Chi-square test and the Mann-Whitney U test.

Results

Our main finding shows that the majority of older adults with support from home care services experience self-determination in the dimensions use of time, and self-care. However, a wide variation was found in self-reported self-determination in all dimensions. Results also show that the group with higher self-reported self-determination also reported a greater degree of experienced quality of life in comparison with the group with lower self-reported self-determination.

Conclusions

In line with earlier research, our results found a positive relation between self-determination and quality of life. The results are relevant for the care of older adults and indicate a need of further research. The results presented in this paper could serve as a guide when planning for improved self-determination among older adults in home care service.

Trial registration

NCT02846246.

'Having to learn this so late in our lives…' Swedish elderly patients' beliefs, experiences, attitudes and expectations of e-health in primary health care

OBJECTIVE

The elderly are an increasing group and large consumers of care in Sweden. Development of mobile information technology shows promising results of interventions for prevention and treatment of chronic diseases. Exploring the elderly patients' beliefs, attitudes, experiences and expectations of e-health services helps us understand the factors that influence adherence to such tools in primary care.

MATERIAL AND METHODS

We conducted focus group interviews with 15 patients from three primary health care centers (PHCCs) in Southern Sweden. Data were analysed with thematic content analysis with codes and categories emerged from data during analysis.

RESULTS

We found one comprehensive theme: 'The elderly's ambivalence towards e-health:  reluctant curiosity, a wish to join and need for information and learning support'. Eight categories emerged from the text during analysis: 'E-health - a solution for a non-existing problem?', 'The elderly's experiences of e-health', 'Lack of will, skills, self-trust or mistrust in the new technology', 'Organizational barriers', 'Wanting and needing to move forward', 'Concerns to be addressed for making e-health a good solution', 'Potential advantages with e-health versus ordinary health care' and 'Need for speed, access and correct comprehensive information'.

CONCLUSIONS

Elderly patients in Sweden described feelings of ambivalence towards e-health, raising concerns as accessibility to health care, mistrust in poor IT systems or impaired abilities to cope with technology. They also expressed a wish and need to move forward albeit with reluctant curiosity. Successful implementation of e-health interventions should be tailored to target different attitudes and needs with a strong focus on information and support for the elderly. Key points Exploring the elderly patients' beliefs, experiences, attitudes and expectations of the fast developing e-health services helps us understand the factors that influence adherence to such tools in primary care. Elderly patients in Sweden reported ambivalence and different experiences and attitudes towards e-health, raising concerns as accessibility to health care, costs and mistrust in poor IT systems or impaired abilities to cope with technology. They also expressed a wish and need to move forward albeit with reluctant curiosity. Successful implementation of e-health interventions should be tailored to target different attitudes and needs with a strong focus on information and support for the elderly.

Managing diabetes in people with dementia: a realist review

BACKGROUND

Dementia and diabetes mellitus are common long-term conditions that coexist in a large number of older people. People living with dementia and diabetes may be at increased risk of complications such as hypoglycaemic episodes because they are less able to manage their diabetes.

OBJECTIVES

To identify the key features or mechanisms of programmes that aim to improve the management of diabetes in people with dementia and to identify areas needing further research.

DESIGN

Realist review, using an iterative, stakeholder-driven, four-stage approach. This involved scoping the literature and conducting stakeholder interviews to develop initial programme theories, systematic searches of the evidence to test and develop the theories, and the validation of programme theories with a purposive sample of stakeholders.

PARTICIPANTS

Twenty-six stakeholders (user/patient representatives, dementia care providers, clinicians specialising in dementia or diabetes and researchers) took part in interviews and 24 participated in a consensus conference.

DATA SOURCES

The following databases were searched from 1990 to March 2016: MEDLINE (PubMed), Cumulative Index to Nursing and Allied Health Literature, Scopus, The Cochrane Library (including the Cochrane Database of Systematic Reviews), Database of Abstracts of Reviews of Effects, the Health Technology Assessment (HTA) database, NHS Economic Evaluation Database, AgeInfo (Centre for Policy on Ageing - UK), Social Care Online, the National Institute for Health Research (NIHR) portfolio database, NHS Evidence, Google (Google Inc., Mountain View, CA, USA) and Google Scholar (Google Inc., Mountain View, CA, USA).

RESULTS

We included 89 papers. Ten papers focused directly on people living with dementia and diabetes, and the rest related to people with dementia or diabetes or other long-term conditions. We identified six context-mechanism-outcome (CMO) configurations that provide an explanatory account of how interventions might work to improve the management of diabetes in people living with dementia. This includes embedding positive attitudes towards people living with dementia, person-centred approaches to care planning, developing skills to provide tailored and flexible care, regular contact, family engagement and usability of assistive devices. A general metamechanism that emerges concerns the synergy between an intervention strategy, the dementia trajectory and social and environmental factors, especially family involvement. A flexible service model for people with dementia and diabetes would enable this synergy in a way that would lead to the improved management of diabetes in people living with dementia.

LIMITATIONS

There is little evidence relating to the management of diabetes in people living with dementia, although including a wider literature provided opportunities for transferable learning. The outcomes in our CMOs are largely experiential rather than clinical. This reflects the evidence available. Outcomes such as increased engagement in self-management are potential surrogates for better clinical management of diabetes, but this is not proven.

CONCLUSIONS

This review suggests that there is a need to prioritise quality of life, independence and patient and carer priorities over a more biomedical, target-driven approach. Much current research, particularly that specific to people living with dementia and diabetes, identifies deficiencies in, and problems with, current systems. Although we have highlighted the need for personalised care, continuity and family-centred approaches, there is much evidence to suggest that this is not currently happening. Future research on the management of diabetes in older people with complex health needs, including those with dementia, needs to look at how organisational structures and workforce development can be better aligned to the needs of people living with dementia and diabetes.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015020625.

FUNDING

The NIHR HTA programme.

Human Factors and Data Logging Processes With the Use of Advanced Technology for Adults With Type 1 Diabetes: Systematic Integrative Review

Background

People with type 1 diabetes (T1D) undertake self-management to prevent short and long-term complications. Advanced technology potentially supports such activities but requires consideration of psychological and behavioral constructs and usability issues. Economic factors and health care provider capacity influence access and uptake of advanced technology. Previous reviews have focused upon clinical outcomes or were descriptive or have synthesized studies on adults with those on children and young people where human factors are different.

Objective

This review described and examined the relationship between human factors and adherence with technology for data logging processes in adults with T1D.

Methods

A systematic literature search was undertaken by using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Quality appraisal was undertaken and data were abstracted and categorized into the themes that underpinned the human factor constructs that were examined.

Results

A total of 18 studies were included. A total of 6 constructs emerged from the data analysis: the relationship between adherence to data logging and measurable outcomes; satisfaction with the transition to advanced technology for self-management; use of advanced technology and time spent on diabetes-related activities; strategies to mediate the complexities of diabetes and the use of advanced technology; cognition in the wild; and meanings, views, and perspectives from the users of technology.

Conclusions

Increased treatment satisfaction was found on transition from traditional to advanced technology use—insulin pump and continuous glucose monitoring (CGM); the most significant factor was when blood glucose levels were consistently <7.00 mmol/L (P ≤.01). Participants spent considerable time on their diabetes self-care. Logging of data was positively correlated with increasing age when using an app that provided meaningful feedback (regression coefficient=55.8 recordings/year; P ≤.01). There were benefits of CGM for older people in mediating complexities and fears of hypoglycemia with significant differences in well-being (P ≤.001).

Qualitative studies explored the contextual use and uptake of technology. The results suggested frustrations with CGM, continuous subcutaneous insulin infusion, calibration of devices, and alarms. Furthermore implications for “body image” and the way in which “significant others” impacted on the behavior and attitude of the individual toward technology use. There were wide variations in the normal use of and interaction with technology across a continuum of sociocultural contexts, which has implications for the way in which future technologies should be designed.

Quantitative studies were limited by small sample sizes, making it difficult to generalize findings to other contexts. This was further limited by a sample that was predominantly white, well-controlled, and engaged with self-care. The use of critical appraisal frameworks demonstrated where research into human factors and data logging processes of individuals could be improved. This included engaging people in the design of the technology, especially hard-to-reach or marginalized groups.

The effect of complex interventions on supporting self-care among community-dwelling older adults: a systematic review and meta-analysis

Background

self-care is critical to enable community-dwelling older adults to live independently. Complex interventions have emerged as a strategy to support self-care, but their effectiveness is unknown. Our objective was to review systematically their effectiveness on both positive (increased scores in self-rated health, Activities of Daily Living, Instrumental Activities of Daily Living, quality of life) and negative aspects (increased incidence of falls, fear of falling, hospital and nursing home admission, increased depression score), and to determine which intervention components explain the observed effects.

Methods

CINAHL, MEDLINE, British Nursing Index, PsycInfo and Cochrane CENTRAL were searched from January 2006 to October 2016. Randomised controlled trials providing at least two of these components: individual assessment, care planning or provision of information were reviewed. Outcomes were pooled by random-effects meta-analysis.

Results

twenty-two trials with 14,364 participants were included with a low risk of bias. Pooled effects showed significant benefits on positive aspects including self-rated health [standardised mean difference (SMD) 0.09, 95% confidence interval (CI) 0.01-0.17] and the mental subscale of quality of life (SMD 0.44, 95% CI 0.09-0.80) as well as on the negative aspect of incidence of falls [odds ratio (OR) 0.60, 95% CI 0.46-0.79]. There was no significant improvement in ADL, IADL, overall quality of life, fear of falling, reduction in health service utilisation or depression levels. Meta-regression and subgroup analysis did not identify any specific component or characteristic in complex interventions which explained these effects.

Conclusion

based on current evidence, supporting self-care in community-dwelling older adults using complex interventions effectively increases self-rated health, reduces the occurrence of falls and improves the mental subscale of quality of life.

Evaluation of the effects of a diabetes educational program: a randomized clinical trial

OBJECTIVE

Evaluate the effectiveness of a diabetes mellitus educational program in primary health care.

METHODS

This cluster randomized trial was conducted in a sample of 470 people with type 2 diabetes mellitus from eight health units, randomly assigned to two groups: intervention (n = 231) and control (n = 239). The intervention group participated in the educational program composed of three strategies: group education, home visit, and telephone intervention. Simultaneously, the control group was monitored individually. Group monitoring took place over nine months in the year 2012. Clinical evaluations were performed at the initial time (T₀), three (T₃), six (T₆) and nine (T₉) months after the beginning of the intervention.

RESULTS

After nine months of follow-up, 341 users remained in the study, 171 in the control group and 170 in the intervention group. The average age of users was 60.6 years. In both groups, statistically significant differences were observed in mean HbA1c levels over the follow-up time (p < 0.05). However, the mean HbA1c level at T₃, T₆ and T₉ times were significantly lower among the people in the intervention group (p < 0.05).

CONCLUSIONS

The educational program model developed was effective to improve the glycemic control of the intervention group participants.

What works for whom in the management of diabetes in people living with dementia: a realist review

BACKGROUND

Dementia and diabetes mellitus are common long-term conditions and co-exist in a large number of older people. People living with dementia (PLWD) may be less able to manage their diabetes, putting them at increased risk of complications such as hypoglycaemia. The aim of this review was to identify key mechanisms within different interventions that are likely to improve diabetes outcomes in PLWD.

METHODS

This is a realist review involving scoping of the literature and stakeholder interviews to develop theoretical explanations of how interventions might work, systematic searches of the evidence to test and develop the theories and their validation with a purposive sample of stakeholders. Twenty-six stakeholders - user/patient representatives, dementia care providers, clinicians specialising in diabetes or dementia and researchers - took part in interviews, and 24 participated in a consensus conference.

RESULTS

We included 89 papers. Ten focused on PLWD and diabetes, and the remainder related to people with either dementia, diabetes or other long-term conditions. We identified six context-mechanism-outcome configurations which provide an explanatory account of how interventions might work to improve the management of diabetes in PLWD. This includes embedding positive attitudes towards PLWD, person-centred approaches to care planning, developing skills to provide tailored and flexible care, regular contact, family engagement and usability of assistive devices. An overarching contingency emerged concerning the synergy between an intervention strategy, the dementia trajectory and social and environmental factors, especially family involvement.

CONCLUSIONS

Evidence highlighted the need for personalised care, continuity and family-centred approaches, although there was limited evidence that this happens routinely. This review suggests there is a need for a flexible service model that prioritises quality of life, independence and patient and carer priorities. Future research on the management of diabetes in older people with complex health needs, including those with dementia, needs to look at how organisational structures and workforce development can be better aligned to their needs.

TRIAL REGISTRATION

PROSPERO, CRD42015020625. Registered on 18 May 2015.

Optimising Health Literacy and Access of Service Provision to Community Dwelling Older People with Diabetes Receiving Home Nursing Support

Background. Health literacy is the ability to access, understand, and use information and services for good health. Among people with chronic conditions, health literacy requirements for effective self-management are high. The Optimising Health Literacy and Access (Ophelia) study engaged diverse organisations in the codesign of interventions involving the Health Literacy Questionnaire (HLQ) needs assessment, followed by development and evaluation of interventions addressing identified needs. This study reports the process and outcomes of one of the nine organisations, the Royal District Nursing Service (RDNS). Methods. Participants were home nursing clients with diabetes. The intervention included tailored diabetes self-management education according to preferred learning style, a standardised diabetes education tool, resources, and teach-back method. Results. Needs analysis of 113 quota-sampled clients showed difficulties managing health and finding and appraising health information. The service-wide diabetes education intervention was applied to 24 clients. The intervention was well received by clients and nurses. Positive impacts on clients' diabetes knowledge and behaviour were seen and nurses reported clear benefits to their practice. Conclusion. A structured method that supports healthcare services to codesign interventions that respond to the health literacy needs of their clients can lead to evidence-informed, sustainable practice changes that support clients to better understand effective diabetes self-management.

Connected health: a review of the literature

The presence of social support, and more recently, connection, has been linked to multiple health benefits and longevity measures and the lack of connection is associated with premature morbidity and mortality. Connected health is a growing industry, and we were interested in determining whether or not scholars in the field have established the ways in which technology could facilitate or promote connection between patients and healthcare providers. This integrative literature review sought to collect and analyze research studies addressing social support or connection in a sample of patients with diabetes to evaluate the social support or connection metrics in use, the type of technology deployed by researchers to achieve connection, and to assess the state of the science in this area. We hypothesized that being connected to someone who cares is good for your health. We believe this holds true even when connection is accomplished with mobile technologies. Thirty five studies were included in this review, 21 utilized technology to enhance patient-provider connection. The articles included in this review were from a total of more than nine countries and took place in hospital, physician office, and community settings. They represented people from childhood through to old age. Technologies evaluated include: telephone interventions, email, text messaging, interactive voice response (IVR), video blogs, apps, websites, and social media. There were multiple operational definitions of social support and self-management used as variables within the studies. Findings from this review suggest that being connected does matter to patients with diabetes, and being connected to family matters the most, even though the associations are complex and not always predictable. Furthermore, patients with diabetes will utilize a variety of technologies to connect with healthcare providers, team members, and even other people with the same disease. The use of technology with diabetes patients positively impacts a variety of health outcomes, such as HbA1c, weight, physical activity, healthy eating, cholesterol and frequency of glycemic monitoring.

eHealth technologies to support nutrition and physical activity behaviors in diabetes self-management

Diabetes is a chronic, complex condition requiring sound knowledge and self-management skills to optimize glycemic control and health outcomes. Dietary intake and physical activity are key diabetes self-management (DSM) behaviors that require tailored education and support. Electronic health (eHealth) technologies have a demonstrated potential for assisting individuals with DSM behaviors. This review provides examples of technologies used to support nutrition and physical activity behaviors in the context of DSM. Technologies covered include those widely used for DSM, such as web-based programs and mobile phone and smartphone applications. In addition, examples of novel tools such as virtual and augmented reality, video games, computer vision for dietary carbohydrate monitoring, and wearable devices are provided. The challenges to, and facilitators for, the use of eHealth technologies in DSM are discussed. Strategies to support the implementation of eHealth technologies within practice and suggestions for future research to enhance nutrition and physical activity behaviors as a part of broader DSM are provided.