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Managing Clinical Problems in Diabetes, Case Study #17: Health Assessment, Management Targets, and Deciding on a Management Plan

Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath

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Mrs. PC was referred to a tertiary diabetes clinic by a practice nurse (nurse working in a general practice): “Can you help me sort out this confusing issue both for the GPs and for myself? I have encouraged the GPs that I work for to allow the older patients to run their BGLs higher rather than lower. Consequently, I saw a 75-year-old lean type 2 woman, who had limited exercise ability, was maintaining a healthy diet, not on OHAs, and had an HbA1c of 7.7%. She uses a walking frame and I thought this was OK. My confusion arises with the older people when their BGs are between 90-126mg/dL (5 and 7 mmol/L) and the HbA1c is above 7% and the GP says we need to improve the HbA1c, especially as many older patients have other illnesses, and impairment in speech, mobility, or understanding. Many of them eat like church mice and the GPs still want to push for unrealistic goals. Help please.”..

Diabetes educator

The most important ‘take-home’ message about HbA1c is that it is only one part of the overall picture and does not tell us everything. We need to avoid making clinical decisions about diabetes targets on chronological age rather than according to the level of functioning, the wishes of the patient, and the degree of support they have. It may be appropriate to use a short-acting sulphonylurea such as glicazide or the long-acting glicazide modified release (MR) that only acts when the blood glucose levels rise in healthy older people with few comorbidities and a positive approach to healthy ageing.

Lean older people are unlikely to have significant insulin resistance, and, therefore, will probably not benefit from metformin or a thiazolidinedione. Metformin is generally contraindicated in people over the age of 80 years due to a higher risk of lactic acidosis, which has up to a 50% mortality rate. Metformin can reduce appetite in older people who often have nutritional deficiencies and may need to eat more. Acarbose does not usually cause hypoglycemia but it only lowers HbA1c by 0.5% and is often not tolerated because it causes flatulence.

We need to consider what we hope to achieve by reducing Mrs. PC’s HbA1c to 7%. Controlling blood pressure and lipids is also necessary to prevent long-term diabetes complications. Lower blood glucose levels in frail, at-risk older people may significantly reduce quality of life and safety by increasing the risk of falls and hypoglycemia, which affects cognitive functioning and independence. That is not to say that we allow blood glucose levels to remain > 15 mmol/L all the time because that carries a risk of dehydration, polyuria, lethargy, intercurrent infections, falls, and hyperosmolar states. Mrs. PC uses a walking frame, which puts her in the high-risk falls category. 

Although the treatment of type 2 diabetes is diet, exercise, and medication, in older people these treatments need to be considered by asking the following questions:

(1) Is it safe?

(2) Does it make sense?

(3) Will it enhance the person’s quality of life?

GPs try to do the right thing for their patients. They are under tremendous pressure to ensure that all their patients reach the desired management targets including HbA1c < 7%. Age-related factors are rarely considered when glycemic goals are discussed. For example, endocrinologists tolerate much higher HbA1c levels in infants and young children with type 1 diabetes than older children, due to the risk of unpredictable hypoglycemia. The same principle can be applied to frailer older people. People with diabetes are more than their HbA1c level. Good communication and education between GPs, practice nurses, and diabetes specialists enables more realistic goals to be negotiated. These goals can be identified and articulated using General Practitioner Management Plans.

Dietitian

I would discuss what the GP sees as the advantages of improving glycemic control in this woman and ask him or her to consider the disadvantages, most of which were outlined by the Diabetes Educator. I would like more information about how long Mrs. PC has had diabetes and her glycemic history. I also need to know her complication status and whether any complications she has are being treated, whether they affect her quality of life, and whether improving her glycemic control would prevent them deteriorating.

I wonder whether she has episodes of hypoglycemia. Tightening her control might exacerbate or precipitate hypoglycemia. It is also important to determine whether her poor control is causing symptoms such as thirst, polyuria, infections, tiredness and fatigue. She may need education about how to manage her diabetes and we should identify what her wishes are. I would advise Mrs. PC to attend structured diabetes self-management education if she is willing to, and include her careers in the education.

Key points
  • Individualized holistic assessment is essential to planning appropriate care for people with diabetes.
  • Mental, spiritual, and general health status should be monitored as assiduously as diabetes status.
  • The individual must be involved in planning and monitoring his or her care.
  • Collaborative, structured multidisciplinary team care is essential to achieving optimal outcomes and continuity of care.

 

 
References:

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Chagnon YC, Perusse L, Weisnagel SJ et al. (2000) The human obesity gene map: the 1999 update. Obesity Research 8: 89–117.

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Howe M (2007) Weighty issue. Australian Doctor 16 March: 43. International Diabetes Federation (IDF) (2006) Incidence of diabetes. Diabetes Atlas 2 (www.eatlas.idf.org/Incidence/). Knowler WC, Barrett-Connor E, Fowler SE et al. (Diabetes Prevention Program Research Group) (2002) Reduction in the incidence of type 2 diabetes with lifestyle intervention and metformin. New England Journal of Medicine 346: 393–403.

Lindström J, Louheranta A, Mannelin M et al. (Finnish Diabetes Prevention Study) (2003) Lifestyle intervention and 3-year results on diet and physical activity. Diabetes Care 26(12): 3230–3236.

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Mooradian A, Failla M, Hoogwerf B et al. (1994) Selected vitamins and minerals in diabetes care. Diabetes Care 17: 464–479.

Moyad M (2007) Fad diets and obesity. Part 1: measuring weight in a clinical setting. Urology Nursing 24(2): 114–119.

National Health and Medical Research Council (NHMRC) (1999) Dietary Guidelines for Older Australians. NHMRC, Canberra.

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Tuomilehto J, Lindström S, Laakso M et al. (2001) Finnish Diabetes Prevention Study Group. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. New England Journal of Medicine 344: 1343–1350.

West D (2007) Motivational interviewing improves weight loss in women with type 2 diabetes. Diabetes Care 30: 1081–1087.

The aims of the book are to: (1) address commonly encountered diabetes management problems; (2) develop comprehensive responses from a range of relevant health professionals who suggest management approaches relevant to their area of practice. The specific health professionals who provide comments about each case depend on the specific clinical issue; and (3) stimulate thought and discussion. 

The target readership is health professionals from a range of professional backgrounds and general as well as specialist professionals such as general practitioners, nurses, dietitians, and podiatrists. The book will be particularly useful for beginner practitioners specializing in diabetes. In addition, it will provide suggestions or food for thought for more experienced practitioners. The cases will be excerpts from the book are all real and are presented exactly as the information was received from the person making the referral. General practitioners, diabetes educators and people with diabetes referred most of the cases; some were self-referrals by people with diabetes. They represent referrals to various diabetic health professionals and concern commonly encountered clinical issues.

Next Week: Case Discussion #18

For more information on the book, just follow this link to Amazon.com, Managing Clinical Problems in Diabetesalt

Copyright © 2008 by Blackwell Publishing Ltd, UK

Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath