By Annette R. Karnash, R.N., M.N.
Most older patients that have diabetes have Type 2, manage it most often through diet, medication, exercise and glucose monitoring. And age does make a difference in how you approach the challenge in helping this patient comply with the necessary treatment regime.
Diets should not be complicated, just plain and simple. Determine the likes and dislikes of the patient and you’ll find they comply more easily if these are included in the diet. A list of foods to be avoided helps. Eating three meals and a light snack at bedtime should be stressed and meals should be no longer than 5 hours apart and not be skipped. Because most diabetics are overweight, they sometimes feel that if they skip a meal this will help them to lose weight, but this can create problems.
In selecting an oral agent for an elderly patient, the physician must be aware of other medications the patient is taking as well as other health problems they may have. The patient should be instructed to check with a pharmacist prior to taking both prescribed and over the counter meds as they can pose drug interactions. Renal function is often a problem with the older patient, so test for proteinuria, creatinine and blood-urea-nitrogen should be done as a base-line prior to prescribing drugs that are broken down by the kidney. When oral agents are unable to control the blood glucose level, insulin may be prescribed. Visual acuity should be determined, since many older people have cataracts, glaucoma, macular degeneration or double vision due to autonomic neuropathy. Various types of visual aids are available to help the patient draw up the appropriate does. Perhaps syringes could be drawn up for a week on a tray marked for each day, if a single type of insulin is used. Or perhaps a family member might be able to assist. A variety of injectors are also available. He should be told that too much or too little insulin may cause a reaction. The signs and symptoms of insulin reactions should be given to them in bold print.
Exercise continues to be important despite age. Walking is the best form of exercise and in winter the malls should be suggested as they are most comfortable at this time of year. Swimming is another form of exercise that may appeal to the older patient. Hormonal changes can result in osteoporosis, making them reluctant to exercise because of aches, pain or stiffness. But exercise and prescribed medication will enable them to feel better.
Dexterity may be a problem for the elderly to handle the blood glucose monitoring meter, especially if they have arthritis. Once again, a family member may give an assist.
We cannot stress enough the importance of taking the correct dose of medication. Because the elderly are often forgetful, they may inadvertently take an overdose of an oral agent that can result in arrhythmias, confusion, seizures and loss of consciousness. Hyperglycemic Hypersomolar Nonketotic Coma (HHNK) can be life threatening to a diabetic and may even occur in patients not diagnosed with diabetes. The elderly often use thiazide diuretics, glucocorticoids, furosemides and immunosuppressant agents which are hyper-glycemic inducing drugs and their underlying conditions such as renal failure, pancreatitis, infections, myocardial infarcts, stress and burns may precipitate HHNK. In this condition the blood sugar becomes extremely high, accompanies by extreme dehydration, absence of ketones, confusion, lethargy, depressed sensorium and increased thirst and urination.
Coronary insufficiency, common among diabetics, predisposes them to heart attacks, hypertension and strokes. Some physiological changes that accompany again such as arteriosclerosis and atherosclerosis diminish vascular supply. When the vascular deficiency affects the brain, it clouds the memory, causes forgetfulness, vertigo and TIA’s. Peripheral insufficiency can result in ulcerations of the extremities. Daily inspection, bathing and massaging of the feet are important aspects of care to preventing problems. Patients are also reminded to insist upon the doctor examining their feet with each visit if it is not included routinely. Periodic visits to the chiropodist is also important because often the patient is unable to see well enough or lacks the mobility to bend over to trim their own toe nails.
In teaching the elderly diabetic, keep in mind their hearing problems, therefore you must speak slowly, clearly and loud enough and be flexible. Because the older patient experiences more stress frequently due to many losses; loved ones, homes, hearing, sight, driving, safety, security and finances, they may experience more hyperglycemic reactions. They should be encouraged to join a support group, a community senior center or service programs so as not to become isolated if they live alone. Understanding the changes that occur in the aging body will impact on how well you teach your elderly patient with diabetes.
