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We are all living longer today. This represents an increasing challenge to diabetes educators. With the influx of older people, we will be seeing more older diabetics who need to learn aobut their care.

As part of the aging process, normal physiological changes occur in the brain. Older adults are susceptible to abnormal changes that can affect cognition, such as Alzheimer’s disease, T.I. A.’s and the use of multiple medications. Therefore it is important as diabetic educators to assess their cognition status prior to implementing a teaching plan, helping to ensure that the patient is capable of learning what you are about to teach.

There are alterations in the ability to learn new knowledge quickly. We as educators need to realize that as we age, reading, verbal skills and general knowledge continue to improve. In assessing the level of attention, memory, alertness, emotional status and visual spatial skills should be identified. If a person falls asleep or is lethargic, this should be brought to the attention of the physician because it is not normal int he elderly population. Their reading, writing, spelling skills, comprehension and coordination should be evaluated to determine the ability of the elderly patient to learn and use this knowledge in their care. The educational experience should be paced according to their needs and abilities. A slow, methodical approach, that includes repetition and stimulus material saves time in the end.

Often we think that the patient is compliant but not necessarily so. Rather than simply imparting knowledge, education should focus on changing behaviors. Telling is not teaching. Unless you see a change in behavior, the individual has not learned. Changing behavior represents rewarding improvements in self care, especially in view of the consequence of non-compliance i.e. elevated glycosolated hemoglobin, hypoglycemia, hyperglycemia, ketoacidosis. They need to see that a give behavior will lead to a favorable outcome. When a patient sees that practicing a partiular skill or behavior leads to a favorable outcome, this may lead to a behavior change. They then will sense a feeling of self-efficiency and enable them to observe favorable improvements in physical functioning. Demonstrating to the patient that the behavior of glucose testing and adjusting the diet correlates with the outcome of the blood sugar and how this affects the control of diabetes. This in and of itself should act as a motivator. Positive reinforcement is the strongest form of behavior change and it involves a reward– a sense of accomplishment.

And finally, we should be realistic in establishing criteria for success. Asking the patient to do too much at one time will lead to failure. One behavior at a time should be addressed. There is a multitude of issues and options to consider. Armed with this, we can offer the patient, in most instances, a acceptable quality of life and ability to pursue their desired interests.
Annette Karnash

Free eye care is available for older adults who haven”t seen an eye doctor in at least three years through the American Academy of Ophthalmology’s Senior Eye Care Program. Qualified adults, age 65 or older, can receive a full exam and up to one year of care. Call 1-800-222-eyes (3937) for details.

The Pennsylvania State Board of Pharmacy recently enacted a law amending the need for a physician’s prescription to obtain hypodermic needles and syringes, with no age restriction nor limits o purchases. Their research concluded that increased access to needles and syringes does not increase injection drug use and it decreases infectious diseases. The needles will not be placed on retail shelves and must be stored behind the pharmacy counter, where a pharmacist would distribute them.
Annette Karnash

Cataracts, a common eye problem related to aging, is a loss of the transparency in the normally clear lens of the eye. At least 40% of those over the age of 75 develop an opacity of the lens causing diminishing vision. Cataracts are more common in individuals with diabetes, develop earlier, progress more rapidly and accelerate the development of diabetic retinopathy. Symptoms may be gradual, painless with increasingly blurred vision of double vision. Halo’s or blurriness around lights, increased sensitivity to light and glare, dulled color perception, milky or yellow appearance of the lens and difficulty driving at night are symptoms of cataract development. Because cataract developement may not be detected by the individual due to gradual changes, drops placed in both eyes and examined using acuity measurements may indicate a problem before symptoms occur. The best examination for cataract detection is with the use of a slit lamp, a high magnification and narrow light, while looking through a dilated pupil. This procedure should periodically monitor the progression of the disease. initially, a small hazy spot may appear in the field of vision and gradually, as the lens grows more opaque, vision becomes more blurry. A cumulative exposure to the sun’s ultraviolet rays over a lifetime, physical injury to or inflammation of the eye, the long term use of corticosteroid drugs, hereditary factors and birth defects may be contributing factors that lead ot cataracts.
Cataracts are extracted surgically with the implantation of intraocular lens, providing a normal post-operative visual correction for most individuals. With those who have diabetes, however, this may be contraindicated because their lens may cause diabetic retinopathy to become worse, possibly due to surgical trauma. Researchers feel cataracts are found more in diabetic individuals because the enzyme aldose reductase converts the sugars, such as glucose and galactose, into sugar alcohols. The alcohols cannot readily diffuse out of the lens, causing an imbalance in osmotic pressure, resulting in a swelling of the lens due ot fluid accumulation. This allows for the changes in the refractive power of the lens causing cloudy vision.
Surgery is determined based on the age, health and the presence of other ocular disease and the degree to which the patient feels handicapped. Extraction may become medically necessary if a person has a narrow angle glaucoma. It is primarily important to prevent cataract development. No diet has been proven to delay the formation of cataracts in healthy individuals, however the contribution of dietary control on blood glucose may help prevent cataracts and complications in those with diabetes. There has been research to support the idea that cataracts may be caused by ultra violet light. Therefore, it is recommended individuals wear sun glasses marked ‘general ro specific purposes’ or those that block at least 95% of UVB (Ultra violet B) rays to filter out much of the radiation.
To minimize outdoor glare, a wide brimmed hat should be worn. Indoors, use large print books and newspapers, floor or desk lamps with incandescent bulbs instead of ceiling or fluorescent lights. Dimmer controls are also advised. Pinpoint halogen lights should be avoided because they cause pupils to constrict.
The importance of blood glucose control with cataracts was evidenced in the Epidemiology of Diabetic Intervention and Complication Trial, a follow up of the original Diabetes Control and Complications Trial Study, the DCCT, completed in 1993. The trial showed a 1% difference between a tightly controlled glucose group and a group less intensely managed in terms of A1c and a very noticeable difference in nephropathy, neuropathy and retinopathy. There was a reduced number of cardiovascular disease events in the intensely controlled group, but not statistically significant. It was found that if diabetes was controlled intensely early on, the best results were obtained in terms of reducing complications and decreasing the need for laser therapy, dialysis and renal transplantation.Definite benefits of blood glucose were recognized for the microvascular complications of nephropathy, neuropathy and retinopathy ans as patients continue to be followed, they are now seeing the benefits of microvascular complications, atherosclerosis the longer the patients are studied.
Annette Karnash, RN