Let Them Eat Cake Clinical Practice Recommendations for Diabetes Management

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1 Let Them Eat Cake Clinical Practice Recommendations for Diabetes Management Mimi Cunningham, MA, RDN, CDE Idaho Health Care Association 2015 Winter Workshop

2 Goals You Go Home With Confidence in your knowledge Tools for better care and management Plans to implement changes big or small

3 Objectives Improved Patient Care Increase knowledge of diabetes clinical practice recommendations Increase knowledge about patient/resident diabetes management to prevent complications Develop quality assurance and performance improvement strategies for better diabetes patient/resident outcomes and improved blood glucose levels

4 Two Thoughts The Big P = PREVENTION The new IT = INDIVIDUAL TREATMENT

7 Demographics: National Diabetes Impact 29.1 million people 1 out of 11 adults >20 years 1 out of 4 adults undiagnosed 86 million have pre-diabetes = 1 out of 3 adults 22-25% of people > 65 years have diabetes 90% to 95% have type 2 diabetes 2014 National Diabetes Statistics Report

8 Demographics: Idaho Impact 8.4% or 99,500 adults > 18 years have diabetes 7.5% or 88,900 adults have pre-diabetes Total: 188,400 adults > 65 years: estimated 22,000 adults diagnosed (22% prevalence rate) 2013 Behavioral Risk Factor Surveillance Survey, Idaho Dept. of Health & Welfare

9 American Diabetes Association

10 Diagnostic Criteria A1c >6.5%* A1c % = pre-diabetes FPG (fasting plasma glucose) >126 mg/dl (8 hr. fast)* 2-h PG 200 mg/dl during an OGTT (75g. Glucose)* In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose 200 mg/dl *Results should be performed by repeat testing Standards of Medical Care in Diabetesd2015: Diabetes Care 2015;38(Suppl. 1):S4

11 2015 Standards of Medical Care in Diabetes New blood glucose targets Pre-meal: mg/dl vs mg/dl Peak postprandial: < 180 mg/dl Blood Pressure 140/90 mm Hg vs. 140/80 mm Hg Depression Adults > 65 years screen and treat Standards of Medical Care in Diabetesd2015: Diabetes Care 2015;38(Suppl. 1):S4

12 2015 Standards of Medical Care in Diabetes Oral Intake Status: Preferred Insulin Management Poor nutritional intake or NPO: basal insulin + correction insulin Good nutritional intake: basal insulin + nutritional insulin + correction dose Thing of the past: sliding scale insulin management

13 P IT : Treatment Challenges Clinical trials don t look at people >75 years Middle age diagnosis More complications = more difficult to treat Later life diagnosis Less complicated, may not need insulin, do well on oral meds IT : Based on life expectancy Ability to self-manage Hypoglycemic vulnerability (ER rate doubled >75 yrs) Cognitive status Ideal A1c: goals determined by life expectancy

14 P IT : A1c Goals Healthy A1c: <7.5% Complex Intermediate A1c: <8.0% Very Complex/Poor Health A1c: <8.5% Diabetes in Older Adults Diabetes Care, Vol.35, Dec.2012 Healthy FBG: mg/dl HS BG: mg/dl Complex Intermediate FBG: mg/dl HS BG: mg/dl Very Complex FBG: mg/dl HS BG:

15 Risks Associated with Having Diabetes: Individual Assessment = P IT Cognitive impairment Depression Coexisting diseases Polypharmacy Anorexia, poor appetite Dehydration Hypoglycemic unawareness Falls Hearing impairment Vision impairment Urinary incontinence Persistent pain

16 Acute Risks: P IT Prevention Individual Treatment Hypoglycemia Hyperglycemia Hyperosmolar hyperglycemic nonketotic syndrome (HHS)

17 Hypoglycemia Causes Slowed counter-regulatory hormones Erratic food intake Insulin mismatch with food intake Medications Slowed intestinal absorption of nutrients

18 Hypoglycemia Symptoms Shakiness Nervousness or anxiety Sweating, chills and clamminess Irritability or impatience Confusion, including delirium Rapid/fast heartbeat Lightheadedness or dizziness Hunger and nausea Sleepiness Blurred/impaired vision Tingling or numbness in the lips or tongue Headaches Weakness or fatigue Anger, stubbornness, or sadness Lack of coordination Nightmares or crying out during sleep Seizures Unconsciousness

19 Hypoglycemia Treatment Challenge: Treat, but not over treat Rule: 15 g. carb 15 minute BG check Symtomatic? Check BG Provide 15 g. carb Check BG after 15 minutes Repeat if BG does not return to normal limit May need to check several more times Guidelines Do not keep eating or feeding until symptoms disappear No high fat foods Protein does not raise BG; does not prevent subsequent hypoglycemia

20 Hypoglycemia Feeding Guidelines Eat or drink 10 to 15 g. carbohydrate 3 to 4 glucose tablets 8 to 10 lifesavers 4 to 6 ounces juice or soft drink (non-diet) 1 piece of fruit 1 cup nonfat or 1% milk

21 Severe Hypoglycemia Able to swallow without risk of aspiration, Juice or soft drink Glucose gel, honey or jelly inside persons cheek Unable to swallow, Glucagon SQ or intramuscular injection Quick response, but short duration Encourage person to drink 15 g. juice or soft drink Recheck BG

22 Hyperglycemia Blood glucose above normal >140 mg/dl Common, but how high and how frequent Micro and macrovascular damage People don t feel well May promote depression May increase risk for poor wound healing Symptoms: thirst, frequent urination, blurry vision Causes High carb foods, more than covered by insulin Sliding scale insulin plan Infections, stress, medications

23 Hyperosmolar Hyperglycemic Nonketotic Syndrome Dehydration Diminished thirst sensation and fluid intake BG >180 mg/dl Kidneys unable to reabsorb glucose = water loss Neurological changes Absence of ketosis Requires hospitalization

24 Care Planning for the Patient with Diabetes P IT Foot care Foot assessment, foot deformities, nail care Skin care Oral health care Periodontal disease Ability to manage self-care Immunization Pneumococcal vaccine Influenza Depression screening

25 Medical Nutrition Therapy Goals Optimize glycemic control Provide adequate calories to meet metabolic needs Provide adequate nutrition to cover micronutrient needs Address individual nutritional needs Allow individual preferences: Let Them Eat Cake!

26 Cuisine Guidelines Generally liberalize the diet Use sugar free beverages Consider sodium content Balanced Follow regulation guidelines

27 Bedtime Snacks 15 g Carbohydrate 1 slice bread 1 6-inch tortilla 6 crackers 3 cups popcorn 12 small pretzels 34/-1 cup cereal 5 vanilla wafers + 1 ounce Protein 2 tablespoons peanut butter 1 string cheese 1 ounce lean meat 1 egg 2 tablespoons sunflower seeds ¼ cup peanuts or nuts 1 cup lowfat milk

28 Sliding Scale Insulin Time to give it up Does not adequately control hypo or hyper glycemia Reactive vs. proactive Rigid: requires a consistent amount of carbohydrate be eaten at each meal Does not consider basal insulin needs, diet, individual insulin requirements Insulin given based on pre-prandial BGs and bedtime BGs Increases risk for hypoglycemia and hospitalizations American Geriatrics Society Beers Criteria Strong recommendation to avoid SSI Strong recommendation to avoid long duration sulfonylurea (glyburide or chlorpropamide) American Family Physician, Vol 81, Number 9, May 1,

29 Physiologic Subcutaneous Insulin Protocols IT Improve patient safety and outcomes Three components Basal insulin (inhibits hepatic gluconeogenesis) Lantus (Glargine) or Levemir (Detemir) 40 % - 50% background Bolus Nutritional insulin (mealtime glucose metabolism) Novolog (Aspart) or Humalog (Lispro) 50% - 60% Correctional insulin (insulin based on patient s insulin sensitivity) Novolog or Humalog Corrects high blood sugar: I unit drops BG 50 mg/dl Glycemic Control in Hospitalized Patients Not in Intensive Care: Beyond Sliding-Scale Insulin, America Family Physician

30 Takes a Team to Manage Diabetes Physician Nursing staff Nutrition/dietary Patient Family

31 Determining Insulin Dosage Determine total daily dose (TDD) units/kilogram body weight 50% as basal Lantus or Levemir 50% bolus Novolog or Humalog Correction dose based on pre-prandial BG Glycemic Control in Hospitalized Patients Not in Intensive Care: Beyond Sliding- Scale Insulin, America Family Physician

32 Bolus-Nutritional Insulin Dose Pre-prandial BG check Determine correctional dose Dietary: carb count for meal Consider patient s appetite and eating behavior Good appetite, usually finishes meal Give insulin immediately before meal Poor appetite Calculate carbs eaten Give insulin immediately after meal

33 QAPI Quality Assurance Performance Improvement Quality Assurance: Meeting quality standards Assuring care meets standards Performance Improvement Proactive, continuous study of processes Involves a team Tools Chronic Care Model PDSA: Plan Do Study Act

35 Chronic Care Model: How It Works Improving Chronic Illness Care MacColl Center for Health Care Innovation, Group Health Research Institute, Seattle Health System: Create a culture, organization and mechanisms that promote safe, high quality care Delivery System Design: Assure the delivery of effective, efficient clinical care and self-management support Decision Support: Promote clinical care that is consistent with scientific evidence and patient preferences Clinical Information System: Organize patient and population data to facilitate efficient and effective care Self-Management Support: Empower and prepare patients to manage their health and health care Community Resources and Policies: Mobilize community resources to meet needs of patients. Advocate for policies to improve patient care. 2

36 PDSA Plan Do Study Act

37 Quality Assurance Performance Improvement Step 1: Plan Plan the test or observation, including a plan for collecting data Step 2: Do Try out the test on a small scale Step 3: Study Set aside time to analyze the data and study the results Step 4: Act Refine the change, based on what was learned from the test

38 Team Work Problem Solving Afternoon Work with your facility members attending this session. Identify a problem or citation regarding diabetes care. How did you or would you resolve it? Who was on your team or who would you need on your team? Consider how you answered the worksheet questions. Use the PDSA model to define a solution. Report to group.

What is Diabetes? American Diabetes Association

What is Diabetes? American Diabetes Association March 2015 What is Diabetes? Diabetes mellitus refers to a group of diseases that affect how your body uses blood sugar (glucose). Glucose is vital to your health because it's an important source of energy