DIABETES IN CARE HOMES Dr J Stephenson. NHS England - Yorkshire and the Humber Strategic Clinical Networks

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1 DIABETES IN CARE HOMES Dr J Stephenson NHS England - Yorkshire and the Humber Strategic Clinical Networks

2 Dr Jenny Stephenson Diabetes Lead for Primary Care, Sheffield GP, Stannington and Walkley Medical Centres GP for Hawkhills Residential Home, Stannington NHS England - Yorkshire and the Humber Strategic Clinical Networks

3 WHAT IS DIABETES? A condition in which a person s blood sugar measurements are generally higher than those in non-diabetic people. The body cannot deal with the sugar which comes out of the food or drink the person has, allowing levels to rise The person then feels thirsty, tired, becomes incontinent & have thrush & other infections NHS England - Yorkshire and the Humber Strategic Clinical Networks

4 WHAT CAN HAPPEN? Diabetes can cause the person to feel unwell - and also to cause several other things to go wrong referred to as diabetic complications Commonest are heart attacks and strokes; blindness and nerve damage in the feet NHS England - Yorkshire and the Humber Strategic Clinical Networks

5 and amputation is a risk NHS England - Yorkshire and the Humber Strategic Clinical Networks

6 and can cause kidney damage NHS England - Yorkshire and the Humber Strategic Clinical Networks

7 HOW COMMON IS IT? In Sheffield there are 26,000 people with diabetes This makes up about 4.7% of adults Two main sorts Type 1 and Type 2: T1 mainly occurs in children & younger adults and has to be controlled with insulin T2 may occur in older people and be more common in the overweight & inactive NHS England - Yorkshire and the Humber Strategic Clinical Networks

8 WHY IS IT IMPORTANT TO US? Up to 1 in 4 of our patients in Care Homes may have diabetes and be on treatment The same number may have it and we don t know they have it Patients on insulin, and on some tablets like gliclazide, run the risk of blood sugar becoming too low (see later) NHS England - Yorkshire and the Humber Strategic Clinical Networks

9 ..and it can need lots of pills NHS England - Yorkshire and the Humber Strategic Clinical Networks

10 DIFFICULTIES WITH DRUGS Patients on insulin, and on some tablets like gliclazide, run the risk of blood sugar becoming too low This is more likely to happen if they miss a meal or don t eat much Care-givers need to know correct doses and how to give insulin, unless the patient can do this themselves. District Nurses can advise NHS England - Yorkshire and the Humber Strategic Clinical Networks

11 HYPOGLYCEMIA Can cause sudden confusion, sweating, faintness, aggression, slurring of speech Can cause few or no symptoms More likely on insulin or medication (but metformin doesn t cause hypos) Be aware of early signs or if the patient is at risk, eg on these meds and not eaten Act: drink with sugar, followed by meal NHS England - Yorkshire and the Humber Strategic Clinical Networks

12 IT S A BALANCE - Between controlling the sugar and at the same time having a nice quality of life In the elderly, tight control is not necessary, but quality of life is The elderly are more likely to get low blood sugar at times and have falls as a result NHS England - Yorkshire and the Humber Strategic Clinical Networks

13 there is hope NHS England - Yorkshire and the Humber Strategic Clinical Networks

14 THINGS WE CAN DO Diagnosing diabetes early be Diabetes Aware Control the blood sugar using medication but not too tightly Regular Home checks on feet & shoes Regular checks done by the GP or Nurse, eye examination every year at certain centres (not by Optician) NHS England - Yorkshire and the Humber Strategic Clinical Networks

15 Presentation 2 NHS England - Yorkshire and the Humber Strategic Clinical Networks

16 Diabetic Foot and the role of the podiatrist Debora Sanger Maria Haley

17 Common Cause for hospital bed occupancy Since 1996 the number of diagnosed diabetics has risen from 1.4million to 2.9 million, half of these people will develop some degree of nerve damage. Of those 2.9 million there is a 1 in 4 chance to develop a foot ulcer, half of those who have an ulcer will get an infection & 20% of infections lead to some form of amputation.

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32 Presentation 3 NHS England - Yorkshire and the Humber Strategic Clinical Networks

33 Dietary advice for Care Home Residents with Diabetes Pauline Cowling Specialist Diabetes Dietitian

34 Aims of care for residents with diabetes in care homes To maintain a good quality of life and wellbeing To provide sufficient support and opportunity to allow residents to manage their own diabetes where this is feasible Achieve an optimum level of blood glucose control which avoids hyperglycaemia and reduces the risk of hypoglycaemia for those residents on insulin or other diabetes medications. Provide a well balanced diet which is nutritionally complete and maintains body weight

35 Nutritional Guidelines for Care Homes Under nutrition is a common problem Dietary recommendations for people with diabetes may not be appropriate for all people in care homes Additional considerations, patients may be underweight and many have low vitamin D levels. Calcium, iron and vitamin C can be low.

36 Practical Guidelines Eat 3 meals evenly spaced over the day this will help blood glucose control. Have a starchy food at each meal, including some high fibre foods may help with problems such as constipation. Include a wide range of fruit and vegetables Include beans and lentils if possible Cutting down on fat can help with weight management only in those patients who are overweight.

37 Managing Hypoglycaemia Timings of meals in relation to timing of medications Ensure that carbohydrate foods are eaten at all meals Snacks may be needed especially for someone with a poor appetite who struggles to finish a meal May need to review diabetes medications

38 Practical Guidelines Limit sugar and sugary foods but you don t need a sugar free diet. Sugar can be included in foods and baking as part of a healthy diet Try and include oily fish where possible There is no need to use diabetic foods Watch salt intake Alcohol is fine in moderation. Encourage hydration, older adults are at particular risk of dehydration particularly if they are confused as they forget to drink. Use low sugar squash and fizzy drinks

39 Pasta Potatoes Rice Breakfast cereals Yam Pastry Plantain Bread Sweet potatoes Noodles Oats Crackers Sweets Chocolate Cakes Toffees Ice-cream Puddings Sugary drinks Biscuits Jam & marmalade Fruit Fruit juice Milk Dried fruit Tinned fruit Yoghurt Starchy Sugary Naturally sweet Nicola J. Scott Specialist Diabetes Dietitian, STHFT. 2010

40 Foods which do not raise blood glucose levels Meat, fish, cheese, eggs Nuts Oils, spreading fats most vegetables and salads diet drinks pickles such as pickled onions sweeteners Cream mayonnaise and salad dressings

41 What about sugar? Generally sugar does not cause a steep rise in blood glucose levels so diabetic products are not needed. Sugar is allowed in moderation in the diet of a well controlled non obese diabetic Residents can eat foods such as rice pudding, custards and other desserts containing sugar especially if they are under weight and have a small appetite

42 STEP 1 Similar Carbohydrate Portions What is a portion? One third of plate as carbohydrate:

43 Ways of increasing calories in underweight residents Use full fat milk for puddings and custards, drinks etc Add butter or margarine to potatoes, consider adding grated cheese Add cream to soups or on tinned fruit Consider peanut butter on toast Crumpets, fruit loaf, cheese and biscuits, full fat yoghurt are all suitable snacks

44 Ways of increasing calories in underweight residents Milky drinks such as Horlicks, Ovaltine or drinking chocolate are suitable or a glass of milk instead of tea or coffee Consider the use of supplements such as Build up or Complan Supplements prescribed by the GP may also be appropriate such as Fortisip for example Medications may need to be reviewed.

45 Summary Weigh clients regularly to ensure they are gaining weight if they need to. Encourage snacks if someone has a small appetite. General diabetes guidelines for diet may not be appropriate with this group of clients. For overweight clients weight maintenance may be the most appropriate goal. Don t forget the fluid!

46 Presentation 4 NHS England - Yorkshire and the Humber Strategic Clinical Networks

47 Medicines associated with the control of Diabetes mellitus Ian Hutchison, Medicines Management Pharmacist Joy Smith, Medicines Standards Officer, Care Homes Sheffield CCG

48 Common types of medication in diabetic patients Glycaemic control e.g. orals, insulin Blood pressure control Lipid management Neuropathic pain Vascular disease Depression

49 Oral Hypoglycaemic Agents I Metformin Reduces glucose production and increases peripheral utilisation of glucose (only effective in type-2 diabetes) Often first choice oral, particularly in obese patients Start with low doses and build up gradually Common side effects are mainly GI e.g. initial diarrhoea Monitor renal and liver function Sulfonylureas (SFU) Act mainly by augmenting insulin secretion Useful in non-obese patients and/or in addition or instead of metformin Associated with hypoglycaemia, particularly with high doses and/or missed meals

50 Oral Hypoglycaemic Agents II Pioglitazone Reduces peripheral insulin resistance Used alone or with metformin and/or a SFU or with insulin Issues with heart failure, fractures and bladder pathology, etc DDP-4 Inhibitors (Gliptins) Moderate efficacy and reasonably well tolerated GLP-1 Agonists (Exenatide, etc) Given by s/cut injection and benefits around weight loss SGLT2s (Gliflozins) Reduce glucose reabsorption but genito-urinary side effects

51 Insulins Required in all type-1s and type-2s where other methods have failed to achieve good control Types include short-acting, intermediate and long-acting Short-acting insulins include soluble and rapid-acting insulin Intermediate insulins include isophane insulin Long-acting insulins include insulin detemir and glargine Insulin therapy needs to be individualised and can be given via a number of regimes e.g. basal insulin, mixed insulin or basal-bolus combinations Many insulins come in convenient pen devices

52 Complications Most important acute complication is hypoglycaemia Most closely associated with insulin and SFU treatment Use glucose to reverse symptoms e.g. sugar, drinks, snacks and/or prescribable gels such as GlucoGel In an emergency, use glucagon injection Do you and the patient (if appropriate) know how to recognise and treat a hypo??

53 Monitoring Main measure of chronic control of blood glucose is via the HbA 1c test This should be measured around 3-6 monthly Each patient should have a documented long term target Some patients may benefit from the use of a blood glucose monitoring device (meter and strip) but this should be clearly recorded in the patient s care plan Consideration should be given to whether type-1 diabetics need to have the ability to measure blood ketones

54 MAR charts meeting the need Printed times/ time of day on MAR charts Use of the reverse of the MAR chart Advice labels

55 Formulations of oral antidiabetic drugs Ordinary release tablets Modified release tablets Sachets Liquids Combination products

56 Missed doses What is the drug for? Reason for dose being missed Consequence of missed dose Individual care plan to manage what to do in the event of a missed dose

57 Summary Aim of medication to treat diabetes (glucose) is to achieve the optimum level of metabolic control i.e. prevent hyperglycaemia and avoid hypos (watch in patients prescribed insulin and/or SFU) Care should be reviewed regularly and individualised allowing easy access to specialist care Does your home have a policy/guidance on the care of patients with diabetes? The importance of effective recording and reporting Do you need to improve your knowledge of diabetes and how to contribute to better care?

58 Scenarios Mary - type 2 diabetic - on oral hypoglycaemic agents and insulin Mrs Patel type 2 diabetic on oral hypoglycaemic agents, also had a stroke