Diabetes mellitus maintains a high prevalence in long-term care facilities and creates a consequential disease burden which results in higher costs. It is common in older adults who are a substantial portion of long-term care patients and can have significant health risks due to the heterogeneity of comorbidities in this population. The problem is in the critical need to efficiently diagnose and manage diabetes with uniquely tailored objectives and health goals which can help to sustain treatment in long-term care environments. Diabetes in older adults occurs due to physiological causes such as increased fat tissue, sarcopenia, and chronic inflammation which cause insulin resistance and defective pancreatic islet function. As a result, diabetes can lead to cardiovascular difficulties and presents an increased risk for various geriatric syndromes and other potentially adverse conditions. The heterogeneity of the older population in long-term care facilities presents many unknown factors and challenges to approach since comorbidities need to be considered. Long-term care creates variability in living conditions and social support structures that may impact diabetes management (Munshi et al., 2016). This case study will seek to investigate the use of health care technology and informatics to address the issue of diabetes management for older adults in long-term care.
Literature Review
Diabetes management guidelines in long-term care settings universally support the notion of individualizing care objectives and treatments. Standards such as the sliding scale insulin (SSI) should be avoided as the primary tool of blood glucose regulation. Some of the recommended goals and strategies include managing hypoglycemia risk as a major factor in adverse outcomes for this population and the use of simplified treatment plans for improved adherence and tolerance. Furthermore, liberal diet plans, as well as regular physical activity based on the range of functional abilities, have shown to improve outcomes and decrease complications from comorbidities (Munshi et al., 2016). As demographics and incidence of type 2 diabetes shift to becoming more prevalent, experts recommend a shift in the standards of medical care for the disease towards the Chronic Care Model (CCM) which is focused on improving quality of care. It focuses on prioritizing lifestyle therapy and supporting patient behavior change, all in an environment where the care system is optimized to become more system in the process of diabetes management (American Diabetes Association, 2015).
Technology can be used as supplementary care in addition to primary medical treatments. It helps to provide educational and emotional support. From an educational perspective, patients can adapt health practices and lifestyle routines which would support proper diabetes management. Technology can serve a wide range of purposes including but not limited to blood glucose monitoring, medication reminders, or exercise and diet planning and tracking. As technology becomes more complex, it creates an opportunity for interactivity and connectivity which can be potentially used for health monitoring and problem-solving (Hunt, 2015).
The use of health information digital technology enables engagement, behavioral changes, and impact analytics. The technology of diabetes management has reached a level of competency and efficiency to be clinically viable, having been proven to improve treatment outcomes and lower healthcare costs. In the current transition of the healthcare sector to a value-based system, it is essential for providers to enable health not just deliver care. Digital technology provides the value for long-term health improvements and is now faced with the challenge of attaining large-scale consumer adoption (Kaufman & Khurana, 2016). Technology encourages self-management of diabetes which is beneficial for patients and allows medical staff to focus on more critical issues at hand.
Patient Situation
Mr. Welch is a 67-year-old male residing in a skilled nursing facility. He has mild arthritis, dementia, and is diagnosed with type 2 onset diabetes. Despite receiving attentive care at the long-term care institution, Mr. Welch is struggling with maintaining his health, particularly issues caused by diabetes. One of the problems that the patient experiences are meeting nutritional and hydrational needs. Diabetes in older patients is associated with sarcopenia, and characteristically, with aging, interest in food is significantly lowered due to comorbidities (such dental or digestive problems). As a result, patients begin to suffer from inconsistent blood sugar levels, fluid imbalance, or decreased renal function. Physical activity is an issue as well, especially for patients with cardiovascular dysfunction and limited mobility, both experienced by Mr. Welch. Exercise programs are necessary to prevent further disability and maintain glycemic control. However, either the patient or medical staff may be against participation due to potential risks of falls and injury (Haas, 2014).
Older adults in long-term care are an extremely vulnerable population in terms of receiving proper diabetes care, especially from the perspective of self-management. As discussed earlier, health and physical limitations may serve as barriers to maintaining healthy behaviors necessary to avoid hyperglycemic episodes. Furthermore, age-related barriers such as impairment in vision, dexterity, or cognitive functions can be detrimental to administering proper self-management. Mr. Welch, who has dementia, often forgets to take medicine and administer insulin, Social and institutional barriers exist as well. Patients and their families may lack understanding about the chronic and progressive essence of diabetes, expecting unrealistic results or failing to adhere to treatment and lifestyle recommendations due to this factor. Institutions, such as skilled nursing facilities can lack the staff and training to offer the necessary continuous care required by older populations with diabetes (Weinger, Beverly, & Smaldone, 2014).
Technology
Blood glucose monitoring has traditionally been the primary aspect of self-management in insulin treatment of diabetes. However, traditional glucometers only show a one time reading. A technology that has experienced significant evolution recently to become more accurate, reliable, and effective is real-time continuous glucose monitoring (rtCGM). The technology seeks to improve glycemic control by monitoring blood glucose levels in real time with appropriate indicators or alerts that signify variations from the norm. This alert can be used as a reminder to administer an appropriate insulin dose, which the rtCGM technology can indicate as well (Pettus & Edelman, 2017). A miniature glucose sensor is inserted under the skin with a needle, which is then removed leaving the sensor in place. Using a wireless transmitter, collected data is sent to a monitor which displays current glucose levels and history of measurements (Allen, Litchman, & May, 2017).
Dementia can be tremendously challenging in diabetes self-management, especially for patients with glucose variability and need for insulin administration. With nursing staff trained to make sensor changes and device calibration, Mr. Welch can focus on using the device. His dementia did not impact long-term memory. Therefore, by continuously wearing the rtCGM device, he was alerted any time there was a need to intake insulin or rapid-acting carbohydrates to normalize blood glucose levels. Through the use of the technology, Mr. Welch, and the long-term care facility staff are able to address one of the primary risks of declining health and morbidity amongst patients with diabetes. The rtCGM devices are FDA approved and can be adapted to a variety of situations for patients with potential dexterity or vision issues in order to make it easier to use (Allen, Litchman, & May, 2017).
Summary of Case
This case study investigated an example of Mr. Welch, an older adult male with several serious health issues, including type-2 diabetes, receiving care at a skilled nursing facility. Although the service at the facility is above standard, there are numerous challenges for Mr. Welch to manage the disease appropriately. Mr. Welch has dementia, which makes him forgetful in tracking his blood glucose levels, taking his medication and insulin on time, and overall behaviors such as consistent nutritional intake that are necessary to competently treat and manage type-2 diabetes. Using the rtCGM, which continuously tracks the glucose level in Mr. Welch’s bloodstream with minimum invasion, discomfort, or calibration, his self-management strategies can improve substantially. The technology allows using alerts to notify Mr. Welch about any abnormal variation in the blood glucose levels and remind to take necessary precautions to avoid hyperglycemia. Thus, addressing a critical risk factor for morbidity in older adult patients in long-term care settings.
Conclusion
In conclusion, it is evident that informatics and technology can play a significant role in the improvement of delivery and management of health care. As technological capabilities expand, it is vital to develop and adapt both hardware and software to resolving critical issues facing patients in various settings today. This allows for the transition towards a value-based optimized health care system which encourages sustainable and effective lifestyle behaviors changes and culture of disease self-management. In turn, it will address the compounded issues of high health care costs and understaffing facing many medical facilities.
References
Allen, N. A., Litchman, M. L., & May, A. L. (2017). Using advanced diabetes technologies in patients with dementia in assisted living facilities: Case studies. Cogent Medicine, 4, 1-8. Web.
American Diabetes Association. (2015). Standards of medical care in diabetes—2015 abridged for primary care providers. Clinical Diabetes: A Publication of the American Diabetes Association, 33(2), 97–111. Web.
Haas, L. B. (2014). Special considerations for older adults with diabetes residing in skilled nursing facilities. Diabetes Spectrum: A Publication of the American Diabetes Association, 27(1), 37–43. Web.
Hunt, C. W. (2015). Technology and diabetes self-management: An integrative review. World Journal of Diabetes, 6(2), 225–233. Web.
Kaufman, N., & Khurana, I. (2016). Using digital health technology to prevent and treat diabetes. Diabetes Technology & Therapeutics, 18(1), 56–68. Web.
Munshi, M. N., Florez, H., Huang, E. S., Kalyani, R. R., Mupanomunda, M., Pandya, N., … Haas, L. B. (2016). Management of diabetes in long-term care and skilled nursing facilities: A position statement of the American Diabetes Association. Diabetes Care, 39(2), 308–318. Web.
Pettus, J., & Edelman, S. V. (2017). recommendations for using real-time continuous glucose monitoring (rtCGM) data for insulin adjustments in type 1 diabetes. Journal of Diabetes Science and Technology, 11(1), 138-147. Web.
Weinger, K., Beverly, E. A., & Smaldone, A. (2014). Diabetes self-care and the older adult. Western Journal of Nursing Research, 36(9), 1272–1298. Web.