Older Adult Holistic Plan of Care

Introduction

The prevalence of diabetes increased with age and appears to be higher among older adults aged 65 years and above. The older adults with diabetes report the highest burden of mortality increased risk of institutionalization, and a lower functional status. Moreover, older adults with diabetes are a significant risk of acute cardiovascular complications. Given the higher prevalence of diabetes in older persons, there is a need for a holistic plan of care. This paper gives a holistic plan of care for older adults. The holistic plan of care will also include goals, holistic self-care interventions, challenges and opportunities for the older adult client, monitoring of the goals, and overall impact of the plan of care to improve outcomes.

Comprehensive Holistic Assessment

According to the American Diabetes Association (2019), 26.8 percent or 14.3 million people aged 65 and older have diabetes. ADA (2019) notes that the occurrence of diabetes increases with age until about 65 years after which prevalence seems to level off. It thus follows that older adults with diabetes who have developed the disease at 65 or in their middle age or earlier.

Non-Hispanic blacks have a higher rate of diabetes than other groups. In the US, non-Hispanic blacks had a prevalence of 13.3 percent, Asians prevalence rate stood at 11.2 percent, Hispanic are 10.3 percent and non-Hispanic whites at 9.4 percent. This shows that the likelihood of being diagnosed with diabetes is 29 percent higher among African Americans compared to non-Hispanic white adults. US Department of Health and Human Services (2018) noted that non-Hispanic blacks are 2.3 times more likely to undergo lower limb amputation than other groups. Moreover, they are two times more likely to die from diabetes than non-Hispanic whites. According to the National Institute of Health (2018), biological risk factors are responsible for increased rates of diabetes in the African American population. These biological factors include a combination of blood pressure, body mass index (BMI), waist dimension, and lung function among others. 

Certain environmental factors can also increase the risk of type 2 diabetes. Dendup et al., (2018)found that walkable neighborhoods were linked to a lower risk of T2DM. The author reasoned that the population in walkable environments has lower obesity, blood pressure, and metabolic syndrome. Access to physical activity resources and healthy food stores have also been shown to have some minor significance in heightening diabetes risk. Older people in areas with poor walkability coupled with lack of access to physical activity resources and healthy food stores can mean an increased risk of diabetes.

Older adults with diabetes are more likely to have depression. Diabetic patients are twice as likely as individuals without diabetes to experience depression. Maraldi (2007) who observed 2,522 community-dwelling participants aged 70-79 for a period of 5.9 years, after adjustment of age, sex, race, and site, found that older persons with diabetes had a higher incidence of depressed mood. The study also found that health outcomes among older diabetic patients tended to be worse. Older patients with diabetes reported more physician office visits, emergency room visits, and inpatient admissions. An older person with diabetes co-existing depression develops difficulties especially hyperglycemia, heart disease, and mortality (De Groot et al., 2016). Through neuronal, immune system and hormonal changes that depression is able to directly exert is negative effects to impair the body’s ability to secrete or utilize insulin. The feeling of hopelessness in older adults with this comorbidity can affect their own goals and preference for treatment.

Falls are a physical concern among elderly persons with diabetes. In general, falls are a leading source of injury among elderly persons and affects approximately one-third of adults aged 65 and above in the US (Crews et al., 2013). Among elderly adults with diabetes, the fall rate was up to 39 percent in those over 65 years and 35 percent in those over 55 years (Crews et al., 2013). Diabetes contributes to falls through foot and body pain, pharmacological complications, decreased sensorimotor function, and musculoskeletal deficits. Other factors that contribute to falls among diabetic patients include impaired vision, lower limb amputation, dementia, and vitamin D deficiency.

Different ethnic groups approach diabetes differently. Concha et al., (2015) noted that how an illness if conceptualized within a culture can influence a patient’s theory about etiology, prognosis, and outcome. The Hispanic/ Latino population, believe that strong or negative emotion can lead to diabetes. This belief is known as “susto” or “fright sickness” and include emotions such as stress. Several studies have argued that Hispanics/Latinos hold the belief that type 2 diabetes is a very serious illness that is likely to shorten one’s life. Concha et al., (2015) observed that most Latinos held that one could not alter the diabetes development since was part of destiny. Among African Americans, spirituality is deeply rooted in their culture and is well interwoven into other aspects of life including beliefs about illness and health. Skelly et al., (2006) observed that African Americans’ approach to illness stems from the long history of abuse and oppression and may thereby viewed illness and death as yet another struggle to overcome. African Americans may also view diabetes as undesirable and may equate it with bad luck, chance, unemployment, domestic turmoil, and poverty. The cultural beliefs among Hispanic and African American populations greatly affect the way they approach the self-management of diabetes. 

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Analysis of Assessment Findings

The holistic assessment of older adults with diabetes finds that this population is associated with various challenges that negatively affect them. For example, they are associated with a physical impairment that increases their tendency to fall. They are also at an increased threat of psychosocial problems such as depression. The assessment also finds that older African American and Hispanic adults hold biased beliefs and practices that may affect the treatment of diabetes. From this assessment, only falls and depression are associated with old age but they become pronounced as when one develops diabetes. Assessment of race and ethnic data on diabetes revealed that African Americans are more burdened with diabetes compared to other groups.

Given that diabetes is largely dependent on the self-management, these challenges must be addressed as they interfere with health outcomes. The assessment reveals that there is a need to address falls, depression, cultural beliefs, environmental factors as well as higher prevalence among African Americans.

Goals

Older adults with diabetes should be subjected to patient education programs to assist them in the management of the illness. The program will have both short term and long-term goals.

Short term Goal 

The short-term goal of the program will be to help older adults monitor their glucose level. This is the primary goal of diabetes. The level of glucose must be maintained within a certain range through medication, and physical activity. It is therefore important that the patient be well versed with blood glucose monitoring. Failure to manage glucose level is associated with hypoglycemia and hyperglycemia whose effects can immediate and long term. Immediate effects include dizziness and visual disturbance which may lead to falls. Recurrent hypoglycemic and hyperglycemic events may eventually lead to significant morbidity, disability, and frailty. Put differently, by controlling their glucose, older adults have the opportunity to limit other complications. The population should have access and knowledge of how to use glucose monitoring tools such as blood glucose meter, insulin syringe, lancet device, and test strip. The education program will ensure they can competently interpret results from these devices.

Long Term Goal

The long term goal of diabetes self-care management education will be to help older adults remain healthy. Some of the actions that older adults with diabetes can do to remain healthy include managing their cholesterol, stop smoking, keeping their eyes healthy, preventing foot problems and marinating their weight. These activities require time to adjust to hence their long-term nature.

Holistic Self-Care Interventions

Blood Glucose Monitoring 

To avoid the negative impact of high and low glucose levels, older adults should continuously monitor their glucose levels. Enough literature seems to agree that older adults are more likely to experience hypoglycemia and higher incidence of hypoglycemia unawareness compared to younger adults (Ruedy et al., 2017). To prevent older people from the impact of unawareness, it is recommended they used Continuous Glucose Monitoring (CGM) device. This device can monitor glucose levels throughout the day and night. Moreover, it can alert the patient during glucose high and lows. When alerted, older patients can readily act to prevent the situation from worsening. 

Older patients who at times fall asleep during the day may require an assistant even when using the CGM devices. This assertion is informed by the fact that failure to act on the alert and one passes out, they will require someone to give them a glucagon injection (Ruedy et al., 2017). Glucagon is a medicine that raises blood sugar. It thus follows that older patients should use a CGM device as a self-care strategy. 

Fall

Fall prevention intervention should take a personalized approach. Older adults should be able to understand what factors are contributing to their fall. This way, the fall prevention strategy would be personalized to their situation. A close family member can help identify the problem. For example, they should identify whether they fall most when walking, standing, rising or lowering themselves, this way intervention can know whether to concentrate on improvement of balance strength or gait. 

Older adults should recognize risky situations and take steps to avoid them. Given that falls in older adults are multifactorial, patients should address these factors. Older adults should clear their houses of home hazards such as loose throw rugs, loose carpet, and risky footwear. In relation to health-based risks, older patients should raise a concern with their physicians when they suspect they have vision problems, and balance weakness. Moreover, they should be able to notice whether falls occur after certain medications.

Depression

For older patients with depressive episodes, they should visit their physicians for any screening of depression. If found to have depression, they should adopt self-care interventions such as taking medications, psychotherapy, and lifestyle changes. 

An older patient with depression should take the medications recommended by the physician. Some of the commonly prescribed medications include serotonin-norepinephrine reuptake inhibitor (SNRI) and selective serotonin reuptake inhibitor (SSRI). If their conditions do not improve or the medication has side effects, they can have their doctors recommend a different antidepressant or a combination plan. Psychotherapy can also help improve how older adults manage or reduce their symptoms of depression. By working with their doctor they can determine which of the two, interpersonal therapy and cognitive behavior therapy, best suits their needs. Therapy would help them identify and replace unhealthy behaviors, recognize potential triggers and develop a positive relationship with themselves. 

Lifestyle changes including a better diet and regular exercise can help overcome depression feelings. Regular exercise relieves symptoms by increasing release of feel-good chemicals, endorphins, and serotonin, in the brain. Physical activity helps, just like antidepressant medications, trigger the growth of new brain cells. Other lifestyle changes include upholding a regular sleep schedule, seeking the support of family and friends and managing stressors.

Proper Medication 

Given that the population under study consist of elderly adults with diabetes, it is likely they are suffering from other comorbid conditions. This means they are prescribed multiple drugs. This increases the likelihood of them experiencing effects of drug interaction and adverse drug reactions. They are also likely to forget other drugs. To avoid such incidences, older patients should discuss with their doctors on ways they can reduce unnecessary drugs. As part of the self-care intervention, older adults should have a list of all the drugs they are taking as well as the required prescription. Additionally, they can have reminders specifically aimed at alerting them when to take the drugs.

Challenges and Opportunities

To reach out to older adults with diabetes, effective coaching strategies must be adopted in the health promotion phase. Health coaching is associated with positive results regarding behavior and lifestyle changes such as improved nutrition, increased physical activity, improved nutrition, and improved management of chronic diseases.

The first strategy will be to communicate in a manner in which older adults can understand and use health information. The coaching will move at their pace since they tend to process information at a slower rate. The coaching will adopt multiple teaching strategies ranging from presentation and hands-on-approach to accommodate the psychological, physical and cognitive changes associated with aging.  

Since older patients may be suffering from other illnesses, the coaching will combine interventions. For example, since the medication is a must on all illness the coaching will focus on adherence to the different medications. Moreover, since physical activity improves outcomes in a variety of illnesses, the coaching will emphasize regular exercise.

Another strategy that will be adopted in the coaching process is cultural competency. Cultural competency is whereby the cultural needs of the patients are incorporated in their care (Ghaddar et al., 2013). The coaching will incorporate the beliefs and customs of ethnic groups in a bid to get them to adhere to self-care management. For example, in both Hispanic and African Americans, the coaching team will be warm and personal as well as treat the group with dignity. Spirituality and the idea of God will also be incorporated.

Evaluation

To measure the impact of the intervention in older diabetic patients, the program will collect data and evaluate its effectiveness. The program will measure multiple focus areas. The program will measure status change which includes improved health outcome indicators such as BMI, average glucose measure, and improved stamina from exercising. The program will also measure behavioral changes in participants. These changes include family awareness, self-management. The affective changes or changes in attitude or feelings to the interventions such as self-efficacy, improved quality of life and beliefs about diabetes will also be assessed.

The data will be collected alongside the older adult’s medical history, health literacy and demographic data such as age, gender, and race. This information will help determine health disparities and inequalities that may have been present in the program. The evaluation data that is collected will be crucial in making adjustments.

Conclusion

Overall the paper has conducted an assessment of diabetes in older adults. The holistic assessment found that older adults with diabetes are associated with falls, depression and are faced with cultural barriers due to the different beliefs they hold. The assessment also found that African Americans have a high prevalence of diabetes. To address these findings, the paper identified two goals to focus on. The short term goal aims at addressing glucose level monitoring while the long term goal aimed at improving the overall health of older adults with diabetes. The paper has also addressed four self-care interventions that should be adopted by the focus population. These self-care interventions touch on falls, depression, medication, and blood glucose monitoring. The paper has also delved into how it intends to evaluate the program.

References

American Diabetes Association (ADA). (2019, July). Statistics About Diabetes. ADA. https://www.diabetes.org/resources/statistics/statistics-about-diabetes

Concha, J. B., Mayer, S. D., Mezuk, B. R., & Avula, D. (2015). Diabetes Causation Beliefs Among Spanish-Speaking Patients. The Diabetes Educator42(1), 116-125. https://doi.org/10.1177/0145721715617535

Crews, R. T., Yalla, S. V., Fleischer, A. E., & Wu, S. C. (2013). A Growing Troubling Triad: Diabetes, Aging, and Falls. Journal of Aging Research2013, 1-6. https://doi.org/10.1155/2013/342650

De Groot, M., Golden, S. H., & Wagner, J. (2016). Psychological conditions in adults with diabetes. American Psychologist71(7), 552-562. https://doi.org/10.1037/a0040408

Dendup, T., Feng, X., Clingan, S., & Astell-Burt, T. (2018). Environmental Risk Factors for Developing Type 2 Diabetes Mellitus: A Systematic Review. International Journal of Environmental Research and Public Health15(1), 78. https://doi.org/10.3390/ijerph15010078

Ghaddar, S., Ronnau, J., Saladin, S. P., & Martínez, G. (2013). Innovative Approaches to Promote a Culturally Competent, Diverse Health Care Workforce in an Institution Serving Hispanic Students. Academic Medicine88(12), 1870-1876. https://doi.org/10.1097/acm.0000000000000007

Maraldi, C., Volpato, S., Penninx, B. W., Yaffe, K., Simonsick, E. M., Strotmeyer, E. S., Cesari, M., Kritchevsky, S. B., Perry, S., Ayonayon, H. N., & Pahor, M. (2007). Diabetes Mellitus, Glycemic Control, and Incident Depressive Symptoms Among 70- to 79-Year-Old Persons. Archives of Internal Medicine167(11), 1137. https://doi.org/10.1001/archinte.167.11.1137

National Institutes of Health (NIH). (2018, January 23). Factors contributing to higher incidence of diabetes for black Americanshttps://www.nih.gov/news-events/nih-research-matters/factors-contributing-higher-incidence-diabetes-black-americans

Ruedy, K. J., Parkin, C. G., Riddlesworth, T. D., & Graham, C. (2017). Continuous Glucose Monitoring in Older Adults With Type 1 and Type 2 Diabetes Using Multiple Daily Injections of Insulin: Results From the DIAMOND Trial. Journal of Diabetes Science and Technology11(6), 1138-1146. https://doi.org/10.1177/1932296817704445

Skelly, A. M., Dougherty, M., Gesler, W., Soward, W., Burns, D., & Arcury, T. (2006). African American beliefs about diabetes. Western Journal of Nursing Research28(1), 9-29.