Seniors with Cognitive Impairment and DSMEMonica Da Re and Shivaughn RupnarainCognitive Functioning and Self-Management in Older People with Diabetes- Little and conflicting research on whether the type of cognitive impairment associated with diabetes affects peoples self-management- Correlation between seniors with diabetes and the risk for dementia- Cognitive functioning is probably also adversely affected by age, illness, duration, glycemic control, and the presence of other co-morbidities - Research study focused on whether minor cognitive impairment would be associated with poorer diabetes self-management- Study: fifty-one people with T2D completed a series of cognitive tests and measures of diabetes self-management. Mean age was 61.5 years, 22/51 were women- Conclusion: cognitive impairment below the threshold for detection by dementia screening is not associated with clinically significant impairment of self-management. Strengths & LimitationsStrengths: (1) Attempts to bridge the gap in the research: little research concerning the relationship between cognitive impairment and seniors, (2) The conclusions from this research are potentially clinically useful. This research can reassure patients that even though they do have age-related MCI,it is unlikely that their self-management will be affected, (3) Fairly equal ration of men and women in study participants. It used approximately eight different test when looking at cognitive impairments, (4) Also, when screening for participants, they only used participants with MCI and no one with a history of dementia. Limitations: (1) Only looking at people with MCI - people with more serious forms are not being studied (I.e., Alzheimers, dementia, etc.). Its not only a limitation of this study, but of this area in general - it is a difficult area to research due to the ethical implications of doing the research itself, (2) Hard to conduct this type of research because of ethical considerations, (3) This research article is rather vague. In terms of methodology did not really explain how they were distributed, who ran them, what the questions were, etc., More research is needed in this area as there was a lack of scholarly research on the topic.Why is it important that we address this issue? (see notes at bottom)Prevalence - More than one-fifth of all patients with diabetes are above the age of 60- 1 in 6 senior males and 1 in 7 senior females diagnosed with diabetes- Normal aging is associated with a progressive increase in A1C Suhl and Bonsignore, 2006 ; Stats Canada, 2008; CDA, 2013Growing area of concern- Canadas senior population is increasing- Number of seniors in the population estimated to 23.6 percent by 2030 (Statistics Canada, 2014). - Age is a non-modifiable risk factor for diabetes- In 2008/09, the 75 to 79 year age group had the highest proportion of people with diagnosed diabetes (23.1% of females and 28.5% of males) (PHAC, 2008/9). - In the next 20 years, the number of people diagnosed with Alzheimers disease and other dementia will increase substantially. - Projected number of Canadians age 65+ years living with Alzheimers and other dementias: 639,700 in 2031 (PHAC, 2011-2012). Definitions: - Seniors, elderly, older adults, etc. How are these age groups defined? - Some studies define it as 60 years of age- Administrative guidelines classify it as >65 years - No agreed-upon definition of senior, but generally accepted that this is a concept that reflects an age continuum- For the purpose of this presentation we consider seniors to be >60 years of age. CDA, 2013What is cognitive impairment?Cognitive impairment is when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life. Cognitive impairment ranges from mild to severe. With mild impairment, people may begin to notice changes in cognitive functions, but stillbe able to do their everyday activities. Severe levels of impairment can lead to losing the ability to understand the meaning or importance of something and the ability to talk or write, resulting in the inability to live independently. (CDC, 2011)Cognitive impairment (CI) What causes CI? Conditions such as stroke, traumatic brain injury, and development disabilities can cause CI-Different severities from MCI to Alzheimers Signs include: - Memory loss- Asking the same questions, or repeating stories- Familiar people or places become unfamiliar- Trouble exercising judgment- Behavior and mood changes- Difficulty planning and carrying out taskCDC, 2011 Class ActivityWhat kinds of self-care tasks do you think would be impacted negatively due to cognitive-impairments in an individual with diabetes? Self-management- Self-management for older adults similar to other age groups- Should be individualized - Weight the potential effects of treatment - Must take into account frailty index. Increased frailty associated with diabetes- Patients with moderate/advanced frailty should not have strict glycemic control CDA, 2013; Blaum, Xue, Tian, 2009Guidelines- A1C, glycemic, blood pressure and lipid targets- Exercise tailored to capabilities - Avoiding medication with hypoglycemic risks- In the nursing home setting, a regular diet may be more useful than the diabetic diet - SMBG may become more difficultComplicated by co-morbidities, capabilities, psychosocial factors, individual circumstances, etc. Special education and care needs required - should be individualized by educators and health-care practitioners CDA, 2013Guidelines for Seniors DSMESlow paced stepwise method using memory aids Choose equipment that is easy to hold and easy to use - take into account visibility issues and ability to use technologiesSimplify the self-care regimenFrequent instructions. Schedule multiple sessionsindividual vs. group educationEngage spouse or other people living with patient Make sure they know how to identify hypoglycemic symptomsIDOP, 2013Self-management and CI- More research needs to be conducted to fully understand the relationship between MCI and self-care activities- Conflicting studies - some find an association, some do notDiabetes and DementiaIssues- increased need to urinated, may have issues locating the washroom - increased of falls because of this- increased confusion if blood glucose levels are high and cause dehydration- distress if usual diet is changed- distress, wandering, rocking movements, may cry and unable to express pain - forgetting to take medications- forgetting they have taken medication, therefore increased risk of overdose, or may miss taking medication- forgetting to do injections or test blood sugar- unable to interpret blood glucose results- missing meals and drinks- forgetting they have eaten or forget to eatIDOP, 2013Developing SM Plans - Care teams- Agree on appropriate BG/A1C- Keep insulin locked in a box away from the patient- Toilet training/having assistance- Meals should be provided in a calm and distraction free environment- Be aware of signs of low BG for people taking insulin or tabletsIDOP, 2013Relationship between cognitive impairment and diabetes- Episodes of severe hypoglycemia may increase the risk of dementia - conflicting literature- Cognitive dysfunction identified significant risk factor for the development of severe hypoglycemia- Self-management goals should be oriented around preventing hypoglycemic episodesWhitmer, Karter, Yaff., 2009; Bruce, Davis, Casey, 2010; CDA, 2013Feil, Szhu, Sultzer, 2011Class ActivityCase Study:Mrs. H is a 72 year-old patient living in a long-term care facility. She was diagnosed with Type 2 diabetes three years ago,is on insulin, and two years ago was found by her GP to exhibit some signs of MCI, which seems to be worsening in severity as of late. Mrs. H has had two hypoglycemic incidences in the last 6 months, and her last A1C measure was 8%. She also struggles with decreased appetite. Mrs. H has good mobility and a positive outlook. However, her sister has expressed concern about her declining cognitive capabilities, A1C levels and her incidences of hypoglycemia. What could be done to improve Mrs. Hs overall health?Questions 1. Although this study found that cognitive impairment below the threshold for dementia does not seem to have clinical significance on self-management, what challenges could be faced by seniors whose cognitive abilities continue to deteriorate?2. Brainstorm some strategies that could potentially make the self-management process easier for seniors with decreased or deteriorating cognitive capabilities.3. There is a lack of research regarding seniors and cognitive impairment, specifically beyond mild cognitive impairments. Do you believe that the lack of research on seniors with more serious impairments, such as dementia or Alzheimers, is due to the ethical barriers of having participants who would potentially not be able to comprehend being a part of a research study?ReferencesAsimakopoulou, K., Hampson, S. (2002). Cognitive Functioning and Self-Management in Older People with Diabetes. Diabetes Spectrum. Volume 15, No. 2 Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes 2013;37(suppl 1):S1-S212.Cognitive Impairment Policy (2009). Source: Centers for Disease Control and Prevention, BRFSS.Feil DG, Zhu CW, Sultzer DL. The relationship between cognitive impairment and diabetes self-management in a population-based community sample of older adults with Type 2 diabetes. J Behav Med.2011;35:190199. doi: 10.1007/s10865-011-9344-6Public Health Agency of Canada. (2011). Diabetes in Canada: Facts and figures from a public health perspective.Institute of Diabetes for Older People, IDOP. (2013) Diabetes and Dementia: Guidance on Practical Management.Stastics Canada. (2009). DiabetesSuhl and Bonsignore Diabetes self-management education for older adults: general principles and practical application.Diabetes Spectrum 19:234240, 2006Whitmer RA, Karter AJ, Yaffe K, Quesenberry CP, Selby JV. Hypoglycemic Episodes and Risk of Dementia in Older Patients with Type 2 Diabetes Mellitus. JAMA: the journal of the American Medical Association. 2009;301(15):1565-1572. doi:10.1001/jama.2009.460. Ravona-Springer R, Luo X, Schmeidler J, Wysocki M, Lesser G, Rapp M, Dahlman K, Grossman H, Haroutunian V, Schnaider Beeri M. Diabetes is associated with increased rate of cognitive decline in questionably demented elderly. Dement Geriatr Cogn Disord. 2010;29:6874.