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Why, When, and How to Initiate InsulinTherapy in Elderly Patients with Type 2Diabetes: A Case-based Approach

Originally presented as a live pro-gram (ACPE #203-999-06-081-L01) at Senior Care Pharmacy‘06, ASCP’s 37th Annual Meetingand Exhibition.

Attendees who received CPEcredit for attending the live pro-gram are not eligible to receivecredit for this online release.

Originally presented as a live pro-gram (ACPE #203-999-06-081-L01) at Senior Care Pharmacy‘06, ASCP’s 37th Annual Meetingand Exhibition.

Attendees who received CPEcredit for attending the live pro-gram are not eligible to receivecredit for this online release.

Supported by an educationalgrant from Novo Nordisk Inc.

PODCAST/MP3 INSTRUCTIONS1. Download the Podcast or MP3 audio file to your player.

2. Listen to the presentation, following along with the slide images contained in this PDF workbook.It should take approximately 105 minutes to listen to the audio and complete the post-test and evaluation.

3. To receive CPE or CE credit, use the link to the online test or print the post-test and evaluation pages found at the end of this PDF file.

4. Follow the provided instructions to complete and submit the CME/CE post-test and evaluation form.

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Summary of Need & Program OverviewMore than 20 million Americans have diabetes—a number that continues to increase in all age groups and all ethnic groups. Of these, 10 million, or 21%, of older Americans (>60 years) have diabetes. Based on death certificate data, diabetes contributed to morethan 220,000 deaths in 2002. Studies indicate that diabetes is generally under-reportedon death certificates, particularly in the cases of older persons with multiple chronic conditions such as heart disease and hypertension. Because of this, the toll of diabetes is believed to be much higher than officially reported.

Type 2 diabetes is the most prevalent form of the disease, accounting for more than 90% of all reported cases. Type 2 diabetes increases the risk of patients developingmany serious complications, including cardiovascular disease, retinopathy, neuropathy,and nephropathy. The majority of patients with type 2 diabetes will eventually fail to adequately respond to oral drug therapy alone. Recently, the American Association ofClinical Endocrinologists reported that 2 out of 3 patients are inadequately treated toreach glycemic targets. Insulin replacement in the form of insulin analogs may be used to reduce glycemic burden and improve outcomes in patients with type 2 diabetes.

This CE activity is designed to enhance the understanding of the progressive natureof type 2 diabetes, the role of insulin analogs, and available treatment options and strategies that can be used to reduce the risk of serious diabetes complications within the elderly population.

Target AudienceThis educational activity is intended for pharmacists and nurses involved in the care ofelderly patients at risk for the adverse effects of type 2 diabetes.

Why, When, and How to Initiate Insulin Therapy in ElderlyPatients with Type 2 Diabetes: A Case-based Approach


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Learning ObjectivesUpon completion of this continuing education activity, the participant should be able to:

1. Identify elderly patients with type 2 diabetes who are not meeting established treatment goals for glycosylated hemoglobin (A1C), postprandial glucose (PPG) targets, and fasting plasma glucose (FPG) targets

2. Describe how to transition elderly patients with type 2 diabetes who are not meetingtreatment goals with more intensive and effective therapeutic regimens to attain andmaintain A1C, PPG, and FPG targets

3. Differentiate the benefits and risks of regular insulin mixes, premixed insulin analogs, and basal-bolus insulin treatment strategies for elderly patients

Accreditation & Credit DesignationPHARMACISTS: The American Society of Consultant Pharmacists is accredited by theAccreditation Council for Pharmacy Education (ACPE) as a provider of continuingpharmacy education. This program is accredited for 1.75 contact hours (0.175

CEUs) of continuing education credit. Universal Program Number 203-999-06-081-H01.

NURSES: NADONA/LTC is an approved provider of continuing nursing educationby Georgia Nurses Association, an accredited approver by the American NursesCredentialing Center’s Commission on Accreditation #1087. This program pro-

vides 1.75 contact hours by NADONA/LTC.

Participants must pass a post-test and complete a program evaluation to receive credit.

None of the contents may be reproduced in any form without prior written permission from the publisher. The opinions expressed in this activityare those of the speakers and do not necessarily reflect the opinions or recommendations of their affiliated institutions, the publisher, theAmerican Society of Consultant Pharmacists, the National Association of Directors of Nursing Administration in Long-Term Care, or Novo Nordisk.Any medications or other diagnostic or treatment procedures discussed by the program speakers should not be utilized by clinicians without eval-uation of their patients’ conditions and possible contraindications or risks, and without a review of any applicable manufacturer’s product informa-tion and comparison with the recommendations of other authorities.

An educationalservice of...


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Disclosure of Financial InterestIn accordance with the guidelines set forth by the Accreditation Council for PharmacyEducation, it is the policy of the American Society of Consultant Pharmacists to ensure balance, independence, objectivity, and scientific rigor in all of its educational activitiesincluding those which are sponsored and cosponsored. All faculty are expected to disclose any significant financial interest or other relationship with the manufacturer(s) ofany commercial product(s) and/or provider(s) of commercial services discussed in an educational presentation. The intent of this disclosure is not to prevent a presenter withsignificant financial interest or other relationship from making the presentation, but ratherto provide the audience with information with which they can make their own judgments.It remains for the audience to determine whether the speaker’s interest or relationshipsmay influence the presentation with regard to exposition or conclusion. Faculty are alsoexpected to openly disclose any off-label, experimental, or investigational use of drugs or devices in their presentations.

Jerry Meece, RPh, FACA, CDM, CDE – Program Chairman

Grant/Research Support: Pfizer

Consultant: Eli Lilly, LifeScan, Novartis, Novo Nordisk

Stock Shareholder: Metrika

Speaker with honorarium: Eli Lilly, LifeScan, Novo Nordisk, Bayer, Sanofi-Aventis,Pfizer

Teresa L. Pearson, MS, RN, CDE

Consultant: LifeScan, Novo Nordisk, AmeriSource-Bergen

Speaker with honorarium: LifeScan, Roche, Novo Nordisk, Bayer, Abbott, Pfizer

Theresa Plog, PharmD

Speaker with honorarium: Novo Nordisk, Sepracor


FacultyJerry Meece, RPh, FACA, CDM, CDE

Jerry Meece, RPh, FACA, CDM, CDE, is a pharmacist and Certified Diabetes Educatorwho is owner and Director of Clinical Services of Plaza Pharmacy and Wellness Center in Gainesville, Texas, one of the first freestanding pharmacies in the country to achieveProvider Education Recognition from the American Diabetes Association.

Mr. Meece has spoken across this country and internationally on the subject of diabetes,disease state management and clinician/patient behavior in the healthcare setting, and has written numerous articles on diabetes care and insulin use in the patient with diabetes.

He is the first practicing community pharmacist ever to be elected to the Board ofDirectors for the American Association of Diabetes Educators and to serve on theirExecutive Board in the position of Vice President.

In August of this year, Mr. Meece was awarded the Innovative Practice Award by theTexas Pharmacy Association, and for his work in the legislative field, was awarded theLegislative Leadership Award by the American Association of Diabetes Educators.

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FacultyTeresa L. Pearson, MS, RN, CDE

Teresa L. Pearson, MS, RN, CDE, is Director of Fairview Diabetes Care for the FairviewHealth System in Minneapolis, Minnesota. She is also co-founder of and a consultant forInnovative Health Care Designs.

Ms. Pearson received a Bachelor of Science degree from Winona State College–Schoolof Nursing in Winona, Minnesota. Subsequently, she obtained a Master of Sciencedegree from the University of Minnesota–School of Nursing in Minneapolis, and a Mini-MBA in Health Care Administration from the University of St. Thomas, also inMinneapolis. In addition, she is a Certified Diabetes Educator and a Certified Trainer in Choices and Changes from the Bayer Institute.

Author or coauthor of 40 journal and newsletter articles, book chapters, and audio andvideo programs, Ms. Pearson has written about quality improvement intervention in diabetes care, primary care and diabetes self-management, and identifying individuals at risk for developing type 2 diabetes. Her article, “Getting the Most From Health CareVisits,” was selected as one of the Best of Diabetes Self-Management in 2002.Additionally, she has delivered presentations to pharmacists, nurses, dietitians, physicians,and diabetes educators nationally and internationally, and serves on several advisoryboards and key opinion leader panels.

Ms. Pearson is a member of the American Association of Diabetes Educators, havingserved as a past First Vice President. Additionally, Ms. Pearson has served the AmericanDiabetes Association, Professional Section; the European Association for the Study ofDiabetes; and the Minneapolis-St. Paul Diabetes Educators. Since 1979 she has been a member of Sigma Theta Tau–Zeta Chapter (International Honor Society of Nursing).

Among her numerous awards, Ms. Pearson has received special recognition from thePresident of HealthPartners for clinical quality improvement work in diabetes care as wellas the HealthPartners’ Presidents Award for work in disease management, specificallycardiovascular disease and diabetes. In 2005, Ms. Pearson received a Best PracticeAward for Fairview Diabetes Care from the American Medical Group Association.


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FacultyTheresa Martin Plog, PharmD

Theresa Martin Plog, PharmD, is an Ambulatory Care Clinical Specialist and AntithrombosisPharmacist in the Shore Health System of Maryland, and a Clinical Pharmacist at ShoreHealth System Memorial Hospital in Easton, Maryland. She is also a Clinical AssistantProfessor at the University of Maryland School of Pharmacy in Baltimore and a Guest Lecturer (endocrine, respiratory, musculoskeletal) for the Wilmington College Certified Nurse Practitioner Program in New Castle, Delaware.

Dr. Plog received a Bachelor of Science degree in Pharmacy and a Doctor of Pharmacydegree from the Philadelphia College of Pharmacy and Science in Pennsylvania. She completed training in the Cardiac Anticoagulation Clinic at the Loma Linda VA Medical Centerin California, and an ASHP Research and Education Foundation–Type 2 Diabetes Patient Care Traineeship Program at the Joslin Diabetes Center, and the University of Maryland inBaltimore. In addition, she is a Certified Smoking Cessation Specialist (University ofPittsburgh School of Pharmacy) and has received certification for Basic Life Support and Advanced Cardiac Life Support.

Dr. Plog has published journal articles on antibiotic-associated seizures and on patient outcomes at a pharmacist-managed anticoagulation clinic. She has also coauthored a guide for pharmacy-based diabetes screening and education programs.

Dr. Plog participates in grand rounds and gives presentations to nursing and pharmacy staff as well as to diabetes support groups and senior citizen groups on diabetes medications, the role of cholesterol/blood pressure monitoring in diabetic patients, and current therapy for Alzheimer's disease, among other topics. In addition, she has served as a clinical investigator and subinvestigator for several clinical research protocols.

Dr. Plog is a member of the Maryland Society of Health System Pharmacists. She is also a recipient of the Preceptor of the Year Award from the University of Maryland School of Pharmacy and has received a Distinguished Young Pharmacist Award from PharmacistsMutual Companies.


The Current State of Diabetes and Impact of the Aging Process

Teresa L. Pearson, MS, RN, CDE

Regardless of how age is defined, diabetes is an increasingly prevalent condition in theolder American. One in 5 Americans 60 years and older has diabetes (equal to slightlymore than 10 million patients). Nearly 40% of seniors have pre-diabetes (ie, impairedfasting glucose). Furthermore, the risk for death among people with diabetes is abouttwice that of people without diabetes of similar age. Clearly, the risk for diabetes-relatedcomplications is also greater.1 Corresponding increases in obesity and physical inactivitywith aging are contributing to the widespread prevalence of diabetes among olderAmericans.

There are unique challenges regarding the diagnosis and treatment of the older popula-tion. Due to physiologic changes associated with aging, the elderly patient with diabetesmay not present with classic symptoms. In addition, with age, there is an increasedprevalence of functional disability and comorbid illness that contributes to the complexityof managing diabetes. Treatment of the older patient with diabetes must take into consideration not only the standard microvascular and macrovascular complications, but also conditions such as cognitive impairment, falls, and impaired function.

Therapeutic interventions can have meaningful outcomes in elderly patients with diabetes.For example, in over 3 years of study, the Diabetes Prevention Program found that dietand exercise sharply reduced the risk of developing diabetes, especially in patients 60years and older.2 In patients with diabetes, improving glycemic control by 1% can reducethe risk of developing microvascular complications by 20%-30%.3,4 The Diabetes Controland Complications Trial/Epidemiology of Diabetes Interventions and Complications(DCCT/EDIC) study research group showed that intensive therapy for diabetes reducedthe risk of cardiovascular events by 42%.5 Benefits were realized as early as 3 years.Recent studies have shown that good glycemic control improves outcomes for olderpatients, including increased survival for those on dialysis6 and decreased hospitalizationwith exacerbated congestive heart failure.7

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Treatment goals in the elderly include not only controlling hyperglycemia and avoidinghypoglycemia, but the ability to minimize, delay, and prevent long-term complications. In addition, special attention should be given to avoiding dehydration with the concomi-tant risks of hyperosmolar hyperglycemic nonketotic syndrome, or diabetic ketoacidosis.Furthermore, because of the likelihood of concomitant medical conditions and, therefore,concomitant medications which may affect diabetes control, special attention is warrant-ed for the older patient.8

Diabetes management also includes attention to nutrition and exercise, as well as thepotential need for medication. Diabetes is a progressive disease, and beta-cell functionalso declines with years of disease; therefore, in these cases, the use of insulin should beconsidered.

In conclusion, diabetes will be increasingly encountered by consultant pharmacists caringfor the elderly. An awareness and appreciation of the special considerations in diagnosisand treatment is warranted, as is the knowledge that interventions can result in improvedpatient outcomes.

References1. Centers for Disease Control and Prevention. National diabetes fact sheet:

general information and national estimates on diabetes in the United States,2005. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2005.

2. Diabetes Prevention Program. Prevention or delay of type 2 diabetes. Diabetes Care. 2004;27(suppl 1):S47-S54.

3. UKPDS Group. Intensive blood glucose control with sulphonylureas or insulincompared with conventional treatment and risk for complications in patientswith type 2 diabetes. Lancet. 1998;352:837-853.

4. Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med.1993;329:977-986.

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5. Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventionsand Complications Research Group. Retinopathy and nephropathy in patients withtype 1 diabetes four years after a trial of intensive therapy. N Engl J Med.2000;342:381-389.

6. Oomichi T, Emoto M, Tabata T, et al. Impact of glycemic control on survival of dia-betic patients on chronic regular hemodialysis: a 7-year observational study.Diabetes Care. 2006;29:1496-1500.

7. Bhatia et al. Association of poor glycemic control with prolonged hospital stay in patients with diabetes admitted with exacerbation of congestive heart failure.Endocr. Pract. 2004;10:467-471.

8. Brown AF, Mangione CM, Saliba D, Sarkisian CA; California HealthcareFoundation/American Geriatrics Society Panel on Improving Care for Elders with Diabetes. Guidelines for improving the care of the older person with diabetesmellitus. J Am Geriatr Soc. 2003;51(suppl guidelines 5):S265-S280.

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Insulin Analogs Added to Oral Antidiabetic Therapy for Older Patients

Theresa Martin Plog, PharmD

Pathophysiology of Diabetes: Progression Over Time

Diabetes is a progressive disease characterized by insulin resistance and increasinginsulin deficiency over time. Beta-cell deterioration in type 2 diabetes occurs progressivelyas well; eventually, the pancreas cannot synthesize and secrete sufficient insulin to meetthe demands of insulin-resistant patients. Although insulin secretion can be boosted withsecretagogues, and the action of endogenous insulin can be enhanced with sensitizers,pancreatic beta-cell failure still occurs over time.

Rationale for Insulin Therapy in Older Patients

It is not surprising that patients seen by consultant pharmacists are those who are likelyto have had diabetes for many years and who have greatly diminished beta-cell function.This may make them less likely to respond to oral therapy or to achieve glycemic targetswith oral therapy alone. The majority of patients with type 2 diabetes will eventuallyrequire insulin.1 Insulin is used in patients with type 2 diabetes who are not at A1C goal(those on 2 to 3 oral agents at maximum doses) or in patients unable to tolerate oralmedications (due to side effects or drug interactions). Basal or premixed insulin can beadded to oral agents, or basal-bolus therapy can be used alone.

Needs for Replacement Insulin: Rationale for Insulin Analogs

The premise of insulin therapy is to mimic the body’s natural insulin production cycle.Patients need a basal insulin to cover background insulin requirements plus bolus insulinto cover meals and fluctuations.2 There are several types of insulin products that can beused to achieve this. Insulin products are divided into rapid, short, intermediate, and long-acting (each type has different onset, peak, and duration). Insulin analogs are largelyreplacing older human insulin products. The advantages and rationale for insulin analogsin elderly patients include a lower risk of hypoglycemia and thus the ability to titrate toachieve A1C goals more closely. Better A1C results may delay disease progression andcomorbidity development, which may be especially important in the elderly whose organfunction is already declining with age. The improved pharmacokinetic profiles of insulin

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analogs more closely mimic physiologic function. This allows more convenient adminis-tration and greater flexibility with meals since the elderly often have declining appetites or skip meals. Insulin analogs also offer the advantages of being better tolerated andcausing less weight gain than traditional human insulins. Finally, they are available in convenient administration devices, such as insulin pens, which can deliver reproducibledoses with less pain.3

Choosing an Insulin Regimen for Older Patients

What insulin regimens are appropriate for older patients? There are many treatmentstrategies that can be considered.

Basal Therapy (+ Oral Agents)

Basal therapy consists of a single injection of a long-acting insulin like glargine or detemirthat provides simple coverage of basal insulin requirements.4,5 However, it does not provide mealtime (prandial) coverage and may require addition of bolus doses of a rapid-acting analog such as aspart, lispro, or glulisine.6 Insulin detemir is the most recent addition to longer-acting insulin analogs and may have the advantage of less weight gainthan other basal insulins.7 Basal therapy may be appropriate for elderly patients who do not have advanced diabetes (ie, limited beta-cell function) or do not have significantpostprandial hyperglycemia.

Premixed Insulin Analogs (+ Oral Agents)

Another simple starting regimen is to use a premixed insulin analog, such as insulin aspart70/30 or insulin lispro 75/25.8,9 Premixed insulin analogs provide basal and prandial coverage in one injection.10,11 This strategy may be started with a single daily dose givenat one meal and increased up to 3 injections per day if needed.11 With this approach, afairly regular meal pattern is recommended. This strategy is appropriate for elderlypatients with elevations in both fasting plasma glucose (FPG) and postprandial glucose(PPG) who desire a simple regimen. In all cases, family member assistance and education must also be included regarding symptoms of hypoglycemia and injection techniques.


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Basal-Bolus Therapy (Multiple Daily Injections)

Finally, there is basal-bolus therapy (or multiple daily injections, MDI), as a way to progressfrom a single basal injection.12 Basal-bolus therapy offers flexibility in meal patterns (includingnumber, timing, and content of meals) as well as more flexibility in activity patterns, includingmore opportunity for sporadic exercise. Long-acting insulin is used to cover basal insulinrequirements, and rapid-acting insulin is used to cover mealtime carbohydrates.13 However,this method requires that patients (or care providers) clearly understand advanced carbohy-drate counting. This strategy may be appropriate in the following elderly patients: the “well-ederly” (those who are very physically active, who travel, and can make appropriatedose adjustments themselves), and also suitable for patients under supervision (eg, nursinghome) where food intake, blood glucose (BG) results, and injection times are supervised byhealth care providers. Other reasons for using basal-bolus therapy in hospitals and nursinghomes include meal delivery times, which do not always correlate with scheduled medicationadministration times. Also, patients may be “nothing by mouth” (NPO) for procedures wherethere is then a need to hold doses/injections.

Choosing the Right Regimen

For elderly patients with type 2 diabetes, consultant pharmacists should conduct a thoroughassessment of charts, nurses and dietician notes, or assess patient home BG monitoring log-books. Review recent laboratory results against the current regimen and ask yourself, “Arethey at the maximum dose of their oral medications?”, “Are there contraindications or signifi-cant comorbidities to any diabetes medications or to insulin?”, and “Have they been gettingA1C levels at appropriate intervals, or do we need more labs before deciding on regimen?”Pharmacists should be able to identify and interpret glycemic patterns (correlate BG valueswith time of day, identify eating patterns, missed meals, and identify lack of participation ingroup exercise or activities) and offer recommendations on how to adjust therapy to achievethe best response possible for the patient. Dose adjustments may be required if the patient is taking certain medications that affect carbohydrate metabolism or responses to insulin.Liver or renal disease can also affect the pharmacokinetics of insulin. Exercise, illness, stress, aberrant eating patterns, alcohol, and travel may also necessitate dose adjustments.

Regardless of which insulin regimen is chosen, insulin remains one of our most powerful toolswith which to achieve glycemic control in elderly patients. Appropriate titration and doseadjustment can improve glycemic control and patient outcome.14


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References

1. Wright A, Burden AC, Paisey RB, et al. Sulfonylurea inadequacy: efficacy of addition of insulin over 6 years in patients with type 2 diabetes in the U.K.Prospective Diabetes Study (UKPDS 57). Diabetes Care. 2002;25:330-336.

2. Polonsky KS, Given BD, Hirsch LJ, et al. Abnormal patterns of insulin secretion innon-insulin-dependent diabetes mellitus. N Engl J Med. 1988;318:1231-1239.

3. Hirsch IB. Insulin analogues. N Engl J Med. 2005;352:174-183.

4. Stoneking K. Initiating basal insulin therapy in patients with type 2 diabetes mellitus. Am J Health Syst Pharm. 2005;62:510-518.

5. Riddle MC, Rosenstock J, Gerich JE; Insulin Glargine 4002 Study Investigators.The treat-to-target trial randomized addition of glargine or human NPH insulin to oral therapy of type 2 diabetic patients. Diabetes Care. 2003;26:3080–3086.

6. Karl DM. The use of bolus insulin and advancing insulin therapy in type 2 diabetes. Curr Diab Rep. 2004;4:352-357.

7. Soran H, Younis N. Insulin detemir: a new basal insulin analogue. Diabetes ObesMetab. 2006;8:26-30.

8. Raskin P, Allen E, Hollander P; INITIATE Study Group. Initiating insulin therapy in type 2 diabetes: a comparison of biphasic and basal insulin analogs. Diabetes Care. 2005;28:260-265.

9. Garber AJ, Wahlen J, Wahl T, et al. .Attainment of glycaemic goals in type 2 diabetes with once-, twice-, or thrice-daily dosing with biphasic insulin aspart70/30 (The 1-2-3 study). Diabetes Obes Metab. 2006;8:58-66.

10. Rolla AR, Rakel RE. Practical approaches to insulin therapy for type 2 diabetesmellitus with premixed insulin analogues. Clin Ther. 2005;27:1113-1125.

11. Garber AJ. Premixed insulin analogues for the treatment of diabetes mellitus.Drugs. 2006;66:31-49.

12. Monnier L, Colette C. Addition of rapid-acting insulin to basal insulin therapy intype 2 diabetes: indications and modalities. Diabetes Metab. 2006;32:7-13.

13. Raslova K, Bogoev M, Raz I, et al. Insulin detemir and insulin aspart: a promising basal-bolus regimen for type 2 diabetes. Diabetes Res Clin Pract.2004;66:193-201.

14. Davidson JA. Treatment of the patient with diabetes: importance of maintaining

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Counseling the Elderly and Strategies for ImprovingAdherence, Safety, and Health Literacy

Jerry Meece, RPh, FACA, CDM, CDE

A growing body of evidence suggests that patients with chronic diseases, such as diabetes, who are engaged and active participants in their health care have better healthoutcomes. However, a recent study showed that a majority of patients with diabetespolled did not know their last A1C level, while only a quarter accurately reported thatvalue.1 Health literacy measures a patient’s ability to read, comprehend, and act on medical instructions. Poor health literacy is common among elderly persons and patientswith chronic conditions. Among primary care patients with type 2 diabetes, inadequatehealth literacy has been shown to be independently associated with worse glycemic control and higher rates of retinopathy.2

Communication skills in discussing treatment regimens are important for all patients, butthere are specific nuances when it comes to the elderly. Communication can be hinderedby the normal aging process, which may involve sensory loss, decline in memory, slowerprocessing of information, lessening of power and influence over their own lives, and sep-aration from family and friends.3

Some simple recommendations include allowing extra time for older patients and avoidingvisual and auditory distractions such as other people and background noise. Verbalbehaviors that are positively associated with health outcomes in patients with diabetesinclude empathy, reassurance and support, various patient-centered questioning tech-niques, encounter length, history taking, explanations, positive reinforcement, humor,friendliness, courtesy, and summarization and clarification.4

Simplifying information and speaking in a manner that can be easily understood is one of the best ways to ensure that your patients will follow your instructions. Speak clearlyand loudly enough for your patients to hear you, but do not shout.

Avoid medical jargon or technical terms that are difficult for the layperson to understand.Repeating statements and summarizing frequently is also helpful.

Writing is a more permanent form of communication than speaking and provides theopportunity for the patient to later review what you have said in a less stressful environ-ment.3 Providing graphical information to patients about their A1C and other laboratoryvalues has been found to improve glycemic control and other diabetes outcomes.5

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Nonverbal behaviors are also important in communication. Nonverbal behaviors positivelyassociated with outcomes include head nodding, leaning forward, and uncrossed legsand arms.4 Other suggestions are to sit face-to-face and to maintain eye contact whileproviding health information. Some older patients have vision and hearing loss, and reading your lips may be crucial for them to receive the information correctly.3

Finally, counseling elderly patients with diabetes requires an assessment of the individualpatient regarding their level of skills, abilities, understanding, and willingness to participatein their health care.

References1. Heisler M, Piette JD, Spencer M, et al. The relationship between knowledge of

recent HbA1c values and diabetes care understanding and self-management.Diabetes Care. 2005;28:816-822.

2. Heisler M, Smith DM, Hayward RA, et al. How well do patients' assessments of their diabetes self-management correlate with actual glycemic control andreceipt of recommended diabetes services? Diabetes Care. 2003;26:738-743.

3. Robinson TE, White GL, Houchins C. Improving communication with olderpatients: tips from the literature. Fam Pract Manag. 2006;13:73-78. Available at: http://www.aafp.org/fpm/20060900/73impr.html#refs. AccessedSeptember 29, 2006.

4. Anderson RM, Funnell MM. Compliance and adherence are dysfunctional concepts in diabetes care. Diabetes Educ. 2000;26:597-604.

5. Cagliero E, Levina EV, Nathan DM. Immediate feedback of HbA1c levelsimproves glycemic control in type 1 and insulin-treated type 2 diabetic patients.Diabetes Care. 1999;22:1785-1789.

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Case Studies

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Suggested ReadingsAshkenazy R, Abrahamson MJ. Medicare coverage for patients with diabetes. A national plan with individual consequences. J Gen Intern Med. 2006;21:386-392.

Aubry W. Reimbursement and coverage implications for CGM. Diabetes Technol Ther. 2005;7:797-800.

Boyd CM, Darer J, Boult C, et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005;294:716-724.

Campbell RK. Role of the pharmacist in diabetes management. Am J Health Syst Pharm. 2002;59(suppl 9):S18-S21.

Choe HM, Mitrovich S, Dubay D, et al. Proactive case management of high-riskpatients with type 2 diabetes mellitus by a clinical pharmacist: a randomized controlled trial. Am J Manag Care. 2005;11:253-260.

Doucet J. Use of antidiabetic drugs in elderly patients. Diabetes Metab.2005;31(spec no 2):5S98-5S104.

Garg SK. New insulin analogues. Diabetes Technol Ther. 2005;7:813-817.

Kuo S, Fleming BB, Gittings NS, et al. Trends in care practices and outcomesamong Medicare beneficiaries with diabetes. Am J Prev Med. 2005;29:396-403.

McCord AD. Clinical impact of a pharmacist-managed diabetes mellitus drug therapy management service. Pharmacotherapy. 2006;26:248-253.

Merin M. New Medicare benefits for people with diabetes. The new year brings new Medicare benefits and services for people with diabetes. Diabetes Forecast.2005;58:77.

Meyer BM. A first step... toward full Medicare recognition of pharmacists asproviders. Am J Health Syst Pharm. 2004;61:991.

Miller CD, Barnes CS, Phillips LS, et al. Rapid A1c availability improves clinical decision-making in an urban primary care clinic. Diabetes Care.2003;26:1158-1163.

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Nathan DM, Buse JB, Davidson MB, et al. Management of hyperglycaemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy.A consensus statement from the American Diabetes Association and the EuropeanAssociation for the Study of Diabetes. Diabetes Care. 2006;29:1963-1972.

Shetty S, Secnik K, Oglesby AK. Relationship of glycemic control to total diabetes-related costs for managed care health plan members with type 2 diabetes. J Manag Care Pharm. 2005;11:559-564.

Strum MW, Hopkins R, West DS, et al. Effects of a medication assistance programon health outcomes in patients with type 2 diabetes mellitus. Am J Health SystPharm. 2005;62:1048-1052.

Zarowitz BJ, Tangalos EG, Hollenack K, et al. The application of evidence-basedprinciples of care in older persons (issue 3): management of diabetes mellitus. J Am Med Dir Assoc. 2006;7:234-240.


CPE/CE Post-TestPlease complete the post-test and evaluation online by clicking here. Please use the printedforms if you do not have an internet connection.

ACPE #203-999-06-081-H01 • Release Date: November 18, 2006 • Credit Expiration Date: February 1, 2008

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Name__________________________________________________________________________________________ Degree/title__________________________

Specialty __________________________________ Hospital or Practice Name __________________________________________________________________

Address____________________________________________________________________________________________________________________________

City ______________________________________________________________________________________ State ______ Zip ________________________

Phone ______________________________ FAX______________________________________ E-mail ____________________________________________

(last) (first) (middle)

1. Which of the following is not true about elderly patients and diabetes?A. Diabetes is common in patients over 65 years of ageB. Obesity plays a central role in the etiology and pathogenesis

of type 2 diabetesC. Diagnosis is more difficult because classic symptoms may

be absent or may be attributed to the aging processD. Glucose control in older patients with longstanding diabetes

is not that important

2. The Diabetes Prevention Project showed all of the following except:A. Lifestyle interventions decreased the development of

diabetes by >50%B. Metformin decreased the development of diabetes by >30%

and worked particularly well in older, more overweight individuals

C. Lifestyle intervention worked in all groups but worked particularly well in people 60 and older (reducing the development of diabetes by >70%)

3. Which of the following is not true about insulin therapy inpatients with diabetes:A. Insulin is always indicated in patients with type 1 diabetesB. Insulin is often necessary for patients with type 2 diabetes to

optimize glycemic controlC. Insulin can be rapid, fast, intermediate, or long actingD. Insulin cannot be used with oral agents

4. Adding insulin to oral agents is more effective at reachingtarget A1C values than oral agents aloneA. True B. False

5. An elderly patient who is experiencing loss of appetite andskipping meals should NOT take their insulin glargine.A. True B. False

6. An elderly patient should NOT be on both metformin andinsulin at the same time.A. True B. False

7. Insulin analogs may be preferred to regular insulin inelderly patients with diabetes for all of the followingreasons EXCEPT:A. Their more physiologic profiles decrease the risk of

hypoglycemia as compared to human insulinB. Associated with increased weight gain, which can be

beneficial for thin, elderly patientsC. Can be given at mealtimes rather than 30 minutes prior

to mealsD. Accurate dosing devices available, which take into account

dexterity and visual acuity

8. The main reason patients do not tell their physicians thatthey stopped taking their medication was they:A. Didn’t think it was importantB. Didn’t think he caredC. Were never askedD. Didn’t have enough time

9. 50% of all patients on long term regimens fail to followdirections.A. True B. False

10. Prevention of hypoglycemia in the elderly requires all ofthe following except:A. Reinforced education for the patient and caregiverB. Knowledge of signs of hypoglycemia and

appropriate treatmentC. Self-monitoring of blood glucose by the patient when

possible, or by a familial or medical caregiver, should be encouraged

D. Discontinuation of insulin therapy if the patient becomes hospitalized

Circle your selected answer.

07 NN DIAB POD

Please check which type of credit you are applying for: r Pharmacist CPE r Nursing CE

If you do not have internet access: To receive credit, please print or type the required information below, complete the followingpost-test and evaluation, remove the form and mail it in an envelope to: Medical Communications Media, 2288 Second Street Pike,Wrightstown, PA 18940. A CPE/CE statement of credit will be awarded for a score of 70% or better and will be mailed within 4-6weeks. There is no charge for CPE/CE credit.

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67

Post-Program Evaluation

I am a: r Pharmacist r Nurse r Other

07 NN DIAB POD

Why, When, and How to Initiate Insulin Therapy in ElderlyPatients with Type 2 Diabetes: A Case-based ApproachACPE #203-999-06-081-H01 • Release Date: November 18, 2006 • Credit Expiration Date: February 1, 2008

Indicate your answer by circling the appropriate number. STRONGLY AGREE STRONGLY DISAGREE1. As a result of my participation in this activity, I am better able to:

Identify elderly patients with type 2 diabetes who are not meeting established treatment goals for glycosylated hemoglobin (A1C), postprandial glucose (PPG) targets, and fasting plasma glucose (FPG) targets. 4 3 2 1Describe how to transition elderly patients with type 2 diabetes who are not meeting treatment goals to more intensive and effective therapeutic regimens to attain and maintain A1C, PPG, and FPG targets. 4 3 2 1Differentiate the benefits and risks of regular insulin mixes, premixed insulin analogs, and basal-bolus insulin treatment strategies for elderly patients. 4 3 2 1

2. This activity increased my awareness and understanding of the subject matter. 4 3 2 1

3. The program was clear and well organized. 4 3 2 1

4. The program was objective, scientifically balanced, and free of commercial bias. 4 3 2 1

5. The speakers were prepared, clear, and well organized. 4 3 2 1

6. About which clinical problems related to the therapeutic area covered in this activity would you or your colleagues like to learn more?

7. Additional comments or suggestions:

Documents

Why, When, and How to Initiate Insulin Therapy in Elderly ... · PDF fileWhy, When, and How to Initiate Insulin Therapy in Elderly Patients with Type 2 ... following along with the