Nutrition 

As older adults age, their nutritional requirements change.

Why is it important?

  • 34% of older Canadians are at nutritional risk, and women more so (1)
  • Older adults are at risk for under-nutrition due to dietary, economic, psychosocial, and physiological factors (2)

Common Causes

  • Increased sedentary lifestyle  and lowered metabolic rate (5)
  • Increased deficiency in key vitamins and minerals; a reduced sense of taste and smell; difficulty chewing or swallowing; a restricted diet for a health condition; eating alone; loss of appetite; and medications (5)
  • Chronic conditions or disability may affect ability to cook (2)
  • Poor oral hygiene (2)

Key Considerations

  • Advise to follow Canada’s Food Guide
  • Discuss any concerns with serving sizes, dietary restrictions, Nutrition Facts table
  • Assess for vitamin/mineral deficiencies with attention vitamin B6, B12, D, calcium and iron (3)
  • Screen for obesity: calculate Body Mass Index•
  • Develop a healthy eating plan- consider budget limitations, refer to a dietician, community programs for meal preparation (e.g. safe cooking practices) and meal planning

Consult the following for patient handout information:

References

1. Dieticians of Canada. (2013). Online nutrition screening tool helps older adults identify if they
    have risk factors leading to poor nutrition
. Retrieved March 12, 2014 

2. DiMaria-Ghalili, R. (2012). Nutrition in the Elderly, Nursing Standard of Practice Protocol: Nutrition in Aging.
    Retrieved March 12, 2014 from:
    http://consultgerirn.org/topics/nutrition_in_the_elderly/want_to_know_more

3. EatRight Ontario. (2014). Seniors Nutrition. Retrieved March 12, 2014 from:
    http://www.eatrightontario.ca/en/Articles/Seniors-nutrition/Older-adults-eating-well.aspx#.UyBs6BbnL7I

4. Health Canada. (2007). Food and Nutrition: What is a Food Guide Serving? Retrieved March 12, 2014 from:
    http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/basics-base/serving-portion-eng.php

5. University of Rochester Medical Center. (2014).  Nutrition Needs in Older Adults.
    Retrieved March 12, 2014 from:
    http://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=1&ContentID=2321

Hydration

Dehydration occurs when an individual’s body loses more water than it takes in. The body will not have enough fluids to
carry out normal functions.

Why is it important?

  • Older adults are vulnerable to shifts in water balance- in both over hydration and dehydration
  • Dehydration can result in serious problems:
    • heat injury
    • cerebral edema
    • seizures
    • low blood volume shock
    • dizziness/fainting and risk of falls
    • kidney failure
    • constipation
    • coma
    • death (2) (3)

Common Causes

  • Age-related changes in body composition resulting in depletion of total body water (4)
  • Decreased renal function (4)
  • Thirst sense becomes less accurate (4)
  • Poor tolerance for hot weather (4)
  • Intense vomiting and diarrhea (3)
  • Vigorous exercise and not drinking enough water
  • Inadequate nutrition intake
  • Increased urination

Key Considerations

  • Risk factors: 85+, female, dementia,  multiple chronic diseases, medications, fever, dehydration history, use of diuretics (water pills) (4)
  • Parkinson’s disease or stroke may cause swallowing difficulties leading to decreased fluid consumption (1)
  • Signs of dehydration: little or no urination, sunken eyes, skin lacking elasticity and resilience when pinched, low blood pressure, a heart rate faster than normal, reduced blood flow to the extremities, dry mouth,  dizziness/sudden confusion, weakness (3) (1)
  • To confirm diagnosis, consider blood tests (electrolytes, kidney function) and urinalysis (3)
  • Treatment usually involves replacing lost fluids and electrolytes as oral rehydration
  • In life threatening emergency situations provide intravenous (3)
  • Identify medications that may be causing water loss (1)
  • Eat Right Ontario recommends: women 9 cups (250ml per cup) a day and men 12 cups (2)
  • Certain liquids, such as fruit juices, coffee, or carbonated drinks can make diarrhea worse (3)

References

1.  Alberta Caregiver College. (2014). Support for Caregivers of Older Adults: Hydration.
     Retrieved February 20, 2014 from:
     http://www.caregivercollege.org/scoa/?Hydration.html

2.  Dieticians of Canada. (2014). Facts on Fluids- How to Stay Hydrated. Retrieved February 19, 2014 from:
     http://www.eatrightontario.ca/en/Articles/Water/Facts-on-Fluids---How-to-stay-hydrated#.UwYiMRbnL7I

3.  MAYO CLINIC. (2014).  Diseases and Conditions: Dehydration. Retrieved February 19, 2014 from:
     http://www.mayoclinic.org/diseases-conditions/dehydration/basics/definition/con-20030056

4.  Mentes, J. (2012).  Hydration Management. Nursing Standard of Practice Protocol: Managing Oral Hydration.
     Retrieved February 19, 2014 from:
     http://consultgerirn.org/topics/hydration_management/want_to_know_more#item_2

Nutrition

As older adults age, their nutritional requirements change. Malnutrition is any disruption to a healthy nutritional status. (2)

Why is it important?

  • 34% of older Canadians are at nutritional risk.  Women are more at risk than men (1)
  • Older adults are at risk for under-nutrition due to dietary, economic, psychosocial, and physiological factors (2)
  • Proper nutrition can lower  the risk for diseases: high blood pressure, osteoporosis, obesity, certain cancers, type 2 diabetes, heart disease (3)

Common Causes

  • Increased sedentary lifestyle (4)
  • Increased deficiency in key vitamins and minerals from a combination of factors: a reduced sense of taste and smell; difficulty chewing or swallowing;  a restricted diet for a health condition; eating alone; loss of appetite; and medication consumption that may prevent absorption of vitamins and minerals (4)
  • Limited income or lack of transportation may affect  access to quality food and the number of meals per day (2)
  • Chronic conditions or disability may affect ability to cook (2)
  • Poor oral hygiene (2)

Key Considerations

  • Follow Canada’s Food Guide
  • Ask for a consultation with a dietitian

References

1. Dieticians of Canada. (2013). Online nutrition screening tool helps older adults identify if they have risk factors
    leading to poor nutrition
. Retrieved March 12, 2014 
2. DiMaria-Ghalili, R. (2012). Nutrition in the Elderly, Nursing Standard of Practice Protocol: Nutrition in Aging.
    Retrieved March 12, 2014 from:
    http://consultgerirn.org/topics/nutrition_in_the_elderly/want_to_know_more

3. FDA.  (2014). Why Nutrition Matter for You. Retrieved March 12, 2014 from:
    http://www.fda.gov/Food/ResourcesForYou/Consumers/ucm267499.htm

4. University of Rochester Medical Center. (2014).  Nutrition Needs in Older Adults. Retrieved March 12, 2014 from:
    http://www.urmc.rochester.edu/encyclopedia/content.aspx?ContentTypeID=1&ContentID=2321

Hydration

Drinking liquids throughout the day is especially important for older adults. Dehydration can lead to dizziness, fainting and
low blood pressure.  Dehydration can make constipation worse. (1)

Why is it important?

  • Older adults are vulnerable to shifts in water balance- in both over hydration and dehydration
  • Serious problems can occur:
      • heat injury
      • swelling of the brain
      • seizures
      • shock
      • dizziness/fainting and risk of falls
      • kidney failure
      • constipation
      • coma
      • death (2) (1)

Common Causes

  • Age-related changes in body composition resulting in depletion of total body water (3)
  • Decreased renal function (3)
  • Thirst sense becomes less accurate (3)
  • Poor tolerance for hot weather (3)
  • Intense vomiting and diarrhea (2)
  • Vigorous exercise and not drinking enough water
  • Inadequate nutrition intake
  • ncreased urination

Key Considerations

  • Risk factors: 85+, female, dementia,  multiple chronic diseases, medications, fever, dehydration history , use of diuretics (water pills) (3)
  • Parkinson’s disease or stroke may cause swallowing difficulties (4)
  • Signs of dehydration: little or no urination, sunken eyes, skin lacking elasticity and resilience, low blood pressure, increased heart rate, dry mouth, dizziness/sudden confusion, weakness (2) (4)
  • Common signs: thirsty or dry mouth; urine is dark yellow with a strong smell; feeling light-headed, headache (1)
  • Seek medical attention if symptoms persist, if  swallowing difficulties/excessive choking or coughing after ingestion of food (4)
  • Treatment usually involves replacing lost fluids through increased oral intake
  • Eat Right Ontario recommends if able:  women drink 9 cups (250mL) a day and men-12 cups (1)
  • Certain liquids, such as fruit juices, coffee, or carbonated drinks can make diarrhea worse (2)
  • Keep beverages available (safe for specific diets, e.g., diabetes);  foods containing water (e.g., fresh fruits and vegetables, yogurt) (4)
  • Drink  frequently throughout the day instead of drinking large amounts in one sitting (4)
  • Limit drinks with caffeine to 3 cups per day (1)
  • Certain circumstances require more fluid intake (e.g. illness, when exercising, hot/humid weather, when staying in heated buildings) (2)

References

1. Dieticians of Canada. (2014). Facts on Fluids- How to Stay Hydrated. Retrieved February 19, 2014 from:
    http://www.eatrightontario.ca/en/Articles/Water/Facts-on-Fluids---How-to-stay-hydrated#.UwYiMRbnL7I

2. MAYO CLINIC. (2014).  Diseases and Conditions: Dehydration. Retrieved February 19, 2014 from:
    http://www.mayoclinic.org/diseases-conditions/dehydration/basics/definition/con-20030056

3. Mentes, J. (2012).  Hydration Management. Nursing Standard of Practice Protocol: Managing Oral Hydration.
    Retrieved February 19, 2014 from:
    http://consultgerirn.org/topics/hydration_management/want_to_know_more#item_2

4. Alberta Caregiver College. (2014). Support for Caregivers of Older Adults: Hydration.
    Retrieved February 20, 2014 from:
    http://www.caregivercollege.org/scoa/?Hydration.html

Aging has a significant impact on the structure and function of the skin and its ability to retain moisture and protect the body from chemical and physical injury. Changes in an individuals aging skin results in a decrease in the skin’s ability to retain moisture. (3)   A multitude of factors including disease, diet, hydration status, stress and the external environment cause alterations in skin barrier function, potentially putting the individual at risk for impaired skin integrity and skin related disorders.(3)  Common geriatric skin problems include dry skin (xerosis), eczemas, pruritus, increased fragility and reduced sensation. (3)(4)

Why is it important?

≥ 70% of the older population suffer from skin conditions. (1)
Skin damage is generally the result of external forces: pressure, shearing, friction and high moisture levels. (4)
The development of pressure ulcers/wounds is an important determinant of health and an individual’s quality of life. (4)
• Pressure ulcers span the continuum of healthcare settings26% overall prevalence with 29% in non-acute settings (LTC), 25% in acute care hospitals, 22% in mixed care facilities ( acute and non-acute)  and 15% in community settings. (5)
One in 4 patients in acute care and 1 in 3 in LTC had a pressure ulcer.(5)   60% of elders in acute care settings develop pressure ulcers usually within 2 wk. of admission. In LTC, pressure ulcers are most likely to develop within the first 4 wk. of admission. (4)
Human burden: includes diminished quality of life, pain, suffering, increased mortality and potential complications such as infection, cellulitis and osteomyelitis. (4)
Financial burden: average cost of 3 month pressure ulcer treatment in LTC was $24,050 and $27, 632 for a 3 month treatment regime in the community. (4)

Risk Factors

Contributing to impaired skin integrity include age, malnutrition, immobility, inactivity, external pressure, medical conditions (i.e. diabetes, malignant disease, vascular disease),  lifestyle choices (smoking), immune system stress (i.e. Infection), multiple medications, loss of lean body mass, decreased cognitive function( i.e. confusion) and the presence of neurological deficits (i.e. stroke).(4)

Key Considerations

Prevention and early intervention is a key factor along with the use of a client centered interprofessional team approach.
Holistic treatment should be based on evidence based practice and utilization of standardized assessment tools (i.e. Norton Scale, Braden Scale). (4)
Elders require specialized care to avoid missed diagnoses, pressure ulcers, and a range of other potential problems associated with this age group. (3)
Clinicians need to focus on the assessment and management of the elderly with, or at risk for, impaired skin integrity.
Effective educational programs are required and should be directed at all levels of health care providers to develop capacity and knowledge translation with a focus on the anatomy and physiology of the skin, physiological changes that occur with aging skin, common geriatric skin conditions, skin assessment techniques, and management of common skin care problems. 

References

1.  Barr, J. (2006). Impaired skin integrity in the elderly. Retrieved March 20, 2014 from:  
     http://www.o-wm.com/article/5635?page=0,0

2.  Keast, D., Parslow, N., Houghton, P., Norton, L., Fraser, C. (2006). Best practice recommendations for the
      prevention and treatment of pressure ulcers
: Update 2006. Wound  Care Canada, 4 (1), 31-43. 

3.   Ostomy Wound Management (2014). Retrieved March 20, 2014 from: 
      http://www.o-wm.com/article/5635?page=0,1

4.   Registered Nurses Association of Ontario. Nursing Best Practice Guidelines Program. (2011). Risk assessment
      and prevention of pressure ulcers
. Retrieved March 20, 2014 from:   
      http://rnao.ca/sites/rnao-ca/files/Risk_Assessment_and_Prevention_of_Pressure_Ulcers.pdf

5.   Woodbury, G. & Houghton. ( 2004). Prevalence of pressure ulcers in Canadian healthcare settings. Ostomy
      Wound management , 50 (10), 22-38.  Retrieved March 2014  from: 
      http://cawc.net/images/uploads/resources/Woodbury.pdf

 

Aging has a significant impact on the structure and function of the skin and its ability to retain moisture and protect the body from chemical and physical injury. Changes in an individuals aging skin results in a decrease in the skin’s ability to retain moisture. (3)   A multitude of factors including disease, diet, hydration status, stress and the external environment cause alterations in skin barrier function, potentially putting the individual at risk for impaired skin integrity and skin related disorders.(3)  Common geriatric skin problems include dry skin (xerosis), eczemas, pruritus, increased fragility and reduced sensation. (3)(4)

Why is it important?

≥ 70% of the older population suffer from skin conditions. (1)
Skin damage is generally the result of external forces: pressure, shearing, friction and high moisture levels. (4)
The development of pressure ulcers/wounds is an important determinant of health and an individual’s quality of life. (4)
Pressure ulcers span the continuum of healthcare settings26% overall prevalence with 29% in non-acute
  settings (LTC), 25% in acute care hospitals, 22% in mixed care facilities ( acute and non-acute)  and 15% in
  community settings. (5)
One in 4 patients in acute care and 1 in 3 in LTC had a pressure ulcer.(5)  60% of elders in acute care settings
  develop pressure ulcers usually within 2 wk. of admission. In LTC, pressure ulcers are most likely to develop
  within the first 4 wk. of admission. (4)
Human burden: includes diminished quality of life, pain, suffering, increased mortality and potential complications
  such as infection, cellulitis and osteomyelitis. (4)
Financial burden: average cost of 3 month pressure ulcer treatment in LTC was $24,050 and $27, 632 for a 3
  month treatmentregime in the community. (4)

Risk Factors

Contributing to impaired skin integrity include age, malnutrition, immobility, inactivity, external pressure, medical conditions
(i.e. diabetes, malignant disease, vascular disease),  lifestyle choices (smoking), immune system stress (i.e. Infection),
multiple medications, loss of lean body mass, decreased cognitive function( i.e. confusion)  and the presence of neurological
deficits (i.e. stroke).(4)

Key Considerations

Prevention and early intervention is a key factor along with the use of a client centered interprofessional team approach.
Holistic treatment should be based on evidence based practice and utilization of standardized assessment tools
  (i.e. Norton Scale, Braden Scale). (4)
Elders require specialized care to avoid missed diagnoses, pressure ulcers, and a range of other potential problems
  associated with this age group. (3)
Clinicians need to focus on the assessment and management of the elderly with, or at risk for, impaired skin integrity.
Effective educational programs are required and should be directed at all levels of health care providers to develop
  capacity and knowledge translation with a focus on the anatomy and physiology of the skin, physiological changes that
  occur with aging skin, common geriatric skin conditions, skin assessment techniques, and management of common skin
  care problems. 

References

1.  Barr, J. (2006). Impaired skin integrity in the elderly. Retrieved March 20, 2014 from:  
     http://www.o-wm.com/article/5635?page=0,0

2.  Keast, D., Parslow, N., Houghton, P., Norton, L., Fraser, C. (2006). Best practice recommendations for the prevention
     and treatment of pressure ulcers
: Update 2006. Wound  Care Canada, 4 (1), 31-43. 

3.  Ostomy Wound Management (2014). Retrieved March 20, 2014 from: 
      http://www.o-wm.com/article/5635?page=0,1

4.  Registered Nurses Association of Ontario. Nursing Best Practice Guidelines Program. (2011). Risk assessment
     and prevention of pressure ulcers
. Retrieved March 20, 2014 from:   
     http://rnao.ca/sites/rnao-ca/files/Risk_Assessment_and_Prevention_of_Pressure_Ulcers.pdf

5.  Woodbury, G. & Houghton. ( 2004). Prevalence of pressure ulcers in Canadian healthcare settings. Ostomy
     Wound management , 50 (10), 22-38.  Retrieved March 2014  from: 
     http://cawc.net/images/uploads/resources/Woodbury.pdf

Aging has a significant impact on the structure and function of the skin and its ability to retain moisture and protect the body from chemical and physical injury. Changes in an individuals aging skin results in a decrease in the skin’s ability to retain moisture. (3)   A multitude of factors including disease, diet, hydration status, stress and the external environment cause alterations in skin barrier function, potentially putting the individual at risk for impaired skin integrity and skin related disorders.(3)  Common geriatric skin problems include dry skin (xerosis), eczemas, pruritus, increased fragility and reduced sensation. (3)(4)

Why is it important?

≥ 70% of the older population suffer from skin conditions. (1)
Skin damage is generally the result of external forces: pressure, shearing, friction and high moisture levels. (4)
The development of pressure ulcers/wounds is an important determinant of health and an individual’s quality of life. (4)
Pressure ulcers span the continuum of healthcare settings:  26% overall prevalence with 29% in non-acute
  settings (LTC), 25% in acute care hospitals, 22% in mixed care facilities ( acute and non-acute)  and 15% in
  community settings. (5)
One in 4 patients in acute care and 1 in 3 in LTC had a pressure ulcer.(5)  60% of elders in acute care settings
  develop pressure ulcers usually within 2 wk. of admission
. In LTC, pressure ulcers are most likely to develop
  within the first 4 wk. of admission. (4)
Human burden: includes diminished quality of life, pain, suffering, increased mortality and potential complications
  such as infection, cellulitis and osteomyelitis. (4)
Financial burden: average cost of 3 month pressure ulcer treatment in LTC was $24,050 and $27, 632 for a 3
  month treatmentregime in the community. (4)

Risk Factors

Contributing to impaired skin integrity include age, malnutrition, immobility, inactivity, external pressure, medical conditions
(i.e. diabetes, malignant disease, vascular disease),  lifestyle choices (smoking), immune system stress (i.e. Infection),
multiple medications, loss of lean body mass, decreased cognitive function( i.e. confusion)  and the presence of neurological
deficits (i.e. stroke).(4)

Key Considerations

Prevention and early intervention is a key factor along with the use of a client centered interprofessional team approach
.Holistic treatment should be based on evidence based practice and utilization of standardized assessment tools
  (i.e. Norton Scale, Braden Scale). (4)
Elders require specialized care to avoid missed diagnoses, pressure ulcers, and a range of other potential problems
  associated with this age group. (3)
Clinicians need to focus on the assessment and management of the elderly with, or at risk for, impaired skin integrity.
Effective educational programs are required and should be directed at all levels of health care providers to develop
  capacity and knowledge translation with a focus on the anatomy and physiology of the skin, physiological changes that
  occur with aging skin, common geriatric skin conditions, skin assessment techniques, and management of common skin
  care problems.  

References

1.  Barr, J. (2006). Impaired skin integrity in the elderly. Retrieved March 20, 2014 from:  
     http://www.o-wm.com/article/5635?page=0,0

2.  Keast, D., Parslow, N., Houghton, P., Norton, L., Fraser, C. (2006). Best practice recommendations for the prevention
     and treatment of pressure ulcers
: Update 2006. Wound  Care Canada, 4 (1), 31-43. 

3.  Ostomy Wound Management (2014). Retrieved March 20, 2014 from: 
      http://www.o-wm.com/article/5635?page=0,1

4.  Registered Nurses Association of Ontario. Nursing Best Practice Guidelines Program. (2011). Risk assessment
     and prevention of pressure ulcers
. Retrieved March 20, 2014 from:   
     http://rnao.ca/sites/rnao-ca/files/Risk_Assessment_and_Prevention_of_Pressure_Ulcers.pdf

5.  Woodbury, G. & Houghton. ( 2004). Prevalence of pressure ulcers in Canadian healthcare settings. Ostomy
     Wound management , 50 (10), 22-38.  Retrieved March 2014  from: 
     http://cawc.net/images/uploads/resources/Woodbury.pdf

Pneumonia

The microbiology (pathogens seen) is similar in LTC to that of community acquired pneumonia. Treatment is usually based on common organisms seen. 34% nasogastric tube fed residents commonly have Pseudomonas aeruginosa.  Almost 50% of cases, a viral infection precedes the development of pneumonia and plays a role in the pathogenesis of pneumonia.  There is a need for early detection as opposed to relying on transfer to acute care. For frail individuals in LTC homes there are potential adverse outcomes related to transfer to acute care.

Why is it important?

• The overall incidence 1-1.2 per 1,000 patient days which is 10x that of community elderly.
• 33 out of 1000 LTC residents are hospitalized versus 1.14 out of 1000 in the community
•  Delay in administration of antibiotics may lead to increased patient morbidity and mortality.
•  Initiation of antibiotics after eight hours is associated with increased mortality.
•  Inappropriate use of antibiotics may adversely affect patient outcomes and increase antimicrobial resistance.

Key Considerations

•  A number of risk factors contribute to this: older age; male; swallowing problems; inability to take oral medications;
   immobility.
•  Increased transmission risk associated with: malnutrition; Chronic disease; Sedative use;  Invasive devices
   (tube feeding);  Prolonged antimicrobial use
•  Environmental risks can contribute to LTC acquired pneumonia; Institution; shared staff; contacts at group activities;
    low immunization rates; excessive antimicrobial use; colonization with antimicrobial resistant organisms and co-
    existing complex care issues including: Co-morbidities such as diabetes, heart failure, chronic obstructive
    pulmonary disease, stroke and dementia

Urinary Tract Infections (UTI)

On its own, the presence of bacteria in the urine (bacteriuria) does not signify infection.  Urinary Tract Infection (UTI) is
the presence of clinical symptoms attributed to the genitourinary tract in association with significant bacteriuria.
Asymptomatic bacteriuria (ASB) is defined as isolation of a specified quantitative count of bacteria in an appropriately
collected urine specimen from an individual without symptoms or signs of urinary tract infection.

Why is it important?

•  Urine of the institutionalized patient may be colonized with bacteria.
•  50% of females and 30% of males in a LTC setting have asymptomatic bacteriuria.
•  There is no evidence to support treatment of Asymptomatic Bacteriuria
•  There must be presence of bacteriuria and symptoms associated with UTIs. These symptoms are generally
    accepted to be new or increased urinary:
     i)    frequency   
     ii)   urgency
     iii)  incontinence
     iv)  flank pain or tenderness
     v)   suprapubic pain or tenderness 
     vi)  gross hematuria

Key Considerations

•  In men, decreased use of condom catheters for incontinence may be beneficial
•  If there are no white blood cells on an initial dipstick: 90% assurance that there is no UTI

References

1.  Abbott-McNeil, D., Barber, D., Murphy, S. and Puxty, J. (2009). Long-Term Care (LTC) Acquired Infections –
     Pneumonia.  Retrieved April 2014 from:   
     http://www.sagelink.ca/sites/default/files/uploads/csah/BTC_LTC/July-2010-toolkits/july2010-pneumonia-in-ltc-
     manual.pdf


2.  Abbott-McNeil, D., Barber, D., Murphy, S. and Puxty, J. (2009). Acquired Infections in Long Term Care (LTC):
     Urinary Tract Infections (UTI).  Retrieved April 2014 from:       
     http://www.sagelink.ca/sites/default/files/uploads/csah/BTC_LTC/July-2010-toolkits/july2010-uti-in-ltc-resource-
     toolkit.pdf

There are 2 types of diabetes:

Type 1 is a disease in which the pancreas does not produce insulin, the hormone which helps the body control the level of glucose (sugar) in the blood. Glucose builds up in the blood instead of being used for energy. Insulin is needed to treat this and given in the form of a special prefilled insulin pen with a needle, a syringe (needle) or pump.(1)
Type 2
is a disease in which the pancreas does not produce enough insulin, or the body does not properly use the insulin it makes. As a result, glucose (sugar) builds up in the blood instead of being used for energy. Type 2 diabetes can be managed through physical activity and meal planning and may require medications and/or insulin to assist the body to control blood glucose more effectively. (1)
Prediabetes
is defined as a state where the blood sugar is higher than normal but not high enough to be diagnosed as Type 2 diabetes

Why is it important?

Nine million Canadians are living with diabetes or prediabetes.(1)  As the population ages and the number of seniors rises, diabetes is increasing : 1 in 6 senior males and 1 in 7 females have diabetes.(2)  High blood sugar levels can contribute to heart disease, kidney disease, vision loss, loss of erection, (impotence) and nerve damage (loss of feeling especially in the hands and feet) 

Risk Factors

Obesity, sedentary lifestyle and inactivity, family history (parent or sibling), advancing age, male gender, unhealthy eating habits, high blood pressure  and high cholesterol, certain high risk groups ( i.e. Aboriginal, African descent), prediabetes, taking certain medications such as cortisone therapy (1) (2)

Key Considerations (1)

People with diabetes can expect to live active, independent and vital lives if they make a lifelong commitment to being careful about managing their disease. The key things in managing the disease include being physically active , eating a healthy diet (what, when and how much food), keeping within a healthy weight, taking all your medications correctly, managing stress , keeping informed and learn about the disease. Elderly people with diabetes should perform aerobic exercise and/or resistance (i.e. light weights or stretchy bands) training, if not contraindicated, to improve blood sugar control. Diabetes in the elderly is often treated by a different approach from diabetes in younger people. As people age, medications to control diabetes may need to be adjusted and the approach to therapy may be different to lower the risk of low blood sugar (hypoglycemia). You need to discuss with your health care provider (doctor, nurse or nurse practitioner). It is important to keep a record of your blood sugar levels and work with your health care team to keep your blood sugar levels in the target range and enjoy a healthy life.

References

1.  Canada Diabetes Association (2014). Retrieved April 23, 2014 from:
     http://guidelines.diabetes.ca/executivesummary/ch3

2.  Statistics Canada (2014). Retrieved April 23, 2014 from:
     http://www.statcan.gc.ca/pub/82-229-x/2009001/status/dia-eng.htm

Diabetes in the elderly is metabolically distinct from diabetes in younger people and the approach to therapy should be different. Healthy elderly people with diabetes should be treated to achieve the same glycemic, blood pressure and lipid targets as younger people with diabetes (2)

Prevention of hypoglycemia in the frail elderly, should take priority over attainment of glycemic targets because the risks of hypoglycemia are magnified in this patient population.(2) Risks include falls, fractures, ventricular arrhythmias, seizures, coma and death. While avoiding symptomatic hyperglycemia, glycemic targets should be A1C (glycated hemoglobin) ≤ 8.5% and fasting plasma glucose (PG) or preprandial PG 5.0–12.0 mmol/L, depending on the level of frailty. (2)

Why is it important?

Diabetes is an important indicator of population health.(4)  With the growing numbers of seniors, the prevalence of diabetes is increasing: 1 in 6 senior males and 1 in 7 females have diabetes.(4)  By 2030, the number of individuals ≥ 65 yr. with diabetes is expected to increase 2.3 fold.(3)  Chronic hyperglycemia is associated with significant long-term microvascular and macrovascular complications. Prevalence of complications is higher among the elderly with diabetes.(1)

Key Considerations(4)

  • Follow the ABC’s for all patients with diabetes for vascular protection:
    A= A1C – optimal glycemic control;
    B= BP – optimal blood pressure control (< 130/80 mmHg);
    C= Cholesterol – LDL-C ≤ 2.0 mmol/L if decision made to treat;
    D= Drugs to protect the heart and kidneys (even if the baseline blood pressure or LDL-C is already at target);
    E= Exercise / Eating – Regular physical activity, healthy eating, achievement and maintenance of healthy body weight;
    s = Smoking cessation
  • Follow the 5 R’s in team care and organization of care:
    Recognize (consider & screen risk factors);
    Register (develop a registry of all patients with diabetes);
    Resource (support self-management through the use of an interprofessional approach);
    Relay (information between all team members to support coordinated care);
    Recall (develop a system for timely reviews and assessment of goals and targets)
  • Regimens should be tailored to the individual’s treatment goals, lifestyle, diet, age, general health, motivation, hypoglycemia awareness status and ability for self-management. Promote patient self-management and S.M.A.R.T. ( Specific, Measurable, Achievable, Realistic, Timely)  goals
  • For the frail elderly or those with limited life expectancy, balance the potential treatment benefits against potential harm (i.e. Hypoglycemia, hypotension, falls). Target A1C ≤ 8.5%
  • In elderly people, if mixture of insulin is required, the use of premixed insulin and prefilled insulin pens should be used to reduce dosing and minimize errors to potentially improve glycemic control
  • Long-acting basal analogues (i.e. detemir, glargine) are associated with a lower frequency of hypoglycemia than conventional insulin in this age group.
  • Glyburide and Sulphonylureas should be used with caution as the risk of hypoglycemic events increases exponentially with age.
  • In elderly people with cognitive impairment, strategies should be used to strictly prevent hypoglycemia, which include the choice of antihyperglycemic therapy and less stringent A1C target. The clock drawing test may be used to predict which elderly subjects will have difficulty learning to inject insulin
  • Elderly people with type 2 diabetes should perform aerobic exercise and/or resistance training, if not contra-indicated, to improve glycemic control
  • In elderly nursing home residents, regular diets may be used instead of “diabetic diets” or nutritional formulas

References

1.   American Association of Clinical Endocrinologists (2007). Retrieved April 24, 2014 from: 
      http://guidelines.diabetes.ca/Browse/Chapter3

2.   Canada Diabetes Association (2014). Retrieved April 23, 2014 from:
      http://guidelines.diabetes.ca/executivesummary/ch3

3.   Mackay, J. et al. (2004). The atlas of heart disease and stroke. Diabetes Care. 27, 1047-1053. 
      Retrieved April 2014 from:
      http://archive.org/stream/atlasofheartdise00mckarich/atlasofheartdise00mckarich_djvu.txt

4.   Statistics Canada.  (2014). Retrieved April 23, 2014 from:
      http://www.statcan.gc.ca/pub/82-229-x/2009001/status/dia-eng.htm

Capacity: A person in incapable of giving or refusing consent to care or medical treatment if he/she is not able to understand the information relevant to the decision or if he/she is not able to appreciate the reasonably foreseeable consequences of such a decision. The health care professional proposing the treatment course of action assesses capacity. (1)

Consent has many elements such as lack of coercion, given by patient or legally authorized substitute decision maker, a reference to the particular administrator and treatment, and comes with full disclosure (e.g. risks, benefits, side effects, alternatives). (1)

Why is it important?

  • The Health Care Consent Act (HCCA) is an Ontario law based on capacity to consent; it governs health practitioners,including physicians (2)
  • Ontario HCCA is also relevant to the Ontario Substitute Decisions Act- a person found to lack capacity for personal care would need a substitute decision maker (3)

Common Causes

  • 73 % of Canadians die from complex chronic diseases and some will be lack capacity; for example, progressive dementing illnesses will affect the person’s decision-making ability at some point (1) (4)

Key Considerations

  • A person will be able to appreciate the consequences of the decision if the following occurs: (1)   
      • Acknowledges that the condition for which treatment is being recommended can affect him/her
      • Understands how proposed action, or lack of action, can effect quality of life
      • Explain why he/she is making a decision in a way that aligns with previously expressed values (e.g. realistic expectations, can communicate choice, can manipulate information rationally (4)
  • If the individual lacks capacity to consent, a substitute decision maker can be used
  • A substitute decision maker can be named in the Power of Attorney-chosen by the patient- and directed by an Advance Directive (a documented expression of wishes written by the patient, when they were capable, with respect to the medical treatment and personal care decisions) (1)
  • It is important to have these conversations earlier on regarding substitute decision makers,  advance directives, advance care planning, treatment options, financial plans etc. with family members, lawyers, and health care professionals

References

1.      Canadian Hospice Palliative Care Association. (2012). Advance Care Planning in Canada: National Framework.
         (2011). Retrieved March 17, 2014 

2.      Service Ontario. (2010). Health Care Consent Act, 1996. Retrieved March 17, 2014 from:
         http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_96h02_e.htm\ServiceOntario_e.htm

3.      ServiceOntario. (2011). Substitute Decisions Act, 1992. Retrieved March 17, 2014 from:
         https://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_92s30_e.htm

4.      The College of Physicians and Surgeons of Ontario. (2007). Determining capacity to consent
          Retrieved March 17, 2014 from: 
          http://www.cpso.on.ca/uploadedFiles/policies/policies/policyitems/capacity_consent_july07dialogue.pdf

Capacity: A person in incapable of giving or refusing consent to care or medical treatment if he/she is not able to understand the information relevant to the decision or if he/she is not able to appreciate the reasonably foreseeable consequences of such a decision. The health care professional proposing the treatment course of action assesses capacity. (1)

Consent has many elements such as lack of coercion, given by patient or legally authorized substitute decision maker, a reference to the particular administrator and treatment, and comes with full disclosure (e.g. risks, benefits, side effects, alternatives).(1)

Why is it important?

  • The Health Care Consent Act (HCCA) is an Ontario law based on capacity to consent; it governs health practitioners, including physicians (2)
  • Ontario HCCA is also relevant to the Ontario Substitute Decisions Act- a person found to lack capacity for personal care would need a substitute decision maker (3)

Common Causes

  • 73 % of Canadians die from complex chronic diseases and some will be lack capacity; for example, progressive dementing illnesses will affect the person’s decision-making ability at some point (1) (4)

Key Considerations

  • A person will be able to appreciate the consequences of the decision if the following occurs: (1)
    • Acknowledges that the condition for which treatment is being recommended can affect him/her
    • Understands how proposed action, or lack of action, can effect quality of life
    • Explain why he/she is making a decision in a way that aligns with previously expressed values (e.g. realistic expectations, can communicate choice, can manipulate information rationally (4)
  • If the person is found incapable to consent, he/she must be advised of  legal rights (unless in emergency situations)and the health professional must follow procedures developed by the professional governing body
  • The health professional must also notify the patient that a substitute decision maker will assist in the understanding of treatment and be responsible for final decisions (4)
  • Health professional should still involve the incapable person to the greatest extent possible (4)
  • If patient disagrees with current substitute decision maker, the physician must advice the patient of his/her options and assist in either finding another substitute decision maker or applying to the Consent and Capacity Board for a review of the finding of incapacity (4)
  • If a substitute decision maker does not exist, the physician should contact the Public Guardian and Trustee
  • If a health professional does not believe the substitute decision maker is acting in the best interest of the patient or according to patient’s prior wishes, then he or she can request a hearing with the Consent and Capacity Board (4)
  • For more information on determining capacity and consent, please consult the following guide for physicians:
    http://www.cpso.on.ca/uploadedFiles/policies/policies/policyitems/capacity_consent_july07dialogue.pdf
  • Health care professionals can also consult OHA’s Practical Guide to Mental Health and the Law in Ontario:
    http://www.oha.com/KnowledgeCentre/Library/Toolkits/Documents/Final
  • NICE also provides a tool on Capacity and Consent, Ontario Edition at:
    http://www.nice-tools.ca/files/Capacity.pdf

References

1.      Canadian Hospice Palliative Care Association. (2012). Advance Care Planning in Canada: National
         Framework
. (2011). Retrieved March 17, 2014 


2.      Service Ontario. (2010). Health Care Consent Act, 1996. Retrieved March 17, 2014 from:
         http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_96h02_e.htm\ServiceOntario_e.htm

3.      ServiceOntario. (2011). Substitute Decisions Act, 1992. Retrieved March 17, 2014 from:
         https://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_92s30_e.htm

4.      The College of Physicians and Surgeons of Ontario. (2007). Determining capacity to consent
         Retrieved March 17, 2014 from: 
         http://www.cpso.on.ca/uploadedFiles/policies/policies/policyitems/capacity_consent_july07dialogue.pdf

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