Geriatric Diabetes Management: Evidence-Based Project

Abstract

Diabetes can be defined as a severe condition that can affect the entire body of any given patient. One of the most characteristic traits of this disease is the fact that it requires never-ending, daily self-care that has to be maintained. The presence of diabetes may provoke several complications such as increase in the levels of blood sugar and blood glucose. This may cause issues related to body functions and impact the prevalence of BMI-related issues in individuals (Kokkinos et al., 2012, p. 1026). Some other complications include joint disorders and a higher risk of being exposed to heart disease. Importantly, diabetes may also impact skin health and cause problems with teeth. Certain medicines or infections can cause emergencies that may subsequently lead to a person’s death. Additional patient education coupled with physical training instruction and exercise, when compared to the amounts of information received under the standard diabetic protocol, can improve understanding and compliance as well as healthcare outcomes in diabetic patients aged 60 or older.

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Introduction

Aging people often develop various chronic disorders including diabetes due to the changes that take place in their bodies. Glucose metabolism becomes impaired, and the health conditions often deteriorate due to older people’s sedentary lifestyles and unhealthy diets (Biensø et al., 2015). The disorder has become a global health concern as diabetes is the cause of death in 14.5% of people worldwide (Essien et al., 2017). Chrvala, Sherr, and Lipman (2016) note that medication-based treatment has proved to be effective, but it can be improved with the help of training and self-management skills development. Healthcare practitioners and scholars have come up with numerous strategies and frameworks. This project proposes additional patient education of diabetic patients as means of improving their compliance with the prescribed treatments and achieving better outcomes.

The Spirit of Inquiry Ignited

Older patients diagnosed with such chronic disease as diabetes tend to follow healthcare professionals’ advice and treatment plan when it comes to medication. However, medication-based treatment has proved to be most effective when accompanied by sound training related to the development of healthy dietary habits and lifestyles (Park et al., 2017). In many cases, treatment can be even impaired if the guidelines related to diets are not followed. The use of certain training and guidance has become common in the clinical setting (Chrvala et al., 2016). For example, Ngandu et al. (2015) implemented a longitudinal study that revealed a positive impact of such treatment on elderly patients’ health including cognitive functions.

However, it has also been acknowledged that some groups do not follow the designed plans especially when it comes to physical activity or diets. For instance, African American patients are often reluctant to follow the developed plan or actively participate in various training programs (Trief et al., 2013). This nonconformity can undermine the expected results of treatment plans and programs that include training concerning diets, physical activity, and lifestyles. It is clear that such populations may need specific frameworks that address their various needs to the fullest.

The PICOT Question Formulated

(P) In elderly patients of 60 to 80 with chronic diseases like diabetes, (I) does additional patient consultation and education paired with physical exercise, (C) compared to standard diabetic protocol, (O) increase their health knowledge and improve their health status (T) in a period of 6 months?

Search Strategy Conducted

The PubMed database was used first to locate peer-reviewed articles that provided level 1 and level 2 evidence. The following key words were used: diabetes, adult, treatment, elderly, education, self-management, knowledge. After that, Science Direct database was also reviewed using the same key words. The focus was on recent primary sources as it was essential to review particular evidence and evaluate the effectiveness of different programs. The studies that focused on older patients aged between 60 and 80 were included.

In order to compare the effects of proposed intervention with current diabetic protocol, it is necessary to estimate the extent to which patient education and training is in the clinical setting. According to Chrvala et al. (2016), training programs aimed at shaping diets, lifestyles and developing self-management skills are becoming an indispensable part of the treatment of diabetes. Additional information regarding alternative medical practices pertaining different types of programs especially when it comes to alternative practices like yoga and Thai Chi was utilized. Armstrong, Colberg, and Sigal (2015) unveil certain peculiarities of the use of traditional and alternative strategies.

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Critical Appraisal of the Evidence Performed

Evidence-based practice implies the use of different types of evidence characterized by validity and reliability. The sources used for this project are published in peer-reviewed articles. Importantly, the vast majority of these studies provide level I and level II evidence, which is regarded as the foundation of a valid and reliable analysis. These articles help in evaluating the effectiveness of different components of training programs that have been used in different clinical settings. For example, such aspects as physical activity, knowledge sharing, and conventional treatment components were included in this research. Level III evidence is utilized sparingly in order to give the proposed interventions context as well as to provide the informational background in order to introduce other sources of information.

A descriptive study was utilized in order to set up the context for the suggested intervention. The value of this research lies in its overview of the use of such alternative practices as yoga and Thai Chi. The present study will use some elements of these practices as they are regarded as beneficial for the development of muscular fitness, mobility, flexibility, balance, and self-control (Armstrong et al., 2015). These outcomes are specifically valuable for the elderly who may suffer from the lack of physical activity and flexibility or self-control.

Habibzadeh, Sofiani, Alilu, and Gillespie (2017) provide important Level I evidence that suggests the effectiveness of educational interventions in improving patient understanding and willingness to learn and utilize practices aimed at reducing symptoms of diabetes. This study is recent and published in a peer-reviewed medical journal, which vouches for the accuracy of its results. Group discussions are to be integrated into the proposed intervention along with other means of patient education.

The information provided by Park et al. (2017) stresses out the importance of focus, peer support, and focus provided by dedicated “diabetes camp” on education and perception of information by the elderly and middle-aged patients. As this is a level III evidence, it cannot be used to base an intervention upon, but it is useful for establishing intergroup relations and consider them when designing an intervention.

The article Essien et al. (2017) presents a randomized control trial that attests for the effectiveness of structured guidelines when implemented in diabetic patients. This information was published last year in a peer-reviewed journal and contains Level I evidence, therefore the interventions described in it could be made part of the complex patient education program proposed in this intervention.

Jahromi, Ramezanli, and Taheri (2015) have conducted a randomized control trial in order to research the importance of summarization of knowledge at the end of each education session in order to improve patient compliance and outcomes. This information is non-contradictory, relatively recent, and peer-reviewed. Therefore, it is trustworthy. The practice of summarizing the lessons in bullet points at the end of the lesson can be implemented in the proposed intervention of additional diabetic education of the patients.

Tan, Li, and Wang (2012) provide Level I evidence that shows the effectiveness of aerobic exercise for elderly patients diagnosed with type 2 diabetes. This information, while peer-reviewed and published in a peer-reviewed journal, is relatively old. Having been published in 2012, it is more than 5 years old. However, its results and methodology are solid, therefore the findings presented in this source should not be dismissed due to age. Additional instructions regarding aerobic exercises should be included into the proposed intervention program.

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Trief et al. (2013) provide the results of a Level II randomized trial that involved the effects of telemedicine and self-care on various ethnic groups. This information is relatively recent and trustworthy as it was published in a peer-reviewed medical journal. The strength of evidence is determined by the randomization of various medically underserved individuals of different races. The information provided can be utilized in order to tailor the proposed educational intervention for different ethnical and social groups.

Evidence Integrated with Clinical Expertise and Patient Preferences to Implement the Best Practice

The suggested program will contain components that have proved to be beneficial for elderly patients. Park et al. (2017) stress that a comprehensive approach to a training program for the elderly is important and beneficial. Researchers claim that the population with a shorter duration of the disease and higher HbA1 baseline benefited most. These findings can be used when evaluating the effectiveness of the program, so it is possible to include diabetes duration and HbA1 baseline in the list of variables for evaluation. Ngandu et al. (2015) also claim that multidimensional programs can result in positive health outcomes for elderly patients and improve or maintain their cognitive functioning.

As for the design of the training sessions, they should contain knowledge sharing as well as a period of physical activity. Essien et al. (2017) describe the outcomes of the program that involved structured guidelines provided to the patients. The researchers found the program effective as the patients’ health conditions improved as compared to the control group. The discussion component has proved to be an important element of such programs. For instance, Jahromi et al. (2015) note that an indispensable part of the sessions was a summary of the major points made at the end of the session. One of the members of the group summarized the material. Habibzadeh et al. (2017) note that experience sharing also contributed to patients’ adherence to treatment plans and program activities.

As has been mentioned above, such practices as Thai Chi and Yoga have proved to be effective as well (Armstrong et al., 2015). Prior et al. (2015) claim that increased capillary density in muscles positively affects glucose metabolism. Biensø et al. (2015) also provide evidence suggesting that physical activity is beneficial for glucose regulation. Therefore, it is possible to assume that rather intensive training may be needed, but it should definitely be age-appropriate.

Trief et al. (2013) provide important insights into the effects such programs may have on different ethnic groups. A telemedicine intervention was evaluated, and it turned out to be less effective in African American and Hispanic American patients. These populations failed to conform with all the prescriptions although they remained active in reporting and discussions. Such variables as disease duration and symptoms severity had a significant impact on the participants’ adherence to the plan. Importantly, the intervention did not include a sound physical component.

Based on these findings, it is possible to describe the major components of the suggested program. The plan will be designed for older adults aged between 60 and 80. The program’s duration will be six months. Each session will include several components including distribution of educational material, physical activity, knowledge and experience sharing, as well as feedback. The trainer will provide certain data on the most appropriate dietary behaviors and lifestyles. It is essential to support all the information provided with the data concerning particular benefits of each strategy, program component, and element. Every session, the participants should obtain evidence-based information as it will encourage the patients to adhere to the plan. Besides, the trainer will address the minority populations’ needs through providing the information concerning available resources, and ways to develop proper diets and lifestyle that can be affordable.

As for the physical activity, the training will include elements of yoga and Thai Chi that will be age-appropriate and intensive enough. Aerobics will also be included. In order to encourage the patients to be more active, it can be effective to encourage the patients to have journals where they note their achievements, as well as emotions, fears, and so on. This information can be used during the process of the project evaluation. Each session will also include the discussion of experiences, concerns, plans, and the like. The patients should feel engaged and empowered. The provision of feedback can contribute to the achievement of these goals.

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Outcome of Practice Change Evaluated

The evaluation of the program is an important process that can help in revealing gaps as well as reasons for failures if any. One of the methods to be employed is self-reporting. After the completion of the program, the participants will provide self-reports that will highlight their attitudes towards the program and intervention outcomes as seen by the patients. The patients will be encouraged to reveal aspects and components of the program that were not effective, pleasant, appropriate, and so on. They will also report on their overall health conditions, improvements or health deterioration, as well as overall satisfaction with health care provided. As has been mentioned above, the participants’ journals can help them be specific and identify the most important points.

Apart from self-reports, it is essential to identify specific health outcomes related to the program. The patients’ HbA1c outcomes can be measured to assess the effectiveness of the program. Finally, it can be important to analyze healthcare professionals’ evaluation of the program. The practitioners’ views can be used to improve the program or to adjust it to particular settings. The practitioners involved in the project can complete questionnaires. Such aspects as patients’ conformity and adherence, availability of resources, possible gaps should be unveiled in these evaluations.

Project Dissemination

The dissemination of the project is an important stage that has to be implemented properly. Therefore, it can be necessary to use several channels to ensure that the findings will be reviewed and can enrich the knowledge base. The findings will be presented to a medical journal for publishing and peer review. This channel is the most appropriate dissemination strategy when it is necessary to share data on the national level. However, it can be appropriate to use such channels as conferences and local workshops. This approach can help in improving the program before the program has started. Such knowledge sharing can help craft the most efficient program that will address the needs of the target population. It is also possible to share the data through the direct communication with nursing professionals working at nursing homes. They may provide their feedback on the results and factors that had an impact on the effectiveness of the project.

Conclusion

In conclusion, it is necessary to note that the suggested program is evidenced-based and addresses an urgent issue. The program can potentially help thousands of older patients especially minority groups that often have limited access to high-quality health care. The program will be evaluated based on the patients’ self-reports and their health-related data, as well as nursing staff’s feedback. The dissemination of the findings will also be implemented through several channels. During the stage of project development, the feedback from healthcare professionals will be used. Knowledge sharing will occur during workshops and conferences. The findings and project outcomes will also be revealed in a scholarly journal. The data (the article itself as well as emails or presentations) will be sent to several nursing professionals working in local nursing homes. The project is likely to have a positive impact on patients’ health as well as the development of the community. The program can be further used in various settings and help older patients maintain healthy and active lifestyles.

References

Armstrong, M., Colberg, S., & Sigal, R. (2015). Moving beyond cardio: The value of resistance training, balance training, and other forms of exercise in the management of diabetes. Diabetes Spectrum, 28(1), 14-23. Web.

Bienso, R., Olesen, J., Gliemann, L., Schmidt, J., Matzen, M., Wojtaszewski, J.,… Pilegaard, H. (2015). Effects of exercise training on regulation of skeletal muscle glucose metabolism in elderly men. The Journals of Gerontology: Series A, 70(7), 866-872. Web.

Chrvala, C., Sherr, D., & Lipman, R. (2016). Diabetes self-management education for adults with type 2 diabetes mellitus: A systematic review of the effect on glycemic control. Patient Education and Counseling, 99(6), 926-943. Web.

Essien, O., Out, A., Umoh, V., Enang, O., Hicks, J. P., & Walley, J. (2017). Intensive patient education improves glycaemic control in diabetes compared to conventional education: A randomized controlled trial in a Nigerian tertiary care hospital. PLoS ONE, 12(1), 1-12. Web.

Habibzadeh, H., Sofiani, A., Alilu, L., & Gillespie, M. (2017). The effect of group discussion-based education on self-management of adults with type 2 diabetes mellitus compared to usual care: A randomized control trial. Oman Medical Journal, 32(6), 499-506. Web.

Jahromi, M. K., Ramezanli, S., & Taheri, L. (2015). Efectiveness of diabetes self-management education on quality of life in diabetic elderly females. Global Journal of Health Science, 7(1), 10-15. Web.

Ngandu, T., Lehtisalo, J., Solomon, A., Levälahti, E., Ahtiluoto, S., Antikainen, R.,… Kivipelto, M. (2015). A 2 year multidomain intervention of diet, exercise, cognitive training, and vascular risk monitoring versus control to prevent cognitive decline in at-risk elderly people (FINGER): A randomised controlled trial. The Lancet, 385(9984), 2255-2263. Web.

Park, S. Y., Kim, S. Y., Lee, H. M., Hur, K. Y., Kim, J. H., Lee, M., … Jin, S. (2017). Diabetes camp as continuing education for diabetes self-management in middle-aged and elderly people with type 2 diabetes mellitus. Diabetes Metabolism Journalism, 41(2), 99-112. Web.

Prior, S., Goldberg, A., Ortmeyer, H., Chin, E., Chen, D., Blumenthal, J., & Ryan, A. (2015). Increased skeletal muscle capillarization independently enhances insulin sensitivity in older adults after exercise training and detraining. Diabetes, 64(10), 3386-3395. Web.

Tan, S., Li, W., & Wang, J. (2012). Effects of six months of combined aerobic and resistance training for elderly patients with a long history of type 2 diabetes. Journal of Sport Science & Medicine, 11(3), 495-501. Web.

Trief, P. M., Izquierdo, R., Eimicke, J. P., Teresi, J. A., Goland, R., Palmas, W.,… Weinstock, R. S. (2013). Adherence to diabetes self-care for white, African-American and Hispanic American telemedicine participants: 5-year results from the IDEATel project. Ethnicity & Health, 18(1), 83-96. Web.

Appendix

Evaluation Table.

Database: PubMed Study #1
Habibzadeh, Sofiani, Alilu, & Gillespie (2017)
Study #2
Tan, Li, & Wang (2012)
Study #3 (Park et al., 2017) Study #4 Essien et al. (2017) Study #5 Jahromi, Ramezanli, & Taheri (2015). Synthesis
(p) Population Patients with type 2 diabetes Elderly patients diagnosed with T2DM Adults with a T2DM diagnosis Individuals diagnosed with T2DM (N=104) at a tertiary care facility (age = 52.7±10.5 years) Patients with type 2 diabetes aged between 60 and 75 years (M = 66.76) Most of the studies focused on elderly T2DM patients. However, a few had subjects aged <50 years.
(i) Intervention Group discussion-based education on diabetes self-management Three weekly sessions of 30-minute aerobic exercises and 10-minute endurance training Participated in a group-based diabetes educational camp focusing on diet and exercise The participants received intensive education (lectures and group discussions) on diet, exercise, self-care, etc. offered in 12 structured sessions Group education on glycemic control, nutrition, physical activity, stress management, and self-care In all the five studies, the intervention tested was diabetes education – diet and exercise – in addition to routine care. The mode of delivery was the group-based approach.
(c) Comparison Routine care only Personal exercise habits Conventional diabetes self-management education Received conventional, unstructured DSME education Control group received standard care treatment The control subjects received either routine care (DSME education) or retained individual exercise habits.
(o) Outcome The intervention group had improvements in “self-organization, self-adjustment, glycemic self-monitoring, and adherence to diet” (Habibzadeh, Sofiani, Alilu, & Gillespie, 2017, p. 499). HbAlc and HDL decreased by 0.55 and 0.09 in the intervention group after the training. The decline in the control group for HbAlc and HDL were 0.06 and 0.06, respectively. A reduction in biomedical variable (HbA1c) in patients who attended the diabetes educational camp There was a significant decline in HbA1c measured with a Clover A1c Analyzer (Essien et al., 2017). The outcomes of interventions were quality of life in terms of glucose control, physical fitness, psychological health, and self-care ability (Jahromi, Ramezanli, & Taheri, 2015). The outcomes of the educational intervention were improved post-intervention HbA1c and HDL scores, quality of life, fitness levels, psychological wellbeing, and diabetes self-management.
(t) time 3 months 6 months 12 months 6 months 3 months The timeframe taken to demonstrate the outcome ranged between 3 and 12 months.

Evaluation Table.

Citation Design Sample size: Adequate? Major Variables: Independent
Dependent
Study findings: Strengths and Weaknesses Level of evidence Evidence synthesis
Habibzadeh, H., Sofiani, A., Alilu, L., & Gillespie, M. (2017). The effect of group discussion-based education on self-management of adults with type 2 diabetes mellitus compared to usual care: A randomized control trial. Oman Medical Journal, 32(6), 499-506. Web. The study design was a randomized control trial The number of study participants were 90 (intervention = 45, control = 45) patients enrolled in two diabetes clinics. This sample size seems inadequate given that 16 subjects were lost to follow-up The independent variables: group education self-care and routine care
Dependent variables were “self-organization, self-adjustment, interaction with health experts, blood sugar self-monitoring, adherence to the proposed diet, and total self-management criterion” (Habibzadeh et al., 2017, p. 500).
There were significant improvements in “self-organization (t=11.24, p< 0.001), self-adjustment (t= 7.53, p< 0.001), interaction with health experts (t= 7.31, p< 0.001), blood sugar self-monitoring (t= 6.42, p< 0.001), adherence to the proposed diet (t= 5.22, p< 0.001), and total self-management (t= 10.82, p< 0.001)” in the intervention group (Habibzadeh et al., 2017, p. 502). The strengths of this study include the use of an RCT and patient blinding. Its weaknesses lie in a small sample size and short follow-up period. Level I evidence – an RCT that provides the most reliable evidence The study gives strong evidence (level I) supporting group-based education as an intervention for equipping patients with self-management knowledge to improve their glycemic control. It supports the use of well-structured group educational programs to improve patient outcomes.
Tan, S., Li, W., & Wang, J. (2012). Effects of six months of combined aerobic and resistance training for elderly patients with a long history of type 2 diabetes. Journal of Sport Science & Medicine, 11(3), 495-501. Web. The design was a randomized controlled trial Thirty patients took part in this study. This sample size seems adequate to test the efficacy of physical education on diabetes management. The independent variables included exercise training and routine care.
The dependent variables included “body composition, glycemic control, lipid profile, and functional capacity” (Tan, Li, & Wang, 2012, p. 496).
The study found that a 6-month aerobic exercise and endurance training have a significant beneficial effect on “composition, glycemic control, lipid profile, leg muscle strength, and walking ability “in elderly T2DM patients (Tan et al., 2012, p. 498). The study gives level I evidence – an RCT design with an exercise group and a control group The study demonstrates that group exercise training has significant therapeutic effects on T2DM risk factors in the elderly population, as HbAlc and HDL decreased by 0.55 and 0.09, respectively, in the exercise group.
Park, S. Y., Kim, S. Y., Lee, H. M., Hur, K. Y., Kim, J. H., Lee, M., … Jin, S. (2017). Diabetes camp as continuing education for diabetes self-management in middle-aged and elderly people with type 2 diabetes mellitus. Diabetes Metabolism Journalism, 41(2), 99-112. Web. It involved a case-control study design. The cases attended a diabetes educational camp. A retrospective selection of the controls was done from a clinical database. 150 subjects (≥65 years) participated in the study. This sample size seems adequate to explain intergroup differences in outcomes. The independent variables included diabetes training on diet and exercise and conventional education (DSME).
The dependent variables were metabolic outcomes, psychosocial measures, medication prescription changes, and HbA1c
HbA1c levels were lower (p=0.01, mean≥6.5%) in patients who attended the training compared to controls and baseline data. Thus, integrated educational interventions can improve the metabolic outcomes of elderly diabetics. Its main strength includes the recording of HbA1c changes over one year for comparison with baseline data. Its weaknesses relate to insufficient data to account for the effect of the educational camp and subject loss to follow-up. Level III evidence – the study involved a case-control design. An integrated diabetes camp in addition to conventional education is an effective intervention in achieving sustained glycemic control in elderly patients with T2DM.
Essien, O., Out, A., Umoh, V., Enang, O., Hicks, J. P., & Walley, J. (2017). Intensive patient education improves glycaemic control in diabetes compared to conventional education: A randomized controlled trial in a Nigerian tertiary care hospital. PLoS ONE, 12(1), 1-12. Web. The study design was a non-blind individually-randomized controlled trial based on the CONSORT standards The number of study participants were 104 (intervention = 53, control = 51) after 12 subjects were lost to follow-up. This sample size seems inadequate, as the diabetic population in Nigeria is high. This aspect limits the generalizability of the results Independent variables: structured group-based education (intervention) on diet, exercise, ulcerated foot care, etc. and conventional DSME (control)
Dependent variable: HbA1c
The study found that a group-based educational program is more effective in reducing HbA1c than conventional DSME due to improved self-care knowledge. The main strength of this study is the use of an RCT with an under-served population. Its limitations include it was physician-led as opposed to nurse-driven intervention, lack of blinding, and the limited generalizability of the findings owing to the small sample size. Level I evidence – an RCT that provides the most reliable evidence that intensive group education is effective in diabetes self-care. The study gives strong evidence (level I) supporting group-based education as an intervention for equipping patients with knowledge to control their blood glucose concentrations. It supports the use of well-structured group educational programs to improve patient outcomes.
Jahromi, M. K., Ramezanli, S., & Taheri, L. (2015). Effectiveness of diabetes self-management education on quality of life in diabetic elderly females. Global Journal of Health Science, 7(1), 10-15. Web. The study design was a randomized control trial The sample size was 90, which was randomized to the experimental group (n = 45) and control group (n = 45). The sample size is inadequate because it represents 1.8% of the study population (N = 5000) The independent variable of the study is group education diabetes management, whereas the dependent variable is the quality of life in terms of glycemic control, self-care, nutrition, physical activity, and stress management. The findings are significant because they show that “QOL score has a significant difference between the two groups (P = 0.012)” (
The strengths of the findings is that they are valid because it used established scale of the quality of life and employed randomized controlled design. However, the weaknesses of the study are the sample size is inadequate and focuses on women only making the findings have low external validity
Due the use of the randomized controlled design, the findings of the study are strong (level1) The findings demonstrate that group education is an effective intervention when compared to standard intervention in improving quality of life of elderly female patients
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