Diabetes Epidemic Now Poses Challenges for Nursing Homes

More and more people with diabetes are living to older ages, thanks to medical advances. But the long-term facilities, such as nursing homes, that care for aging Americans may not be ready for the additional challenges that come with treating patients with diabetes.

"We need to spend appropriate time to think of a way to successfully provide care for people with diabetes as they enter their elder years, and we're just beginning to understand how to do that," said Dr. Paul Strumph, vice president and chief medical officer for the Juvenile Diabetes Research Foundation.

Although as many as one in four nursing home residents has diabetes, not all are getting care that meets the American Diabetes Association's goals for community-dwelling adults, according to a recent study.

The study, published in Diabetes Care, found that while 98 percent of nursing home residents with diabetes had their blood glucose levels monitored, only 38 percent met short-term glucose goals.

The better news from the study was that 67 percent of the nursing home residents with diabetes met their long-term glucose control goals, which meant they scored less than 7 percent on their A1C tests. A1C is a measure of long-term blood sugar control.

"One of the key differences in managing diabetes in a nursing home is that it's often not the condition of primary importance," said Helaine Resnick, director of research at the Institute for the Future of Aging Services for the American Association of Homes and Services for the Aging.

Resnick said one of the concerns she had with the study findings was that no one has yet to come up with specific guidelines for caring for elderly people with diabetes. Glucose control goals for someone who's 40 and living at home may well be different than for someone who's 85, cognitively impaired, and living in a long-term care facility, she said.

"Diabetes medications are designed to lower glucose levels, which can prevent complications from developing in diabetic people. But, when you take medicines to lower blood glucose, it can go too low, which can be extremely dangerous, especially for older adults," Resnick said, noting that it's difficult to find "the appropriate balance between keeping sugars low with the risk of keeping it too low."

Strumph pointed out that the needs of older people with diabetes may be different as well. People with type 1 diabetes and people with type 2 diabetes who need insulin often choose to use an insulin pump when they're younger, but pumps may not be the best choice for someone who's older and not as aware, he said.

"Someone in a nursing home could pull out a pump site and not know. In that case, you may want to be on a longer-acting insulin instead. We haven't yet defined what the ideal insulin [regimen] is for someone in a facility with a fairly predictable schedule," Strumph said.

Both Strumph and Resnick said it's important for family members, the nursing home resident, and the staff to come up with a realistic care plan.

"Families need to become more actively involved in working with care teams, and that's true for diabetes and for other conditions. Ensure that the facility understands the family's and the resident's preferences. Is your mother more interested in keeping her blood glucose control tight and risk [low blood sugar]? Or is it better for her to ease up on glucose control and work more on quality-of-life issues? Resnick said.

"Families have to be very involved, and the communication needs to be ongoing, because people's values can change," she added.

More information

For tips on selecting a nursing home, visit the AARP Web site.

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The 'not so old' suffer from Alzheimer's too: study

Alzheimer's disease affects not only the elderly, said a study Monday that found 14 percent of the estimated 500,000 Canadians suffering from dementia are under the age of 65.

The Alzheimer Society warned that an expected doubling of cases in the coming two decades, due to the aging population and the trend toward earlier diagnosis, risks overwhelming Canada's health care system.

"As it stands today, the number of Canadians living with Alzheimer's disease or a related dementia will double within a generation," Ray Congdon of the Alzheimer Society said in a statement.

"This new data only reinforces the fact that Alzheimer's disease and related dementias are a rising concern in this country, an epidemic that has the potential to overwhelm the Canadian health care system."

In the meantime, businesses and industry sectors "are also being affected as our boomer generation, a generation of leaders and mentors, are affected by dementia," said the Canadian society's chief executive Scott Dudgeon.

More than 70,000 Canadians diagnosed with Alzheimer's are under age 65, and around 50,000 of them are under age 60, the society said.

Alzheimer's disease is a brain disorder that manifests itself as premature senility.

Studies have shown it to be associated with plaques in the brain and according to the Alzheimer's Society, one in 11 Canadians over age 65 suffer from it.

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Shaping good health as teens outgrow pediatrician

Ever watched a teen skulk in the corner of a toddler-packed pediatrician's waiting room, obviously wishing to be anywhere else?

Adolescents aren't just big kids, and too many start falling through cracks in the health care system when they pass the stage of preschool shots and summer camp checkups — what a major new report calls missed opportunities to shape the next generation's well-being.

The period between ages 10 and 19 is unique, bringing more rapid biological changes than perhaps any age other than infancy. Even though most of the nation's 42 million adolescents seem to be thriving, it is a time of risk-taking and pushing boundaries in ways that can mean immediate consequences: Car crashes, experimenting with alcohol or drugs, teen pregnancy, sexually transmitted disease.

And it's also an age when many of the habits that determine good health during adulthood are set, or not.

"They are quite literally our future. If we don't take good care of them, there's a strong likelihood when they're running the ship they're not going to have a good time running the ship," said Dr. Frank Biro of Cincinnati Children's Hospital's long-running adolescent medicine program.

Yet the system of care for tweens and teens is fragmented and poorly designed. Few doctors specialize in adolescents' complex needs, or provide comprehensive care that earns their trust, concludes a recent probe by the National Research Council and Institute of Medicine. Most at risk are the poor.

The result: The past decade has brought declines in teen pregnancy and smoking but little other overarching progress. Tweens and teens increasingly are overweight; physical activity's dropping; chronic diseases like asthma and diabetes are on the rise; and injuries, chiefly from car crashes, remain this age's leading cause of death.

While 20-somethings tend to see primary-care doctors the least, a gradual falloff begins in adolescence. Only a fraction of tweens and teens have been screened for risky behavior so doctors can intervene before a problem arises, the report found. Between 10 percent and 20 percent of adolescents annually experience a mental health disorder, such as depression or anxiety, with less access to that specialty care. Five million are uninsured, too often even left out of federal-state programs designed to provide health coverage to children.

Yet half of deaths among adults are due to health-related behaviors that often start during adolescence.

"A 10-year-old is probably the healthiest person in America," notes Dr. Frederick Rivara of the University of Washington, a co-author of the new report. "Something happens between age 10 and age 25."

Teens do tend to see a doctor, clinic or school-based care program somewhat regularly, if not because parents demand it, then for vaccinations or the 15-minute physical required by sports teams. But the report notes it can take at least 40 minutes to do a thorough adolescent checkup, including screening and counseling for risky behaviors — the kind that may prompt enough trust for the teen to return with a problem he or she doesn't want Mom to know about.

But with fewer than 500 doctors certified as adolescent medicine specialists between 1996 and 2005 — some states have none — most families will need to hunt a pediatrician or family physician with the communication and social skills and, perhaps more importantly, the true interest to engage a teen.

"Adolescents have so much energy. They see the world so differently than you or I," says Biro, Cincinnati's adolescent medicine chief, who wasn't part of the report and says society's stereotype of sex and drugs isn't the typical teen.

The relationship starts with the doctor making clear that the adolescent has a right to patient confidentiality that grows with age, although he or she must work with the parents, too.

As Biro describes the balancing act: "As long as you're not hurting yourself, another person or getting hurt by another person, I will hold that information confidential. ... If there's a direct health risk that could involve their life, then I will share that."

Then comes recognizing that the early teen years are when kids move from concrete thinking to more abstract thought — they begin to connect the dots, Biro explains. They may assume the doctor connected the dots the same way, meaning a girl who complains of stomach pain may not volunteer that she's fears pregnancy.

"It's not that they're withholding information. They figure they've just told you everything you need to know because the rest of it you should be able to figure out," Biro says. "I prove to them I am indeed about as smart as mud and I have to ask them more probing questions."

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EDITOR's NOTE — Lauran Neergaard covers health and medical issues for The Associated Press in Washington.

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On the Net:

Society for Adolescent Medicine: http://www.adolescenthealth.org

Adolescent medicine report: http://www.iom.edu

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