Assessment of Barriers to Improve Diabetes Management in Older Adults

Abstract

OBJECTIVETo evaluate whether assessment of barriers to self-care and strategies to cope with these barriers in older adults with diabetes is superior to usual care with attention control. The American Diabetes Association guidelines recommend the assessment of age-specific barriers. However, the effect of such strategy on outcomes is unknown.RESEARCH DESIGN AND METHODSWe randomized 100 subjects aged ≥69 years with poorly controlled diabetes (A1C >8%) in two groups. A geriatric diabetes team assessed barriers and developed strategies to help patients cope with barriers for an intervention group. The control group received equal amounts of attention time. The active intervention was performed for the first 6 months, followed by a “no-contact” period. Outcome measures included A1C, Tinetti test, 6-min walk test (6MWT), self-care frequency, and diabetes-related distress.RESULTSWe assessed 100 patients (age 75 ± 5 years, duration 21 ± 13 years, 68% type 2 diabetes, 89% on insulin) over 12 months. After the active period, A1C decreased by −0.45% in the intervention group vs. −0.31% in the control group. At 12 months, A1C decreased further in the intervention group by −0.21% vs. 0% in control group (linear mixed-model, P < 0.03). The intervention group showed additional benefits in scores on measures of self-care (Self-Care Inventory-R), gait and balance (Tinetti), and endurance (6MWT) compared with the control group. Diabetes-related distress improved in both groups.CONCLUSIONSOnly attention between clinic visits lowers diabetes-related distress in older adults. However, communication with an educator cognizant of patients’ barriers improves glycemic control and self-care frequency, maintains functionality, and lowers distress in this population.

Levels and Barriers of Glycemic Control and Self-Management Among Diabetic Patients in Primary Health Care in Jeddah: A Cross-Sectional Study.

“…Further obstacles to glycemic control have been reported, including treatment costs, absence of social support, poor patient literacy level, awareness or understanding of the disease, and negative attitudes towards diabetes. These are in addition to factors pertaining to self-management, particularly practices in medication compliance, blood glucose testing, and noncompliance with dietary recommendations (13)(14)(15)(19)(20)(21)(22)(23)(24)43,48).…”

Managing diabetes in people with dementia: a realist review

“…In a RCT 116 focused on improving diabetes management in older people, the authors found that older adults were reluctant to make changes to their medication between clinic visits. However, regular telephone contact from a diabetes educator encouraged people to adjust their insulin dosage, leading to better glycaemic control.…”

“…The quotation suggests that care at the GP surgery, where the patient was known, was preferable to the less personalised (and less comprehensive) care received at the diabetic clinic. Clearly this is only one person's experience; however, many of the studies we included 39,59,62,64,66,116,130 support the link between regular contact with the same HCP, the development of a good relationship and improved SM practices. For example, a controlled study 59 of diabetes SM education for people with cognitive impairment found that regular contact with a single diabetes educator led to the development of a rapport, which was important in helping participants to develop strategies to improve SM (e.g.…”

“…116,142 Current care pathways, however, lack the capacity to consistently assess SM capabilities or provide SM support. 119 This is illustrated by the following quotation:…”

“…A RCT to assess barriers to SM experienced by older people with type 2 diabetes demonstrated the importance of assessing the specific self-care barriers faced by this cohort and then individualising diabetes management. 116 Individualisation was aided by a diabetes educator making telephone contact between clinic visits.…”