How to Approach Diabetes Self-care in a Patient with Cognitive Impairment


60 percent of patients with diabetes participating in a community-based disease management program in New York saw significant improvements in health outcomes.

Patients with diabetes who follow a self-care regimen generally have success in controlling their disease. But what about patients whose other health conditions, such as cognitive impairment and/or depression, create barriers to effective treatment?

It is those individuals facing such obstacles to successful diabetes management that New York City College of Technology (City Tech) Nursing Professor Kathleen Falk made the focus of a year-long study. She provided a community-based care plan -- followed by testing and evaluation every three months to monitor disease markers -- to see if such a strategy could make a difference in health outcomes.

Falk, chairperson of the Adult Day Health Council (ADHC) Research Collaborative Diabetes Management Study, obtained the participation of 104 clients from 10 Adult Day Health Care Centers in New York City (including three in Brooklyn), Long Island, upstate New York and Buffalo.

“These centers primarily serve those with low incomes, low health literacy and the least access to health care,” Falk says. “They have a higher rate of Diabetes Mellitus, especially those who are elderly, immigrants and/or have multiple co-existing illnesses.”

The study employed what are known as the ABC’s of diabetes care: A1C blood tests (to check blood sugar), blood pressure control and cholesterol management. An interdisciplinary medical team, led by nurse case managers, included endocrinologists, dieticians, physical therapists and social workers. The team prepared individual care plans for clients and gave podiatry, eye and dental/oral exams.

At each three-month assessment point, at least 60 percent of participants, including those with depression or cognitive impairment, showed a statistically significant decrease in A1C levels, while approximately 25 percent worsened. The analyses demonstrated the program’s general effectiveness in reducing the A1C levels of participants.

Falk, formerly a visiting nurse in Brooklyn for 15 years, explains, “In a hospital, the nurses do everything for people living with diabetes, but when such clients go home, they can become overwhelmed with the complexity of their own care. Self-management involves needles, medications, insulin, blood sugar checks, dietary changes and many follow-up appointments. Many people can’t handle that, especially those who are depressed.”

Nurse practitioners provided particularly valuable input. “Nurses who work in ADHC centers are very astute in identifying symptoms of depression which is the first step towards treatment,” says Falk, a Westerleigh, Staten Island, resident who lived for many years in Bay Ridge. “More than a third of the clients had cognitive impairment and one-third had depression.”

Falk attributes the positive outcomes to the way the centers conducted the clients’ evaluation visits. Clients were able to get immediate feedback about the A1C test, which reinforced their efforts and engaged them in setting goals for managing diabetes. “Any time you have people participating in their own health care management,” Falk says, “they do better when they go home.”

The study’s second phase is following a control group of ADHC clients from other centers; a retrospective chart review will be completed by the end of this year.

“Successful diabetes management in New York City is more important than ever,” says Falk. “The statistics are sobering -- the epidemic rate of diabetes in New York City is twice the national average and climbing. Of the city’s population, 9.5 percent have diabetes. The more than 100,000 New Yorkers with very poorly controlled diabetes are at high risk of heart attack, stroke, kidney failure, blindness and amputations.”

According to the New York City Department of Health, in the past 10 years, the city’s number of diabetics has more than doubled, and an estimated 265,000 people are still undiagnosed. While Asians constitute the largest group of diabetics, African Americans have the highest death rate.

A nursing doctoral student at the CUNY Graduate Center, Falk wants to build on her study in order to educate community nurses on identifying depression among diabetics and making interventions on their behalf. She will most likely write her dissertation on the subject.

“This work has the potential to be a national model,” Falk notes. “It will be a lot of work, but worthwhile. Nurses are on the frontline in pulling together management of care.

“Although the new buzz phrase in healthcare reform is the ‘medical home’ -- that is, providing clients with assistance in organizing and coordinating their care -- it is ‘old school’ to nurses,” she continues. “Nurses have been practicing with the emphasis on care coordination for decades. Care coordination is what nurses do best and will continue to be an important factor in reducing the rate of hospitalization and improving quality of health.”

Source: New York City College of Technology

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