Seniors with Cognitive

Impairment and DSME

Monica Da Re and Shivaughn Rupnarain

Cognitive Functioning and Self-Management in Older People with Diabetes

Little and conflicting research on whether the type of cognitive impairment associated with diabetes affects peoples selfmanagement

Correlation between seniors with diabetes and the risk for dementia

Cognitive functioning is probably also adversely affected by age, illness, duration, glycemic control, and the presence of
other co-morbidities

Research study focused on whether minor cognitive impairment would be associated with poorer diabetes selfmanagement

Study: fifty-one people with T2D completed a series of cognitive tests and measures of diabetes self-management. Mean
age was 61.5 years, 22/51 were women

Conclusion: cognitive impairment below the threshold for detection by dementia screening is not associated with clinically
significant impairment of self-management.

Strengths & Limitations

Strengths: (1) Attempts to bridge the gap in the research: little research concerning the relationship between cognitive
impairment and seniors, (2) The conclusions from this research are potentially clinically useful. This research can reassure
patients that even though they do have age-related MCI, it is unlikely that their self-management will be affected, (3) Fairly equal
ration of men and women in study participants. It used approximately eight different test when looking at cognitive impairments,
(4) Also, when screening for participants, they only used participants with MCI and no one with a history of dementia.

Limitations: (1) Only looking at people with MCI - people with more serious forms are not being studied (I.e., Alzheimers,
dementia, etc.). Its not only a limitation of this study, but of this area in general - it is a difficult area to research due to the ethical
implications of doing the research itself, (2) Hard to conduct this type of research because of ethical considerations, (3) This
research article is rather vague. In terms of methodology did not really explain how they were distributed, who ran them, what the
questions were, etc.,

More research is needed in this area as there was a lack of scholarly research on the topic.

Why is it important that we address this issue? (see notes

at bottom)

Prevalence
-

More than one-fifth of all patients with diabetes are above the age of 60
1 in 6 senior males and 1 in 7 senior females diagnosed with diabetes
Normal aging is associated with a progressive increase in A1C

Suhl and Bonsignore, 2006 ; Stats

Canada, 2008; CDA, 2013

Growing area of concern

-

Canadas senior population is increasing

Number of seniors in the population estimated to 23.6 percent by 2030 (Statistics Canada, 2014).

Age is a non-modifiable risk factor for diabetes

In 2008/09, the 75 to 79 year age group had the highest proportion of people with diagnosed diabetes (23.1% of
females and 28.5% of males) (PHAC, 2008/9).

In the next 20 years, the number of people diagnosed with Alzheimers disease and other dementia will increase
substantially.

Projected number of Canadians age 65+ years living with Alzheimers and other dementias: 639,700 in 2031
(PHAC, 2011-2012).

Definitions:
-

Seniors, elderly, older adults, etc. How are these age groups defined?
Some studies define it as 60 years of age
Administrative guidelines classify it as >65 years
No agreed-upon definition of senior, but generally accepted that this is a
concept that reflects an age continuum
For the purpose of this presentation we consider seniors to be >60 years of
age.
CDA, 2013

What is cognitive impairment?

Cognitive impairment is when a person has trouble remembering, learning
new things, concentrating, or making decisions that affect their everyday
life. Cognitive impairment ranges from mild to severe. With mild impairment,
people may begin to notice changes in cognitive functions, but still be able to
do their everyday activities. Severe levels of impairment can lead to losing the
ability to understand the meaning or importance of something and the ability to
talk or write, resulting in the inability to live independently. (CDC, 2011)

Cognitive impairment (CI)

What causes CI?
Conditions such as stroke, traumatic brain injury, and development disabilities can cause CI
-Different severities from MCI to Alzheimers
Signs include:
-

Memory loss
Asking the same questions, or repeating stories
Familiar people or places become unfamiliar
Trouble exercising judgment
Behavior and mood changes
Difficulty planning and carrying out task

CDC, 2011

Class Activity
What kinds of self-care tasks do you think would be impacted negatively due
to cognitive-impairments in an individual with diabetes?

Self-management
-

Self-management for older adults similar to other age groups

Should be individualized

Weight the potential effects of treatment

Must take into account frailty index. Increased frailty associated with diabetes

Patients with moderate/advanced frailty should not have strict glycemic control

CDA, 2013; Blaum,

Xue, Tian, 2009

Guidelines
-

A1C, glycemic, blood pressure and lipid targets

Exercise tailored to capabilities
Avoiding medication with hypoglycemic risks
In the nursing home setting, a regular diet may be more useful than the diabetic diet
SMBG may become more difficult

Complicated by co-morbidities, capabilities, psychosocial factors, individual circumstances, etc.

Special education and care needs required - should be individualized by educators and health-care practitioners

CDA, 2013

Guidelines for Seniors DSME

Slow paced stepwise method using memory aids
Choose equipment that is easy to hold and easy to use - take into account visibility issues and ability to use technologies
Simplify the self-care regimen
Frequent instructions. Schedule multiple sessions
individual vs. group education
Engage spouse or other people living with patient
Make sure they know how to identify hypoglycemic symptoms

IDOP, 2013

Self-management and CI
-

More research needs to be conducted to fully understand the relationship between MCI and self-care activities

Conflicting studies - some find an association, some do not

Diabetes and Dementia

Issues
-

increased need to urinated, may have issues locating the washroom

increased of falls because of this
increased confusion if blood glucose levels are high and cause dehydration
distress if usual diet is changed
distress, wandering, rocking movements, may cry and unable to express pain
forgetting to take medications
forgetting they have taken medication, therefore increased risk of overdose, or may miss taking medication
forgetting to do injections or test blood sugar
unable to interpret blood glucose results
missing meals and drinks
forgetting they have eaten or forget to eat

IDOP, 2013

Developing SM Plans - Care teams

-

Agree on appropriate BG/A1C

Keep insulin locked in a box away from the patient
Toilet training/having assistance
Meals should be provided in a calm and distraction free environment
Be aware of signs of low BG for people taking insulin or tablets

IDOP, 2013

Relationship between cognitive impairment and diabetes

-

Episodes of severe hypoglycemia may increase the risk of dementia - conflicting literature

Cognitive dysfunction identified significant risk factor for the development of severe hypoglycemia

Self-management goals should be oriented around preventing hypoglycemic episodes

Whitmer, Karter, Yaff.,

2009; Bruce, Davis, Casey,
2010; CDA, 2013

Feil, Szhu, Sultzer,

2011

Class Activity
Case Study:
Mrs. H is a 72 year-old patient living in a long-term care facility. She was diagnosed with Type 2
diabetes three years ago, is on insulin, and two years ago was found by her GP to exhibit some signs of
MCI, which seems to be worsening in severity as of late. Mrs. H has had two hypoglycemic incidences
in the last 6 months, and her last A1C measure was 8%. She also struggles with decreased appetite.
Mrs. H has good mobility and a positive outlook. However, her sister has expressed concern about her
declining cognitive capabilities, A1C levels and her incidences of hypoglycemia. What could be done to
improve Mrs. Hs overall health?

Questions
1. Although this study found that cognitive impairment below the threshold for dementia does not seem to have
clinical significance on self-management, what challenges could be faced by seniors whose cognitive abilities continue
to deteriorate?

2. Brainstorm some strategies that could potentially make the self-management process easier for seniors with
decreased or deteriorating cognitive capabilities.
3. There is a lack of research regarding seniors and cognitive impairment, specifically beyond mild cognitive
impairments. Do you believe that the lack of research on seniors with more serious impairments, such as dementia or
Alzheimers, is due to the ethical barriers of having participants who would potentially not be able to comprehend being
a part of a research study?

References
Asimakopoulou, K., Hampson, S. (2002). Cognitive Functioning and Self-Management in Older People with Diabetes. Diabetes Spectrum. Volume 15, No. 2
Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and
Management of Diabetes in Canada. Can J Diabetes 2013;37(suppl 1):S1-S212.
Cognitive Impairment Policy (2009). Source: Centers for Disease Control and Prevention, BRFSS.
Feil DG, Zhu CW, Sultzer DL. The relationship between cognitive impairment and diabetes self-management in a population-based community sample of older adults with Type 2
diabetes. J Behav Med.2011;35:190199. doi: 10.1007/s10865-011-9344-6
Public Health Agency of Canada. (2011). Diabetes in Canada: Facts and figures from a public health perspective.
Institute of Diabetes for Older People, IDOP. (2013) Diabetes and Dementia: Guidance on Practical Management.
Stastics Canada. (2009). Diabetes
Suhl and Bonsignore Diabetes self-management education for older adults: general principles and practical application.Diabetes Spectrum 19:234240, 2006
Whitmer RA, Karter AJ, Yaffe K, Quesenberry CP, Selby JV. Hypoglycemic Episodes and Risk of Dementia in Older Patients with Type 2 Diabetes Mellitus. JAMA: the journal of
the American Medical Association. 2009;301(15):1565-1572. doi:10.1001/jama.2009.460.
Ravona-Springer R, Luo X, Schmeidler J, Wysocki M, Lesser G, Rapp M, Dahlman K, Grossman H, Haroutunian V, Schnaider Beeri M. Diabetes is associated with increased rate
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