Diabetes is a chronic illness characterized by absent or reduced pancreatic production of insulin and decreased cellular sensitivity to insulin. The result is a rise in blood sugar levels which does harm to body tissues. Obesity, or a body mass index (BMI) of 30 or greater, accounts for up to 85% of an individual’s risk of having type 2 diabetes (T2DM), which is the more common type (Eckel et al., 2011). Statistics show that obesity occurs more in older adults with more than a third of adults 65 years old and over considered obese (Eckel et al., 2011). In turn, lifestyle is the biggest risk factors to obesity. High-calorie diets coupled with sedentariness results in the accumulation of adipose tissue. At the same time, older people also lose much of their muscle mass as they continue to age.
Diabetes has reached epidemic proportions with certain groups experiencing a greater burden of disease than others. Older adults are among the groups experiencing disparity in relation to this illness. Statistics show that more than 25% of those 65 years or over have diabetes (Kirkman et al., 2012). That fewer older adults compared to the general population take part in clinical trials investigating the effectiveness of pharmacological and non-pharmacological interventions in diabetes contributes to the disparity (Kirkman et al., 2012). When poorly managed, diabetes leads to many complications with an increased risk of mortality, decreased functional capacity, and a higher likelihood of being institutionalized (Kirkman et al., 2012).
There are many serious complications of poorly controlled diabetes and include heart disease, stroke, chronic kidney disease, blindness, neuropathies, and amputations from wounds that do not heal (ADA, 2016). However, complications can be prevented through effective disease self-management. This paper describes an evidence-based diabetes self-management program for older adults.
Problem Statement
The chronic nature of diabetes means that patients need to take greater responsibility and control over their own health. Diabetes treatments consist of medications and lifestyle changes. However, less than half of patients actually achieve the target outcomes (ADA, 2016). Patients need to adhere to the treatment plan and, foremost, to actively participate in the creation of such a plan to ensure their preferences and personal context are taken into consideration. Participation leads to an appropriate, acceptable, and individualized plan of care (Powers et al., 2015). This approach will improve diabetes outcomes such as glycemic control, incidence of complications, health care costs, and quality of life.
However, patients need to learn certain skills to achieve good control. Such skills would inevitably include communication, problem solving, medications management, and planning (Powers et al., 2015). The importance of a chronic disease self-management program focused on diabetes is evident. Access to such a program in the community will enable older adults to benefit from enhanced knowledge and skills in managing chronic illness. Nurses are best positioned to design, implement, and evaluate such a program. By employing evidence-based practice and their clinical experience while also taking into account the needs and preferences of potential program users, nurses can increase the proportion of self-managing older adults and contribute to improving diabetes outcomes.
The focus of this paper is on the creation of a diabetes self-management program (DSMP) for this patient population. One aim is to identify evidence-based practices in promoting DSMP in older adults. An evidence review is warranted which may help in identifying an exemplar program model. Another aim is to design a program integrating best practices and with consideration of supportive and challenging factors in the present health care system.
Evidence Review
There is strong (Level I) evidence supporting the effectiveness of DSMP on specific outcomes. A systematic review of 31 randomized controlled trials (RCTs) showed that DSMP catering to adults demonstrated a 0.76% mean reduction in glycated hemoglobin (HbA1c) when compared to the control intervention (Norris et al., 2002). However, the RCT samples in this review were not limited to older adults. The average participant age was 55 with an age range from 18-67 years (Norris et al., 2002). Chobosh et al. (2005) corroborated the DSMP impact on HbA1c in a meta-analysis of 26 RCTs conducted specifically among older adults. The most recent systematic review and meta-analysis by Sherifali et al. (2015) of 13 RCTs in older adults continued to uphold the earlier impact on HbA1c. The authors found a greater mean HbA1c decrease of approximately 0.81% which was of significance both statistically and clinically (Chobosh et al., 2005).
Effectiveness also extends to ethnic minority subgroups of older adults and to outcomes other than glycemic control. Sarkisian et al. (2003), in a systematic review of 12 RCTs on DSMP in Hispanic and African American older adults showed that in 5 of these studies, glycemic control manifested by the HbA1c decreased in the participants. In 4 of the RCTs, there were also significant improvements in quality of life (Sarkisian et al., 2003). A quasi-experimental study by Speer et al. (2008) similarly found that self-management behaviors including adherence to a healthy meal plan, consumption of more vegetables and fruits, spaced carbohydrate intake, and feet inspection increased by at least one day per week increased by at least one day with DSMP.
Effectiveness is equally effective in non-clinical settings and is influenced by contact time. The systematic review of 11 RCTs by Norris et al. (2002) found that DSMPs were effective in reducing HbA1c in adults aged 43-71 years old even when the intervention is conducted in community gathering places. For example, one RCT investigated a church-based and culturally tailored DSMP targeting African American older adults and it resulted in significant behavioral modifications in the participants (Norris et al., 2002). Speer et al. (2008) also found that community-based DSMPs were equally effective in enhancing glycemic control and self-management behaviors. The positive effect on HbA1c increased as the duration of educator contact with the patient increased. For instance, a mean 0.26% reduction in the HbA1c was achieved after 1-3 months of program participation and another 0.26% after 4 months or longer (Norris et al., 2002). On the average, a 1% decline in the HbA1c occurred for every 23.6 hours of contact time added (Norris et al., 2002).
Characteristics of Effective DSMPs
Effective DSMPs engage and promote communication between providers and older adults. Heisler et al. (2007), in a cross-sectional study, found that overall diabetes self-management outcomes were associated with patients obtaining sufficient information from their providers and being actively involved in treatment decision-making. Improved outcomes related to complex behavioral changes, namely adopting a healthy diet, increasing physical activity, and self-monitoring blood glucose. In addition, DSMP goals must be linked to patients’ life goals in order to elicit commitment. A qualitative study by Morrow et al. (2018) found that older adults agreed to health goals and self-management practices if they believed that these would assist them in achieving broader goals in life.
Programs that are theory and curriculum-based, incorporate guidelines (Speer et al., 2008), and are tailored to culture and age (Sarkisian et al., 2003; Speer et al., 2008) were found to be the most effective. The use of multimedia was also emphasized by King et al. (2010). Furthermore, educators need not necessarily be healthy care professionals to be effective as federal program evaluations showed that successful programs have employed lay but well-educated persons (Speer et al., 2008). DSMPs were also effective if delivered in group settings because of the social interaction involved (King et al., 2010; Speer et al., 2008) and the support or counseling given and received among participants (Sarkisian et al., 2003). Class size also matters specifically in terms of completion rate. Erdem and Korda (2014) found that a DSMP class of less than 6 participants achieved the highest completion rate of 80.7%. In addition, a class of between 6-10 older adults is associated with a lower completion rate than those with <6 participants but is higher compared to classes with 11-16 participants.
Furthermore, DSMPs that involved older adults’ family members or enabled older adults to elicit social support from their families were the most successful (King et al., 2010; Sarkisian et al., 2003; Wen, Shepherd & Parchman, 2004). Such support was noted to independently and positively influence diet and exercise behaviors (King et al., 2010; Wen, Shepherd & Parchman, 2004). DSMPs were also effective if they boosted older adults’ self-efficacy (King et al., 2010; Wen, Shepherd & Parchman, 2004), problem-solving skills (King et al., 2010), and optimism (Speer et al., 2008). Finally, DSMPs need to focus on promoting medication adherence, blood sugar monitoring, healthy diets, physical activity, and feet inspection in order to help older adults achieve the best outcomes (Speer et al., 2008).
Enhancing Older Adult Participation in DSMP
Pain, mental health problems, cognitive dysfunction, and functional disabilities limit the full participation of older adults in DSMP. Krein et al. (2005) found that older adults with poorly managed severe and very severe chronic pain reported suboptimal DSMP outcomes compared to those with mild and moderate pain. In particular, severe and very severe pain was associated with an increased difficulty of adhering to exercise plans and diabetes medications (Krein et al., 2005). Based on evaluation data of 47 DSMPs under the federal Communities Putting Prevention to Work, Erdem and Korda (2014) noted that older adults with depression were less likely to complete the program. Sherifali et al. (2015) affirmed that programs with psychological interventions worked best. Those with cognitive dysfunction, impairments in vision and hearing, have a recent history or fear of falls, and difficulties with the performance of activities of daily living also had less optimal improvements in glycemic control (Munshi et al., 2006). It is important to assess prospective participants for these barriers and identify strategies to meet special needs in order to promote program participation and completion.
Exemplar Model
The Stanford Diabetes Self-management Program which is based on the original Chronic Disease Self-management program is an exemplar DSMP as many of its aspects are consistent with the evidence described above. It recognizes implementation in community settings such as community centers, libraries, and churches (Stanford School of Medicine, 2016). It employs a highly standardized curriculum described in a manual and is delivered by a pair of trained lay facilitators who may both be diabetics themselves (Stanford School of Medicine, 2016). As such, they serve as peers and role models who can relate directly to participants’ experiences. The program also adopted a multimedia approach with participants receiving a book and a tape on relaxation exercises aside from taking part in workshops (Stanford School of Medicine, 2016).
However, the Stanford DSMP considers as sufficient 15 hours of contact divided into once-weekly 2.5-hour sessions over 6 weeks (Stanford School of Medicine, 2016). This duration is lower than the 4 months recommended in the above evidence review for the achievement of the highest reductions in HbA1c. Classes are also bigger with 12 to 16 participants rather than 10 or less which is associated with a higher program completion rate (Stanford School of Medicine, 2016). The program was formalized following the conduct of 2 RCTs supporting its effectiveness albeit in a general adult population (Stanford School of Medicine, 2016). The RCTs showed that the positive impact of the program on diet, patient engagement, patient-provider communication, depression, and self-efficacy were sustained even at 12 months after program conclusion (Stanford School of Medicine, 2016). Improvements in glycemic control were, however, minimal because HbA1c levels in many RCT participants were actually within the clinically acceptable range at baseline compared to those in the studies reviewed above (Stanford School of Medicine, 2016). It is reasonable, therefore, to argue that a longer program would be more appropriate among older adults with suboptimal glycemic control at baseline.
The Stanford DSMP also incorporated many of the characteristics of successful programs for older adults described in the evidence review. Curriculum content includes healthy eating, exercises that are appropriate in maintaining or enhancing endurance and strength, medication use as prescribed, and effectively partnering or working with care providers (Stanford School of Medicine, 2016). Problem-solving skills were also promoted within the Stanford DSMP specifically in addressing several of the barriers identified in the evidence review. These barriers are pain and depression (Stanford School of Medicine, 2016). In addition, the program fostered techniques in coping with diabetes symptoms, hyperglycemia, hypoglycemia, fatigue, stress, fear, frustration, and anger (Stanford School of Medicine, 2016) which were not identified by the selected studies in the review.
Furthermore, the Stanford DSMP is implemented in a group setting as recommended by the literature and encourages workshop participants to help each other in solving problems encountered in the creation and enactment of individual self-management plans (Stanford School of Medicine, 2016). This approach also makes the program highly participative and supportive which proponents and the literature found was effective in building participants’ self-efficacy and confidence in self-management (Stanford School of Medicine, 2016). The Stanford DSMP was moreover found to be effective among English-speaking and Spanish-speaking patients and this makes the program applicable to ethnic minority Hispanic older adults (Stanford School of Medicine, 2016).
Supportive and Challenging Factors
Interest in research on DSMP has been growing since the 2000s evidenced by several systematic reviews of RCTs. The strong evidence of effectiveness has established the DSMP as an essential component of the treatment and management of diabetes (Stanford School of Medicine, 2016). This has led to standardized programs which can be adapted to different settings and subpopulations of older adults. Such programs have been developed through federal research grants which helped disseminate the need for DSMP and related best practices in the country. Patient referrals can now be made by care providers to DSMPs.
In addition, there is now an accreditation process for DSMPs and is a supportive factor because it ensures program adherence to existing standards (AADE, 2016). Programs applying for accreditation via the American Association of Diabetes Educators (AADE) and involves providing proof of adherence to existing standards. Such standards include having a mission and goals, a clear target population, mechanisms to guarantee that patient needs are fulfilled, an education plan, a patient follow-up plan, sustained patient self-management support, and a continuous quality improvement plan (AADE, 2016). Accreditation helps ensure that DSMPs provide quality interventions.
Medicare now also reimburses patient participation in accredited DSMPs and is another supportive factor. Medicare requires that the DSMP should be in group settings and with a total duration of 10 hours (Hodorowicz, 2013). The curriculum must cover 10 topic areas as recommended by national diabetes self-management education standards but as needed by the patient (Hodorowicz, 2013). The DSMP must also aim to increase patient knowledge of rationale for self-management behaviors and skills in changing key behaviors (Hodorowicz, 2013). However, unlike the Stanford DSMP and evidence from the literature, instructors are required to be health care professionals, namely registered nurses, registered dieticians or physicians.
As such, one challenge seems to be how to reconcile changing best practices and the reimbursement guidelines or criteria to ensure that the latter does not curtail the translation of current evidence-based practices in DSMPs. For instance, although lay but trained educators have been found to be effective among diabetes patients, the adoption of this practice is discouraged by the Medicare criterion that only health care professional educators are considered. In addition, the reimbursement system itself can be difficult to navigate as the requirements are numerous and the process complicated, confusing, and periodically changing (Hodorowicz, 2013).
Another challenge is patient participation in DSMPs. In Georgia, for instance, only 45% of older adults aged 65 years of older had attended a diabetes self-management education (Georgia DPH, 2013). As such, one goal of the state Diabetes Prevention and Control Program was to enhance access to DSMPs and other resources for preventive care (Georgia DPH, 2013). The need for increased access by older adults with diabetes has also been recognized at the federal level by the Administration on Aging (AOA, 2016). Successful strategies in promoting access need to be developed to increase the number of older adults who benefit from DSMP especially those with low-income and belong to ethnic minority groups who are vulnerable to disparity (AOA, 2016).
In addition, the International Diabetes Federation (IDF, 2012) identified the shortage of accredited diabetes educators as a contributor to the inadequate number of DSMPs. Currently, there are approximately 15,000 accredited diabetes educators in the U.S. (IDF, 2012). This number is inadequate to fulfill the demand especially in the older adult population that is predicted to keep growing for the next decade. A third challenge is limited funding to sustain existing DSMPs and create new ones.
Conclusion
Diabetes disproportionately affects older adults and leads to serious complications if inadequately managed. The chronic nature of the illness requires that patients be more active in its management. DSMPs are effective in helping older adults develop the knowledge and skills they need for everyday self-management and achieve improvements in glycemic control, quality of life, and lifestyle change. The evidence supporting DSMPs include RCTs, systematic reviews, and meta-analyses. The literature recommends as best practices, among others, an evidence-based, curriculum-based, and group-based DSMP available in community settings and facilitated by trained lay persons or health care professionals. Important topics include diet, exercise, problem-solving and coping with illness-related challenges or barriers to successful self-management, patient-provider communication, medication taking, and eliciting social support. The Stanford DSMP serves as an exemplar as it has many of the characteristics of a successful DSMP described in the literature. However, it differs in terms of class size and intervention duration as this DSMP was based on 2 RCTs conducted specifically to investigate its effectiveness. Sustained research interest and the availability of strong supporting evidence is a supportive factor in making DSMP a recognized component of treatment and management. There are now standards, accreditation, and Medicare reimbursement criteria. Challenges are to keep reimbursement criteria consistent with current evidence, improve access, increase funding, and increase the number of trained educators.
References
Administration on Aging (AOA) (2016). American Recovery and Reinvestment Act Communities Putting Prevention to Work: Chronic disease self-management program. Retrieved from http://www.aoa.gov/AoA_programs/HPW/ARRA/index.aspx
American Association of Diabetes Educators (AADE) (2016). Applying for accreditation. Retrieved from https://www.diabeteseducator.org/practice/diabetes-education- accreditation-program-(deap)/applying-for-accreditation
American Diabetes Association (ADA) (2016). Complications. Retrieved from http://www.diabetes.org/living-with-diabetes/complications/
Chodosh, J., Morton, S. C., Mojica, W., Maglione, M., Suttorp, M. J., Hilton, L., Shekelle, P. (2005). Meta-analysis: Chronic disease self-management programs for older adults. Annals of Internal Medicine, 6, 427–438. Retrieved from http://onlinelibrary.wiley.com/o/cochrane/cldare/articles/DARE- 12005008496/frame.html
Eckel, R. H., Kahn, S. E., Ferrannini, E., Goldfine, A. B., Nathan, D. M., Schwartz, M. W., Smith, S. R. (2011). Obesity and type 2 diabetes: What can be unified and what needs to be individualized? The Journal of Clinical Endocrinology and Metabolism, 96(6), 1654–1663. http://doi.org/10.1210/jc.2011-0585
Erdem, E., & Korda, H. (2014). Self-management program participation by older adults with diabetes: Chronic Disease Self-Management Program and Diabetes Self-Management Program. Family & Community Health, 37(2), 134–46. http://doi.org/10.1097/FCH.0000000000000025
Georgia Department of Public Health (DPH) (2013). 2013 diabetes self-management report. Retrieved from https://dph.georgia.gov/sites/dph.georgia.gov/files/DiabetesSelfManagement_WebVer sion.pdf
Heisler, M., Cole, I., Weir, D., Kerr, E., & Hayward, R. (2007). Does physician communication influence older patients’ diabetes self-management and glycemic control? Results from the Health and Retirement Study (HRS). Journal of Gerontology: Medical Sciences, 62(12), 1435–1442. http://doi.org/62/12/1435
Hodorowicz, M. (2013). Diabetes self-management training (DSMT) reimbursement. Retrieved from http://www.qioprogram.org/sites/default/files/editors/106/DSMT- Reimb-Presentation-062513.pdf
International Diabetes Federation (2011). Position statement: Self-management education. Retrieved from http://webcache.googleusercontent.com/search?q=cache:tzQA6cg3c5QJ:www.idf.org/ node/23502%3Flanguage%3Dfr+&cd=17&hl=en&ct=clnk&gl=ph
King, D. K., Glasgow, R. E., Toobert, D. J., Strycker, L. A., Estabrooks, P. A., Osuna, D., & Faber, A. J. (2010). Self-efficacy, problem solving, and social-environmental support are associated with diabetes self-management behaviors. Diabetes Care, 33(4), 751– 753. http://doi.org/10.2337/dc09-1746
Kirkman, M. S., Briscoe, V. J., Clark, N., Florez, H., Haas, L. B., Halter, J. B., Swift, C. S. (2012). Diabetes in older adults. Diabetes Care, 35(12), 2650–2664. http://doi.org/10.2337/dc12-1801
Krein, S.L., Heisler, M., Piette, J.D., Makki, F., & Kerr, E.A. (2005). The effect of chronic pain on diabetes patients’ self-management. Diabetes Care, 28(1), 65-70. http://dx.doi.org/10.2337/diacare.28.1.65
Morrow, A.S., Haidet, P., Skinner, J., & Naik, A.D. (2008). Integrating diabetes self- management with the health goals of older adults: A qualitative exploration. Patient Education and Counseling, 72(3), 418-423. doi: 10.1016/j.pec.2008.05.017.
Munshi, M., Grande, L., Hayes, M., Ayres, D., Suhl, E., Capelson, R., Katie Weinger, E. (2006). Cognitive dysfunction is associated with poor diabetes control in older adults. Diabetes Care, 29(8), 1794–1799. http://doi.org/10.2337/dc06-0506
Norris, S. L., Lau, J., Smith, S. J., Schmidt, C. H., & Engelgau, M. M. (2002). Self- management education for adults with type 2 diabetes: A meta-analysis of the effect on glycemic control. Diabetes Care, 25(7), 1159–1171. http://doi.org/10.2337/diacare.25.7.1159
Norris, S. L., Nichols, P. J., Caspersen, C. J., Glasgow, R. E., Engelgau, M. M., Jack, L., McCulloch, D. (2002). Increasing diabetes self-management education in community settings: A systematic review. American Journal of Preventive Medicine, 22(4 SUPPL. 1), 39–66. http://doi.org/10.1016/S0749-3797(02)00424-5
Powers, M.A., Bardsley, J., Cypress, M., Duker, P., Funnell, M.M., Fischl, A.H., Vivian, E. (2015). Diabetes self-management education and support in type 2 diabetes: A joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Diabetes Care, 38(7), 1372-1382. http://dx.doi.org/10.2337/dc15-0730
Sarkisian, C.A., Brown, A.F., Norris, K.C., Wintz, R.L., & Managione, C.M. (2003). A systematic review of diabetes self-care interventions for older, African American, or Latino adults. The Diabetes Educator, 29(3), 467-479. doi: 10.1177/014572170302900311
Sherifali, D., Bai, J.W., Kenny, M., Warren, R., & Ali, M.U. (2015). Diabetes self- management programmes in older adults: A systematic review and meta-analysis. Diabetic Medicine, 32(11), 1404-1414. doi: 10.1111/dme.12780
Speer, E. M., Reddy, S., Lommel, T. S., Fischer, J. G., Heather, S., Park, S., & Johnson, M. A. (2008). Diabetes self-management behaviors and A1c improved following a community-based intervention in older adults in Georgia senior centers. Journal of Nutrition For The Elderly, 27(1-2), 179–200. http://doi.org/10.1080/01639360802060298
Stanford School of Medicine (2016). Diabetes Self-management Program. Retrieved from http://patienteducation.stanford.edu/programs/diabeteseng.html
Wen, L.K., Shepherd, M.D., & Parchman, M.L. (2004). Family support, diet, and exercise among older Mexican Americans with type 2 diabetes. The Diabetes Educator, 30(6), 980-993. doi: 10.1177/014572170403000619
Appendix 1. Evidence Matrix
* Based on the Joanna Briggs Institute 2014 evidence hierarchy
