CLC – Evidence-Based Practice Project: Intervention Presentation on Diabetes Part 2

TABLE OF CONTENTS

THis presentation is going to tackle the issue of lifestyle intervention in diabetes management among the elderly patients. This will be guided by a PICOT formed against the chosen article for effective analysis on the impact of the intervention.

PICOT

In elderly individuals (P), does the implementation of a structured exercise program (I), compared to standard care or no intervention (C), lead to better glycemic control (O) over a six-month period, as measured by changes in HbA1c levels (T)?

Diabetes is a chronic condition that can be managed using different strategies, including medication and lifestyle modification. While lifestyle modification is recommended as the most effective treatment for diabetes in people of all ages, there is little evidence to support the efficacy of using lifestyle modification for treating diabetes in older adults. As a result, the study aimed to investigate whether lifestyle modifications would improve glycemic control and other relevant outcomes in older adults aged 65 or older with diabetes and related comorbidities. As a result, an experiment involving patients on a structured exercise program was compared to patients undergoing standard care or not intervention at all after a 1-year period to see which cohort had better glycemic control as marked by positive changes in HbA1c levels.

POPULATION

❖Older adults with diabetes

❖Patients aged 65 or older

❖Heterogeneous diabetes

❖Type 2 and Type 1 diabetes mellitus

In analyzing the study, the population that was selected for the intervention included older adults with a diabetes diagnosis. The individuals who were selected for the study were at least 65 years or older and had diabetes (Celli et al., 2022). The study recognized that this population has a heterogeneity in diabetes outcomes. There are individuals in the population who have type 2 diabetes which is common in this population while others have type 1 diabetes due to improved care and survival. Older adults aged 65 or older are more susceptible to type 2 diabetes mellitus due to a wide array of factors, including reduced physical activity, changes in metabolism, and potential age-related reduction in insulin sensitivity.

Intervention

❖Lifestyle modification

❖ 1-year intensive lifestyle intervention (ILI)

❖ Combined exercise and dietary interventions

❖ Start at a facility then community fitness centers and homes

The lifestyle modification intervention used in this study is a 1-year intensive life intervention (ILI) meant to assess the impact of regular exercise and dietary adjustment on glycemic outcomes (Celli et al., 2022). Exercises and dietary interventions were used to reduce weight, insulin resistance and improve patients’ outcomes. Therefore, the intervention involved a structured exercise and diet program that patients were put on for a year. The intervention started off at a facility then transitioned to the community fitness centers and ended up in homes. Starting the program at a facility and slowly transitioning it to community fitness centers and later ending it in homes ensured the patients under study developed the discipline to adhere to the programs.

PICOT OUTCOMES

●Study involved 100 older adults with diabetes in two groups.

●Primary outcome was change in HbA1c, with several secondary outcomes.

●ILI group showed greater HbA1c reduction than HL group.

●Improved insulin sensitivity and disposition index in ILI versus HL group.

●ILI participants experienced significant physical and functional benefits.

●ILI group saw insulin dose reduction but more mild hypoglycemia.

This slide presents the core outcomes of a study involving 100 older adults with diabetes, divided into two groups: an intensive lifestyle intervention group and a healthy lifestyle group. The primary focus was the significant reduction in HbA1c levels in the intervention group, highlighting improved glycemic control. Additionally, the intervention led to better insulin sensitivity, weight loss, reduced visceral fat, and enhanced physical performance (Celli et al., 2022). Notably, there was a decrease in insulin dosage but an increased risk of mild hypoglycemia, underscoring the need for careful management.

Pathophysiological Insights

●ILI improves metabolic health via enhanced insulin sensitivity.

●Lifestyle interventions reduce body weight and visceral fat.

●Better glucoregulation through restored pancreatic function and glucose metabolism.

●Structured exercise crucial for blood glucose regulation and diabetes prevention.

●Improvements in physical function and quality of life noted.

●Findings highlight the role of nurses in monitoring and care adjustment.

The study provided valuable insights into how lifestyle interventions impact metabolic health, specifically through improved insulin sensitivity and better glucose metabolism. These findings emphasize the importance of exercise in managing diabetes, showing significant benefits in body composition, physical function, and overall quality of life (Celli et al., 2022). For nurses, these insights are crucial for developing effective care plans and monitoring patient progress.

Clinical and Nursing Practice Relevance

●Study supports lifestyle interventions’ efficacy in older adults’ diabetes management.

●Nurses essential in tailoring lifestyle interventions for individual needs.

●Importance of monitoring for hypoglycemia in lifestyle interventions.

●Collaboration across disciplines necessary for holistic diabetes management.

●Nurses provide crucial education and support for lifestyle changes.

●Findings suggest updates needed for practice guidelines and nursing curricula.

The efficacy of lifestyle interventions in managing diabetes among older adults is clear, underscoring the role of personalized care strategies. Nurses play a key role in implementing these interventions, monitoring for potential hypoglycemia, and providing education and support (Celli et al., 2022). The study highlights the need for interdisciplinary collaboration and suggests that current practice guidelines and nursing curricula may need updates to reflect these findings .

NURSING PRACTICE

A little change can go a long ways.

❖Diet

❖Exercise

Lifestyle intervention strategies, encompassing diet and exercise, play a crucial role in nursing practice by promoting holistic patient care and addressing the root causes of various health conditions. Integrating these strategies into nursing practice involves a comprehensive approach that considers individual patient needs, preferences, and cultural factors. The evidence supporting the efficacy of lifestyle interventions is substantial, particularly in the management and prevention of chronic diseases such as diabetes, cardiovascular diseases, and obesity (Celli et al., 2022).

Lifestyle  interventions

Numerous studies, such as the Diabetes Prevention Program (DPP), have demonstrated the effectiveness of lifestyle interventions in preventing or delaying the onset of diabetes through dietary modifications and increased physical activity (NIH, 2023). The DPP showed that people who are at high risk for type 2 diabetes can prevent or delay the disease by losing a modest amount of weight through lifestyle changes such as dietary changes and increased physical activity (NIH, 2023). Nurses play a pivotal role in educating patients about the impact of diet and exercise on their health. This includes providing information on nutritional choices, portion control, and the benefits of regular physical activity. Patient education should be tailored to individual needs and preferences, considering cultural and socioeconomic factors (Romero-Castillo, et al., 2022).

Nurses can collaborate with patients to set realistic and achievable lifestyle goals. Regular monitoring of progress, including dietary adherence and exercise frequency, helps reinforce positive behavior changes (Romero-Castillo, et al., 2022). This involves ongoing communication and adjustment of goals based on the patient’s response and evolving health status. The implementation of goal-setting strategies has been proven effective in various interventions, such as weight management programs. Studies indicate that goal-setting enhances patient motivation and adherence to lifestyle changes (Celli et al., 2022).

Disease Process

For individuals already diagnosed with diabetes, a well-designed diet and exercise plan can help manage blood glucose levels. Nurses can provide guidance on meal planning, monitoring blood sugar, and incorporating physical activity into daily routines. Nurses can educate patients about the impact of nutrition and exercise on diabetes. This includes explaining how certain foods affect blood sugar, the importance of portion control, and the role of regular physical activity in glucose regulation (Romero-Castillo et al., 2022). Empowering patients with the knowledge and skills to make healthier lifestyle choices enhances their ability to manage their condition independently. A healthy diet and regular exercise contribute to overall well-being. Nurses can promote a holistic approach to health that extends beyond managing diabetes, addressing other potential comorbidities and enhancing the patient’s overall quality of life.

Implementing a healthy diet and exercise plan involves collaboration among healthcare professionals, including nurses, dietitians, and exercise specialists (Levengood et al., 2019). Nurses can play a central role in coordinating care, ensuring that patients receive comprehensive and cohesive support for their diabetes management. Interdisciplinary collaboration facilitates a more holistic view of the patient, enabling tailored interventions that address both medical and lifestyle aspects (Levengood et al., 2019).

Nursing Considerations

Introduction of lifestyle changes can be met with resistance.  Many in the elderly population are steadfast in their thinking and do not welcome change easily (Celli et al., 2022). That being said, it is important that nurses are aware of the challenges they will face when addressing psychological, cultural, and spiritual considerations in order to achieve optimal outcomes.

Compassionate care is patient centered care. We are all diverse and this is wonderful.  Acknowledge the differences with acceptance and pivot accordingly, in your plan of care.  Psychological, cultural, and spiritual care are the foundation of patient centered care. Nursing considerations for the elderly patient in these areas, are to be adjusted accordingly, being aware of medical and physical issues that arise with age, how these impact the elderly cognitively, emotionally, and socially, is of utmost importance in providing compassionate care. Through increasing our awareness of the issues that arise as we age, our care plans are able to focus on specific, age related needs and through this, we can see our patients achieve optimal health outcomes.

Psychological

The participants in this study ranged in age from 65-85.  The average age was 71 in the healthy lifestyle (HL) group.  In the intensive lifestyle intervention (ILI) group,the average age was 72. The HL participants had an average duration of diabetes of 13.7 years. The ILI participants, 13.7 years.  Most participants in both groups were still married, although there were participants that were single, divorced, and widowed. There were also participants in both groups, who were on antidepressants (Celli et al., 2022). Taking this information into consideration, the nurse needs to be aware that these factors can lead to depression, anxiety, and social isolation.  In this particular study, the ILI group had the added benefit of group behavior therapy sessions (Celli et al., 2022). These sessions were designed to help older adults achieve better understanding of weight loss. These group sessions decreased social isolation which can in turn, decrease depression and anxiety. Exercise management was also addressed as older citizens need to be aware of programs like Silver Sneakers, in which Medicare part C covers (Celli et al., 2022). How can we as nurses, incorporate the psychological needs of our elderly patients into our plan of care? We need to be aware of the factors influencing depression, anxiety, and isolation.  Educate our patients on the use of antidepressants.  Educate them on emotional benefits of weight loss.  Provide resources for support groups specifically designed for older adults like the one mentioned above, Silver Sneakers.

Cultural

In older adults, the nurse needs to be able to understand cultural considerations and the impact they can have on diseases like diabetes. 

In this study, 40% of participants were of the Black and 18% were Hispanic or Latino (Celli et al., 2022). Nurses should be culturally sensitive to races and ethnicities other than their own.  There can be dietary restrictions and requirements that can directly impact diabetes. How can we become more culturally aware in our plan of care? Participate in your facility’s cultural awareness workshops and training, actively reassess yourself for areas of incompetence, and strive to incorporate diversity in your field.

The participants in the study were mostly college graduates. The study provides a possible correlation between education level and achievement of intervention goals (Celli et al., 2022). This is another area that nurses need to be able to adjust the educational resources they provide patients. How can we make the appropriate adjustments in our plan of care? From the time the patient enters our care until time to leave, we should be asking questions that help us understand how a patient learns.  For example, some patients are more visual in their learning style.  We should then be offering diabetes resources that correspond to this.

The study acknowledges difficulty in participation from groups that do not speak English.  Medicare does not cover translation services and this fact can impact older adults and their ability to achieve intervention goals associated with diabetes  (Celli et al., 2022). As nurses, we must be aware of our facility’s onsite translation services to better assist our patients with language barriers. Older adults may also have issues with hearing.  As we age, our ability to hear changes.  There were participants in this study that had comorbidities of stroke (Celli et al., 2022). How do we effectively offer support in our plan of care?  By working with speech therapy, understanding Medicare’s role in providing hearing aids, and adjusting how we interact with our patients.  Speak slowly, clearly, and if necessary, use hearing assistance devices provided at our place of work.

Spiritual

In this study, spirituality and/or religion was not part of participant data (Celli et al., 2022). However, nurses have a duty to provide patient centered care which includes appropriate spiritual interventions. How can we incorporate spiritual care into our plan of care for our elderly patients?

Showing respect.  Older adults have come to their place of spirituality, religion, or lack thereof, through years of participation in what is important to them.  As nurses, we are never to judge a patient on their views but rather, respect them and be able to provide resources that speak to their needs. For example, if a patient would like you to pray to Jesus with them but you are of the Jewish faith, be honest, be transparent.  Offer yourself as is comfortable for you but also be able to enlist the help of clergy if needed. Nurses need to also be aware of the older patient’s perception of spirituality. This can change as fear and uncertainty surrounding death, arise. Our patients may need us to just listen, be a sounding board, as they navigate this part of their spiritual journey.  Nurses need to be patient with the older patient.  It is not uncommon for older adults to speak in a harsh or abrasive tone when in the hospital setting. There are stressors present and this impacts how are patients talk to us. If a patient is critical of your own religion or spirituality, be patient with them.  Adjust your plan of care to include calm listening, even tone, and be genuinely compassionate in the way you interact, even if there is impatience on the part if the patient.  Lastly, be understanding.  Our elderly patients have had a lifelong journey with religion or spirituality.  Being aware of this facta lone, can help you in planning care around spiritual needs of the patient. For example,  If your elderly patient wants to pray before taking a scheduled medication, make allowances and adjustments to incorporate this patient need.