How do you manage patient preferences and clinical care in older adults with diabetes?
Elbert Huang, MD, MPH, FACP is a professor of medicine, director of the Center for Chronic Disease Research and Policy, and associate director of the Chicago Center for Diabetes Translation Research at the University of Chicago. He has extensive clinical and research experience with diabetes in older adults, with a focus on personalizing diabetes care goals.
Q: What do you feel are the most pressing challenges health care providers face in working with older adults with diabetes?
A: For older patients, the challenge is that they have a very high risk of diabetes complications, which we're all trying to prevent, and they're also the group at highest risk for the side effects of the treatments we use to prevent those complications. This creates a really tricky balance.
As health care providers, we need to try and figure out how to align the goals of diabetes care with patient preferences. For instance, many older patients may be more interested in what they need to do to maintain independence than maintaining an A1C or blood pressure goal. Goal-setting is something we probably don't spend enough time doing with our older patients. Sometimes we skip over goal-setting and go straight to drug selection. And let's say that we even agree on the goals for an individual patient, health care professionals still need to navigate the challenges of selecting the right medications or care plan for an older person who is at higher risk for health problems.
Older adults may have a lot of functional challenges with taking medicines, or managing the day-to-day routine monitoring we expect with diabetes. For instance, as people get older, arthritis is very common, so it's hard to administer something like an insulin injection, use a lancet to draw blood for glucose monitoring, or participate in some physical activities.
So the goal-setting is hard, the decision-making is hard, and then the execution of any care plan is difficult, so those are the kinds of challenges we face.
Q: What are some practical tips that you would recommend for health care providers to navigate these challenges and help their older adults with diabetes stay healthy?
A: A really basic tip is to sit down with your patient and their family members and explicitly review goals and their medication list – and do this at least annually. This sounds simple, but it can be hard to do within the chaos of clinical practice. Some ways that we try to deal with the constraints of the individual clinic visit is to reach out to patients outside of the clinical encounter to set goals and check on them to see how they're doing. These additional activities can complement what providers do in the clinical encounter.
I also think that developing the simplest care plan possible is a strategy to consider when it comes to managing diabetes in older adults. Again, this goes back to setting goals.
Q: Can you share guidance for health care providers on balancing intensive diabetes care management with quality of life and end-of-life care in older adults?
A: Most of us are not trained to think about this too much; we're motivated to make people as healthy as possible and to extend their lives. We are uncomfortable discussing end-of-life care.
The solution is for clinicians to bring up issues around goals and overall advanced care planning much earlier in the relationship. It's easier for everyone if this is done when they are healthy—in a relaxed, non-threatening way. I try to make this discussion a routine part of health maintenance. You can take the annual exam, for example, as an opportunity to bring up advanced care planning along with goal-setting for diabetes care and management of other chronic conditions. You revisit this with the patient and family every single year.
Diabetes in older adults is on the continuum between traditional chronic disease management and the world of hospice and palliative care. I document who will be the surrogate decision-maker if my patient has set limits on what kind of care they want in the event that they become really sick and unable to make decisions.
For patients who are cognitively impaired, I go out of my way to try to find a family member or support person to help with decision-making. This person may be administering the treatments and can play a big role in helping to make these decisions.
Q: Can you share an example of what you would say to the family member when there may be conflict about a loved one's diabetes care?
A: Sometimes a family member does not completely capture the desires and preferences of a loved one. Typically what happens is that a child of an older patient wants to hold on to very aggressive diabetes care, even though the older patient may have actually said at one point, "I don't want these things." As health care professionals, we have to be careful to honor the wishes of the patient, and not indirectly treat the family member.
Remind family members that we're weighing the risks and benefits of every treatment, and that sometimes the right thing to do is actually less. That approach usually works.
Q: Is social isolation a concern when it comes to the health of older adults?
A: This is a profound problem. Families are smaller, and children of older parents are now, more than ever, living far away from their parents. The natural social network that you would historically have around doesn't exist as much now.
But one important point about social isolation and loneliness is that you can actually be totally by yourself and not feel or perceive yourself as lonely. But you can also feel lonely when you are surrounded by people. And it's really the perception of loneliness on the part of an older person that we want to tackle, because loneliness is what's connected with poor health outcomes.
As a health care professional, this means asking your patient about feelings of loneliness and depression. Above and beyond even knowing about our patients' social networks, we need to know even more about a person's life.
I have a patient in his 90's who is a retired Tuskegee airman. He lives by himself, but he is online a lot. He is active with veterans groups and in online chat rooms. He's very socially engaged and happy. I think this case demonstrates that you can't assume that older people are computer illiterate or opposed to using technology as a tool to create a virtual social network.
Q: Can you tell us how technology might be used to engage older adults in goal-setting?
A: We conducted a pilot study to assess a personalized Web-based decision support tool, which showed that even in an older population, where around 20 percent of patients had been exposed to computers, electronic surveys were used successfully in the clinic. We can use this technology to engage patients in goal-setting. The future is probably figuring out ways to move this kind of tool into the electronic medical record itself.
We're in the midst of doing a related study using the same kind of survey, but we reach out to older patients through patient portals that are now available in electronic medical records. That opens up a whole future of patient engagement and patient-centered care.
There is a lot of excitement around Alexa and Google Home as technologies that could help us support an older person who is socially isolated. So technology provides some help—but from my experience with taking care of patients, it is clear there is still no substitute for having a rich network of friends and family. People who have that kind of regular personal interaction just seem to do better.
What are some of the challenges you face when it comes to addressing the unique needs of older adults with diabetes?
About Elbert S. Huang, MD, MPH, FACP
Elbert S. Huang, MD, MPH, FACP, is Professor of Medicine, Director of the Center for Chronic Disease Research and Policy, and Associate Director of the Chicago Center for Diabetes Translation Research at the University of Chicago. Dr. Huang is a primary care doctor who studies clinical and health care policy issues at the intersection of diabetes, aging, and health economics. Using methods from health economics, the decision sciences, and clinical epidemiology, his research has provided the theoretical and evidence-base foundation for the concept of personalizing diabetes care goals and care for older people with diabetes.