Running head: A HOLISTIC APPROACH TO DIABETES IN THE ELDERLY 1

A Holistic Approach to Diabetes in the Elderly

Dayle Lauren

Stenberg College Running head: A HOLISTIC APPROACH TO DIABETES IN THE ELDERLY 2

A Holistic Approach to Diabetes in the Elderly

Treatment of diabetes mellitus in the elderly is complicated by aging, health status and risk factors such as depression. By identifying the effects that depression has on diabetes, one can approach care of the elderly diabetic in a more holistic manner, incorporating empowerment, complementary and alternative health practices and focused aged care.

According to the American Diabetes Association, and the Centers for Disease Control and Prevention (2003), two out of five adults over age of 65 have diabetes or impaired glucose tolerance (DeCoster & Dabelko, 2008). Highly prevalent among these diabetics is the presence of depression. According to Atlantis, Browning, Sims & Kendig (2009), depression significantly increases the risk of developing type II diabetes by 60%: several theories actually consider depression the etiology of diabetes. The connection between the two is found in the fact that the cortisol levels of depressed individuals is inversely associated with glucose control as well

(Atlantis, Browning, Sims, & Kendig, 2009). A ten year follow up study was conducted by

Atlantis et al., (2009) and their findings indicated that several depressive episodes “at least doubled the risk of developing diabetes” (Atlantis et al., 2009, p. 693). These depressive episodes may cause increases in cortisol levels in circulation (Atlantis et al, 2009). Furthermore,

Atlantis et al point out that binge eating disorders are strongly associated with both diabetes and depression, and as well low levels of physical activities are strong predictors of depression and diabetes (2009). By understanding the underlying health risks associated with the depressed patient, and educating them further about the risks of binge eating, insufficient exercise, and how their anti-depressant medications may exacerbate their risk for developing type II diabetes, a good nurse can develop a holistic approach to patient care that encompasses recognition and treatment of depression as a possible risk factor in diabetes II (Atlantis et al., 2009). A HOLISTIC APPROACH TO DIABETES IN THE ELDERLY 3

Using empowerment techniques can be a powerful tool in the management of diabetes

(DeCoster & Dabelko, 2008). DeCoster & Dabelko (2008) offer 44 techniques to help empower the older diabetic, taking into consideration the following areas: Validation and Support,

External Barriers, Problem Solving, Adequate Knowledge and Skills, and Mutual Aid and Self-

Help. Under the heading of Validation and Support, DeCoster & Dabelko suggest empowerment occurs when we “acknowledge and champion the experiences of marginalized people” (2009, p.77), recognize them as experts, assist them with support in acknowledging their diabetes, encourage them to express their feelings and maximize opportunities by encouraging older adults to interact, support and problem solve together (2009). Furthermore, DeCoster & Dabelko

(2009) state that by creating a psychologically safe environment that honors diabetic support and respect is vital to empowerment. Working alongside the patient and helping to create groups in which they can all advocate for their needs is another way to promote empowerment, as is supporting familial balance (DeCoster & Dabelko, 2009). In the area of External Barriers, empowering the elderly diabetic comes with recognizing the elder in their environment by constructing a goal-oriented and diabetic-friendly community map, as well as enlisting various organizations to act as mediators within the larger community, (DeCoster & Dabelko, 2009).

DeCoster & Dabelko also suggest that by promoting equal balance of control among health care providers, the diabetic, and other older adults, there is a fostering of relationships that “support and supplement rather than supplant” (2009, p.78). Problem Solving empowerment can come in many different forms, such as encouraging 5 minute walks each day: although there may be little physical gain in it, the feeling of wellness and self control gained from that moment can be significant for the older diabetic (DeCoster & Dabelko, 2009). Teaching the older adult diabetic how to capitalize on resources, identifying their own existing strengths, reinforcing their A HOLISTIC APPROACH TO DIABETES IN THE ELDERLY 4 perception of control by illustrating behavior and subsequent outcome, and teaching them about doing more of “what works” aids further in the development of empowerment (DeCoster &

Dabelko, 2009, p. 78). DeCoster & Dabelko point out that empowerment gained through

Adequate Knowledge and Skills can be fostered by providing the older adult diabetic with accessible materials to help educate them on their condition and their resources and raising their awareness on how others influence their health: this can assist them in focusing on taking accountability for their own behaviours, leading to the encouragement of “solution experiments”

(p. 78) in which the older adult is urged to try new behavior strategies and assess problems and effectiveness (2009). DeCoster & Dabelko (2009) state that Mutual Aid and Self Help can also foster empowerment when older adults are encouraged to create buddy systems through which they can dialogue about living with diabetes and its challenges, promote storytelling of their successes and failures, and even encourage older adults to run health fairs, teach classes and establish partner systems when attending medical appointments.

According to statistics cited by Yeh, Eisenberg, Davis and Phillips (2002), one in 7 health care dollars within the US is spent on persons with diabetes. At the same time, Yeh et al posit that the care of the diabetic is influenced by growing interest in complementary or alternative methods of treatment: this has resulted in a growing interest in research and clinical studies

(2002). Of the population of people surveyed by Yeh et al (2002), 35% of the diabetic respondents report the use of complementary and alternative medicine in the management of their diabetes. This primarily involves the use of spiritual prayer or spiritual practices: of the number of participants that utilized alternative medicine in the management of their diabetes,

26.5% stated that they had sought the advice of an alternative practitioner as well, with the second most common therapy utilized next to prayer being herbal remedies (Yeh, Eisenberg, A HOLISTIC APPROACH TO DIABETES IN THE ELDERLY 5

Davis, & Phillips, 2002). Interestingly enough, according to Yeh et al., the bulk of the diabetics find solitary prayer to be “very helpful” in the management of their diabetes, even over herbal remedies (2002, p. 1650). A separate study done by Polychronopolous, Zeimbekis, Kastorini,

Papairakleous, Vlachou, Bountziouka, & Panagiotakos (2008) weighed the benefits of the consumption of green tea for diabetics. Tea has been credited with decreased risk of mortality and morbidity in some studies, and its intake has been associated with lower blood glucose levels in non-obese people specifically, with analysis of various studies showing that moderate tea consumption of 1-2 cups per day lowered the risk of obtaining diabetes by 88%

(Polychronopoulos et al., 2008). Biochemical analysis has shown that green tea contains significant vitamins and minerals such as Vitamin C, riboflavin, niacin, folic acid, pantothenic acid, magnesium, potassium, manganese and fluoride, and ”may reduce the risk of many chronic disease, including cardiovascular disease and cancer” (Polychronopoulos et al., 2008, p. 11).

According to Polychronopoulos et al., (2008), this may be attributed to the high quantities of polyphenols; potent antioxidants that are beneficial in lowering blood pressure and reducing blood glucose levels and body weight. A recent study in Japan showed that green tea consumption of 1-6 cups per week was directly associated with a remarkable 34% decrease in risk for diabetes following a five year follow-up (Polychronopoulos et al., 2008). Besides diet considerations, exercise plays a pivotal role in maintaining health and wellness: diabetes is predominant among obese people and lack of proper exercise is therefore considered a contributing factor in the progression to diabetes due to “impaired metabolism, imbalance of trace elements, and abnormal expression of inflammation” (Chen, Ueng, Lee, Sun, & Lee, 2010, p. 1153). A study conducted by Chen et al., (2010) considered the effects that T’ai Chi exercise had on obese diabetics in Taiwan. Chen et al posited that it is a known fact that strenuous A HOLISTIC APPROACH TO DIABETES IN THE ELDERLY 6 exercise increases the burden on the cardiovascular system of obese diabetics, and therefore increases the incidence of hypoglycemia, but at the same time, it is known that aerobic exercise and moderate stretching enhances cardio-respiratory function and aids in reducing UTIs, respiratory disease and facilitates efficient management of blood glucose levels (2010). It was not surprising then, when they discovered that T’ai Chi exercise significantly improved BMI

(Body Mass Index), triglyceride serum levels, HDL levels and reactive protein levels in diabetic patients (Chen et al., 2010). Chen et al concluded that T’ai Chi exercise “can be an alternative exercise intervention for increasing glucose control, diabetic self-care activities, and quality of life” (p. 1157), while also citing Wang et al (2008) as stating that an 8 week T’ai Chi study showed positive effects on blood glucose, high and low affinity insulin receptor numbers and their binding capacity in those with type II diabetes (2010). The key benefits of incorporating

T’ai Chi exercise into diabetes management is not focused on consumed calories, but rather in the efficacy of “enhanced metabolism, cardiopulmonary function, and antioxidation and anti- inflammatory activation” (Chen et al., 2010, p. 1158).

Further holistic approach to diabetic care in older adults involves focused aged care through routine monitoring of three key areas. Giles, Visentin & Phillips (n.d.) label these areas as The Medical ABCs: the acronym ‘A’ stands for A1c (known as HbA1c), which gives an overview of blood glucose levels: ideal levels would be 7% or less, dependent on individual hypoglycemia and complication risks; B is blood pressure, with ideal systolic BP around

130mHg or less; C is for cholesterol ideally around 4mM or less; and S for salicylates: low dose aspirin to reduce the risk of cardiovascular events. By being aware of these 4 key areas of consideration, care for the diabetic becomes innately holistic in that the understanding of the disease surpasses the simple recognition of insulin in their care. Further assessment and A HOLISTIC APPROACH TO DIABETES IN THE ELDERLY 7 planning of self-care in the elderly diabetic helps to monitor these key areas. This may include planning for healthy target weight, physical activity, smoking risks, self-care education and careful screening for complications such as foot and eye problems related to diabetes (Giles,

Visentin, & Phillips, n.d.).

It is understood that the greatest increase in diabetes diagnoses within the next 40 years will occur among people 75 years of age and older (Fravel, McDaniel, Ross, Moores, & Starry,

2011). Being prepared to face the large numbers of these aging adults in the health care system will require health care providers to be diligent in their knowledge surrounding diabetes and the available tools for preventative and therapeutic modalities. By taking a holistic approach to diabetes management, the health care provider can offer a variety of lifestyle measures to incorporate into the care of the diabetic, such as recognition and consideration of the risk that depression can play in the development of diabetes, personal empowerment, various alternative measures to help foster a healthy lifestyle, and age-relative care considerations. Staying current with the latest research, available therapies and education will help create the best possible environment to facilitate a successful diabetic management plan. A HOLISTIC APPROACH TO DIABETES IN THE ELDERLY 8

References

Atlantis, E., Browning, C., Sims, J., & Kendig, H. (2009). Diabetes incidence associated with

depression and antidepressants in the Melbourne Longitudinal Studies on Healthy Aging

(MELSHA). International Journal of Geriatric Psychiatry, 25, 1648-1652.

doi:10.1002/gps.2409

Chen, S., Ueng, K., Lee, S., Sun, K., & Lee, M. (2010). . Effect of T’ai Chi exercise on

biochemical profiles and oxidative stress indicators in obese patients with type 2

diabetes, 16, 1153-1159. doi:10.1089/acm.2009.0560

DeCoster, V. A., & Dabelko, H. I. (2008). Forty-four techniques for empowering older adults

with diabetes. National Association of Social Workers, 77-80. Retrieved from

http://search.ebscohost.com/login.aspx?

direct=true&db=pbh&AN=32185566&site=ehost-live

Fravel, M. A., McDaniel, D. L., Ross, M. B., Moores, K. G., & Starry, M. J. (2011, March 15).

Special considerations for treatment of type 2 diabetes mellitus in the elderly. American

Journal of Health-System Pharmacology, 68, 500-509. doi:10.2146/ajhp080085

Giles, J., Visentin, K., & Phillips, P. (n.d.). Diabetes in aged care. Australian Nursing Journal,

16(7), 40. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=

rzh&AN=2010179654&site=ehost-live

Polychronopoulos, E., Zeimbekis, A., Kastorini, C., Papairakleous, N., Bountziouka, V., &

Panagiotakos, D. B. (2008). Effects of black and green tea consumption on blood glucose

levels in non-obese elderly men and women from Mediterranean islands (MEDIS

epidemiological study). European Journal of Nutrition, 47, 10-16. doi:10.1007/s00394-

007-0690-7 A HOLISTIC APPROACH TO DIABETES IN THE ELDERLY 9

Yeh, G. Y., Eisenberg, D. M., Davis, R. B., & Phillips, R. S. (2002, October). Use of

complementary and alternative medicine among persons with diabetes mellitus: Results

of a national survey. American Journal of Public Health, 92, 1648-1652. Retrieved from

http://search.ebscohost.com/login.aspx?direct=true&db=pbh&AN=8840805&site=ehost-

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Grade 29.00 / 30.00 Graded on Wednesday, 10 October 2012, 8:30 AM Graded by Vicki Hammond Nice job, and very interesting. I like that you have decided to take a different approach and demonstrate alternatives to medication. Insulin makes us hungry and Feedback fat just though its mechanism of action. Green tea! Tai Chi! Buddy systems. comments Excellent. the paper is well written with style and mechanics well addressed. YOu have excellent flow and the literature is relevant. Could I send this paper to the manger at LMH who has asked for papers related to upcoming inservices?