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 Charting The Course Of Colliding Diseases

Newly uncovered links between diabetes and dementia and other diagnoses bring person-centered care to a new level.

 

When research links one disease or condition to another, it presents an opportunity for practitioners and caregivers to improve care by identifying at-risk individuals, recognizing and treating problems before they exacerbate. By connecting the dots, the interdisciplinary team can create a complete picture of a resident that maximizes their ability to provide targeted, effective, person-centered care.

Diabetes And Dementia

There are many illnesses and conditions common in the elderly that have connections, many of them surprising. However, perhaps the most significant one—the link between diabetes and dementia—has received tremendous attention and study in recent years.

Studies have shown that type 2 diabetes significantly increases the risk of dementia. For example, a study published in The New England Journal of Medicine tracked blood glucose levels of over 2,000 patients. Some had type 2 diabetes at the study’s start, but none had dementia. The authors saw a steadily increasing risk of dementia with rising blood glucose levels, even in patients who didn’t have diabetes. Patients with diabetes also had a higher risk of cognitive impairments, which may be early signs of Alzheimer’s disease or other dementia.

Data presented at the 2013 Alzheimer’s Association International Conference showed that a diabetes drug may be associated with a reduced risk of dementia. In a study of nearly 15,000 people with type 2 diabetes aged 55 and older, those who started on metformin, an insulin sensitizer, had a much lower risk of developing dementia in comparison with people who started other diabetes therapies.

Among the results from various other studies in recent years:
■ Researchers found that the amyloid precursor protein gene, often involved in Alzheimer’s disease, interrupts the insulin pathway—a hallmark of diabetes.

■ A 2007 study in the Journal of the American Geriatrics Society looked at women (average age 72 years) with various levels of cognitive function and discovered that the strongest factor associated with good cognitive function was lack of diabetes.

■ A 2009 study in Diabetes Care found that people with diabetes and high hemoglobin A1C levels had lower levels of cognitive function than those with lower hemoglobin levels.

Explaining The Link

During a session at the 2014 Alzheimer’s Association International Conference, speakers pondered the reasons for the links between diabetes and dementia. They talked about the possibility of a shared set of genes that predisposes people to both conditions, as well as the possibility that diabetes affects the brain in a way that may cause dementia.

Davis Smith, MDDavid Smith, MD, CMD, president of Geriatric Consultants in Brownwood, Texas, suggests, “The dementia-diabetes connection will probably be explained by the fact that diabetes increases atherosclerosis—heart disease in which the arteries harden and narrow (increasing stroke risk)—and vascular dementia, caused by impaired supply of blood to the brain,” sometimes caused by a series of small strokes.

“The connection to Alzheimer’s disease is harder to explain, but we do know that all things bad for your heart lead to Alzheimer’s disease,” Smith says. This is at least partly because of the link between heart disease and artery damage that causes changes in the brain. “Additionally, we may learn that hyperglycemia is neurotoxic [causes damage from exposure to toxic substances in the body]. We believe that is the cause of diabetic neuropathy. Of course, hypoglycemia [low blood sugar] can kill brain cells, too.”

Bruce Robinson, MD, a geriatrician in Sarasota, Fla., adds, “I’ve always believed that vascular disease has to do with incidences of dementia. This is an important factor, and the best way to reduce the risk of dementia is to recognize and manage diabetes and address issues such as hypertension, smoking, and obesity.”

The challenge of this, says Robinson, is that “by the time patients come to the nursing facility, the cow is out of the barn. We really need to address this link 20 years before the patients come to us.” He notes that by the time patients enter long term care, they have “a short life expectancy and increased burdens that make us wonder whether we should try to aggressively treat vascular risk factors.” Nonetheless, he says, “Things like age-appropriate diabetes control and exercise are imperative.”
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Balancing Conflicting Treatments

Robinson cautions against tightening control of diabetes in the elderly. “Tight glycemic control generally isn’t recommended for nursing home patients, and there is some evidence that patients with aggressively managed diabetes have more cognitive decline,” he says.

Guidelines issued by the American Diabetes Association recommend looser blood sugar targets for people older than 65 or 70 than for younger patients with a long life expectancy and no history of heart disease.
“If dad has dementia, we can take a good guess about his life expectancy, assess the consequences of less-than-perfect diabetes control, and balance that with quality-of-life issues,” says Smith.

He notes that looser control is justifiable in this population, and most family members can understand this. “It’s about teaching them about the epidemiology of diabetes and the timetable on its progress. It’s about helping them understand that the time for tight glycemic control was when dad was 40, not now that he’s 85 and has multiple comorbidities,” Smith says.

“That’s an important teachable moment for those genetic relatives, too.”

Tread Gently, Educate Family

Especially if a person has one serious illness such as diabetes, Robinson reminds care teams that a diagnosis of dementia can be devastating. The physician and interdisciplinary team leaders can ease the shock and fears. “People are looking for something to make themselves feel better when they have dementia. If you are talking to someone with a new diagnosis of dementia, it is helpful to be positive and not talk about the disease as if it’s the end of the world.” He adds, “We emphasize the uncertainty—the dramatic variability in the course of dementia and what we can do to potentially slow the course of the disease.”

It is hard to have this discussion in a 10-minute office visit, according to Robinson. “We block out an hour. I come in and talk about brain imaging and medical findings. Then a counselor takes over and talks for about 50 minutes about how to make tomorrow a better day.” This is an opportunity to have an open discussion with the patient and family, he says.

Part of this discussion may include a lesson for the family. “If they are dealing with a loved one who has diabetes and/or dementia, they are at risk as well,” Robinson says. “We can help them understand that they can avoid taking the same route as their mom or dad by making certain lifestyle changes now.”

Steven Arnold, MD, professor of psychiatry and neurology at the University of Pennsylvania and director of the Penn Memory Center, agrees. “We know that family history is a risk factor, so it motivates people to take care of their own health once they see that will make a big difference later on,” he says.

While there isn’t a definitive way to prevent Alzheimer’s disease yet, Arnold says, “we have biomarkers—such as spinal fluid tests and amyloid PET scans—to determine if Alzheimer’s disease is brewing in the brain. These can be used to educate and motivate people to change behaviors early on.”
Knowing the possible downstream consequences of diabetes should motivate younger patients to manage their condition, Smith agrees. “We don’t have definitive evidence yet, but we’ll likely learn eventually that controlling diabetes will help patients dodge the bullet on dementia or at least delay its onset.”
In the long term care setting, he says, “The presence of diabetes is alerting us to pay attention to the development of cognitive deficits.”

Psoriasis: Beyond Itching

While everyone who works in long term care likely knows that illnesses such as diabetes and dementia are very serious and potentially life-threatening, few may understand that problems such as itchy, red skin can cause tremendous health problems in this population. 

Psoriasis not only can affect quality of life: The presence of this condition increases a person’s risk of other illnesses that can result in serious disability or even shortened lifespan.

Psoriasis most commonly appears as raised, red patches covered with a buildup of dead skin cells. It can appear on any part of the body, but it most commonly affects the outside of the elbows, knees, or scalp. People with psoriasis often report stinging, itching, or burning sensations. If a patient has not previously been diagnosed with psoriasis but exhibits any signs of the condition, staff should alert a nurse or other practitioner, who likely will be able to make a diagnosis just by visual inspection.

While psoriasis most commonly presents when a person is between 18 and 25 years old, it is not uncommon for the condition to start when a person is 60 or older. It is important for practitioners and caregivers alike to understand the implications of this condition and its link to arthritis, as well as depression and related problems.

There are a variety of topical and systemic drug therapy options to treat psoriasis in the elderly. In determining the best possible treatment for each patient, the physician should consider the patient holistically—what the person’s activity level is, how he or she socializes, and what quality-of-life concerns he or she has. Topical medications, such as corticosteroids, salicylic acid, tar, and dithranol preparations, are considered first-line treatments for elderly patients. Narrow ultraviolet B phototherapy is another option. Systemic agents such as methotrexate, acitretin, and cyclosporin should be reserved for severe cases.

Arthritis A Threat

“The greatest concern in elders with psoriasis is the risk for psoriatic arthritis, which affects about 30 to 40 percent of people with the skin disease,” says Jerry Bagel, MD, director of the Psoriasis Treatment Center of Central New Jersey in East Windsor, N.J. Psoriatic arthritis involves mild to severe joint pain, stiffness, and swelling. It can affect any body part, including fingertips and spine.

Jerry Bagel, MDFlare-ups of the condition may alternate with periods of remission. There currently is no cure, but treatments include nonsteroidal anti-inflammatory drugs (NSAIDs), disease-modifying antirheumatic drugs (DMARDs), immunosuppressants, and TNF-alpha inhibitors such as Enbrel or Humira. Steroid injections to reduce inflammation also might be helpful. When joints have been severely damaged by the disease, joint replacement surgery may be necessary.

If an elder has psoriasis, it is important to watch for signs of psoriatic arthritis. These include swollen fingers and toes, foot pain, lower back pain, and morning stiffness. The clinician will confirm a diagnosis of psoriatic arthritis with imaging tests such as x-rays and magnetic resonance imaging (MRI), as well as laboratory tests such as rheumatoid factor (RF) and joint fluid tests.

It is critical to recognize signs of psoriatic arthritis and treat the condition promptly. Untreated, the condition can contribute to problems such as falls or depression. Additionally, a small number of people with psoriatic arthritis develop arthritis mutilans, which is a severe, painful, and disabling condition.

Arthritis mutilans slowly destroys small bones in the hands and leads to permanent deformity and disability.

Bagel notes that psoriatic arthritis often is undertreated in the elderly, partly because clinicians are hesitant to use drugs such as Enbrel and Humira because they worry about side effects. However, Bagel says, studies to date haven’t indicated that side effects are more severe in the elderly.
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Look Beyond Physical Signs

While it is important to watch patients with psoriasis for signs of psoriatic arthritis, practitioners and caregivers should realize that psoriasis can lead to other problems as well.

“When patients are scratching, itching, and/or bleeding, this discomfort can increase anxiety and impair sleep,” says Bagel. In addition to the other risks psoriasis patients face, they also have a higher risk of early death, heart attack, and diabetes, he says.

Bagel stresses that staff should understand that even if a person has had psoriasis for years, he or she may be self-conscious about it in a new environment. “Other residents will look at them and wonder what they have and if it’s contagious. The person with psoriasis may feel stigmatized. As a result, he or she may become isolated and depressed,” he says.

Staff must be educated about the condition as well. “They need to know that it’s not contagious and that it can be treated,” says Bagel. They also need to understand how people feel about having this disease and be sensitive to their feelings. Staff can model behavior for others by hugging or touching the person with psoriasis, he suggests.

Colby Evans, MD, founder of Evans Dermatology Partners in Austin, Texas, observes that patients with psoriasis should be monitored for depression. There are well-documented studies about the link between psoriasis and depression. He adds that people with psoriasis also have double the normal risk for suicidal thoughts and have a higher rate of alcoholism.

“It’s a chicken and egg connection. A person has psoriasis so he doesn’t go out, so he’s isolated and depressed, so he drinks, and that exacerbates his depression,” Evans says.

“Make sure patients with psoriasis have access to support groups, education, etc. You can help by treating them like you would any person. Make it clear that you’re not disgusted by their condition or afraid to touch them.”

Make psoriasis care a priority, Evans urges. “The patient’s whole existence can be made worse or better, depending on what you do. You need to understand and address how their disease impacts their social relationships, nutritional status, physical activities, and social interactions. In addition to treating their psoriasis—and if they have it—psoriatic arthritis, we also need to watch their cholesterol, weight, and smoking.”

Oral Disease Affects More Than The Mouth

In recent years, studies linking poor oral hygiene to a variety of conditions and illnesses have received much attention. As a result, a growing number of long term care facilities have begun to make their residents’ oral health a priority.

The incident that triggered one physician’s passion for oral hygiene in long term care exemplifies how significantly poor oral hygiene can affect overall health. Paul Mulhausen, MD, chief medical officer of Telligen, a population health management firm in Des Moines, Iowa, recalls, “I had a patient who was very ill with a brain abscess from poor dentition. We were able to treat her successfully, although she was left disabled by her illness.

“She believed that I saved her life. I thought that the health care system failed her.” Unaddressed poor oral hygiene substantially impacted her independence, quality of life, and living choices, Mulhausen says. “If practitioners and caregivers throughout the continuum had paid more attention to her oral health, her illness could have been avoided. This experience moved me to become an active oral health advocate.”

Problems Linked To Oral Health

A variety of systemic health conditions are clearly related to oral health and hygiene. Among the documented links:
■ Mouth problems have been linked to a higher risk of diabetes, lung conditions, and heart disease.

■ Tooth infections can become systemic.

■ At least one study showed a strong link between tooth loss and heart disease. The risk of heart disease actually is nearly doubled for people missing six to 31 teeth, compared with those who have all of their teeth.

■ Poor oral health influences the occurrence of pulmonary infections in the elderly. This is particularly dangerous when someone has aspiration pneumonia, says Mulhausen. “When elders aspirate the germs of oral infections, they can become very ill.” Additionally, sleeping in dentures has been shown to double the risk of pneumonia in the elderly.

■ A more subtle connection, Mulhausen says, is between mouth inflammation and blood glucose levels. “Better oral health and treatment of gum inflammation can actually improve blood sugar control,” he says.
Poor oral health also can cascade into problems such as weight loss and depression.

“There is a connection between mouth pain caused by poor oral health and poor eating, lack of interest in activities, behavioral issues, and the possibility of a spiral into general decline,” Mulhausen says. “This is especially problematic in patients who can’t articulate pain.”

Ensuring that patients have a clean, comfortable mouth cavity is as important as keeping skin clean and healthy, says Mulhausen.

“I can’t say that this care is easy. It’s hard, challenging work. But it’s doable if we give caregivers the skill sets to address this challenge.”

A Holistic Approach

The link between various illnesses and conditions that affect frail elders supports the value of a holistic approach to care, Mulhausen says. “Comprehensive and holistic care is how you end up with the best quality of care.”

Dan Haimowitz, MDThe challenge to this approach, he observes, is that “all of us tend to educate and train ourselves in silos. For example, after the first year of medical school, they pretty much ignore the mouth.” However, he notes, “You don’t have to be a world expert to be comprehensive and holistic. Instead, you need a basic level of understanding and be able to view the patient as a whole.”

This requires practitioners and caregivers to be careful to look at people in their entirety. “Of course, you want to acknowledge that a person has dementia,” says Dan Haimowitz, MD, CMD, a multifacility medical director in Levittown, Pa.

“But it is important to realize there’s more to it than just labeling a person with dementia. We need to look beyond that diagnosis when assessing signs and symptoms and look at what’s really important—how can we improve someone’s functioning and quality of life. We need to take our blinders off and not just assume that their dementia is the cause of a behavior, complaint, or change of condition.” Haimowitz says the person-centered care approach the profession has embraced encourages an individualized, holistic approach to care for each patient.

That means taking into account that conditions and illnesses may be linked and thinking about how providers can balance treatment and interventions with a focus on prevention, early recognition of illnesses or conditions, adherence to treatments and lifestyle changes, and, most importantly, quality of life.

Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Pa.

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