Motivational Interviewing
Many HCPs are frustrated that they are unable to persuade patients to adhere to their DM care recommendations. Health care providers often use strategies such as badgering or blaming patients for being nonadherent or scare tactics about the negative consequences of the disease. 21 This approach is often ineffective and results in patients becoming more resistant to change.
Motivational interviewing using open-ended questions is an evidenced-based counseling technique that has been shown to elicit sustained behavioral changes. Motivational interviewing increases intrinsic motivation within patients and establishes a goal of incorporating patient-centered values into care by examining ambivalence and passivity in a nonjudgmental way. 22 Motivational interviewing facilitates empowerment by using a decision-making process based on each individual’s unique physical, emotional, and environmental circumstances. With guidance from HCPs, patients are able to set the ground rules for DM management by defining a plan that works best for them. For example, a patient may consider a meal plan with stricter caloric intake vs one with a higher calorie count but with more frequent insulin injections or blood glucose monitoring. This strategy puts patients at the center of decision making about medications, diet, and exercise. It also allows them to implement an individualized plan that they believe will work best for them based on their own perceived goals, priorities, and stressors. This approach is shown to work effectively in DM care. 8,23
Medication Regimen and Glucose Monitoring
Hypoglycemia is a major concern when managing DM in older adults. 20 Hypoglycemia can be triggered by polypharmacy, cognitive impairment, renal insufficiency, sedatives, alcohol intake, malnutrition, and the use of sulfonylureas or insulin. Medications should be considered within the context of other geriatric problems such as falls, depression, urinary incontinence, and pain. 20 A simplified approach based on the patient’s functional and cognitive abilities is a good starting point. 20 Unless contraindicated, medication initiation could begin with a biguanide. 1 Sulfonylureas should generally be avoided in older adults due to the high risk of hypoglycemia. 1 Older adults with frequent hypoglycemia should be referred to an endocrinologist or diabetes educator for further management. 24
Insulin therapy is recommended if oral therapy alone is insufficient or fails. 20 Insulin can be prescribed with adequate DM education and blood glucose monitoring. When prescribing insulin, HCPs should consider older patients’ physical dexterity, visual acuity, cognitive function, financial circumstances, and family support to determine whether insulin therapy is a realistic option that patients can appropriately manage. 12,20
Many older adults are resistant to starting insulin and are often reluctant to titrate insulin doses between clinic visits as prescribed by HCPs. 12 Older adults on insulin need reassurance and education from a diabetes educator or HCP to gain confidence in adjusting insulin. 12 A simple approach to starting insulin can be to start with an evening dose of long-acting insulin. 20 Short-acting agents can be added later as needed to control postprandial hyperglycemia. 20 Prefilled insulin flex pens also provide a quick and easy way to administer insulin in precise doses. 20