XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

The standardisation of terminology of lower urinary tract function: Report from the standardistation sub-committee of the International Continence Society.

The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society.

The standardisation of terminology in lower urinary tract function: report from the standardisation sub-committee of the International Continence Society.

Dementia prevention, intervention, and care

As people get older, they may fall more often for a variety of reasons including problems with balance, poor vision, and dementia. Up to 30% may fall in a year. Although one in five falls may require medical attention, less than one in 10 results in a fracture.
This review looked at the healthcare literature to establish which fall prevention interventions are effective for older people living in the community, and included 159 randomised controlled trials with 79,193 participants.  
Group and home-based exercise programmes, usually containing some balance and strength training exercises, effectively reduced falls, as did Tai Chi. Overall, exercise programmes aimed at reducing falls appear to reduce fractures.
Multifactorial interventions assess an individual's risk of falling, and then carry out treatment or arrange referrals to reduce the identified risks. Overall, current evidence shows that this type of intervention reduces the number of falls in older people living in the community but not the number of people falling during follow-up. These are complex interventions, and their effectiveness may be dependent on factors yet to be determined.  
Interventions to improve home safety appear to be effective, especially in people at higher risk of falling and when carried out by occupational therapists. An anti-slip shoe device worn in icy conditions can also reduce falls.
Taking vitamin D supplements does not appear to reduce falls in most community-dwelling older people, but may do so in those who have lower vitamin D levels in the blood before treatment.  
Some medications increase the risk of falling. Three trials in this review failed to reduce the number of falls by reviewing and adjusting medications. A fourth trial involving family physicians and their patients in medication review was effective in reducing falls. Gradual withdrawal of a particular type of drug for improving sleep, reducing anxiety, and treating depression (psychotropic medication) has been shown to reduce falls.
Cataract surgery reduces falls in women having the operation on the first affected eye. Insertion of a pacemaker can reduce falls in people with frequent falls associated with carotid sinus hypersensitivity, a condition which causes sudden changes in heart rate and blood pressure.
In people with disabling foot pain, the addition of footwear assessment, customised insoles, and foot and ankle exercises to regular podiatry reduced the number of falls but not the number of people falling.
The evidence relating to the provision of educational materials alone for preventing falls is inconclusive.

Interventions for preventing falls in older people living in the community

Despite the many diabetes applications available, the rate of use is low, which may be associated with design issues. This study examined app usability compliance with heuristic design principles, guided by the Self-determination Theory on motivation. Four top-rated commercially available apps (Glucose Buddy, MyNetDiary, mySugr, and OnTrack) were tested for data recording, blood glucose analysis, and data sharing important for diabetes competence, autonomy, and connection with a healthcare provider. Four clinicians rated each app's compliance with Nielsen's 10 principles and its usability using the System Usability Scale. All four apps lacked one task function related to diabetes care competence or autonomy. Experts ranked app usability rated with the System Usability Scale: OnTrack (61) and Glucose Buddy (60) as a "D" and MyNetDairy (41) and mySugr (15) as an "F." A total of 314 heuristic violations were identified. The heuristic principle violated most frequently was "Help and Documentation" (n = 50), followed by "Error Prevention" (n = 45) and "Aesthetic and Minimalist Design" (n = 43). Four top-rated diabetes apps have "marginally acceptable" to "completely unacceptable." Future diabetes app design should target patient motivation and incorporate key heuristic design principles by providing tutorials with a help function, eliminating error-prone operations, and providing enhanced graphical or screen views.

Usability Evaluation of Four Top-Rated Commercially Available Diabetes Apps for Adults With Type 2 Diabetes.

The relationship between diuretics and involuntary urine loss is poorly understood This study presents data on 130 community-dwelling women with urinary incontinence Forty-five of these women took diuretics and 85 did not These groups were compared with regard to clinical and urodynamic characteristics and severity of urinary incontinence and of diurnal and nocturnal micturition frequency Subjects on diuretics were heavier (P<001), had higher systolic blood pressure (P<0001), and had a higher prevalence of cardiovascular disease (P<0001) and diabetes (P<0001) In addition, they used cardiovascular medications more often (P<0001) and had been treated for incontinence previously more frequently (P<0001) Urodynamic variables showed essentially no significant differences other than the volume voided during uroflowmetry, with subjects on diuretics voiding significantly smaller volumes than subject not taking such drugs (P<005) Those on diuretics had significantly more incontinent episodes (P<001) and diurnal urinary frequency (P = 0001) In addition, those subjects on diuretics who had bladder instability lost significantly larger quantities of fluid during testing (P<005) and had more episodes of nocturia (P<001) Although some findings can be explained by an increased diuresis, others cannot A local pharmacologic effect is thought unlikely Changes in sensitivity threshold due to habit, or behavior is considered possible Diuretics and/or conditions associated with their use seem to influence the severity of the syndrome of urinary incontinence

Diuretics and urinary incontinence in community‐dwelling women

Older adults admitted to nursing homes (NHs) are at risk for low social engagement, which has associations with medical, psychological, and social well-being. Minorities may be at a disadvantage for social engagement because of their racial or ethnic group identity. This study assessed whether there were racial/ethnic disparities in social engagement among older adults (N = 15,927) at 1 year after their NH admission using multi-level predictors. No racial or ethnic-based disparities in social engagement were found; hence, an analysis of risk factors at NH admission that predicted low social engagement at 1 year for all residents was conducted. Significant risk factors for low social engagement were low social engagement at admission, deficits in activities in daily living and cognition, problems with vision and communication, and residing in an NH in an urban community. Results highlight the importance of initiating interventions to increase social engagement at the time of NH admission.

Social Engagement After Nursing Home Admission: Racial and Ethnic Disparities and Risk Factors.

This article is a report of a task force formed from a discussion group hosted by the American Nurses Association on the AHCPR Guidelines on Urinary Incontinence. The need to standardize content related to bladder incontinence to be used in curriculums was identified as an initial step in implementing the guidelines. A task force was formed to develop educational competencies to be used by schools in identifying content that should be addressed at various levels of preparation. Although special training is needed when continence care is a significant part of a nurse's practice, it is expected that by using the educational competencies, schools will produce graduates at the basic level able to provide beginning continence care and graduate nurses able to address advanced incontinence problems.

Addressing Urinary Incontinence with Educational Continence-Care Competencies

Little is known about cardiorespiratory fitness and aerobic exercise training in older adults with Alzheimer's disease (AD). The purposes of this article are to describe the change in cardiorespiratory fitness after 2 months of aerobic training and the feasibility of aerobic training in 4 men with moderate-to-severe AD. A one-group, pretest-posttest test design was used to measure cardiorespiratory fitness using symptom limited, graded cycle ergometer testing. In exit interviews, participants and spouses identified exercise facilitators and barriers. The results show that cardiorespiratory fitness increased in 2 participants with moderate AD but decreased in 2 with severe AD. Participants showed great variability in exercise progression and doses actually delivered. In conclusion, older men with moderate-to-severe AD can engage in aerobic training. Two months might be better used as the adaptive period for longer duration aerobic training, such as a 6-month program. Suggestions and implications for future exercise research in AD are detailed.

Jean F. Wyman

Papers

Usability Evaluation of Four Top-Rated Commercially Available Diabetes Apps for Adults With Type 2 Diabetes.

Diuretics and urinary incontinence in community‐dwelling women

Social Engagement After Nursing Home Admission: Racial and Ethnic Disparities and Risk Factors.

Addressing Urinary Incontinence with Educational Continence-Care Competencies

Aerobic training for older men with Alzheimer's disease