A CADENZA Initiated Research

1. A Community Model for Care of Older Persons with Diabetes Mellitus:a Randomised Controlled TrialDr Elsie Hui, FRCPSenior Medical Officer, Shatin Hospital A CADENZA Initiated Research

2. Diabetes among older people in Hong Kong:how big is the problem? • 1 in 5 persons aged 65 to 84 have diabetes • Among adults diagnosed with diabetes, half are elderly • By 2036, the number of older diabetics is expected to be 300,000 (McGhee et al, 2009)

3. Burden of diabetes • On patients • Complications • Disability & handicap • Poor quality of life • Pre-mature death and increase in mortality • Increase in health care cost • On society • More dependent persons • Increase in utilization of healthcare services • Increased demand for personal care

4. Barriers encountered by older people with diabetes • Special needs of older diabetics • Co-morbidities (e.g. hypertension, heart diseases, stroke) • Co-existing geriatric syndromes (e.g. cognitive impairment, depressive symptoms, falls, urinary incontinence) • Poor (health) literacy • Over-emphasis on hospital- and clinic-based services and medication therapy • Lack of support in the community

5. Behaviour in managing diabetes (older HK men) (Department of Health, HKSAR & Department of Community Medicine, HKU, 2005)

6. Behaviour of managing diabetes (older HK women) (Department of Health, HKSAR & Department of Community Medicine, HKU, 2005)

7. Behaviour in managing diabetes among older HK persons • Therapeutic management • Majority (80%) taking oral hypoglycemics • ~ 20% older women taking ‘over the counter’ drugs • Lifestyle modifications • Older men are more capable than older women • Older diabetics much worse than younger patients, especially women

8. Patient education for older diabetics • Address common geriatric syndromes and co-morbid conditions • Besides glycemic control, focus on • managing symptoms (e.g. hypoglycemia, vision, neuropathic pain) • maintaining functional independence • improving quality of life • lifestyle restrictions • depression • Take into account learning habits of older people • simple instructions • intensive training on practical skills • reinforcement and maintenance

9. Pilot study: single arm, pre-, post-test design8-week intervention Significant changes were observed in the following outcomes • Diabetes Knowledge Test • Mean post-prandial blood glucose (12  8 mmmol/l) • Nutritional status • dietary intake (carbohydrates, protein, fat) • Body Mass Index (25.4  24.9) • weight reduction in 36% of subjects • QOL • Diabetes QOL questionnaire (all domains) • SF-36 (6 out of 8 domains) Chan WM, Woo J, Hui E, et al. A Community model for care of elderly people with diabetes via telemedicine. Appl Nurs Res 2005;18:77-81.

10. CADENZA Initiated Research • “CADENZA: A Jockey Club Initiative for Seniors” initiated a research study on a community-based, chronic disease management programme for older persons with diabetes • The Cadenza Research Team collaborated with Dr. E Hui of Shatin Hospital to develop the intervention and evaluate outcomes

11. A Community Model for Care of Older Persons with Diabetes Mellitus: a randomised controlled trial E Hui & Cadenza Research Team

12. Community-based community social centres & day care centres for the elderly in Shatin Small groups 6-10 participants 8 sessions, 2 hours each, once a week 3 core components Education Exercise Peer support Added relevant topics blood pressure management Self-management concepts Conducted by non-professional personnel 1 or 2 research assistants leaders’ training following a standardized “Leader’s Manual” Features of programme

13. Components of programme (1) • Educational talks • Visual aids • Games • Group discussion

14. Behavioral modification strategies Action plan Goal setting Problem solving Components of programme (2)

15. Components of programme (3) • Group exercise • Aerobic & resistance • Home exercise prescribed

16. Research design • Randomized controlled trial • Since January 2008 & still on-going • Comparing the changes in physical and quality of life outcomes in programme participants (intervention group) with those did not join the programme (control group) at 8 weeks

17. Participants • Aged 50 or above • Confirmed diagnosis of diabetes • Receiving medical treatments • oral medications • insulin injection • Living in the community • Satisfactory cognitive function (MMSE ≥ 19)

18. Procedure Recruitment in community elderly centres, day care centres, out-patient clinics in health centres and public hospitals Baseline Complete baseline assessment Randomization Intervention group Control group Community-based Diabetes Management Programme 8 weeks Complete follow-up assessment

19. Outcome measurements (1) • Physical measures • Body mass index (BMI) • Waist-hip ratio (WHR) • Random glucose • HbA1c • Systolic and diastolic blood pressure • Process measure • Diabetes knowledge scale1 • Quality of life measures • Chinese Diabetes quality of life Score2 • Medical Outcomes Study SF-36 (Hong Kong)3 1Beeney LJ, Dunn SM, Welch G. 1994; Measurement of diabetes knowledge: The development of the DKN scales. In C. Bradley (Ed.), Handbook of psychology and diabetes. London: Harwood Academic Publishers, pp 159-189. 2Cheng AY, Tsui EY, Hanley AJ, Zinman B. Developing a quality of life measure for Chinese patients with diabetes. Diabetes Res Clin Pract 1999;46:259-267. 3Lam LK, Gandek B, Ren X, Chan MS. Tests of scaling assumptions and contruct validity of the Chinese (HK) version of the SF-36 health survey. J Clin Epidemiol 1998;51:1139-1147.

20. Focus Group Interviews • 14 subjects randomly selected from intervention group • Group discussion led by a facilitator • Open-ended questions • 4 themes identified • Comments on existing health care services for diabetics • Experiences of participation in the new service model (intervention) • Motivation to join the programme • Suggestions for improvement of the new service model

21. Interim findings

22. Participants Until September 2009 Recruited participants (n=208) Baseline Intervention group (n=107) Control group (n=101) Community-based Diabetes Management Programme Drop-out: n=13 (12.9%) Pending assessment: n=8 (7.9%) Drop-out: n=15 (14.0%) Pending assessment: n=9 (8.4%) Completed 8-week programme and follow-up n=83 (77.6%) n=80 (79.2%)

23. Characteristics of participants

24. Outcomes of intervention group at baseline and 8 weeks– physical and process measures (n=83)

25. Outcomes of intervention group at baseline and 8 weeks– quality of life measures (n=83)

26. Comparing outcome changes between intervention and control groups at 8 weeks – physical and process measures

27. Comparing outcome changes between intervention and control groups at 8 weeks – quality of life measures

28. Some comments arising from Focus Group • Existing services for older people with diabetes were inadequate and could not address their needs • Participating in the current programme allowed participants to equip themselves with knowledge and skills, encouraged a positive attitude towards diabetes self-management, and provided emotional support • The programme should be run on a regular basis, targeting newly diagnosed patients, and provide more strategies in stress and psychological management

29. Discussion

30. Effectiveness of the programme • At the end of the Diabetes Management Programme, participants in the intervention group had improvements (pre- and post-test) in • HbA1c • Systolic and diastolic blood pressure • Diabetes-related knowledge • Diabetes quality of life • higher satisfaction • lower impact • worry • Mental health

31. Effectiveness of the programme • Comparing with those in the control group, participants in the intervention group had significant difference (improvements) in • Diabetes-related knowledge • Satisfaction in diabetes control • Mental health

32. Limitations and Suggestions • Follow-up period of 8 weeks was too short • Physical outcomes take longer to change • A small subset (n=37) was assessed at 6 months • BMI continued to decrease • Subjects’ diabetic control was fair • HbA1c 7.45% (intervention), 7.06% (control) • Future study - target ‘high risk’ patients with poor control, complications and history of DM-related hospitalization

33. Recommendations

34. Incorporate into regular community services • Disseminate the concept of “Community Model for Care of Diabetes” (and other chronic diseases) to different organizations in both health and social sectors • Incorporate such programmes as routine services offered in community or day case centres serving older persons • Explore the possibility of training non-healthcare professionals or older volunteers to be the leaders of such programme (CDSMP lay-leader model) • To establish effective referral systems from hospitals and clinics to such community-based programmes • e.g., Risk Assessment & Management Programme for Diabetes

35. Address special needs of older people with diabetes • There is a high prevalence of older diabetics with depression, cognitive impairment and co-morbidities • Programme design should meet the diversified needs of older people with multiple problems • Content of such programmes should be adapted to be more ‘elder-friendly’

36. The EndThank you! huie@ha.org.hk