CHRONIC CONDITIONS
Lesson 7: Understanding Chronic Illness
CHRONIC ILLNESS
• Occur in people of every age, socioeconomic level, and
culture.
• Medical conditions or health problems with associated
symptoms that require long-term (3 months or longer)
management.
• Conditions that do not resolve or for which complete cures
are rare.
• Management means that people must learn to live with the
symptoms or disabilities, and carry out lifestyle changes or
treatment regimens.
• A chronic illness isn't the name of just one illness.
• It's a word used to describe a group of health conditions
that last a long time.
• The root word of chronic is "chronos," which refers to
time.
• The literature does not support a single uniform definition
for chronic disease, but the concept of chronicity includes
the knowledge that patients experience persistent and
recurring health problems.
• Definitions of chronic disease also reflect the
pathophysiology of disease and, more importantly, consider
the meaning of chronic illness and the experience of the
patient, family, and provider as they struggle to cope with
the range of mildly complicated to extreme challenges.
• Curtin and Lubkin (1995, pp. 6–7) defined chronic illness
as “the irreversible presence, accumulation, or latency of
disease states or impairments that involve the total human
environment for supportive-care and self-care, maintenance
of function, and prevention of further disability.”
• Anderson and Horvath (2004) defined chronic conditions
as conditions lasting 1 year or more and requiring ongoing
medical attention and/or the limiting of activities of daily
living (ADLs).
• Chronic disease or a chronic condition is also defined as
any condition that requires ongoing adjustments by the
affected person and requires periodic interaction with the
health-care system (Improving Chronic Illness Care, 2016).
DEMOGRAPHIC OF CHRONIC ILLNESS
• Increased life expectancy and health-care advances are the
main reasons for the overwhelming increase in numbers of
patients with chronic illness.
• The population of individuals age 65 years and older is
now 46.2 million or 14.5% of the population. That number
is projected to increase to 21.7% of the population in 2040
(Administration on Aging [AOA], Administration for
Community Living [ACL], U.S. Department for Health and
Human Services [USDHHS], 2016).
• As of 2012, about half of adults, or 117 million people, had 4. Anxiety and depression (20-25% experience
one or more chronic health conditions. The most common
chronic diseases in the population age 65 years and older
include hypertension (60%), dyslipidemia (41%), arthritis
(28%), cardiac disease (25%), and eye disease (23%)
(Robert Wood Johnson Foundation [RWJF], 2010).
• Seven of every 10 deaths in the United States are caused by
chronic conditions. Heart disease, cancer, chronic
obstructive pulmonary disease (COPD), and stroke are the
leading causes of death, with heart disease as the number one
cause of death among both men and women. Other major
diseases that contribute to the 70% death rate from chronic
disease include diabetes and Alzheimer ’ s disease (Centers
for Disease Control and Prevention [CDC], 2016). Heart The Impact of Chronic Illness – The Family
disease and cancer together accounted for nearly
48% of all deaths (CDC, 2016).
 Chronic Conditions are now the leading cause of illness,
disability, and death .
 Affects people of all ages , the majority are the very old.
Accounts for 7 of the 10 leading causes of death in the
U.S.
 Cause of 1.7 million deaths per year (7 out of 10 deaths)
 Affects the quality of life of 100 million Americans
 90% of the elderly have at least one chronic illness
 Approximately 77% have at least two illnesses
 25% have 4 or more chronic illnesses
TERMINOLOGIES RELATED TO CHRONIC
ILLNESS
Chronic conditions - a general term that includes chronic
illnesses and impairment.
Chronic Illness – the presence of a long term( i.e. 3 or
more months) disease or symptoms. Example: arthritis,
diabetes, cancer or heart ailment.
Secondary condition - conditions related to the main
illness or impairment that further diminish the person’s
quality of life, threaten his health or increase vulnerability
to further disability. Example: pain, depression and
pressure illness.
LIFE WITH CHRONIC ILLNESS
 The diagnosis of chronic illness has a significant impact
on the patient and their caregivers.
 People who have low incomes are more likely to report
poor health.
 Factors such as poverty and inadequate health insurance
decrease the likelihood that people with chronic illness
receive health care and health screening measures such
as mammography, cholesterol testing, and routine check
ups.
  Few persons are prepared to live with chronic illness.
  Chronic illness involves suffering.
1. Suffering is one of the most profound and disturbing of
human experiences
2. Suffering does not refer to just maladies, and pains,
with which we can and should
cope. (Stan van Hooft, Hastings Center Report, 28, # 5,
1998)
 Suffering involves crisis and threats that constitute a
degradation or alienation of our
being. (Eric J. Cassell, The Nature of Suffering and the
Goals of Medicine, 2nd ed.,2003)
The Impact of Chronic Illness – The Individual
 Initial Impact
1. Shock
2. Denial
3. Loss and grief
psychological symptoms)
 If these reactions last too long, they can have a
negative effect on the illness
 Must adjust to:
1. Symptoms of the disease
2. Stress of Treatment
3. Feelings of vulnerability
4. Loss of Control
5. Threat to self-esteem
6. Financial Concerns
7. Changes in family structure
 Must adjust to:
1. Increased stress
2. Change in the nature of the relationship 8. Peripheral vascular disease.
3. Change in family structure/roles
4. Lost income all have impact RISK FACTORS
 Different issues for different relationships 1. Family history
1. Adult children of ill parents 2. Marital status (adds 10 yrs in men; 4 yrs in women)
2. Spouse of ill person 3. Economic status
3. Parents of ill children 4. Body weight
 Chronic illness affects the person on many levels and can 5. Exercise
bring suffering on all of these 6. Alcohol (add 2 years if drink 1-3 drinks/day)
levels 7. Smoking
 Psychologically- Some patient’s say: 8. Disposition (add 2 yrs if reasoned, practical)
They may feel unsafe by themselves. 9. Education
1. Loss of independence 10. Environment (add 4 yrs if rural)
2. Fear 11. Sleep (more than 9 hours subtract 5 years)
They have a change in self perception/self image 12. Temperature (add 2 yrs if thermostat is < 68)
1. Feelings of loss 13. Health care – regular check ups add 3 yrs
2. Grief
 Socially 1. HEART DISEASE
Due to changing self perception the person may limit social  Heart failure (HF) is generally defined as the inability
interactions of the heart to supply sufficient blood flow to meet the
1. “I don’t like being seen with oxygen on.” needs of the body.
Fear of exposure to “germs” may lead to decreased social  HF is a complex clinical syndrome that can result from
interactions. any structural or functional cardiac disorder that impairs
1. “I am afraid that if I get another infection I’ll die, so I the ability of the ventricle to fill with or eject blood.
don’t go to parties anymore.”  In systolic heart failure the dominant feature is a
 Physically reduction in cardiac output
We cannot rely exclusively on physiologic outcomes for  In diastolic heart failure the dominant feature is
evaluating and assessing a impaired filling of the left ventricle.
patient’s “well being.” Or evaluating and assessing your own  Heart Failure is Primarily a Condition of the Elderly
“well being.”
When people with activity limitations are unable to meet CHARACTER OF HEART FAILURE
their needs for health care and  Signs and symptoms of intravascular and interstitial
personal services: volume overload, including shortness of breath, rales, and
1. they may be unable to carry out their therapeutic regimens edema.
or have their  Manifestations of inadequate tissue perfusion, such as
prescriptions filled on time impaired exercise tolerance,fatigue, and renal dysfunction.
2. may miss appointments and office visits with their health
care provider CLASSICAL SYMPTOMS OF HF
3. may be unable to carry out their ADL  Fatigue or inability to exercise well; having less
 Spiritually energy, feeling mor tired than usual;
Feelings of Isolation  Dyspnea at rest or exertion.
Why me?/ Why me, God?  Paroxysmal nocturnal dyspnea shortness of breath
Feelings of abandonment that can lead to spiritual alienationwhile sleeping or that wakes you at night
 Orthopnea-Shortness of breath while lying down,
3 REASONS FOR THE RAPID INCREASE OF gets worse when you lie flat
CHRONICALLY ILL PERSONS  Cough – can be wet or dry, with crackles, and usually
1. Aging of the population worse with lying down. Weight gain
2. Success of medical science  Swelling in the feet or ankles, usually worse at the
 good medical care actually increases the amount of end of the day or after standing for long periods;
chronic illness shoes may no longer fit. Sometimes edema is painful
 illness diagnosed earlier but usually pressure indents the skin
 many patients who may have died survive  Abdominal swelling with decreased appetite and
3. Worsening Obesity decreased muscle strength (Cardiac Cachectic)
 obesity will soon surpass smoking cigarettes as the #  Abdominal distention (Ascites) usually a sign of right
1preventable cause of morbidity heart failure.
 Urination- frequent urination, usually at night.
Lesson 8: Major chronic illness of older adult Increased urination (Due to high BNP)
understanding the Pathophysiology and Nursing
Intervention Common causes of heart failure
 Myocardial infarction
MAJOR CHRONIC ILLNESSES  Ischemic heart disease- Ischemic Heart disease and
1. Essential hypertension Prior MI account for 2/3 of systolic
2. Arthritis heart failure
3. Musculoskeletal impairments  Hypertension- Essential Hypertension is a major cause
4. Cancer of ischemic and non ischemic
5. Heart disease systolic heart failure. Hypertension increases afterload and
6. Diabetes accelerates the progression of
7. Chronic airway obstruction heart failure. HTN causes chronic pressure overload.
 Valvular heart disease 1. Chest x-ray shows increased pulmonary and left
 Cardiomyopathy ventricular hypertrophy
 Other causes of Non ischemic heart failure are genetic  Right-sided failure:
diseases, Toxic/drug induced, 2. Chest x-ray reveals pulmonary congestion,
Immune mediated, infiltrative process cardiomegaly, and pleural effusions
 Metabolic disorders
 Heart failure is a common, costly, disabling, and KEY TREATMENTS
potentially deadly condition.  Angiotensin-converting enzymes(ACE) inhibitors: -
 In developed countries, around 2% of adults suffer from ACE inhibitors relieve symptoms,
heart failure, but in those over the reduce hospitalizations and improve survival in patients
age of 65, this increases to 6–10%. with systolic and diastolic heart
failure and should be used regardless of the severity of
Functional classification Classes (I-IV) CHF.
 Class I: no limitation is experienced in any activities; 1. Captopril (Capoten)
there are no symptoms from ordinary 2. Enalapril (Vasotec)
activities. 3. Lisinopril (Prinivil)
 Class II: slight, mild limitation of activity; the patient is  Cardiac glycoside
comfortable at rest or with mild 4. Digoxin (lanoxin)
exertion.  Inotropic agents
 Class III: marked limitation of any activity; the patient is 5. Dopamine hydrochloride (Intropin)
comfortable only at rest. 6. Dobutamine hydrochloride (Dobutrex)
 Class IV: any physical activity brings on discomfort and  Diuretics- Sodium and Water retention are the hallmark
symptoms occur at rest. of CHF and diuretics are
mandatory treatment for patients with pulmonary or
ACC/AHA Classification of CHF Peripheral edema.
RIGHT-SIDED HEART FAILURE 1. Furosemide (lasix)
 Backward failure of the right ventricle leads to congestion 2. Bumetadine (Bumex)
of systemic capillaries. This generates excess fluid they have 3. Metolazone (zaroxolyn)
that accumulation in the body.  Nitrates
 S/SX 4. Isosorbide dinitrate (Isordil)
1. Peripheral edema 5. Nitroglycerine (Nitro-bid)
2. Foot and ankle Swelling  Vasodilator-
3. Sacral edema 1. Nitroprusside sodium (Nitropress)
4. Fluid retention without dyspnea or rales.
5. Often associated with weight gain, dilation of the right KEY INTERVENTIONS
ventricle.  Assess cardiovascular status including vital signs and
hemo dynamic variables
LEFT-SIDED HEART FAILURE  Assess respiratory status
 Backward failure of the left ventricle causes congestion  Keep the patients in semi-fowler’s position
of the pulmonary vasculature, and so the symptoms are  Administer oxygen
predominantly respiratory in nature.  Weigh the patient daily
S/SX
1. Shortness of breath on exertion PROGNOSIS
2. Dyspnea at rest  Class IV has 30 to 70% annual mortality.
 Class III has 10 to 20% annual mortality.
TYPES OF LEFT-SIDED HF  Class II has 5 to 10% annual mortality
 Systolic dysfunction- reduced LV ejection fraction.
 Diastolic dysfunction- increased ventricular stiffness or 2. COPD
impaired myocardial relaxation.  Chronic obstructive pulmonary disease, or COPD,
Often with preserved LV ejection fraction. refers to a group of diseases that cause
 Physiologic states where the heart cannot compensate for airflow blockage and breathing-related problems.
increased circulation or  It includes emphysema, chronic bronchitis, and in some
metabolic requirements. (Regurgitant valvular disease, intra cases asthma.
cardiac shunts, disorders  The primary cause of COPD is
of heart rate or rhythm.) 1. Tobacco smoke
Other risk factors include:
COMPLICATIONS OF CHRONIC HEART FAILURE 1. Indoor air pollution (such as biomass fuel used for
 An irregular heartbeat leading to death (VT) cooking and heating)
 A stroke leading to death 2. Outdoor air pollution:(Occupational dusts and
 A heart attack leading to death chemicals (vapors, irritants, and fumes)
 Deep vein thrombosis 3. Frequent lower respiratory infections during
 Pulmonary embolism  In the developing world, indoor air quality is thought to
 Anemia play a larger role in the development
 Cognitive impairment and progression of COPD than it does in the developed
 Mitral valve regurgitation world.
Specific assessment and focus and management of heart  WHO estimates that in 2005 5.4 million people died
failure due to tobacco use.
 Left sided failure:
 Tobacco-related deaths are projected to increase to 8.3  3. Allow activity, as tolerated, to avoid fatigue and
million deaths per year by 2030. reduce O2 demands
 4. Assess respiratory status, ABGs, and pulse oximetry
Signs and symptoms: to detect respiratory compromise,
 Chronic cough severe hypoxemia, and hypercapnia
 Sputum production  5. Assist with turning, coughing, and deep breathing to
 Dyspnea mobilize secretions and facilitate
 History of exposure to risk factors for the disease removal
 Confirmed by a simple test called:  6. Keep patient in high-Fowler’s position to improve
 Spirometry (which measures how deeply a person can ventilation
breathe and how fast air can move  7. Monitor and record the color, amount, and
into and out of the lungs) consistency of sputum. Changes in sputum
 Should be considered in any patient who has symptoms characteristics may signal a respiratory infection
of a chronic cough, sputum  8. Maintain the patient’s diet and administer small,
production, dyspnea (difficult or labored breathing), and a frequent feedings to avoid fatigue when
history of exposure to risk eating and reduce pressure on the diaphragm from full
factors for the disease. stomach
 Confirmed by a simple test called spirometry, which  2. EMPYSEMA
measures how deeply a person can  Is damage to the alveolar structures, causing them to
breathe and how fast air can move into and out of the lungs. enlarge and be damaged resulting
 A low peak flow is consistent with COPD but may not be in reduction of the alveolar-capillary diffusion interface
specific to COPD because it can and airway closure caused by the
be caused by other lung diseases and by poor performance loss of support for the airway structures
during testing.  Abnormal permanent enlargement of the airspaces
 Chronic cough and sputum production often precede the distal to the terminal bronchiole,
development of airflow limitation accompanied by destruction of their walls without fibrosis.
by many years, although not all individuals with cough and  Causes:
sputum production go on to a. Deficiency of alpha1- antitrypsin: is a genetic disorder
develop COPD. that may result in lung
disease or liver disease
Three major types that affect older adults b. Smoking
 1. CHRONIC BRONCHITIS  Assessment findings
 Assessment Findings: 1. Anorexia, weight loss
1. Dyspnea 2. Barrel chest
2. Airway mucosa edema 3. Decreased breath sounds
3. Copious sputum production with a tendency to airway 4. Dyspnea
closure on expiration 5. Finger clubbing, late in the disease
4. Productive cough 6. Prolong expiration
5. Prolonged expiration 7. Pursed-lip breathing
6. Rhonchi,wheezes 8. Use of accessory muscles for breathing
7. Use of accessory muscles  Diagnostic Findings
8. Weigth gain, edema, jugular venous distention 1. Chest X-ray in advanced disease reveals a flattened
 Key test results: diaphragm, reduced vascular
a. Chest X-ray shows hyperinflation and increased markings in the lung periphery, enlarged antero-posterior
brochovascular markings chest diameter, and a
b. PFT’s may reveal increased residual volume, decreased vertical heart
vital capacity and forced 2. CBC shows increased Hb late in disease when patient
expiratory volumes, normal static compliance and has severe persistent hypoxia3. PFT’s show increased
diffusion. residual volume, total lung capacity, diffusing capacity,
Treatment and
a. Chest physiotherapy, postural drainage, and incentive expiratory volumes
spirometry  Nursing Interventions and Rationales
b. Dietary changes, including establishing a diet high in 1. Administer low-flow O2 because emphysema patients
protein, vitamin C, calories, have chronic hypercapnia, so
and nitrogen they have a hypoxic respiratory drive. Higher flow rates
c. Fluid intake up to 3,000 ml/day, if not contraindicated may eliminate this hypoxic
d. Intubation and mechanical ventilation if respiratory status respiratory drive
deteriorates 2. Allow activity as tolerated to avoid fatigue and reduce
e. O2 therapy or mechanical nebulizer treatments O2 demands
 NURSING INTERVENTIONS 3. Assist with turning, coughing, and deep breathing to
 1. Administer low-flow O2 mobilize secretions and facilitate
 Rationales: removal
1. They have a hypoxic respiratory drive. 4. Monitor laboratory studies. Follow drug levels for
2. Higher flow rates may eliminate this hypoxic respiratory evidence of toxicity. Electrolytes
drive imbalances may occur with the use of diuretics. Reduced
 2. Administer medications, as prescribed, to relieve Hb and HCT affect the
symptoms and prevent complication oxygen-carrying capacity of the blood
5. Assist with diaphragmatic and pursed lip breathing to  Disease in which the body doesn’t produce or properly
strengthen respiratory muscles. use insulin, leading to
6. Weigh the patient daily to detect edema caused by right- hyperglycemia.
sided heart failure  In the writings of Aretaios (Aretaeus) of Cappadocia, a
 3. ASTHMA Greek physician who lived during
 Is a form of COPD in which the bronchial linings the period 120-200 A.D., there is a reference, probably to
overreact to various stimuli, causing Diabetes. Amongst the disease
episodic spasms and inflammation that severely restrict the described, he mentioned a condition associated with
airways unquenchable thirst, excessive
 Types of asthma: drinking of water and excessive passing of urine. The
1. Extrinsic(atopic) is caused by sensitivity to specific word "Diabetes" is perhaps derived
external allergens from a Greek word signifying a siphon, appropriately
2. Intrinsic (nonatopic) is caused by a reaction to internal, describing how in the disease the
nonallergic factors fluid cannot be retained in the body. Greek physicians,
 Causes of asthma like ancient Hindu physicians, used
 Extrinsic asthma- Extrinsic asthma symptoms occur in to taste the patient's urine to detect abnormal constituents.
response to allergens, such as dust This unpleasant practice
mites, pollen, and mold. It is also called allergic asthma and perhaps enabled them to detect diabetic patients.
is the most common form of Thomas Willis, in 1764, observed that the urine of a
asthma. diabetic patient was sweet and he
1. Allergens (pollen, dander, dust, sulphite food additives) surmised that it contained either sugar or honey.
 Intrinsic asthma- Intrinsic asthma has a range of triggers,  Diabetes mellitus comes from the Greek word
including weather conditions, "diabainein" meaning "to pass through,"
exercise, infections, and stress. People may call it and the Latin word "mellitus" meaning "sweetened with
nonallergic asthma. honey." Put the two words together
1. Endocrine changes and you have "to pass through sweetened with honey."
2. Noxious fumes  Is highly prevalent and increasing in person over 65
3. Respiratory infection  Poor glycemic controls synergistically interact with
4. Stress normal changes of aging and other
5. Temperature and humidity coexisting diseases to accelerate diabetes complications.
 Assessment Findings  About 41% of the population with diabetes is over the
1. Absent or diminished breath sounds during severe age of 65.
obstruction  Older people have higher rates than younger people
2. Chest tightness (National Academy of an Aging
3. Dyspnea Society, 2000)
4. Productive cough with thick mucous  Optimizing glucose control and decreasing risk factors
5. Prolong expiration for microvascular, macrovascular
6. Tachypnea, tachycardia and neurologic complications can improve the quality and
7. Use of accessory muscles quantity of life for patients of all
8. Usually asymptomatic between attacks ages.
9. Wheezing, primarily on expiration but also sometimes on  The digestion of carbohydrate. The complex
inspiration polysaccharide starch is broken down into
 Treatment glucose by the enzyme’s amylase and maltase (secreted by
1. Desensitization to allergens the small intestine).
2. Intubation and mechanical ventilation if respiratory status  Insulin Secretion- Panel 2. Insulin secretion - Insulin
worsens secretion in beta cells is triggered
3. Oxygen therapy at 2L/minute by rising blood glucose levels. Starting with the uptake of
4. Fluids to 3,000 ml/day as tolerated glucose by the GLUT2
 Nursing Interventions transporter, the glycolytic phosphorylation of glucose
1. Administer low-flow humidified O2 to reduce causes a rise in the ATP:ADP ratio.
inflammation of the airways, ease This rise inactivates the potassium channel that
breathing and increase SaO2 depolarizes the membrane, causing the
2. Administer medications. As prescribed, to reduce calcium channel to open up allowing calcium ions to flow
inflammation and obstruction of inward. The ensuing rise in levels
airways of calcium leads to the exocytotic release of insulin from
3. Encourage patient to express feelings about fear of their storage granule.
suffocation to reduce anxiety.  The process by which insulin is released from beta
4. Keep patients in higher-fowler’s position to improve cells, in response to changes in blood
ventilation glucose concentration, is a complex and interesting
5. Monitor and record vital signs. Tachycardia may indicate mechanism that illustrates the intricate
worsening asthma or drug nature of insulin regulation. Type 2 glucose transporters
toxicity. Hypertension may indicate hypoxemia. Fever may (GLUT2) mediate the entry of
signal infection glucose into beta cells (see panel 2). As the raw fuel for
6. Provide chest physiotherapy, postural drainage, incentive glycolysis, the universal energy
spirometry, and suction to producing pathway, glucose is phosphorylated by the rate-
aid in the removal of secretions limiting enzyme glucokinase.

3. DIABETES MELLITUS
This modified glucose becomes effectively trapped within
the beta cells and is further metabolized to create ATP, the
central energy molecule. The increased ATP:ADP ratio
causes the ATP-gated potassium channels in the cellular
membrane to close up,
preventing potassium ions from being shunted across the cell
membrane. The ensuing
rise in positive charge inside the cell, due to the increased
concentration of potassium
ions, leads to depolarization of the cell. The net effect is the
activation of voltage-gated
calcium channels, which transport calcium ions into the cell.
The brisk increase in
intracellular calcium concentrations triggers export of the
insulin-storing granules by a
process known as exocytosis. The ultimate result is the
export of insulin from beta cells
and its diffusion into nearby blood vessels. Extensive
vascular capacity of surrounding
pancreatic islets ensures the prompt diffusion of insulin (and
glucose) between beta cells
and blood vessels.
 Insulin release is a biphasic process. The initial amount of
insulin released upon glucose
absorption is dependent on the amounts available in storage.
Once depleted, a second
phase of insulin release is initiated. This latter release is
prolonged since insulin has to be
synthesized, processed, and secreted for the duration of the
increase of blood glucose.
Furthermore, beta cells also must regenerate the stores of
insulin initially depleted in the
fast response phase
 How insulin works
Insulin binding to the insulin receptor induces a signal
transduction cascade which allows
the glucose transporter (GLUT4) to transport
glucose into the cell.
Insulin molecules circulate throughout the blood stream until
they bind to their associated
(insulin) receptors. The insulin receptors promote the uptake
of glucose into various
tissues that contain type 4 glucose transporters (GLUT4).
Such tissues include skeletal
muscles (which burn glucose for energy) and fat tissues
(which convert glucose to
triglycerides for storage). The initial binding of insulin to its
receptor initiates a signal
transduction cascade that communicates the message
delivered by insulin: remove
glucose from blood plasma (see panel 3). Among the wide
array of cellular responses
resulting from insulin ‘activation,’ the key step in glucose
metabolism is the immediate
activation and increased levels of GLUT4 glucose
transporters. By the facilitative transport
of glucose into the cells, the glucose transporters effectively
remove glucose from the
blood stream. Insulin binding results in changes in the
activities and concentrations of
intracellular enzymes such as GLUT4. These changes can
last from minutes to hours.
 Insulin-mediated glucose uptake - Insulin binding to the
insulin receptor induces a signal
transduction cascade which allows the glucose transporter
(GLUT4) to transport glucose
into the cell.
 As important as insulin is to prevent too high of a
blood glucose level, it is just as important
that there not be too much insulin and hypoglycemia. As
one step in monitoring insulin
levels, the enzyme insulinase (found in the liver and
kidneys) breaks down blood
circulating insulin resulting in a half-life of about six
minutes for the hormone. This
degradative process ensures that levels of circulating
insulin are modulated, and that
blood glucose levels do not get dangerously low 
 What goes wrong in diabetes?
 The body’s response to blood sugar requires the
coordination of an array of mechanisms.
Failure of any one component involved in insulin
regulation, secretion, uptake, or
breakdown can lead to the build-up of glucose in the
blood. Likewise, any damage to the
beta cells, which produce insulin, will lead to increased
levels of blood glucose. Diabetes
mellitus, commonly known as diabetes, is a metabolic
disease that is characterized by
abnormally high levels of glucose in the blood. Whereas
non-diabetics produce insulin to
reduce elevated blood glucose levels (i.e. after a meal), the
blood glucose levels of
diabetics remain high. This can be due to insulin not being
produced at all, or not in
quantities sufficient to be able to reduce the blood glucose
level. The most common forms
of diabetes are Type 1 diabetes (juvenile onset, 5-10% of
cases), which is an autoimmune
disease that destroys beta cells, and Type 2 diabetes (adult
onset, 90-95% of cases),
which is associated with insufficient insulin. In either
case, diabetes complications are
severe, and the disease can be fatal if left untreated.
 Insulin is the foundation for the management of
insulin-dependent diabetes. Unfortunately,
the use of insulin is not a cure nor without side effects. In
certain parts of the world, it is
not even available. Insulin is also not completely effective
in preventing complications of
the disease such as blindness, heart disease, kidney failure,
etc. While millions of men,
women, and children await a life without diabetes, let us
hope that policy makers and the
scientific community can converge on strategies that
promote discovery for a cure.
 Action of Insulin on the Cell Metabolism
 Insulin is a polypeptide hormone that travels around
the bloodstream. Most of the cells in
the body carry receptors for the molecule in their cell
membranes. Once the hormone has
become bound to one of these receptors, the receptor gives
a signal to the cell's interior.
This signal leads to many enzyme-controlled reactions
which, in turn lead to changes in
the metabolism of the cell.
 Many of the effects of insulin depend on the cell type
in which it stimulates. However, in
nearly all the cells that have insulin receptors in their cell
membrane, the binding of insulin
to the receptors leads to increased glucose uptake of the
cell.
 The two types of cells that are the main exceptions are
the brain and the liver. However,
this is only because these cells are readily permeable to
glucose, even in the absence of
insulin. Liver cell membranes do contain insulin and
glucagon receptors but binding of the
hormone to them affects cellular processes other than
glucose permeability. The animation below illustrates the
way insulin brings about the increase in glucose uptake
 Glucose enters the cells of the body through glucose
transporter (GLUT) proteins which
are embedded within the cell membrane. This is a process
called facilitated diffusion.
When insulin binds to its receptor, the intracellular domain
of the receptor changes shape
slightly. This sets off a chain of reactions. These reactions
serve to activate certain
enzymes.
 As a result, more glucose transporter proteins are released
from intracellular stores and
move to the plasma membrane and become embedded within
it.
 Action of Insulin on Carbohydrate, Protein and Fat
Metabolism
 1. CARBOHYDRATE- In general we can say that
insulin favors anabolic reactions;
glucagon, catabolic reactions. Put more simply, insulin
favors storing energy and
production of proteins while glucagon activates release of
stored energy in the form of
glucose or fatty acids. The actions of these two hormones on
individual metabolic
processes are summarized:
1. Facilitates the transport of glucose into muscle and
adipose cells
2. Facilitates the conversion of glucose to glycogen for
storage in the liver and muscle.
3. Decreases the breakdown and release of glucose from
glycogen by the liver.
 2. PROTEIN
 A protein-rich meal leads to release of both insulin and
glucagon. The latter stimulates
gluconeogenesis and release of the newly formed glucose
from the liver to the blood
stream. The very moderate rise in insulin associated with the
protein meal stimulates
uptake of the sugar formed in the liver by muscle and fat
tissue.
1. Stimulates protein synthesis
2. Inhibits protein breakdown; diminishes gluconeogenesis
 3. FATS
 One of the primary actions of insulin is to control
movement of fatty acids in and out of
adipocytes. It does this through two mechanisms; regulation
of hormone-sensitive lipase
and activation of glucose transport into the fat cell via
recruitment of GLUT4.
 Storage of triglycerides after a meal is dependent upon
insulin-stimulated glucose uptake
and glycolysis. Fat cells take up both fatty acids and glucose
simultaneously. The fatty
acids come from the action of lipoprotein lipase at the
capillary wall. Glucose uptake is
stimulated by insulin and occurs through the insulin-
sensitive glucose transport protein
GLUT4. Thus, insulin increases glucose uptake and
glycolysis in fat cells, inhibits
hormone-sensitive lipase and thereby increases storage of
lipids as triglycerides in
adipocytes.
1. Stimulates lipogenesis- the transport of triglycerides to
adipose tissue
2. Inhibits lipolysis – prevents excessive production of
ketones or ketoacidosis
TYPE 1 DIABETES
 The total lack of insulin leads to two metabolic crises:
a marked increase in the rate of
lipolysis in adipose tissue and activation of hepatic
gluconeogenesis in spite of high
plasma glucose levels. The dramatically increased rate of
lipolysis in adipose tissue
follows the lack of insulin inhibition of hormone-sensitive
lipase. The increase in fatty acids
that results leads to a massive synthesis of ketone bodies
in the liver. These then exceed
the buffer capacity of the blood, leading to ketoacidosis.
Excess acid is a potent poison
for the brain. Coma and death follow ketoacidosis.
 Low or absent endogenous insulin
 Dependent on exogenous insulin for life
 Onset generally < 30 years
 5-10% of cases of diabetes Onset: sudden:
 Symptoms: 3 P’s: polyuria, polydipsia, polyphagia
TYPE II DIABETES
 Insulin levels may be normal, elevated or depressed
 Characterized by insulin resistance,
 diminished tissue sensitivity to insulin,
 and impaired beta cell function (delayed or inadequate
insulin release)
 Often occurs >40 years
 Blood sugar levels are dependent upon glucose uptake
after meals and hepatic release
of glucose between meals. The sugar released from the
liver comes either from stored
glycogen or production of glucose from lactate and amino
acids. This production of
glucose is largely responsible for stabilization of
postprandial blood sugar levels. The
hyperglycemia noted in type 2 diabetes partially results
from lack of control over hepatic
glucose formation due to resistance to insulin. It has
recently become clear that part of
this insulin effect occurs indirectly through insulin-
sensitive receptors in the brain (more
precisely, in the hypothalamus).
 Type 2 diabetes has a stronger genetic basis than type
1, yet it also depends more on
environmental factors. Sound confusing? What happens is
that a family history of type 2
diabetes is one of the strongest risk factors for getting the
disease but it only seems to
matter in people living a Western lifestyle.
 Americans and Europeans eat too much fat and too
little carbohydrate and fiber, and they
get too little exercise. Type 2 diabetes is common in
people with these habits. The ethnic
groups in the United States with the highest risk are
African Americans, Mexican
Americans, and Pima Indians.
 In contrast, people who live in areas that have not
become Westernized tend not to get
type 2 diabetes, no matter how high their genetic risk.
 Obesity is a strong risk factor for type 2 diabetes.
Obesity is most risky for young people
and for people who have been obese for a long time.
 The insulin secretion is insufficient to compensate for
the insulin resistance, which occurs
in response to decreased insulin effectiveness in stimulating  Genes alone are not enough. One proof of this is
glucose production. identical twins. Identical twins have
 The body attempts to compensate for rising blood glucose identical genes. Yet when one twin has type 1 diabetes,
levels by producing more the other gets the disease at
insulin most only half the time. When one twin has type 2
 90% of all diabetes usually females diabetes, the other's risk is at most 3
 Often associated with obesity in 4.
 Strong inheritability  In most cases of type 1 diabetes, people need to inherit
Signs and symptoms risk factors from both parents. We
1. Blurring of vision think these factors must be more common in whites
2. Vulvovaginitis because whites have the highest rate
3. Neuropathy of type 1 diabetes. Because most people who are at risk do
 RISK FACTORS not get diabetes, researchers
1. family history, sedentary lifestyle, obesity and aging want to find out what the environmental triggers are.
2. Controlled by weight loss, oral hypoglycemic agents and  One trigger might be related to cold weather. Type 1
or insulin diabetes develops more often in
 MANAGEMENT OF DM winter than summer and is more common in places with
1. Nutrition management cold climates. Another trigger
2. Blood glucose monitoring might be viruses. Perhaps a virus that has only mild
3. Medications – insulin or oral hypoglycemic agents effects on most people triggers type
4. Physical activity/exercise 1 diabetes in others.  Early diet may also play a role.
5. Behavior modification Type 1 diabetes is less common in people who were
 MEDICAL NUTRITION THERAPY Balance food breastfed and in those who first ate solid foods at later
intake with insulin (or oral agents) and activity to achieve ages.
blood glucose  In many people, the development of type 1 diabetes
levels as near normal as possible. seems to take many years. In
 Achieve and maintain normal lipid (cholesterol) levels experiments that followed relatives of people with type 1
1. Primary Goal – improve metabolic control diabetes, researchers found that
2. Blood glucose most of those who later got diabetes had certain
3. Lipid (cholesterol) levels autoantibodies in their blood for years
4. Provide energy to reach and maintain short and long term before. (Antibodies are proteins that destroy bacteria or
body weight viruses. Autoantibodies are
5. Reach and maintain normal growth and development in antibodies 'gone bad,' which attack the body's own
children and adolescents tissues.)
6. Prevent or treat complications  Complications that can develop due to poor
7. Improve and maintain nutritional status glycemic control include the following:
8. Provide optimal nutrition for pregnancy  Eye disease leading to loss of vision or even blindness
 Nutritional Management for Type I Diabetes  Kidney failure
1. Consistency and timing of meals  Heart disease
2. Timing of meals and administration of insulin  Nerve damage that may cause a loss of feeling or pain
3. Insulin plans should be designed to match the person’s in the hands, feet, legs or other
eating pattern parts of the body (peripheral neuropathies)
4. Monitor blood glucose regularly  Stroke
 Nutritional Management for Type I Diabetes  Poor wound healing due to impaired immune response
1. Weight loss and poor tissue perfusion in
2. Smaller meals and snacks peripheral vascular disease.
3. Physical activity  Older patients with DM have higher rates of:
4. Monitor blood glucose and medications  Premature death
 NUTRITION RECOMMENDATION  Functional disability
 Carbohydrate  Coexisting illnesses, such as hypertensions, coronary
1. 60-70% calories from carbohydrates and monounsaturated heart disease and stroke than other
fats older adults.
 Protein  Goals of Management
1. 10-20% total calories  Older patients should be taught to perform blood
 Fat glucose testing and to keep track of their
1. <10% calories from saturated fat readings using a daily log.
2. 10% calories from PUFA  This log will provide feedback to the older patient and
3. <300 mg cholesterol guide day-to-day choices regarding
 Fiber exercise, food and medication.
1. 20-35 grams/day  The normal readings and treatment goals should be
 Alcohol clearly written in the log book for easy
1. Type I – limit to 2 drinks/day, with meals referral.
2. Type II – substitute for fat calories  Oral Hypoglycemics
 Type 1 and type 2 diabetes have different causes. Yet two  Sulfonylureas
factors are important in - promote insulin secretion by direct stimulation of B-cells
both. First, you must inherit a predisposition to the disease. - reduction of serum glucagon
Second, something in your - increase binding of insulin to receptors
environment must trigger diabetes. - Tolbutamide, Glipizide
 Biguanides 3. Breast Cancer
- reduces hepatic production of glucose by inhibiting 4. Pancreatic Cancer
glycogenolysis 5. Kidney Cancer
- decrease intestinal absorption of glucose 6. Leukemia
- Metformin 7. Colon Cancer
 a-Glucosidase inhibitor  It is important to keep in mind that more than one-third
- decreases absorption of starch and disaccharides of cancers occur in people over
4. CANCER the age of seventy-five. Unfortunately, older adults can be
 Known as carcinoma or malignancy, is a tumor that under-treated. Age should not
invades the surrounding tissue with be a factor in cancer treatment. Instead, the older adult’s
the capability of spreading to other tissues at distant site. overall health should determine
 Physical changes result from the disease process, and the the course of care. I
treatments have a great impact  t’s not just the risk of under-treatment that poses a
on the patient’s quality and quantity of life.  Cancer – just concern for older adults. Even though
the word itself can send chills through a person. An actual they account for the largest demographic among cancer
diagnosis can cases in the U.S., adults over the
cause the patient and their family to go into a tailspin. age of 65 are under-represented in clinical trials.
However, modern medicine and  The most common cancers in older adults are:1.
technology has come a long way in the diagnosis and Prostate Cancer – half of all cases are in men over the age
treatment of cancer. It is not always of seventy-five
the death sentence it once was. Early detection and 2. Bladder Cancer – 70% or more of all cases are in men
recognizing certain warning signs are between the ages of fifty and
important factors one needs to be aware of when caring for eighty
the older adult. 3. Pancreatic Cancer – most cases are in adults over the
 It is a leading cause of death in the elderly; the most age of sixty-five
common malignancies include 4. Lung Cancer – 80% or more of all cases are in adults
neoplasm of the lung, breast, and prostate, leukemia, over the age of sixty
lymphoma and colorectal  The warning signs of cancer in older adults include:
carcinoma. 1. Bladder Cancer – Elderly patients will see warning
 Progression from normal tissue to invasive cancer is 5 – signs that include frequent
20 years urination, blood in urine, a distended bladder and a
 Driven by a series of accumulative genetic changes burning sensation when urinating.
Risk factors for cancer development 2. Lung Cancer – Elderly patients will see warning signs
 Chemical Factors including chest pain caused by
1. Organ-specific coughing, intense or ongoing coughing, breathing
2. Genotoxic (cause genetic damage) difficulty, chronic pneumonia, and
3. Environmental exposures coughing up blood.
4. Activation of endogenous mutagenic pathways (nitric 3. Bone Cancer – Elderly patients will find that the most
oxide & oxy radicals) common warning sign is pain.
5. Requires accumulated exposure Swelling near a bone is also a symptom that needs to be
6. Gross chromosomal changes checked out by a doctor.
7. Tobacco Smoke 4. Colon Cancer – Older patients may find that there are
8. Air Pollution no warning signs during the
9. Diet early stages. Later stages of colon cancer in elderly adults
10. Alcohol may include such
 Chemotherapy is one treatment of which side effects from symptoms as blood in their stool, a change in bowel
the medication may not be habits, vomiting, and stomach
tolerated by the elderly patients because of the changes that pain.
occur with age, such as 5. DEMENTIA
poorer wound healing, comorbidities, and less organ reserve.  Is an acquired syndrome that causes progressive loss of
 Radiation therapy on the other hand can weaken bones intellectual abilities.
and make them more susceptible  Dementing disorders are characterized by gradual onset
to fracture which is already a high risk for the elderly. plus continuing decline that is not due to other brain
Aging and Cancer disease.
 Age is the greatest risk factor for developing cancer. In  Short term memory impairment is usually the first
fact, 60% of people who have symptom of dementia. Clinical diagnosis
cancer are 65 or older. So are 60% of cancer survivors. If requires:
you are an older adult with  Loss of an intellectual ability with impairment severe
cancer, you are not alone. But you should know that age is enough to interfere with social or
just one factor in your cancer occupational functioning.
and treatment. The best treatment plan for you depends on  Characterized by multiple cognitive deficits that
your general health, lifestyle, include impairment of memory which
wishes, and other factors. develops slowly
 For adults in general, some of the most common cancers 1. 80-90% irreversible
diagnosed at any age are the 2. Reversible due to pathologic process
following: 3. Most common: Alzheimer’s Dementia
1. Lung Cancer  4 Symptoms of Dementia
2. Bladder Cancer 1. Loss of memory
2. Deterioration of language function prevents blood from getting to part of the brain. The
3. Loss of ability of think abstractly, plan, initiate, sequence, hemorrhage may occur in any blood
monitor or stop complex vessel in the brain, or it may occur in the membrane
behavior surrounding the brain.
4. Loss of ability to perform ADLs  Symptoms of a cerebrovascular accident
 Later changes in Dementia  The quicker you can get a diagnosis and treatment for a
1. Aphasia – speech stroke, the better your prognosis
2. Apraxia – purposeful activity will be. For this reason, it’s important to understand and
3. Agnosia – sensory stimuli recognize the symptoms of a
4. Anomia – memory of items stroke.
5. Amnesia – loss of memory  Stroke symptoms include:
 Prognosis: Irreversible 1. difficulty walking
 Manifestations: 2. dizziness
 Early: personality change, altered language pattern, 3. loss of balance and coordination
neglect of personal appearance & 4. difficulty speaking or understanding others who are
hygiene speaking
 Progressive: Wandering, Incontinence, Sundowning, 5. numbness or paralysis in the face, leg, or arm, most
Confabulation likely on just one side of the body
6. blurred or darkened vision
6. CEREBROVASCULAR ACCIDENT 7. a sudden headache, especially when accompanied by
 The medical term for a stroke. A stroke is when blood nausea, vomiting, or dizziness
flow to a part of your brain is stopped  The symptoms of a stroke can vary depending on the
either by a blockage or the rupture of a blood vessel. There individual and where in the brain it
are important signs of a stroke has happened. Symptoms usually appear suddenly, even if
that you should be aware of and watch out for. they’re not very severe, and
 May result from tumor, large blood clot, swollen brain they may become worse over time.
tissue.  Remembering the acronym “FAST” helps people
 The risk of stroke more than doubles for each decade recognize the most common symptoms
after age 55. About 75% of new of stroke:
strokes and 88% of stroke deaths occur in those ages 65 and 1. Face: Does one side of the face droop?
older. About one third of all 2. Arm: If a person holds both arms out, does one drift
initial stroke clients die within a year, with the percentage downward?
being higher in older adults. 3. Speech: Is their speech abnormal or slurred?
About 2/3s of surviving stroke clients die within 12 years 4. Time: It’s time to call 911 and get to the hospital if any
post stroke, although women of these symptoms are present.
tend to out live men. Assessment Findings During Stroke Progression
 The major issues for older persons who survive a stroke  When providing nursing care for people with strokes, it
have: is important not only to understand
1. activity limitations across multiple domains (basic and the cause of stroke but also to be able to recognize its
instrumental activities of daily precipitating & progressive
living) manifestations:
2. psychological distress 1. Headache, vomiting, seizures, coma, nuchal rigidity,
3. communication difficulties. fever, hypertension, ECG
 Stroke prevention are: abnormalities (prolonged ST segment), sclerosis of
a. maintaining normal blood pressure peripheral & retinal vessels,
b. not smoking, exercising confusion, disorientation, memory impairment, & other
c. maintaining normal weight. mental changes
 There are two main types of cerebrovascular accident, or  Focal warning signs:
stroke: 1. hemiplegia, transient loss of speech, paresthesia
1. An ischemic stroke is caused by a blockage involving half of the body
2. A hemorrhagic stroke is caused by the rupture of a blood  General warning signs:
vessel. Both types of stroke 1. mental confusion, drowsiness, dizziness, headache
deprive part of the brain of blood and oxygen, causing brain  Complete hemiplegia is common because the basal
cells to die. ganglia & adjacent internal capsule
 Ischemic stroke are affected >2/3 of the time
 An ischemic stroke is the most common and occurs when  Speech center is usually located in the left side of the
a blood clot blocks a blood brain producing aphasia & right
vessel and prevents blood and oxygen from getting to a part sided hemiplegia.
of the brain. There are two  Extensive cerebral lesions often produce conjugate
ways that this can happen. One way is an embolic stroke, deviation of the eyes or head or both
which occurs when a clot forms toward the lesion.
somewhere else in your body and gets lodged in a blood  Pupillary abnormalities may occur if the lesion
vessel in the brain. The other produces edema pressing on the 3rd cranial
way is a thrombotic stroke, which occurs when the clot nerve in the midbrain.
forms in a blood vessel within the Intervention During Acute Phase Of Stroke
brain.  First Aid
 Hemorrhagic stroke A hemorrhagic stroke occurs 1. Maintain a patent airway
when a blood vessel ruptures, or hemorrhages, and then
2. Loosen tight clothing to facilitate respiration & circulation apnea, osteoarthritis, gallbladder disease, respiratory
to the head problems, some types of cancer,
3. Send for medical help & keep the person quiet and depression (Jenson et al., 2014).
4. Position an unconscious patient on the side to facilitate  It is known that 85.2% of people with type 2 diabetes
drainage & prevent aspiration5. A conscious patient may be are overweight or obese (American
in the most comfortable position Diabetes Association, 2015).
6. Elevate patient’s head to avoid headache  There is strong evidence that modest weight loss (5%
7. If patient is cyanotic, administer O2 if available to 15%) can greatly reduce the risk
8. Keep the patient warm of these conditions. An expert panel (Jensen et al., 2014)
9. Offer assurance & explain procedures also recommends intensive
 Treatment goals management of CVD risk factors (hypertension,
1. Preserve life dyslipidemia, prediabetes, diabetes, and
2. Minimize residual disability sleep apnea) in addition to weight loss measures.
3. Prevent recurrence
 Nursing Intervention Guidelines for effectively teaching older adults
 Assessment  Vision – large easy-to-read typeface; emphasize black
1. Continuous NVS/GCS monitoring & white; avoid blues & greens;
2. Document changes in the level of consciousness, motor & use non-glare paper, write short simple paragraphs, make
sensory functions, sure glasses are clean & in
aphasia, respiratory difficulty, visual & perceptual defects place.
 Administer medications & fluids as prescribed  Hearing – speak slowly; enunciate clearly; lower pitch
1. avoid sedatives, tranquilizers & opiates that depress the of your voice, eliminate
respiratory center background noise; face the learner; use nonverbal cues;
 Alteration in bowel elimination, constipation due to have hearing aid in place &
paralysis working correctly
 Energy level / attention – use short teaching sessions,
1. encourage patient to avoid straining (increases intracranial
& vascular pressures) offer liquid refreshments &
at bowel movement bathroom breaks, promote comfort
2. bowel retraining as soon as possible  Information processing/memory – present most
important info first, clarify information w
use of examples; motor skills – teach one step at a time
Lesson 9: Health Education in Chronic Illness {have written easy to understand
Heath Risk Behavior instructions}; be concrete & specific, eliminate
 According to the CDC, four health risk behaviors are distractions; correct wrong answers/
responsible for the majority of chronic reinforce correct answers; offer praise & encouragement
disease and death, including lack of physical activity, poor
nutrition, tobacco use, and Teaching Older Adults About Individual
excessive use of alcohol. Responsibility and Assertiveness for Maintaining
 The prevalence of cigarette smoking is still close to 20% Wellness
of adults (USDHHS, 2014). The  Learn to do some of the simple health checks yourself:
American Heart Association tells us that there is a sharp 1. Pulse
increase in CVD risk with even 2. Blood pressure
low levels of exposure to cigarette smoke, including 3. Breast exam - Ask your physician or nurse to teach you
secondhand smoke. how. Stop smoking
 On average, male smokers die 13.2 years earlier than  Keep active, both mentally and physically. Reduce
male nonsmokers, and female stress
smokers die 14.5 years earlier than female nonsmokers (Go  Take a few medicines as possible, but do not stop
et al., 2013). Binge or heavy taking any without discussing it with
drinking can lead to high risk sexual behavior, unintentional your physician. Discuss the possible need for vitamin,
injuries (e.g., motor vehicle mineral and calcium supplements
crashes), falls, violence, and suicide. with your physician.
 Excessive alcohol consumption can also lead to  Ask your physician about the benefits and risk of
development of high blood pressure, specific medicines, treatments and
liver disease, some cancers, dementia, and alcohol surgeries. Ask for clear information in writing.
dependence (Chowdhury et al., 2016).  Prepare for all physician’s office visits by writing
The age-adjusted prevalence of obesity in 2013 to 2014 was down all of your questions and concerns
35.0% among men and a few days before the visit and do not leave until you get
40.4% among women (Flegel, Kruszon-Moran, Carroll, answers to your questions from
Fryar & Ogden, 2016). Individuals the physician and/or nurse.
who are obese can suffer serious health problems, face  Keep your own written record of the dates of physician
discrimination, and have a visits, immunizations and BP
reduced life expectancy. readings.
 The greater the body mass index (BMI) (and waist  Select physicians and hospitals that have the special
circumference), the greater the risk of services, staff and equipment to give
CVD, including hypertension, coronary artery disease, and quality care to older adults.
stroke.  Be assertive in seeking quality health care for yourself
 In addition, obese individuals have an increased incidence and your family.
of type 2 diabetes, sleep
 Take responsibility for your own health and that of your
family and insist on quality care.
 Do not change your health insurance unless you can
obtain better benefits at the same or
lowest cost. Be sure to understand exactly what the benefits
are. Ask questions.
 Do not sign anything that you do not completely
understand
Behavioral Management in Chronic Illness
 Behavioral and Personal Factors
1. Good “copers” have hardy or resilient personalities – can
remain positive
2. Men have more difficulty adjusting to chronic illness
3. Timing during the lifespan affects reactions
4. Personal health belief issues
Physical and Social Environmental Factors
1. Hospital environments can be depressive
2. Home/hospital environments may not foster self-
sufficiency
3. Social support enhances coping
4. Network members may act as bad examples
The Tasks and Skills of Coping
1. Cope with symptoms or disabilities
2. Adjust to hospital or procedures
3. Develop and maintain good relationships with
practitioners
Psychosocial Functioning Tasks
1. Control negative feelings and remain positive
2. Maintain satisfactory self-image
3. Preserve good relationships
4. Prepare for uncertain future
Coping Skills
1. Denying or minimizing
2. Seeking information
3. Learning to provide one’s own medical care
4. Setting concrete, limited goals
5. Recruiting support
6. Considering possible future events
7. Gaining a manageable perspectivePeople with chronic
illness must work harder at well being
 Well-being is more complex than just having good health
 It involves: Mind, Body and Spirit
 It involves the whole person
Issues and Trends in Chronic Care
• Costly chronic care needs are growing and exerting
considerable demand on health
systems.
• Chronic diseases and conditions are on the rise worldwide.
• An ageing population and changes in societal behaviour are
contributing to a steady
increase in these common and costly long-term health
problems.
• The middle class is growing; and with urbanisation
accelerating, people are adopting a
more sedentary lifestyle.
• This is pushing obesity rates and cases of diseases such as
diabetes upward.
• According to the World Health Organization, chronic
disease prevalence is expected to
rise by 57% by the year 2020.
• Emerging markets will be hardest hit, as population growth
is anticipated be most
significant in developing nations. Increased demand on
healthcare systems due to
chronic disease has become a major concern.
• Another rising health concern is global pandemics. The
pandemics of the past decade
have clearly demonstrated the speed at which infections
spread across the globe. Ebola,
SARS, MERS, and H1N1—to name but a few—demand
coordinated and agile
healthcare responses.
• Pandemics will likely exert periodic and significant
disruptive pressure on health
systems.
• Healthcare organisations across the globe need to be
ready to work together to contain
outbreaks quickly when they occur.
ECONOMIC BURDEN OF CHRONIC DISEASE
• Eighty-six percent of all health care spending in 2010
was for people with one or more
chronic medical conditions (CDC, 2016).
• The latest economic reports of chronic disease indicate
that the cost burden associated
with five of the most common chronic diseases was $28
billion greater than had been
predicted.
• This unexpected increase relates to the prevalence of
chronic, preventable conditions
among people in the United States, largely due to the
effects of obesity.
• In all diseases other than CVD, the numbers of patients
with chronic disease rose above
projections, and actual treatment costs and productivity
losses exceeded estimates. Total
overall treatment costs and lost productivity in the United
States presently amounts to $1.3
trillion (Chatterjee, Kubendran, King, & Devol, 2014).
• A few of the more common chronic diseases have
substantial cost estimates. The
estimated total cost of diagnosed diabetes in 2012 was
$245 billion, a 41% increase from
the previous estimate of $174 billion (American Diabetes
Association, 2013).
• Total payments in 2016 for individuals with Alzheimer ’
s disease and other dementias are
estimated at $236 billion, with Medicare and Medicaid
payments of $160 billion, or 68%,
and out-of-pocket spending expected to be $46 billion, or
19% of total payments
(Alzheimer ’ s Association, 2016, p. 45).
• The total costs of heart disease and stroke in 2010 were
estimated to be $315.4 billion
with $193.4 billion, respectively, for direct medical costs,
excluding costs of nursing home
care (CDC, 2016).
• Additional costs of chronic disease relate to the multiple
acute care hospitalizations
experienced by the seriously chronically ill population. In
a 2004 classic study, almost one-fifth of Medicare patients
had unplanned rehospitalizations within 30 days of
release, with
a cost of $17.4 billion (Jencks, Williams, & Coleman,
2009).
• Cost and complexity of care are greater for individuals
with multiple chronic diseases, who