1. Delivering Quality Care to Your Patients With Diabetes Slide Presentation for Certified Nursing Assistants and Medical Technicians © 2013 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.13.02.019 Optional: [Facility Logo]

2. © 2013 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.13.02.019 Your Role in the Care of Your Patients With Diabetes Is Important You are a valuable member of a team that provides care for elderly patients with diabetes. Your role is to help your patients better manage their diabetes by encouraging them to –Eat a proper diet –Exercise if possible –Take good care of their feet, skin, and personal hygiene –Report any potential problems to nursing staff 2

3. © 2013 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.13.02.019 What Is Diabetes? Diabetes is a disease that affects the way your body uses food for energy. 1 When you eat food, your body changes it into sugar. Your body also makes insulin. –Insulin helps move the sugar from your blood into your body’s cells to be used for energy. 2 –Your body normally keeps blood sugar (S) and insulin (I) in balance. S=sugar, I=insulin 3 1.Center for Disease Control and Prevention. Diabetes http://www.cdc.gov/diabetes/consumer/learn.htm. Updated September 2012. Accessed February 25, 2013.http://www.cdc.gov/diabetes/consumer/learn.htm 2.American Diabetes Association. Type 2 diabetes. http://www.diabetes.org/diabetes-basics/type-2/. Accessed February 25, 2013.http://www.diabetes.org/diabetes-basics/type-2/

4. © 2013 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.13.02.019 The 2 Types of Diabetes Type 1 diabetes – A patient’s body no longer produces insulin, so the sugar cannot move into the cells to become energy. 1 Type 2 diabetes – A patient’s body doesn’t produce enough insulin and/or cannot use it well enough to get the blood sugar into the body’s cells for energy. 1 In both situations, blood glucose builds up in the patient’s body and can lead to serious health problems and premature death. 1 S=sugar, I=insulin 4 1.American Heart Association. About diabetes. http://www.heart.org/HEARTORG/Conditions/Diabetes/AboutDiabetes/About-Diabetes_UCM_002032_Article.jsp#.TxCcHr_hnfY. Accessed February 25, 2013.http://www.heart.org/HEARTORG/Conditions/Diabetes/AboutDiabetes/About-Diabetes_UCM_002032_Article.jsp#.TxCcHr_hnfY

5. © 2013 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.13.02.019 How Diabetes Affects the Elderly in Nursing Homes Diabetes is quite prevalent in the elderly population. In fact: 27% of Americans 65 years or older have diabetes 1 Approximately 1 in 4 nursing home residents has diabetes 2 This is important because diabetes can lead to other issues with the heart, kidneys, eyes, feet, and nerves. 3. 5 1.American Diabetes Association. Diabetes Statistics. Data from the 2011 Diabetes Fact Sheet. http://www.diabetes.org/diabetes-basics/diabetes-statistics/. Accessed February 25, 2013.http://www.diabetes.org/diabetes-basics/diabetes-statistics 2.Resnick H, Alwan M. Diabetes in U.S. nursing homes. http://www.leadingage.org/Article.aspx?id=3069. Updated May 2011. Accessed February 25, 2013.http://www.leadingage.org/Article.aspx?id=3069 3.National Diabetes Information Clearinghouse. Complications of diabetes. http://diabetes.niddk.nih.gov/complications/index.htm. Accessed February 25, 2013.http://diabetes.niddk.nih.gov/complications/index.htm

6. © 2013 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.13.02.019 The Importance of Controlling Blood Sugar It is important for elderly patients with diabetes to get their blood sugar under control and keep it that way to reduce the risk of further damage to their bodies. Things that affect blood sugar levels: –Food raises blood sugar –Exercise lowers blood sugar –Diabetes medicine (oral or insulin) lowers blood sugar 1 6 1.American Diabetes Association. Medication. http://www.diabetes.org/living-with-diabetes/treatment-and-care/medication/medication-video.html. Accessed February 25, 2013.http://www.diabetes.org/living-with-diabetes/treatment-and-care/medication/medication-video.html

7. © 2013 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.13.02.019 How Blood Sugar Is Managed 1. Blood sugar monitoring Finger stick test –Done 1 or more times a day –Shows what blood sugar level is at that moment 1 Blood sugar goals for people who have diabetes 2 2. A1C test 1 –Draw blood and have it sent to a lab –Done a few times a year –Shows average blood sugar level over the past 2 to 3 months –Goal for most patients is <7%. Consider less stringent goals for elderly patients such as 8% (frail, short life expectancy, risk of hypoglycemia, or other risk factors) 2 Before meals70 to 130 mg/dL (milligrams per deciliter) 1 to 2 hours after the start of a mealLess than 180 mg/dL 7 1.Agency for Healthcare Research and Quality. Medicines for type 2 diabetes: a review of the research for adults. http://www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?productid=721&pageaction=displayproduct. Accessed February 25, 2013. http://www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?productid=721&pageaction=displayproduct 2.American Diabetes Association. Standards of medical care in diabetes—2013. Diabetes Care. 2013;36(suppl 1):S11-S66.

8. © 2013 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.13.02.019 8 Guidelines for Eating With Diabetes It is important to understand what people with diabetes can and cannot eat. Here are some guidelines. People with diabetes can 1 : –Eat sugar as part of a healthy meal plan –Have fruit –Eat a healthy diet—low in fat; moderate in salt and sugar; meals with whole grains, vegetables, and fruit –Enjoy all carbohydrates (sugar, as well as breads, pasta, cereals, and grains) Important: The key to a healthy diet is to eat well-balanced meals and control your portions. 1.American Diabetes Association. Diabetes myths. http://www.diabetes.org/diabetes-myths.jsp. Accessed February 25, 2013.http://www.diabetes.org/diabetes-myths.jsp

9. © 2013 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.13.02.019 How to Help Your Patients With Eating Keep notes on what patients like or refuse to eat and let the dietary department know 1 Observe whether a food portion is enough or too little for the patient 2 Encourage patients to eat meals at the same time every day 2 Don’t let patients skip meals or go more than 4 to 5 hours without eating 2 Keep patients hydrated by offering them a second glass of liquid during or after meals 3 Be consistent—try to encourage patients to eat the same amount of food each day 2 9 1.Koehler MO, Dumonceaux M. Keeping diabetes at bay. Provider. 2005;31:47-49. 2.Medline Plus. Diabetes diet—type 1 and type 2. http://www.nlm.nih.gov/medlineplus/ency/article/002440.htm. Accessed February 25, 2013.http://www.nlm.nih.gov/medlineplus/ency/article/002440.htm 3.Acello B. Some hints on restorative dining. Provider. 2005;31:63-64.

10. © 2013 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.13.02.019 Observe Your Patients While They Eat While patients are eating, see if they have: –Swallowing problems 1 –Trouble seeing their food 2 –Feeding problems 1 –Mouth pain 3 If you suspect a patient is having trouble eating, contact a nurse right away. 10 1.Pelletier CA. Feeding difficult-to-feed patients. Provider. 2006:49-51. 2.Acello B. Some hints on restorative dining. Provider. 2005;31:63-64. 3.Nelson S. The importance of oral health. Provider. 2005;31:39.

11. © 2013 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.13.02.019 Benefits of Exercise for Patients With Diabetes The potential benefits include: –Reducing the risk of falling 1 –Weight control 2 –Improving strength, balance, and flexibility 2 –Controlling blood sugar 2 Regular exercise is not always a good idea for every patient and can even be dangerous. 3 Check with your supervisor or follow health care provider’s orders. 11 1.Waugh D, Harroun M. Stepping up ambulation. Provider. 2008;34(7):37-39. 2.American Diabetes Association. What is exercise? http://www.diabetes.org/food-and-fitness/fitness/fitness-management/what-is-exercise.html. Accessed February 25, 2013.http://www.diabetes.org/food-and-fitness/fitness/fitness-management/what-is-exercise.html 3.Cayea D, Durso SC. Management of diabetes mellitus in the nursing home. Ann Long-Term Care. 2007;15(5):27-33.

12. © 2013 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.13.02.019 How to Help Your Patients With Diabetes Exercise Walking 1 Strength or resistance activities 2 Swimming 2 Lifting light weights 1,3 Taking the stairs or step exercises 3 Stretching 3 Flexibility exercises 3 Important: Never exercise a patient without the prior approval of a health care provider. 12 1.American Diabetes Association. What is exercise? http://www.diabetes.org/food-and-fitness/fitness/fitness-management/what-is-exercise.html. Accessed February 25, 2013.http://www.diabetes.org/food-and-fitness/fitness/fitness-management/what-is-exercise.html 2.MayoClinic.com Exercise: how much do I need every day? http://www.mayoclinic.com/health/exercise/AN01713. Accessed February 25, 2013.http://www.mayoclinic.com/health/exercise/AN01713 3.American Academy Diabetes. Types of exercise. http://www.diabetes.org/food-and-fitness/fitness/ideas-for-exercise/types-of-exercise.html. Accessed February 25, 2013.http://www.diabetes.org/food-and-fitness/fitness/ideas-for-exercise/types-of-exercise.html

13. © 2013 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.13.02.019 Be Aware of the Increased Risk of Falling As many as 2 out of every 3 nursing home residents fall each year. 1 Diabetes can increase the risk for falls due to 2,3 –Slower reflexes– Vision problems– Obesity –Medications– Foot problems Other things that can increase falling risk 1 : –Inadequate lighting – Uneven flooring– Loose carpets –Clutter– Poorly fitting clothing –Not wearing eyeglasses or hearing aids If you notice any of the above problems, contact nursing. 13 1.Cantrell L. Promoting safety, reducing falls. Provider. 2004;30(5):39-40. 2.Cayea D, Durso SC. Management of Diabetes Mellitus in the Nursing Home. Ann Long-Term Care. 2007;15(5):27-33. 3.Fall Prevention Task Force. For Senior Adults, Families, and Caregivers. http://www.fallpreventiontaskforce.org/senior_family_caregivers.htm. Accessed February 25, 2013.http://www.fallpreventiontaskforce.org/senior_family_caregivers.htm

14. © 2013 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.13.02.019 Help Your Patients Avoid Falls 1,2 Make sure beds are in the lowest position Keep the path between the bed and bathroom well-lit and clutter free Be sure there is adequate lighting in the bathroom Create a toileting schedule to minimize urgent trips to the bathroom Remind patients to rise slowly from a seated or reclining position Inspect clothing for proper size and fit Encourage patients to wear nonskid footwear Make sure assistive devices (canes, walkers, etc) are in good working condition and used properly Keep hearing aids, eyeglasses, and frequently used items within reach Be alert to signs of side effects from new medicines like dizziness or light-headedness 14 1.Cantrell L. Promoting safety, reducing falls. Provider. 2004;30(5):39-40. 2.Fall Prevention Task Force. For Senior Adults, Families, and Caregivers. http://www.fallpreventiontaskforce.org/senior_family_caregivers.htm. Accessed February 25, 2013.http://www.fallpreventiontaskforce.org/senior_family_caregivers.htm

15. © 2013 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.13.02.019 Be Aware of Hypoglycemia (Low Blood Sugar) Low blood sugar occurs when a patient’s blood sugar level drops too low to provide enough energy for the body’s activities. Low blood sugar is most often caused by 1 –Excessive doses of insulin or some diabetes medications –Meals or snacks that are too small, delayed, or skipped –Increased activity or exercise –Excessive drinking of alcohol Hypoglycemia can occur without symptoms and can be difficult to recognize in an elderly patient, so be sure to regularly check blood sugar levels. 15 1.National Diabetes Information Clearinghouse. Hypoglycemia. http://www.diabetes.niddk.nih.gov/dm/pubs/hypoglycemia. Accessed February 25, 2013.http://www.diabetes.niddk.nih.gov/dm/pubs/hypoglycemia.

16. © 2013 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.13.02.019 Symptoms of Hypoglycemia 1 Hunger Nervousness Dizziness Shakiness Drowsiness Feeling anxious Weakness Confusion Sweating What to Do for Hypoglycemia If you suspect a patient has low blood sugar, contact a nurse right away. 16 1. National Diabetes Information Clearinghouse. Hypoglycemia. http://www.diabetes.niddk.nih.gov/dm/pubs/hypoglycemia. Accessed February 25, 2013.http://www.diabetes.niddk.nih.gov/dm/pubs/hypoglycemia

17. © 2013 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.13.02.019 Be Aware of Hyperglycemia (High Blood Sugar) High blood sugar occurs when a patient’s body has too little insulin or when the body can’t use insulin properly. 1 Causes 1 : –Type 1 – patient may not have received enough insulin –Type 2 – patient may not have an adequate level of medication –Too much food –Too little exercise –Stress of an illness, such as a cold or flu 17 1.American Diabetes Association. Hyperglycemia. http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/hyperglycemia.html.http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/hyperglycemia.html Accessed February 25, 2013.

18. © 2013 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.13.02.019 Symptoms of Hyperglycemia The signs of hyperglycemia are often difficult to detect but include: Blurred vision 1 Frequent hunger 1 Frequent thirst 1,2 Frequent need to urinate 2 Fatigue 1 Weight loss 1 What to Do for Hyperglycemia If you suspect a patient has high blood sugar, contact a nurse right away. 18 1.American Medical Directors Association. Diabetes Management in the Long-Term Care Setting: Clinical Practice Guidelines. Columbia, MD: AMDA 2008, revised 2010. 2.American Diabetes Association. Hyperglycemia. http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/hyperglycemia.html. Accessed February 25, 2013.http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/hyperglycemia.html

19. © 2013 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.13.02.019 Medication for Type 1 Diabetes – Insulin There are several ways your patients may take insulin 1 : By injection –Using a vial and syringe or an insulin pen Using an insulin pump –Small machine worn outside of the body Using an insulin jet injector –Looks like a large pen 19 1.National Diabetes Information Clearinghouse. What I need to know about diabetes medicines. http://diabetes.niddk.nih.gov/dm/pubs/medicines_ez. Accessed February 25, 2013.http://diabetes.niddk.nih.gov/dm/pubs/medicines_ez

20. © 2013 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.13.02.019 Medication for Type 2 Diabetes People with type 2 diabetes may take medication in the following ways 1 : Pills Insulin 20 1.National Diabetes Information Clearinghouse. What I need to know about diabetes medicines. http://diabetes.niddk.nih.gov/dm/pubs/medicines_ez. Accessed February 25, 2013.http://diabetes.niddk.nih.gov/dm/pubs/medicines_ez

21. © 2013 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.13.02.019 Protect Your Patients’ Skin 1 Help patients keep their skin clean and dry Use moisturizing soaps when bathing patients Moisturize your patients’ skin to prevent chapping, especially in cold or windy weather Treat cuts right away Important: Make sure your patients see a nurse right away if they get a major cut, burn, or infection. 21 1.American Diabetes Association. Skin Care. http://www.diabetes.org/living-with-diabetes/complications/skin-care.html. Accessed February 25, 2013.http://www.diabetes.org/living-with-diabetes/complications/skin-care.html

22. © 2013 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.13.02.019 Protect Your Patients’ Feet 1 Check your patients’ feet every day Make sure your patients’ shoes fit well and protect their feet Wash your patients’ feet regularly Rub lotion over the tops and bottoms of your patients’ feet but not between their toes Trim patients’ toenails when needed Don’t use hot water bottles, heating pads, or electric blankets on their feet Encourage patients to put their feet up when sitting Important: Tell a nurse immediately if you notice that a patient has pain or less sensitivity in their feet. Also, if they have cuts, blisters, corns, ingrown toenails, color or shape changes, or calluses. 1 22 1.American Diabetes Association. Foot care. http://www.diabetes.org/living-with-diabetes/complications/foot-complications/foot-care.html. Accessed February 25, 2013.http://www.diabetes.org/living-with-diabetes/complications/foot-complications/foot-care.html

23. © 2013 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.13.02.019 You Play an Important Role in the Health of Your Patients With Diabetes Eat wisely Exercise appropriately Prevent falls Recognize the warning signs of low blood sugar and high blood sugar Be aware of their medication needs Take care of their skin and feet 23

24. © 2013 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.13.02.019 Thank you for your participation. Are there any questions? 24

25. 25 Self-Assessment Quiz Please print copies of the following slide and distribute to all attendees after the presentation. The quiz answers are provided on the last slide. © 2013 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.13.02.019

26. 26 © 2013 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.13.02.019

27. 27 © 2013 sanofi-aventis U.S. LLC, A SANOFI COMPANY All rights reserved Printed in the USA US.NMH.13.02.019