1. Project Partners: 計劃夥伴： Funded by: 捐助機構： 1 A Community Model for Care of Older Persons with Diabetes Mellitus: a Randomised Controlled Trial Dr Elsie Hui, FRCP Senior Medical Officer, Shatin Hospital A CADENZA Initiated Research

2. Project Partners: 計劃夥伴： Funded by: 捐助機構： 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. Project Partners: 計劃夥伴： Funded by: 捐助機構： 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. Project Partners: 計劃夥伴： Funded by: 捐助機構： 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. Project Partners: 計劃夥伴： Funded by: 捐助機構： 5 Behaviour in managing diabetes (older HK men) ( Department of Health, HKSAR & Department of Community Medicine, HKU, 2005)

6. Project Partners: 計劃夥伴： Funded by: 捐助機構： 6 Behaviour of managing diabetes (older HK women) ( Department of Health, HKSAR & Department of Community Medicine, HKU, 2005)

7. Project Partners: 計劃夥伴： Funded by: 捐助機構： 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. Project Partners: 計劃夥伴： Funded by: 捐助機構： 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. Project Partners: 計劃夥伴： Funded by: 捐助機構： 9 Pilot study: single arm, pre-, post-test design 8-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. Project Partners: 計劃夥伴： Funded by: 捐助機構： 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. Project Partners: 計劃夥伴： Funded by: 捐助機構： 11 A Community Model for Care of Older Persons with Diabetes Mellitus: a randomised controlled trial E Hui & Cadenza Research Team

12. Project Partners: 計劃夥伴： Funded by: 捐助機構： 12 Features of programme 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 ”

13. Project Partners: 計劃夥伴： Funded by: 捐助機構： 13 Components of programme (1) Educational talks Visual aids Games Group discussion

14. Project Partners: 計劃夥伴： Funded by: 捐助機構： 14 Components of programme (2) Behavioral modification strategies Action plan Goal setting Problem solving

15. Project Partners: 計劃夥伴： Funded by: 捐助機構： 15 Components of programme (3) Group exercise Aerobic & resistance Home exercise prescribed

16. Project Partners: 計劃夥伴： Funded by: 捐助機構： 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. Project Partners: 計劃夥伴： Funded by: 捐助機構： 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. Project Partners: 計劃夥伴： Funded by: 捐助機構： 18 Procedure Recruitment in community elderly centres, day care centres, out-patient clinics in health centres and public hospitals Randomization Complete baseline assessment Intervention groupControl group Community-based Diabetes Management Programme Complete follow-up assessment Baseline 8 weeks

19. Project Partners: 計劃夥伴： Funded by: 捐助機構： 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 scale 1 Quality of life measures Chinese Diabetes quality of life Score 2 Medical Outcomes Study SF-36 (Hong Kong) 3 1 Beeney 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. 2 Cheng 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. 3 Lam 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. Project Partners: 計劃夥伴： Funded by: 捐助機構： 20 Focus Group Interviews 14 subjects randomly selected from intervention group Group discussion led by a facilitator Open-ended questions 4 themes identified i)Comments on existing health care services for diabetics ii)Experiences of participation in the new service model (intervention) iii)Motivation to join the programme iv)Suggestions for improvement of the new service model

21. Project Partners: 計劃夥伴： Funded by: 捐助機構： 21 Interim findings

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

23. Project Partners: 計劃夥伴： Funded by: 捐助機構： 23 Characteristics of participants DemographicsIntervention group (n=92)Control group (n=88)P-value Age (years)71.84 (7.98)72.05 (7.88)0.860 % Female65.2 %75.0%0.152 Education level0.010 Illiterate or no formal education21.7%37.5% Primary39.1%42.0% Secondary or above39.1%20.5% Years of having DM12.74 (9.28)12.17 (9.24)0.680 % DM-related admission in last year12.9%10.5%0.610 Total number of medications5.60 (2.99)5.51 (2.75)0.840 % Oral hypoglycemic agent93.5%90.9%0.715 % Insulin Injection21.7%25.0%0.605 Total number of comorbid diseases3.96 (2.32)3.55 (1.89)0.194 % Hypertension73.9%71.6%0.726 % Hyperlipidemia26.1%36.4%0.137 % Heart disease14.1%17.0%0.590 % Stroke17.4%15.9%0.790 Exercise time per week (minutes)299.13 (254.95)323.13 (258.58)0.532

24. Project Partners: 計劃夥伴： Funded by: 捐助機構： 24 Outcomes of intervention group at baseline and 8 weeks – physical and process measures (n=83) Baseline mean (SD)8 weeks mean (SD)P-value Physical outcome measures BMI (kg/m 2 )24.86 (3.58)24.84 (3.76)0.891 Waist hip ratio0.97 (0.07) 0.907 Random glucose (mmol/L)10.63 (4.59)10.14 (4.61)0.317 HbA1c (%)7.45 (1.52)7.23 (1.46)0.022 Systolic BP (mmHg)137.49 (14.94)130.99 (16.16)0.001 Diastolic BP (mmHg)76.58 (10.71)73.00 (11.48)0.003 Process outcomes measure Diabetes knowledge score (0-14)  10.64 (2.43)11.87 (2.15)<0.0005

25. Project Partners: 計劃夥伴： Funded by: 捐助機構： 25 Outcomes of intervention group at baseline and 8 weeks – quality of life measures (n=83) Quality of life measuresBaseline mean (SD)8 weeks mean (SD)P-value DMQOL (1-5)  Satisfaction2.53 (0.43)2.41 (0.44)0.026 Impact1.84 (0.52)1.77 (0.47)0.031 Worry1.85 (0.68)1.73 (0.60)0.012 SF-36 (0-100)  Physical functioning70.06 (22.93)72.83 (22.89)0.082 Role-physical63.86 (40.62)63.55 (39.49)0.993 Bodily pain65.41 (29.18)65.65 (27.37)0.750 General health43.02 (24.86)44.43 (24.01)0.873 Vitality58.13 (25.77)61.08 (22.85)0.470 Social functioning83.13 (27.01)85.09 (25.78)0.442 Role-emotional63.45 (40.53)67.07 (40.15)0.425 Mental health71.08 (24.61)75.71 (19.49)0.046 SF-36 Physical component60.59 (22.38)61.62 (22.33)0.641 SF-36 Mental component68.95 (23.79)72.24 (22.32)0.128

26. Project Partners: 計劃夥伴： Funded by: 捐助機構： 26 Comparing outcome changes between intervention and control groups at 8 weeks – physical and process measures Intervention group (n=83)Control group (n=80) Physical outcome measuresBaseline mean (SD) 8 weeks adjusted mean changes Baseline mean (SD) 8 weeks adjusted mean changes P-value BMI (kg/m 2 )24.86 (3.58)-0.0224.58 (3.75)+0.120.413 Waist hip ratio0.97 (0.07)+0.000.96 (0.08)+0.000.844 Random glucose (mmol/L)10.63 (4.59)-0.179.35 (3.55)-0.260.884 HbA1c (%)7.45 (1.52)-0.187.06 (1.18)-0.060.284 Systolic BP (mmHg)137.49 (14.94)-5.53134.43 (16.15)-4.520.673 Diastolic BP (mmHg)76.58 (10.71)-3.1176.14 (10.82)-1.630.402 Process outcomes measure Diabetes knowledge score (0-14)  10.64 (2.43)+1.479.67 (2.82)-0.20<0.0005

27. Project Partners: 計劃夥伴： Funded by: 捐助機構： 27 Comparing outcome changes between intervention and control groups at 8 weeks – quality of life measures Quality of life measuresIntervention group (n=83)Control group (n=80) DMQOL (1-5)  Baseline mean (SD) 8 weeks adjusted mean changes Baseline mean (SD) 8 weeks adjusted mean changes P-value Satisfaction2.53 (0.43)-0.112.49 (0.45)+0.010.037 Impact1.84 (0.52)-0.081.80 (0.55)-0.100.740 Worry1.85 (0.68)-0.091.63 (0.71)-0.120.713 SF-36 (0-100)  Physical functioning70.06 (22.93)+3.1868.58 (23.32)+1.080.383 Role-physical63.86 (40.62)+4.1758.81 (40.83)+1.300.625 Bodily pain65.41 (29.18)+0.2966.42 (28.78)+0.450.969 General health43.02 (24.86)+1.0546.55 (24.35)+3.910.346 Vitality58.13 (25.77)+3.6658.01 (23.22)+0.520.293 Social functioning83.13 (27.01)+1.5684.23 (24.53)+1.820.944 Role-emotional63.45 (40.53)+6.7862.50 (42.83)-1.610.163 Mental health71.08 (24.61)+5.1672.95 (21.10)-1.360.006 SF-36 Physical component60.59 (22.38)+1.6660.09 (22.18)+2.220.840 SF-36 Mental component68.95 (23.79)+4.1269.42 (22.89)+0.020.151

28. Project Partners: 計劃夥伴： Funded by: 捐助機構： 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. Project Partners: 計劃夥伴： Funded by: 捐助機構： 29 Discussion

30. Project Partners: 計劃夥伴： Funded by: 捐助機構： 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. Project Partners: 計劃夥伴： Funded by: 捐助機構： 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. Project Partners: 計劃夥伴： Funded by: 捐助機構： 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. Project Partners: 計劃夥伴： Funded by: 捐助機構： 33 Recommendations

34. Project Partners: 計劃夥伴： Funded by: 捐助機構： 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. Project Partners: 計劃夥伴： Funded by: 捐助機構： 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. Project Partners: 計劃夥伴： Funded by: 捐助機構： 36 The End Thank you! huie@ha.org.hk