To avoid judging patients with diabetes and dementia solely based on screening scores and perceived risks

They have dementia.

They have diabetes.

Their blood glucose control has collapsed, leading to hospitalization.

They live alone.

When such information is presented, we naturally think, "Isn't life at home difficult?"

I do not believe that perspective is wrong.

If there is a decline in cognitive function, it may affect medication, diet, blood glucose monitoring, regular medical visits, and responses to hypoglycemia. If diabetes management is becoming unstable, I believe we must also carefully examine the medical risks.

However, I want to pause here and think about this together.

"It's difficult because they have dementia."

"It's dangerous because they live alone."

"Life at home is difficult because blood glucose control is poor."

Before making such judgments, what are we looking at?

And what are we not looking at?

I believe that what is important in advanced practice nursing is to capture the subject by integrating both medical and holistic perspectives.

In this article, I would like to organize together what kind of assessment is necessary to avoid judging patients with diabetes and dementia solely based on screening scores or superficial risks.

First, looking at things medically is unavoidable.

I believe it is dangerous to judge solely based on the word "dementia."

However, at the same time, I also think it is dangerous to talk about "living life their way" while leaving the decline in cognitive function ambiguous.

This is not about deciding between "can" or "cannot."

First, I believe it is necessary to conduct an assessment from a medical perspective.

For example, use HDS-R or MMSE to evaluate cognitive function. Check blood glucose levels, HbA1c, the presence of hypoglycemia, medication details, and the management status of insulin or oral medications. Observe to what extent dietary therapy, exercise, medical visit behavior, and blood glucose monitoring are being performed.

However, I do not think we should reach a conclusion based solely on screening scores or numerical values.

What is important in evaluating cognitive function is not just "being caught up in the numbers," but looking at "which aspects of daily life are being affected."

Are they prone to forgetting the time to take medication?

Are they confused about the procedure for blood glucose monitoring?

Is it becoming difficult to make judgments about dietary content?

Is the preparation for shopping and cooking becoming a burden?

Is it becoming difficult to manage medical visit dates?

The way it manifests in life is different for everyone.

Therefore, do not end the assessment with a judgment based on scores alone.

It is necessary to take the evaluated scores and think about them by returning them to the context of the life the person is leading.

Look specifically at a day in their life.

Just as important as medical evaluation is the person's living situation.

For example, what time does the person wake up in the morning?

Who prepares breakfast, at what time, and how?

Who manages the pre-meal or post-meal medication, how is it managed, and at what timing is it taken?

If they are monitoring blood glucose, where and by what procedure are they doing it?

What do they do during the morning?

Do they go shopping? If so, how far from home, how often, and by what method do they go?

What time do they eat lunch, and what kind of food do they eat?

During the time until dinner, do they spend it inside the house, go outside, or meet someone?

For dinner, do they cook, buy prepared meals, or are they increasingly getting by with sweet buns or simple foods?

What time do they go to sleep?

Is there a risk of hypoglycemia or falls at night? What is the environment and structure of the home like?

When hospitalized in an acute care hospital, such information may at first glance seem far from medical information and unnecessary.

But diabetes self-management is not performed inside the hospital, but in life after discharge.

Meals, medication, blood glucose monitoring, and medical visit behavior are not completed only inside the hospital.

Therefore, if you look only at blood glucose control without looking at the flow of life, isn't it difficult to see what is happening to that person?

For example, suppose you get information that "prepared meals and sweet buns have increased."
If you take only that, you tend to see it as mere disruption of eating habits.

However, if you look at the background,
there might be difficulty in shopping,
there might be a burden in cooking,
they might be feeling fatigue,
the motivation for eating might be declining due to eating alone,
the economic situation might be affecting it,
nearby stores might have changed and they can no longer go there,
changes in relationships with family or the community might be occurring.
Various factors can be considered.

Instead of judging by looking at visible, easy-to-understand information, why did that diet come about?

By broadening your perspective even a little to such invisible parts, I think the things that can be considered as nursing will increase.

Look not only at "what they are not doing," but also at "what they have been continuing."

They were hospitalized due to poor blood glucose control.

That in itself is important information.

But what if that person has been living with diabetes for over 30 years?

There is a long accumulation of time lived with the illness.

There is time spent living with a disease that lacks subjective symptoms, unlike pain or difficulty breathing, while continuing regular medical visits, taking medication, choosing meals, and adjusting life.

Of course, that does not mean it was medically perfect.

But I think it is too early to judge that "it will be difficult from now on" regarding the self-management behavior the person has performed so far, based only on the fact at one point in time that blood glucose control was poor.

What were they able to do?

By what method were they continuing it?

What changed that caused that method to stop working well?

Isn't this perspective necessary?

For example, suppose blood glucose monitoring was also possible at the time of admission.

In that case, there is a possibility that at least the action of monitoring remains.

However, there is a possibility that difficulties are arising in the parts of meal preparation or food selection.

Or, even if blood glucose monitoring is possible, it may have become difficult to judge the results and connect them to action.

Instead of deciding by "can" or "cannot," analyze which part of self-management needs support.

I believe that is where nursing assessment lies.

What do they look forward to, and what kind of role have they played?

When looking at life, I do not think it is enough to just check meals and medication.

What does the person look forward to in life?

What kind of roles have they played until now?

What have they cherished in their home?

What kind of connections did they have in the community?

Were there people with diabetes around them?

Who have they talked to about their illness and treatment?

Is there someone they can consult when they are in trouble?

Such information may tend to be put on the back burner in discharge support situations.

However, if the person wishes to continue living in the community they are used to, I do not think we can consider support without excluding the meaning and role of continuing life.

What does living at home mean to that person?

What value does being in the community have?

Even if it looks like they are living alone, there may be resources that support their life, such as neighbors, familiar shops, community comprehensive support centers, visiting nursing, day services, family doctors, and pharmacies.

Conversely, even if it looks like there are connections, they may not actually function as support.

That is precisely why I believe it is necessary to look at connections with the community not just as "there" or "not there," but in what situations and what kind of resources exist.

Integrate medical risks and life hopes with multiple professions.

What we have looked at so far is not for a nurse to reach a conclusion alone.

Evaluation of cognitive function, medical management of diabetes, medication management, nutrition, life functions, long-term care insurance services, community resources, and the person's own wishes.

Collaboration with multiple professions is necessary to think about these in an integrated way.

Bring together information seen from the perspectives and fields of view of doctors, nurses, pharmacists, registered dietitians, rehabilitation professionals, medical social workers, care managers, community comprehensive support centers, visiting nursing, etc.

And think about it including the patient themselves.

Can they be discharged, or not?

Home, or a facility?

Before rushing to such a binary choice, think about how to provide patient-centered medical care.

For example, who will support medication management?

How will meals be arranged?

What kind of mechanism will be used for blood glucose monitoring and checking physical condition changes?

How will medical visits be continued?

To what extent can the rhythm of life and pleasures that the person cherishes be protected?

I think it is dangerous to ignore medical validity and say "to home because the person wishes it."

But on the other hand, deciding "home is difficult" by looking only at medical risks may not be a judgment that has sufficiently looked at the person's life.

Look at it medically, look at life, turn your eyes to the parts the person cherishes, and explore realistic options together with the person, their family, and multiple professions.

Isn't it important to think about how to support the life the patient desires based on that?