Diabetes Mellitus in the Elderly PDF

Diabetes Mellitus Prof: Shazly Baghdadi Ali Assist. Prof. OF PULMONOLOGY ASWAN UNIVERSITY Most common clinical conditions associated with aging  What is diabetes? Diabetes mellitus (DM) is a group of diseases characterized by high levels of blood glucose resulting from defe...

Diabetes Mellitus Prof: Shazly Baghdadi Ali Assist. Prof. OF PULMONOLOGY ASWAN UNIVERSITY Most common clinical conditions associated with aging  What is diabetes? Diabetes mellitus (DM) is a group of diseases characterized by high levels of blood glucose resulting from defects in insulin production, insulin action, or both. a metabolic disorder of multiple aetiology characterized by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism. The effects of diabetes mellitus include long– term damage, dysfunction and failure of various organs.  Diabetes present with characteristic symptoms such as thirst, polyuria, blurring of vision, and weight loss. In its most severe forms, ketoacidosis or a non–ketotic hyperosmolar state may develop and lead to stupor, coma and, in absence of effective treatment, death. Often symptoms are not severe, or may be absent,.  Types of Diabetes Type 1: Autoimmune destruction of insulin-producing cells. Type 2: Insulin resistance, common in elderly.  Types of Diabetes Type 1: Autoimmune destruction of insulin-producing cells. Type 2: Insulin resistance, common in elderly. Other Types of Diabetes Type 1 Diabetes Mellitus Type 2 Diabetes Mellitus Gestational Diabetes Other types: LADA (Latent Autoimmune Diabetes mellitus in Adults) MODY (Maturity-Onset Diabetes of Youth) Secondary Diabetes Mellitus Prevalence of Diabetes in the Elderly Nearly 25% of Why it’s common in people over the age the elderly: of 65 have diabetes. Age-related insulin Higher risk of resistance. complications in elderly due to Lifestyle factors coexisting conditions. like inactivity, poor diet, and obesity. Other Types of Diabetes Prevalence of Diabetes in the Elderly Nearly 25% of Why it’s common in people over the age the elderly: of 65 have diabetes. Age-related insulin Higher risk of resistance. complications in elderly due to Lifestyle factors coexisting conditions. like inactivity, poor diet, and obesity. Prevalence of Diabetes in the Elderly Nearly 25% of Why it’s common in people over the age the elderly: of 65 have diabetes. Age-related insulin Higher risk of resistance. complications in elderly due to Lifestyle factors coexisting conditions. like inactivity, poor diet, and obesity. Risk Factors in Elderly Age-related decline in pancreatic function. Family history of diabetes. Sedentary lifestyle. Obesity and poor diet. Hypertension and high cholesterol. Risk Factors in Elderly Age-related decline in pancreatic function. Family history of diabetes. Sedentary lifestyle. Obesity and poor diet. Hypertension and high cholesterol. Symptoms of DM in the Elderly Common Symptoms: Increased thirst and urination. Fatigue and weakness. Blurred vision. Slow wound healing. Unintentional weight loss. Symptoms often mistaken for aging. Symptoms of DM in the Elderly Common Symptoms: Increased thirst and urination. Fatigue and weakness. Blurred vision. Slow wound healing. Unintentional weight loss. Symptoms often mistaken for aging. Values of Diagnosis of Diabetes Mellitus  Complications Short-term Complications: Hypoglycemia. Hyperglycemia. Long-term Complications: Cardiovascular diseases. Neuropathy. Retinopathy. Nephropathy. Foot ulcers.  Complications Short-term Complications: Hypoglycemia. Hyperglycemia. Long-term Complications: Cardiovascular diseases. Neuropathy. Retinopathy. Nephropathy. Foot ulcers. Diagnosis and Monitoring Diagnosis: Fasting blood sugar test (>126 mg/dL). HBA1C test (>6.5%). Oral glucose tolerance test. Monitoring: Regular blood glucose monitoring. Checking for complications (foot checks, eye exams).  Treatment Treatment Goals: Maintain blood glucose levels within a target range. Avoid complications. Lifestyle Modifications: Diet: Balanced meals with low sugar. Exercise: Moderate, regular physical activity.  Treatment Treatment Goals: Maintain blood glucose levels within a target range. Avoid complications. Lifestyle Modifications: Diet: Balanced meals with low sugar. Exercise: Moderate, regular physical activity.  Secondary DM Secondary causes of Diabetes mellitus include: Acromegaly, Cushing syndrome, Thyrotoxicosis, Pheochromocytoma Chronic pancreatitis, Cancer Drug induced hyperglycemia: ◦ Atypical Antipsychotics - Alter receptor binding characteristics, leading to increased insulin resistance.  Secondary DM ◦ Beta-blockers - Inhibit insulin secretion. ◦ Calcium Channel Blockers - Inhibits secretion of insulin by interfering with cytosolic calcium release. ◦ Corticosteroids - Cause peripheral insulin resistance and gluconeogensis. ◦ Fluoroquinolones - Inhibits insulin secretion by blocking ATP sensitive potassium channels. ◦ Naicin - They cause increased insulin resistance due to increased free fatty acid mobilization. ◦ Phenothiazines - Inhibit insulin secretion. ◦ Protease Inhibitors - Inhibit the conversion of proinsulin to insulin. ◦ Thiazide Diuretics - Inhibit insulin secretion due to hypokalemia. They also cause increased insulin resistance due to increased free fatty acid mobilization.  Management of DM The major components of the treatment of diabetes are: e rcis Exe A and py t thera Die emic B glyca hypo y Oral rap C The ulin Ins A. Diet Diet is a basic part of management in every case. Treatment cannot be effective unless adequate attention is given to ensuring appropriate nutrition. Dietary treatment should aim at: ◦ ensuring weight control ◦ providing nutritional requirements ◦ allowing good glycaemic control with blood glucose levels as close to normal as possible ◦ correcting any associated blood lipid abnormalities A. Diet (cont.) The following principles are recommended as dietary guidelines for people with diabetes: Dietary fat should provide 25-35% of total intake of calories but saturated fat intake should not exceed 10% of total energy. Cholesterol consumption should be restricted and limited to 300 mg or less daily. Protein intake can range between 10-15% total energy (0.8-1 g/kg of desirable body weight). Requirements increase for children and during pregnancy. Protein should be derived from both animal and vegetable sources. Carbohydrates provide 50-60% of total caloric content of the diet. Carbohydrates should be complex and high in fibre. Excessive salt intake is to be avoided. It should be particularly restricted in people with hypertension and those with nephropathy. Exercise Physical activity promotes weight reduction and improves insulin sensitivity, thus lowering blood glucose levels. Together with dietary treatment, a programme of regular physical activity and exercise should be considered for each person. Such a programme must be tailored to the individual’s health status and fitness. People should, however, be educated about the potential risk of hypoglycaemia and how to avoid it. B. Oral Anti-Diabetic Agents There are currently four classes of oral anti- diabetic agents: i. Biguanides ii. insulin secretagogues Sulphonylureas Non-sulphonylureas iii. α-glucosidase inhibitors iv. Thia zolidine diones (TZDs)  B.1 Oral Agent Monotherapy If glycaemic control is not achieved (HbA1c > 6.5% and/or; FPG > 7.0 mmol/L or; RPG >11.0mmol/L) with lifestyle modification within 1 –3 months, ORAL ANTI-DIABETIC AGENT should be initiated. In the presence of marked hyperglycaemia in newly diagnosed symptomatic type 2 diabetes (HbA1c > 8%, FPG > 11.1 mmol/L, or RPG > 14 mmol/L), oral anti- diabetic agents can be considered at the outset together with lifestyle modification.  B.1 Oral Agent Monotherapy As first line therapy: Obese type 2 patients, consider use of metformin, acarbose or TZD. Non-obese type 2 patients, consider the use of metformin or insulin secretagogues Metformin is the drug of choice in overweight/obese patients. TZDs and acarbose are acceptable alternatives in those who are intolerant to metformin. If monotherapy fails, a combination of TZDs, acarbose and metformin is recommended. If targets are still not achieved, insulin secretagogues may be added  Diabetes Management Algorithm Oral Hypoglycaemic Medications  General Guidelines for Use of Oral Anti- Diabetic Agent in Diabetes In elderly non-obese patients, short acting insulin secretagogues can be started but long acting Sulphonylureas are to be avoided. Renal function should be monitored. are not recommended for diabetes in pregnancy are usually not the first line therapy in diabetes diagnosed during stress, such as infections. Insulin therapy is recommended. Targets for control are applicable for all age groups. However, in patients with co-morbidities, targets are individualized When indicated, start with a minimal dose of oral anti-diabetic agent, (2-16 weeks depending on agents used)  C. Insulin Therapy Short-term use: Acute illness, surgery, stress and emergencies Pregnancy Breast-feeding Insulin may be used as initial therapy in type 2 diabetes in marked hyperglycaemia Severe metabolic decompensation (diabetic ketoacidosis, hyperosmolar nonketotic coma, lactic acidosis, severe hypertriglyceridaemia) Long-term use: If targets have not been reached after optimal dose of combination therapy or BIDS, consider change to multi-dose insulin therapy. When initiating this,insulin secretagogues should be stopped and insulin sensitisers e.g. Metformin or TZDs, can be continued.  Insulin regimens The majority of patients will require more than one daily injection if good glycaemic control is to be achieved. However, a once-daily injection of an intermediate acting preparation may be effectively used in some patients. Twice-daily mixtures of short- and intermediate-acting insulin is a commonly used regimen. In some cases, a mixture of short- and intermediate-acting insulin may be given in the morning. Further doses of short-acting insulin are given before lunch and the evening meal and an evening dose of intermediate-acting insulin is given at bedtime. Other regimens based on the same principles may be used. A regimen of multiple injections of short-acting insulin before the main meals, with an appropriate dose of an intermediate-acting insulin given at bedtime, may be used, particularly when strict glycaemic control is mandatory. Overview of Insulin and Action  Self-Care Patients should be educated to practice self-care. This allows the patient to assume responsibility and control of his / her own diabetes management. Self-care should include: ◦ Blood glucose monitoring ◦ Body weight monitoring ◦ Foot-care ◦ Personal hygiene ◦ Healthy lifestyle/diet or physical activity ◦ Identify targets for control ◦ Stopping smoking  Hypoglycemia in Elderly Patients Causes: Skipping meals. Too much insulin or oral hypoglycemics. Physical activity without adjustment to medication or meals. Signs: Dizziness, confusion, sweating. Shakiness, weakness. Loss of consciousness in severe cases. Treatment: Immediate intake of fast-acting carbohydrates (e.g., glucose tablets, juice). Hypoglycemia in Elderly Patients Causes: Poor adherence to medications. Illness or stress. Overeating or lack of exercise. Signs: Excessive thirst, frequent urination. Fatigue, blurred vision. Treatment: Adjusting medications. Rehydration and balanced meals.  Nursing Care Plans for Diabetes Mellitus Nursing care planning goals for patients with diabetes include effective treatment to normalize blood glucose levels and decrease complications using insulin replacement, a balanced diet, and exercise. The nurse should stress the importance of complying with the prescribed treatment program through effective patient education. Tailor your teaching to the patient’s needs, abilities, and developmental stage. Stress the effect of blood glucose control on long-term health. Risk for Unstable Blood Glucose The goal of diabetes management is to normalize insulin activity and blood glucose levels to prevent or reduce the development of complications that are neuropathic and vascular in nature. Glucose control and management can dramatically reduce the development and progression of complications Nursing diagnosis Risk for Unstable Blood Glucose as evidenced by inadequate blood glucose monitoring, inability to follow diabetes management Risk factors Inadequate blood glucose monitoring Lack of adherence to diabetes management Medication management Deficient knowledge of diabetes management Developmental level Lack of acceptance of diagnosis Stress, sedentary activity level Insulin deficiency or excess  Desired outcomes Patient has a blood glucose reading of less than 180 mg/dL; fasting blood glucose levels of less than 160 mm Hg (systolic). Administer hypertensive as prescribed. Hypertension is commonly associated with diabetes. Control of BP prevents coronary artery disease, stroke, retinopathy, and nephropathy. 5. Instruct the patient to avoid heating pads and always to wear shoes when walking. Patients have ↓ sensation in the extremities due to peripheral neuropathy..  Nursing Interventions and Rationale 6. Instruct patient to take oral hypoglycemic medications as directed: Sulfonylureas: glipizide (Glucotrol), glyburide (DiaBeta) , glimepiride (Amaryl) Sulfonylureas stimulate insulin secretion by the pancreas, used mostly in type 2 diabetes to control blood glucose levels. They also enhance cell receptor sensitivity to insulin and decrease the liver synthesis of glucose from amino acids and stored glycogen. Meglitinides: repaglinide (Prandin) Stimulates insulin secretion by the pancreas.  Nursing Interventions and Rationale 6. Instruct patient to take oral hypoglycemic medications as directed: (cont.) Biguanides: metformin (Glucophage) These drugs↓ the amount of glucose produced by the liver and improve insulin sensitivity. They enhance muscle cell receptor sensitivity to insulin. Phenylalanine derivatives: nateglinide (Starlix) Stimulates rapid insulin secretion to reduce the increases in blood glucose that occur soon after eating. Alpha-glucosidase inhibitors: acarbose (Precose), miglitol (Glyset). Inhibits the production of glucose by the liver and increases the body’s sensitivity to insulin. Used in controlling blood glucose levels in type 2 diabetes.  Nursing Interventions and Rationale 6. Instruct patient to take oral hypoglycemic medications as directed: (cont.) Thiazolidinediones: pioglitazone (Actos), rosiglitazone (Avandia) Sensitizes body tissues to insulin and stimulates insulin receptor sites to lower blood glucose and improve the action of insulin. Incretin modifiers: sitagliptin phosphate (Januvia), vildagliptin (Galvus) Increases and prolongs the action of incretin which increases insulin secretion and decreases glucagon levels.  Nursing Interventions and Rationale 7. Instruct patient to take insulin as directed: Rapid-acting insulin analogs: lispro insulin (Humalog), insulin aspart Has a clear appearance. Have an onset of action within 15 minutes of administration. The duration of action is 2 to 3 hours for Humalog and 3 to 5 hours for aspart. Patient must eat immediately after injection to prevent hypoglycemia. Short-acting insulin (regular insulin): regular, Humulin R Short-acting insulins have a clear appearance, has an onset of action within 30 minutes of administration, duration of action is 4-8 hours. Regular insulin is the only insulin approved for IV use.  Nursing Interventions and Rationale 7. Instruct patient to take insulin as directed (cont.) Intermediate-acting insulin (NPH insulin): neutral protamine Hagedorn (NPH), insulin zinc suspension (Lente) They appear cloudy and have either protamine or zinc added to delay their action. Onset of action for the intermediate-acting is one hour after administration; duration of action is 18 to 26 hours. This type of insulin should be inspected for flocculation, a frosted-whitish coating inside the bottle. If frosted, it should not be used. Long-acting insulin: Ultralente, insulin glargine (Lantus) Have a clear appearance and do not need to be injected with a meal. Long-acting insulins have an onset of one hour after administration, and have no peak action because insulin is released into the bloodstream at a relatively constant rate. Duration of action is 36 hours for Ultralente is 36 hours and glargine is at least 24 hours. They cannot be mixed with other insulin because they are in a suspension with a pH of 4, doing so will cause precipitation. Intermediate and rapid: 70% NPH/30% regular Premixed concentration has an onset of action similar to that of a rapid-acting insulin and a duration of action similar to that of intermediate-acting insulin.  Nursing Interventions and Rationale 8. Instruct patient on the proper injection of insulin. The absorption of insulin is more consistent when insulin is always injected in the same anatomical site. Absorption is fastest in the abdomen, followed by the arms, thighs, and buttocks. It is recommended by the American Diabetes Association to administer insulin into the subcutaneous tissue of the abdomen using insulin syringes. 9. Educate patient on the correct rotation of injection sites when administering insulin. Over time, injection of insulin in the same site will result in lipoatrophy and lipohypertrophy with reduced insulin absorption. Repeated use of an injection site can cause the development of fatty masses called lipohypertrophy, which can impair the absorption of insulin when used again.  Nursing Interventions and Rationale 10. Instruct the patient on the proper storage of insulin. Insulins should be refrigerated, not be allowed to freeze, avoid extremes of temperatures, and avoid exposure to direct sunlight. To prevent irritation from “cold insulin,” vials may be stored at temperatures of 15º - 30ºC (59º to 86ºF) for 1 month. Opened vials are to be discarded after that time, while unopened vials may be stored until expired date.. their expiration date. Instruct patient to keep a spare vial of 11. Instruct the insulin patient that insulin vial types prescribed. that is Cloudy in use should insulins shouldbe be kept at room temperature. thoroughly mixed by rolling the vials between the hands Keeping insulin at room temperature helps reduce local irritation at the before injectiondrawing site. the solution. 12. Stress the importance of achieving blood glucose control. Control of blood glucose levels within the nondiabetic range can significantly reduce the development and progression of complications.  Nursing Interventions and Rationale 13. Explain the importance of weight loss to obese patients with diabetes. Weight loss is an important factor in the treatment of diabetes. loss of around 5-10% of the total body weight can reduce or eliminate the need for medications and significantly improve blood glucose levels. their expiration date. Instruct patient to keep a spare vial of the insulin types prescribed. Cloudy insulins should be thoroughly mixed by rolling the vials between the hands before drawing the solution. 14. Explain the importance of having consistent meal content or timing. The recommendation is 3 meals of equal size, evenly spaced meal times (5-6 hours apart), with one or two snacks. Pacing food intake throughout the day places more manageable demands on the pancreas. 15. Refer the patient to support groups, diet and nutrition education, and counseling. To help the patient incorporate weight management and learn new dietary habits..  Nursing Interventions and Rationale 16. Educate the patient on maintaining consistency in food and the approximate time intervals between meals. A consistent amount of food and time interval between meals helps prevent hypoglycemic reactions and maintain overall blood glucose control. 17. Educate the patient about the health benefits and importance of exercise in the management of diabetes. Exercise plays a role in lowering blood glucose and reducing cardiovascular risk factors for patients with diabetes. Exercise lowers blood glucose levels by increasing the uptake of glucose and improving the utilization of insulin. 18. Review exercise precautions for patients taking insulin. Hypoglycemia may occur hours after exercise, stressing the patient’s need to eat a snack at the end of the exercise session.  Nursing Interventions and Rationale 19. Provide instructions to patients using self-monitoring blood glucose (SMBG). Frequent SMBG is another important factor in diabetes management. When patients know their SMBG results, they can adjust their treatment regimen and obtain optimal blood glucose control. Additionally, SMBG helps motivate patients to continue their treatment. It can also help in monitoring the effectiveness of exercise, diet, and oral antidiabetic agents. 20. Observe and review the patient’s technique in self-monitoring blood glucose (SMBG). Determines if there are errors in SMBG due to incorrect technique (e.g., blood drop too small, improper cleaning and maintenance, improper application of blood, damage to reagent strips). The patient may obtain erroneous blood glucose values when using incorrect techniques in SMBG. Additionally, the patient should compare their device’s result with lab-measured blood glucose levels to determine the validity of the device’s reading. 21. For patients using insulin pumps, educate the patient on the importance of maintaining its patency. The needle or tubing in an insulin pump may become occluded (from battery drainage or depletion of insulin), which may increase the patient’s risk for DKA.  OU K Y AN TH