Diabetes mellitus refers to a series of metabolic disorders related with high blood glucose and caused by several metabolic defects in either insulin secretions or insulin actions or both. Exposure to chronic hyperglycemia may lead to microvascular complications in retina of the eye, kidney or peripherals. (Díaz-Gerevini et al., 2014 p.528). Diabetes is rapidly on the rise especially in old age. This can be contributed to by different factors such as changes in lifestyle and degraded metabolic functions in old age. Unlike type 1 diabetes, the symptoms and complications of type 2 diabetes appear late in the course of the disease. But it can sometimes be difficult to tell the difference between these two diseases especially in with old age.
The patient is Mr. P born in Italy and is 83 years old. He has had quite a good life until recently he was admitted with diabetic Mellitus. He has also lost significant weight recently. He has had a good and simple life, worked in several farms in Italy and schooled for five years and then migrated to Australia in 1952. Mr. P likes reading the newspaper and enjoys listening to radio, watching old movies and playing cards. He has a current interest in gardening and playing piano too. He is described as being quiet but enjoys other people’s company.
Mr. P was admitted in RAH due to aphasia with secondary diagnosis of chronic renal impairment, hypertension, gastro-esophageal reflux disease, and diabetes. After undergoing treatment Mr. P was shifted to an aged care facility where he has been living since March 2016. His past medical history entails insulin dependent diabetes, gastro-esophageal reflux disease, early dementia, short-term memory loss, lumbar disc bulge, and osteoarthritis, shortness of breath, urinary incontinence, deafness, asthma, vitamin D deficiency and renal impairment. He is allergic to panadeine forte. Mr. P is currently on the following medications;
- Esomeprazole Tablet (20 mg): 20 mg, oral, daily
- Atorvastatin Tablet (20mg): 80 mg, oral, daily
- Perindopril arginine Tablet (10mg):10mg oral daily
- Frusemide Tablet (40mg): 60 mg. oral daily
- Metoprolol tartrate (50mg): 25mg, oral, BD
- Clopidogrel and Aspirin (coplavix) (75-100mg): 75mg, oral, daily
- Insulin Glargine (Lantus solostar) (3ml; 100 units/ml): 20 units, subcut, nocte
- Insulin (Novorapid Flexpen) (3ml; 100 units/ml): 4 units, subcut, TDS with meals
On admission, Mr. P presented with thirst when his glucose level was too high. Thirst in diabetic patients arises because their bodies become dehydrated as a result of losing fluid, electrolytes, and salt in urine. After around two hours Mr. P became palpated and sweaty. This could be an indication that his glucose blood concentration had gone too low. Mr. P also looked weak and tired. His urine examination indicated the presence of large amounts of glucose in urine. This could be as a result of the body trying to eliminate as much insulin as possible. (Hales & Barker, 2013 p.1220)
Excess weight is in itself a cardiovascular risk, in addition to that of diabetes.
Mr. P’s weight was monitored by:
Body mass index, BMI.
Measurement of waist circumference: it is another risk factor when it is greater than 102 centimeters in men, 88 centimeters in women.
It looked for risk factors and evaluated the impact of diabetes on Mr. P:
Measurement of blood pressure, at rest (after 15 minutes in the extended position) and on both arms, with a cuff of appropriate size in the case of obesity, knowing that the BP should not exceed 130/80 mmHg. (Díaz-Gerevini et al., 2014 p.529)
Pulse monitoring checks heart rate and rhythm.
Signs of heart failure presented by Mr. P included: tachycardia, exercise dyspnea, lower limb edema, liver pain, and abnormalities noted on cardiac and pulmonary auscultation (performed by the doctor).
Finding signs of macro-angiopathy by palpation of the peripheral distal pulse and the search for vascular breaths on auscultation performed by the nurse.
Search for orthostatic hypotension on Mr. P- drop in blood pressure when passing from standing to standing - evidence of vegetative neuropathy.
Ophthalmologic examination (requiring specialist consultation)
Diabetes is responsible for often severe ophthalmologic lesions. The examination of the fundus of the eye makes it possible to appreciate the state of the vascularization of the retina. It is complemented by the study of visual acuity. (Huang et al., 2014 p.248).
Examination of the skin
Skin examination was performed on Mr. P to look for infected lesions, such as boils, especially in unapparent places (nostrils, buttocks, auditory ducts ...). Examination of the feet it was essential and indispensable
The blood glucose regulation by the body is largely related to the ability of cells to absorb blood glucose and hence lowering its concentration in blood. Insulin is a hormone secreted by the pancreatic cells, whose function is to increase the entry of glucose into the cells in case of hyperglycemia (hence its hypoglycemic action). (Díaz-Gerevini et al., 2014 p.530)
The polyuria seen in Mr. P on examination- polydipsia (literally, "many urination and thirst") was a consequence of hyperglycemia (increased blood sugar). The kidneys could only recover all the filtered glucose, which passes through the urine and by osmosis calls the water from the primary urine and causes a significant water loss in the urine, resulting in dehydration and permanent thirst. Mr. P drunk a lot of water because he urinated too much and not the opposite.
At the onset of the disease, insulin production by the pancreas is normal (or even excessive). But, the cells of the body responsible for capturing and using glucose become insensitive to insulin, hence an increase in blood sugar. This could have resulted in Mr. P being hyperglycemic. Type 2 diabetes is most often not insulin dependent, but insulin therapy may be needed to control glycemic control just as seen in Mr. P’s success with insulin chemotherapy. (Hales & Barker, 2013 p.1222)
The diabetes type 2 is often associated with other factors of cardiovascular risks, such as high blood pressure, the android fat distribution, the hypertriglyceridemia, and lower rates HDL cholesterol, the metabolic syndrome. Its incidence increases, as due to the changes in lifestyle e.g. (sedentary lifestyle, hypercaloric, hyperlipidemic diet)
Obesity is growing concern in the old age and is majorly related to a metabolic syndrome of diabetes mellitus, cognitive dysfunction, hypertension and hyperlipidemia. Reduced physical exercise and energy use in old age put could have put Mr. P at a risk of the accumulation of fats and redistribution, loss of muscles which result in resistance to insulin by body organs. Meta-analyses of exercise with diet on Mr. P finalized that hemoglobinA1c (HbA1c) can be reduced through aerobic and exercises and by diet management, by 0.6–0.8 percent and 0.5 percent in that order. Recent guidelines require that diabetes mellitus patients should do not less than 150 minutes every week of moderate intensity aerobic exercise and take part in resistance exercises 4 times every week. This means that the focus of treatment of diabetes mellitus is good to be based on reducing intra-abdominal fats with appropriate balancing of diet restriction coupled with preserving muscle strength and mass. (Hales & Barker, 2013 p.1222)
Nurses encouraged high levels of hygiene on Mr. P. This is important especially with bleeding that usually takes place in the lower limbs. Maintaining hygienic conditions reduce chances of infection from pathogens. Encouraging exercise to Mr. P reduced the pathophysiology of the disease due to increased blood flow to the tissues and increased metabolic rates that may then result in degradation of the excess sugars.
Oral antidiabetic agents
Oral hypoglycemic agents were a group of drugs which were very important in management of Mr. P’s condition. Metformin is used as an oral hypoglycemic agent. Metformin is currently useful in first line therapy of diabetics. It is commonly used as an insulin sensitizer in the old age because it is effective in reducing blood glucose and has low risks of developing hypoglycemia and also has a relatively mild adverse drug effects. (Díaz-Gerevini et al., 2014 p.531)
Sulfonylureas: They stimulate insulin production by attaching to a specific binding site on the sulfonylurea receptor cell (KATP channel complexes) thereby limiting its activity which results in depolarization of the cell membrane and eliciting the series of events resulting in insulin release. It is still an effective means of lowering blood glucose concentration after the failure of using diet only in elderly patients. (Huang et al., 2014 p.248). Weight gain by overeating prevents hypoglycemia and are main limiting factors to obtaining good glycemic control.
In medication therapy, nurses have different roles including; ensuring that Mr. P swallow the drugs in case of difficulty in swallowing, administering the drug to the patient through the right route e.g. subcutaneous and oral routes. They observe the medication course and identify any adverse drug reactions that may occur on Mr. P.
Medical nutrition therapy with exercise:
Dieting is the major area of control of hyperglycemia in the elderly pharmacological therapy not-withstanding. Medical nutrition therapy is centered on a carbohydrate-controlled meal plans. The amounts and distributions of carbohydrate were tailored with Mr. P’s needs relating to the clinical settings for example hunger, weight gain, control of glycemia, and ketosis. (Díaz-Gerevini et al., 2014 p.532)
Nurses played a very important role in medication nutrition therapy on Mr. P. They made sure that nutritional management plan developed for him was strictly adhered to. They also developed nutritional plans suitable for Mr. P.
Insulin was administered to Mr. P when nutrition therapy failed. Insulin administration is the most accurate treatment plan when medical nutrition therapy fails to meet the targeted glycemic management. The duration of a trail of medical nutrition therapy is to be given before starting insulin therapy is unknown. Without an agreement for the duration of starting insulin therapy, some differences are seen at the threshold of fasting blood glucose concentration. Either greater than 95 or greater than 105 mg/dl have been proposed. (Huang et al., 2014 p.249).
Nurses have a responsibility of ensuring that insulin therapy is a success in Mr. P management. They can did this by helping him to administer the right dose at the right frequencies. Maintaining proper drug plasma insulin concentration especially after meals to prevent hyperglycemic conditions from developing. (Hales & Barker, 2013 p.1224)
Critique the nursing and pharmacological management
Nurses provided education to Mr. P with the aim of enhancing self-care plans. This self-management can only be assured by the person affected if they have been properly trained in the management of a long-term disease on a daily basis. Health workers are given an additional mission: to teach the "skills" that Mr. P. needed to carry out a therapeutic project, of course, but also a project for his life. The nurse had a decisive role to play alongside him. Diabetes needs a careful meeting care-giver, who is committed to the wellbeing of the patient. Illness is seen as a feeling of injustice to most patients. The nurse took good care of Mr. P and accompanied him in the different phases of accepting the disease. (Huang et al., 2014 p.250). Nurses played important role in the life of Mr. P because almost all parts of the management plan required nursing interventions such as helping in diagnosis, drug administration, patient education and patient lifestyle management. The nursing function should, therefore, be improved more modern techniques and skills aimed at achieving better patient care.
The initial examination of Mr. P was an essential time and had to be the starting point of a regular follow-up. Hygiene was emphasized on Mr. P. It took time to explain the importance of treatment and hygiene-dietetic rules. Regular consultations was therefore necessary to adapt the treatment and reduce the risks of complications which, in the long term, alter the quality of life. (Huang et al., 2014 p.250). The examination of Mr. P required all the attention of the general practitioner and the diabetologist, as well as that of the paramedical team (chiropodist, nurse, and dietician). That is to say the importance of coordination between the various stakeholders and the need to take the time to listen to and examine Mr. P.
Abitbol, R., Rej, S., Segal, M. and Looper, K.J., 2015. Diabetes mellitus onset in geriatric patients: does long?term atypical antipsychotic exposure increase risk? Psychogeriatrics, 15(1), pp.43-50.
American Diabetes Association, 2014. Diagnosis and classification of diabetes mellitus. Diabetes care, 37(Supplement 1), pp.S81-S90.
American Diabetes Association, 2014. Executive summary: standards of medical care in diabetes—2014.
American Diabetes Association, 2014. Standards of medical care in diabetes—2014. Diabetes care, 37(Supplement 1), pp.S14-S80.
Dall, T.M., Yang, W., Halder, P., Pang, B., Massoudi, M., Wintfeld, N., Semilla, A.P., Franz, J. and Hogan, P.F., 2014. The economic burden of elevated blood glucose levels in 2012: diagnosed and undiagnosed diabetes, gestational diabetes mellitus, and prediabetes. Diabetes care, 37(12), pp.3172-3179.
Daniele, G., Mendoza, R.G., Winnier, D., Fiorentino, T.V., Pengou, Z., Cornell, J., Andreozzi, F., Jenkinson, C., Cersosimo, E., Federici, M. and Tripathy, D., 2014. The inflammatory status score including IL-6, TNF-α, osteopontin, fractalkine, MCP-1 and adiponectin underlies whole-body insulin resistance and hyperglycemia in type 2 diabetes mellitus. Acta diabetologica, 51(1), pp.123-131.
De, S. and Sahu, D.P., 2015. Effect of Aerobic and Yogic Training on Blood Sugar Level of Type-2 Diabetes Mellitus of Elderly Rural Population of Bengal.
Díaz-Gerevini, G.T., Repossi, G., Dain, A., Tarres, M.C., Das, U.N. and Eynard, A.R., 2014. Cognitive and motor perturbations in elderly with longstanding diabetes mellitus. Nutrition, 30(6), pp.628-635.
Hales, C.N. and Barker, D.J.P., 2013. Type 2 (non-insulin-dependent) diabetes mellitus: the thrifty phenotype hypothesis. International journal of epidemiology, 42(5), pp.1215-1222.
Handelsman, Y., Bloomgarden, Z.T., Grunberger, G., Umpierrez, G., Zimmerman, R.S., Bailey, T.S., Blonde, L., Bray, G.A., Cohen, A.J., Dagogo-Jack, S. and Davidson, J.A., 2015. American Association of Clinical Endocrinologists and American College of Endocrinology–clinical practice guidelines for developing a diabetes mellitus comprehensive care plan–2015. Endocrine Practice, 21(s1), pp.1-87.
Huang, E.S., Laiteerapong, N., Liu, J.Y., John, P.M., Moffet, H.H. and Karter, A.J., 2014. Rates of complications and mortality in older patients with diabetes mellitus: the diabetes and aging study. JAMA internal medicine, 174(2), pp.251-258.
Kimbro, L.B., Mangione, C.M., Steers, W.N., Duru, O.K., McEwen, L., Karter, A. and Ettner, S.L., 2014. Depression and All?Cause Mortality in Persons with Diabetes Mellitus: Are Older Adults at Higher Risk? Results from the Translating Research Into Action for Diabetes Study. Journal of the American Geriatrics Society, 62(6), pp.1017-1022.
Korsatko, S., Deller, S., Madero, J.K., Glettler, K., Koehler, G., Treiber, G., Urschitz, M., Wolf, M., Hastrup, H., Søndergaard, F. and Haahr, H., 2014. Ultra-long pharmacokinetic properties of insulin degludec are comparable in elderly subjects and younger adults with type 1 diabetes mellitus. Drugs & aging, 31(1), pp.47-53.
Li, L., Shen, J., Bala, M.M., Busse, J.W., Ebrahim, S., Vandvik, P.O., Rios, L.P., Malaga, G., Wong, E., Sohani, Z. and Guyatt, G.H., 2014. Incretin treatment and risk of pancreatitis in patients with type 2 diabetes mellitus: systematic review and meta-analysis of randomised and non-randomised studies. Bmj, 348, p.g2366.
Norris, S.L., Zhang, X., Avenell, A., Gregg, E., Brown, T., Schmid, C.H. and Lau, J., 2016. Long-term non-pharmacological weight loss interventions for adults with type 2 diabetes mellitus. Sao Paulo Medical Journal, 134(2), pp.184-184.
Ruscica, M., Macchi, C., Morlotti, B., Sirtori, C.R. and Magni, P., 2014. Statin therapy and related risk of new-onset type 2 diabetes mellitus. European journal of internal medicine, 25(5), pp.401-406.
Sardu, C., Marfella, R. and Santulli, G., 2014. Impact of diabetes mellitus on the clinical response to cardiac resynchronization therapy in elderly people. Journal of cardiovascular translational research, 7(3), pp.362-368.