Management Of Type 2 Diabetes Mellitus In Elderly Patients: An Essay.

Critically analysis of care for a diabetic patient suffering from diabetes type 2 in a care setting, demonstrate deep understanding of important issues relating to caring for a diabetic patient.
Use and apply evidence based practice or research
Relate physiology/pathophysiology to therapeutic interventions and management.
Quality arguments and counter arguments to put forward

Diabetes Mellitus and its complications

Diabetes Mellitus is a medical condition that affects one's metabolism and is characterized by hyperglycemia. This condition is as a result of insulin secretion that is defective and/or action of insulin. Chronic hyperglycemia leads to long term dysfunction, damage, or failure of various organs especially the blood vessels, heart, nerves, kidneys, and eyes. There are several pathogenic processes that are involved in diabetes development. Long term diabetes complications include: nephropathy that can result in kidney failure; retinopathy that can result in complete vision loss; autonomic neuropathy that can result in cardiovascular, genitourinary, gastrointestinal symptoms as well as sexual dysfunction. Patients that have diabetes report higher incidences of cerebralvascular, peripheral arterial, and atherosclerotic cardiovascular disease. Global diabetes prevalence varies form region to region and is accelerated by lifestyle changes. According to WHO estimates, there are over 100 million people across the globe who are suffering from diabetes (National Diabetes Fact Sheet, 2011) 

Persons diagnosed with diabetes ought to seek medical assistance from a coordinated team headed by a Physician. These teams should also include pharmacists, dieticians, nurses, physician assistants, nurse practitioners, and mental health expert in diabetes.  It is critical that in this integrated and collaborative team, that a diabetic patient plays an active role in their own care. There is sufficient and compelling evidence that good glucose control results in improved clinical outcomes among diabetics that are hospitalized compared to outpatient settings (Gerstein, Miller, and Byington ,et al., 2008, p.2545; Spain and  Edlund, 2011, p.10; Neumiller and Setter, 2009, p. 324) In addition, the good glucose target levels have been shown to be unachievable for patients who attend both government and private hospitals (Ismail-Beigi, Moghissi, and Tiktin, 2011, p.154) Patients who seek care in a diabetes clinics are able to receive superior care compared to those who opt to seek care in general medical care settings (Pascal, Ofoedu, and Uchenna, et al., 2012, p.310) 

The main management goal of type 2 diabetes is to reach the correct glucose levels and also maintain these levels as well as reduce long-term complications risk.  Several studies have indicated that  with modern management, complications related to chronic diabetes can be delayed, limited, or prevented, by utilising  intensive glycemic control modern management. However, this intensive treatment of diabetes is linked to increased hypoglycaemia (Cryer and  Axelrod, 2009, p. 709), and more so in persons with type 1 diabetes and also in patients with prolonged diabetes insulin treatment (Cryer, 2007a, p. 127; Cryer, 2007b, p. 868; Davis, Mann, and Biscoe, 2009, p. 701)

Integrated team approach to DM management

Hypoglycaemia presents a serious medical emergency that needs quick recognition and equally faster treatment for the prevention of brain and organ damage. The symptoms spectrum is dependent on the severity and duration of hypoglycemia and varies with regard to behahvioral changes and autonomic activation, as well as coma, seizures, and cognitive function that are altered. Other complications include cardiovascular events, trauma, neurological damage, and death  (Alagiakrishnan and  Mereu , 2010, p. 129; Abbaszadeh, Tabatabaei, and  Pajouhi, 2009, p. 113). Severe hypoglycemia that goes untreated can result in significant personal and economic burden hence, prompt identification and treatment of hypoglycaemia  can hep in reducing the burden of diabetes.

90-95% of Type 2 diabetes mellitus (T2DM) is reported among adults (Olokoba,, Obateru, and Olokoba, 2012,p. 269). Similar to management of diabetes in younger persons, achieving as well as maintaining control of glucose is critical in elderly patients suffering from T2DM. This helps in preventing the risk of developing acute hyperglycaemic complications and other long term complications( Duncan, 2012, p. 6195; Corsino,Dhatariya,Umpierrez,2014). Although it is possible to maintain glycemic control by taking oral anti-diabetic drugs OADs) as well s lifestyle changes, most elderly patients will still require insulin in the long run due to T2DM progression (Bramlage , Gitt , and Binz, 2012, p. 122; Kansagara, Fu, and Freeman, et al., 2011, p. 268; Qaseem, Humphrey, andChou, et al., 2011, p. 260).

T2DM management among the elderly is further complicated by this population's functional and clinical heterogeneity(Pratley and Gilbert, 2012, p. 133). The disease may have started developing in some elderly T2DM patients in their mid years and lived in years of comorbidities. On the other hand, some elderly patients may be diagnosed for the first time or may have lived for years with few complications or undiagnosed comorbidities.

Another difference that  arises in T2DM patients that are elderly with regard to cognitive and physical functioning, physical robustness, life expectancy, and health status. It is critical that this heterogeneity amongst elderly patients be considered by the clinicians treating them with regard to treatment goal prioritization and setting. Further, elderly T2DM patients have higher chances compared to non T2DM elderly persons, to develop geriatric syndromes including urinary incontinence, polypharmacy, cognitive impairment, injurious falls, as well as depression and chronic pain, (Sinclair, Conroy, and Bayer, 2008, p. 233; Braun, Kubiak, and Kuntsche J, et al., 2009, p. 390; Bahrmann , Abel, Specht-Leible, 2010, p. 386). Pharmacokinetics should also be considered in the establishment of a medication regimen among T2DM elderly patients (Sinclair, Morley, and Rodriguez, 2012, p. 497).  More specifically, alteration in renal functioning is quite common among this group of patients and this can affect the way drugs are metabolized in the body.

Management goals for T2DM

Most medications that are used in treating T2DM in elderly patients work through one or multiple pathophysiological impairments: increasing secretion of insulin, reducing production of  hepatic glucose, increasing sensitivity of insulin, decreasing secretion of glucagon, increasing  levels of incretin, and decreasing feelings of satiety. Unfortunately, most clinical trials have an under-representation of older patients which leads to anti-hyperglycemic medications data to be extrapolated from populations that are younger (Cigolle, Lee, and Langa, et al., 2011, p. 272) Treatment of T2DM in elderly patients should account for the disease's progression over a time period (Tanwani ,2011, p.24). Due to the reduction in the functionality of β-cell which is age-related, maintaining the glycemic control target levels may call for drug dose escalations or for other anti-hyperglycaemic agents to be added (Mallery, Ransom, and Steeves, et al., 2013) Thus, drugs that target the β-cells for example GLP-1 related drugs or sulfonylureas will tend to reduce in efficacy over time. Drugs such as sodium glucose transporter 2 (SGLT2), thiazolidinediones (TZDs), as well as metformin may aid in the reversal of some vicious cycles that contribute to hyperglycaemia however, they do not address in a direct manner, the impact of aging on β-cells.

A review of the hyperglycaemia pharmacological treatment has been discussed in different literature (Nathan, D. M., Buse, J. B., Davidson,et l., 2009, p 193; Nyenwe, , Jerkins, and Umpierrez,. et al., 2011). Appendix 1 shows a list of the most recent literature with regard to insulin and non insulin anti-hyperglycemic agents (noninsulin and insulin),  and includes a short description of the medications' physiological action as well as the pros and cons when used in treating elderly patients.

The choice of treatment ought to be tailored to an individual patient's specific situation which is partly determined by the first patient's comprehensive assessment of cognition, comorbidities, functional status, financial situation, and care support (Kezerle, Shalev, and Barski, 2014, p. 391). Although it is typical for elderly patients to have functional and cognition impairment, multiple comorbidities, and financial support that is limited, a support system that is strong could be sufficient in helping the patient to implement a medical treatment that is complex and in a safe manner

The aim of the treatment plan should be the minimizing of hypoglycaemia risk and more so in vulnerable, frail patients, when utilizing agents that increase this such as sulfonylureas and insulin. Thus, the emphasis should be on classes of drugs which do not result in hypoglycaemia as well as focusing on lifestyle interventions (Williams, Pollack, and Dibonaventura, 2010, p.363). This will often result in achieving lower A1C targets that are safe and more so in T2DM early stage.  As the effectiveness of these safer interventions decrease due to effects of progressive failure of β-cell that comes with aging, insulin may be required while the A1C target may require to be enhanced in order to avoid the occurrence of hypoglycaemia. The use of sulfonylurea drugs in vulnerable elderly patients ought to be done with extreme caution. In addition, the patients should be provided with frequent follow up so as to ensure the smooth progression of the treatment program and to avoid occurrence of hypoglycaemia (Abdelhafiz, Rodríguez-Mañas, and  Morley, et al., 2015, p. 156).

Hypoglycemia in T2DM

When managing elderly patients with T2DM, minimizing the possibility of occurrence of Hypoglycemia is important. Elderly patients are at a higher risk of developing hypoglycemia even after glycemic control (Bakatselos, 2011, p. 92). Further, hypoglycemia presents a greater risk in occurrence of comorbid events as well as mortality in T2DM elderly patients in comparison to younger patients (Kirkman,  Briscoe, and Clark, 2012, p.2650). A hypoglycemic event is also independently associated with increased risk of falling and related fractures as well as cardiovascular events. Studies indicate that these events adversely impact the quality of health in a similar or increased level than other T2DM complications(McAulay and Frier, 2009, p. 287)In addition, there is evidence suggesting that severe episodes of hypoglycemia may exacerbate risk of dementia in elderly T2DM patients (Whitmer, , Karter, and Yaffe, et al., 2009, p. 363). On the other hand, the presence of age related syndromes can result in the increased hypoglycemia risk and its accompanying complications and should be analyzed during hypoglycemia risk evaluation (see Appendix 2)

Geriatric effects modify the symptomatic, cognitive, and hormonal counter-regulatory response to hypoglycaemia (Abdelhafiz ,Bailey, and Loo, 2013, p. 899). Although hypoglycaemia is the main causant of tight glycemic control, the risk of complication maybe increased by other co-morbidities such as polypharmacy, malnutrition, chronic heart disease, and renal impairment (Budnitz, Lovegrove, Shehab, and Richards, 2011, p. 2002). Low blood brain circulations occur due to hypoglycaemia which may accelerate the possibility of getting neurological damage and death (Huang,Liu, and Moffet, et al., 2011, p. 1329).

The well being, quality of life, and productivity of T2DM elderly patients can be affected by severe hypoglycaemia . Management goals ought to be individualized and should include several considerations. There are several studies that have shown that severe hypoglycaemia should not be prevented by intensive attenuation of HbA1C. Training patients on the early symptoms and signs of hypoglycaemia can greatly reduce the rate of cognitive impairment which affects the functionality and independence of elderly persons, hospitalization rates, as well as mortality.

Of critical importance with regard to in-patients suffering from recurrent hypoglycaemia, is to identify the time that the episodes occur and then use this information to adjust the treatment (Chen,Lin , and Lai, et al., 2008, p. 1975).  Morning fasting hypoglycaemia under a basal-bolus insulin program may be due to insulin that is intermediate or long acting. Daytime hypoglycaemia is often due to short or rapid acting insulin, while nocturnal hypoglycaemia could be as a result of any of the two. By substituting regular short acting insulin with the rapid such as aspart and lispro, the daytime hypoglycaemia frequency is greatly reduced. By substituting the longer acting insulin such as determir or glargine for the intermediate such as premix 70/30 or NPH, the frequency of daytime and nocturnal hypoglycaemia is reduced (American Geriatrics Society 2013).

T2DM management in the elderly

Using a rapid acting insulin Continuous subcutaneous insulin infusion (CSII) reduces hypoglycaemic rates and improves glycemic control  with multiple injections on a daily basis (Canadian Diabetes Association  2013).In addition, as mentioned earlier, patients that take oral diabetic drugs area at  higher risk of being hypoglycaemic hence they should not use sulfonylureas but rather thiazolidines, dipeptidyl peptidase inhibitors, and metformin (Tschöpe, Bramlage, and Binz, et al., 2012).

Individualized treatment of T2DM elderly patients should comprise of a working relationship that is close and the healthcare team and the patient. The professional team should work at improving the patient's knowledge so as to produce positive lifestyle changes as well as self-care decisions. The team should also monitor the long and short term complications for management following and early detection ( Jacobson, Musen, and Ryan, et al. 2007, p. 1842).

Conclusion:

The probability of developing hypoglycaemia that is common with geriatric effects and anti-diabetic agents may be the greatest hindrance in the treatment and control of diabetes in elderly T2DM patients. What this means is that the therapies that have the lowest or least probability of hypoglycaemia should be the first option in the treatment of hyperglycaemic elderly patients. There are several treatment options that are emerging and these include investigational approved therapies that are incretin base and also sodium glucose co-transporter 2 (SGLT2) inhibitors. Other options include ultra-long-acting insulin. Meanwhile, lifestyle changes and glycemic control under the supervision of a healthcare team is the best option for managing T2DM in elderly patients.

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