REFERENCES Uol
ADA American Diabetes Association 1995 Clinical practice recommendations. Diabetes Care, 18 Suppl. 1 , 1-96. BDA British Diabetic Association 1997 Recommendations for the Management of Diabetes in Primary Care. London BDA. BDA British Diabetic Association 1999 Guidelines of Practice for Residents with Diabetes in Care Homes. London BDA. Benbow SJ, Walsh A, Gill GV 1997 Diabetes in institutionalised elderly people a forgotten population. British Medical Journal, 314, 1868-1869. Black D, Bowman C...
The Atrisk Foot
The mainstay of risk reduction must lie with footcare education and the amelioration of other risk factors if present. Footcare education should be concise and repeated regularly in order to have the maximum effect on patient behaviour Barth et al 1991 . Video presentations have been shown to be effective at imparting knowledge about footcare Knowles et al 1992 , but they should not supplant one-to-one or small-group education. The main aspects of footcare education include the need for...
Lactic Acidosis
Lactic acidosis can be due to either biguanide therapy and other primarily metabolic disorders Type B , or shock and tissue hypoxia Type A due to severe organ failure Krentz and Nattrass 1997 . This chapter concentrates on that due to biguanide therapy. Lactic acidosis is much less common with metfor-min which enhances the mitochondrial oxidation of lactate Stumvoll et al 1995 , compared with older biguanides with which patients would unexpectedly tip into fatal lactic acidosis despite the...
The Diabetic Charcot Foot
The devastating effects of Charcot neuroarthropathy in the diabetic foot have been well described in the literature Sinha, Munichoodappa and Kozak 1972 Cofield, Morrison and Beabout 1983 Sammarco 1991 . Diabetes is now believed to be the leading cause of Charcot neuroarthropathy in the developed world Fryckberg 1987 . Eighty percent of the patients who develop Charcot neuroarthropathy have a known duration of diabetes of over 10 years. The long duration of diabetes prior to the initiation of...
Establishing The Diagnosis Of Diabetes Mellitus In Elderly People
Prior to 1997, the widely accepted criteria for the diagnosis of diabetes mellitus had been those recommended by the National Diabetes Data Group NDDG 1979 , which were later slightly modified by the World Health Organization WHO 1985 . Fasting hyperglycaemia was defined as plasma glucose gt 7.8 mM, while normality and diabetes for the 2-hour value in the standard 75 g oral glucose tolerance test OGTT were lt 7.8 mM and gt 11.1 mM respectively. In patients without unequivocal glucose elevation...
Anticoagulation in Hyperglycaemic Coma
There is a major threat of acute thrombotic events in HONK coma, and full anticoagulation has been employed. However, unless the indications are strong pulmonary embolism, large deep vein thrombosis, unstable angina the author would not fully anti-coagulate the subject, since many with HONK have haemorrhagic gastritis, the vascular event may already have happened prior to medical attention, and there are no studies to guide us on this decision. Other authors Krentz and Nattrass 1997 Alberti...
Sulfonylureas
Sulfonylureas SFUs have been used extensively worldwide since the introduction of tolbutamide and carbutamide in 1956. Shortly thereafter, other compounds were developed acetohexamide, tolazamide and chlorpropamide. These so called 'first generation sulfonylureas' were followed by the development of 'second-generation sulfonylureas' glyburide or glib-enclamide, glipizide, gliclazide, gliquidone and gli-meperide Table 15.2 . The primary mechanism of action of SFUs is through the depolarization...
The Patient With Diabetic Retinopathy
Diabetic retinopathy is a significant cause of visual impairment in elderly people. In the Framingham Study, 3 of all people aged 65-74 y had diabetic retinopathy, with 7 of 75-85 y olds being affected Kini et al 1978 . The duration of diabetes is the critical risk factor in the development of retinopathy those with Type 2 diabetes have a similar risk as those with Type 1 diabetes mellitus Nathan et al 1986 . Strategies to prevent or retard the development of diabetic retinopathy are described...
Metabolic Alterations
The metabolic alterations occurring in middle-aged subjects with Type 2 diabetes have been characterized extensively DeFronzo 1988 . When compared with age- and weight-matched controls, both lean and obese middle-aged subjects have elevated fasting hepatic glucose production, marked resistance to insulinmediated glucose disposal, and a profound impairment in glucose-induced pancreatic insulin release. Recently, metabolic factors have been characterized in lean and obese elderly patients with...
REFERENCES Dav
Brooks B, Molyneux L, Yue DK 1999 Augmentation of central arterial pressure in Type 1 diabetes. Diabetes Care, 22, 17221727. Curb JD, Pressel SL, Cutler JA, Savage PJ, Applegate WB, Black H, Camel G, Davis, BR, Frost PH, Gonzalez N, Guthrie G, Ober-man A, Ruton GH, Stamler J 1996 Effect of diuretic-based antihypertensive treatment on cardiovascular disease risk in older diabetic patients with isolated systolic hypertension. Systolic Hypertension in the Elderly Program Cooperative Research...
Insulininduced Hypoglycaemia in Type Diabetes
Few large-scale studies have recorded the frequency of hypoglycaemic episodes in people with Type 2 diabetes treated with insulin over a protracted period. The proportion of patients experiencing hypoglycaemia during the first 10 years of the UKPDS is shown in Table 10.10. People in the intensively treated group of the UKPDS experienced significantly more episodes of hypoglycaemia than did those in the conventionally treated group UK Prospective Diabetes Study Group 1998 but this was still much...
REFERENCES Mmk
Abbott CA, Carrington AL, Boulton AJM 1996 Reduced bilateral amputation rate in diabetic patients effect of a foot care clinic. Diabetic Medicine, 13 Suppl. 7 , S45. Barth R, Campbell LV, Allen S, Jupp JJ, Chisholm DJ 1991 Intensive education improves knowledge, compliance, and foot problems in Type 2 diabetes. Diabetic Medicine, 8, 111-117. Bartlett FF, Gibbons GW, Wheelcock FC 1986 Aortic reconstruction for occlusive disease comparable results in diabetics. Archives of Surgery, 121,...
I
Figure 6.10 Anteroposterior view of sole of a Charcot foot showing a plantar prominence which has ulcerated verse arches leading to a rocker bottom foot see Figures 6.10 and 6.11 . Charcot neuroarthropathy passes from this acute phase of development through a stage of coalescence, in which the bone fragments are reabsorbed, the oedema lessens and the foot cools. It then enters the stage of reconstruction, in which the final repair and regenerative modelling of bone takes place to leave a...
Appointments and Recall
Follow-up at regular intervals 3-6 months to measure weight and blood glucose, and a yearly review for signs of complications eyes, feet, cardiovascular diseases and risk factors evaluation are the core of structured care. Older diabetics with poor memory and communication problems forget their appointments and become non-attenders. Education about the importance of regular supervision is necessary. An appointment card with the date of a new visit, and a staffmember receptionist or medical...
CONCLUSION Mib
There has been a huge increase in knowledge about diabetes in old age, but much work remains to be done. Knowledge has advanced particularly in the management of risk factors for the complications of diabetes, such as hypertension, hyperlipidaemia and diabetes control. There has also been some advance in service organization of diabetes care in old age. In the UK, we have seen improvements with the development of shared-care guidelines between primary healthcare general practice and secondary...
Info Lir
Grundy SC, Benjamin IJ, Burke GL, Chait A, Eckel RH, Howard BV, Mitch W, Smith SC, Sowers JR 1999 Diabetes and cardiovascular disease, a statement for healthcare professionals from the Heart Association. Circulation, 100, 1134-1146. Gu K, Cowie CC, Harris MI 1998 Mortality in adults with and without diabetes in a National Cohort of the US population, 1971-1993. Diabetes Care, 21, 1138-1145. Haffner SM, Stern MP, Hazuda HP, Mitchell BD, Patterson JK 1990 Cardiovascular risk factors in confirmed...
Aids And Adaptations
Technology has much to offer in minimizing disability and handicap. A large variety of aids often called assistive devices can assist with such activities of daily living as dressing, toiletting and housework as well as with recreational pursuits. Those in common use have been described by Mulley 1989 they range Table 16.3 Aids and orthoses sometimes prescribed for patients with diabetes Forefoot calluses Transmetatarsal amputation Foot drop CVA or peripheral neuropathy Foot ulcer Unable to...
The Management Of Diabetic Patients Undergoing Surgery Hughes
Alberti KGMM, Marshall SM 1988 Diabetes and surgery. In Alberti KGMM, Krall LP eds . The Diabetes Annual. Amsterdam Elsevier, 248-271. Alberti KGMM, Thomas DJB 1979 The management of diabetes during surgery. British Journal of Anaesthesia, 51, 603-710. Alberti KGMM, Gill GV, Eliott MJ 1982 Insulin delivery during surgery in the diabetic patient. Diabetes Care, 5, 65-77. Allison SP, Tomlin PJ, Chamberlain MJ 1979 Some effects of anaesthesia and surgery on carbohydrate and fat metabolism. British...
Info Xqv
20-39 40-49 50-59 60-74 75 Age-std Figure 1.2 Prevalence of diabetes in men and women in the U.S. population age gt 20 years, based on NHANES III. Diabetes includes previously diagnosed and undiagnosed diabetics defined by fasting plasma glucose gt 126mg dl. Age-std, age-standardized. Reproduced by permission from Harris et al 1998 20-39 40-49 50-59 60-74 75 Age-std Figure 1.2 Prevalence of diabetes in men and women in the U.S. population age gt 20 years, based on NHANES III. Diabetes includes...
Predictors Of Mortality
Many factors are documented to increase the risk of cardiovascular mortality in young diabetic patients Rosengren et al 1989 Rossing et al 1996 , but very few studies have addressed this topic in older patients Ford and De Stefano 1991 . Since the strength of predictors of mortality can change with age Frost et al 1996 , further studies are needed. Recognition of the predictors of mortality is the first step in planning an intervention aimed at reducing mortality. Predictors can be divided into...
Management in Insulinrequiring Diabetes
This section includes true Type 1 diabetes patients, Type 2 patients on insulin treatment including those on a combination of oral hypoglycaemics and insulin , and patients with Type 2 diabetes requiring temporary perioperative insulin because of poor glycaemic control or planned major surgery. Historically, a confusing number of systems have been advocated at various times including early bizarre systems such as complete omission of insulin, or insulin with no subsequent glucose Gill and...
Adaptation To Life With Reduced Vision
For the elderly patient, adapting to life with reduced vision is an immense challenge. It is important that, where appropriate the individual be registered either partially sighted or blind according to national guidelines so that local social services can assess the need for involvement of the support agencies. There is a wide spectrum of visual impairment very few patients loose all sight and each case needs to be assessed individually. The patient should be referred to a low visual aid LVA...
REFERENCES Mrz
Abraira C, Colwell JA, Nuttall FQ, Sawin CT, Nagel NJ, Comstock JP, Emanuele NV Levin SR, Henderson W, Lee HS 1995 Veterans Cooperative Study on glycemic control and complications in Type II diabetes VA CSDM . Results of the feasibility trial. Veterans Affairs Cooperative Study in Type II Diabetes. Diabetes Care, 18, 1113-1123. Alberti KGMM 1991 Diabetes and surgery. Anaesthesiology, 74, 209-211. Bantle J, Neal L, Frankamp L 1993 Effects of the anatomical region used for insulin injections on...
Human Insulin Preparations
The most commonly used human insulin preparations are summarized in Table 15.3 Heinemann and Richter 1993 . These preparations differ in their pharmacoki-netics. Hypoglycemia is still the most frequently encountered side-effect of insulin therapy and the major limiting factor in intensive glycemic control Diabetes Control and Complications Trial 1993 UKPDS 1998a . Hypoglycemia is commonly precipitated by erratic meal timing, excessive insulin dosage and unplanned exercise. The failure to give...
Improvements in Hyperglycaemic Malaise and Quality of Life
Many elderly diabetic patients with high fasting glucose values and elevated HbA1c levels deny typical osmotic symptoms of thirst, polyuria and polydipsia but have malaise, lassitude and admit to feeling generally unwell. The latter symptoms are sometimes not admitted at the time but are recognized in retrospect after starting insulin. These covert symptoms of the syndrome of 'hyperglycaemic malaise' may persist for many years until progressive weight loss or overt osmotic symptoms develop and...
Quality Of Life
Diabetes mellitus, like many chronic diseases, imposes life-long stresses on achieving optimal quality of life and well-being, and this goal may be strongly influenced by how well an individual views their own health Linn et al 1980 . By virtue of high levels of comorbidities and marked disability from long-term vascular complications Morley et al 1987 , diabetes mellitus in older adults presents significant challenges in delivering healthcare, making the attainment of a satisfactory quality of...
Hyperglycaemic Conditions
There are three hyperglycaemic problems occurring in the elderly diabetic keto-acidosis DKA hyper-osmolar non-ketotic HONK coma Normo-osmolar, non-ketotic, hyponatraemic hyperglycaemia associated with impaired renal function. The key to management is to recognize the problem, so all sick elderly subjects must have plasma glucose estimation. Elderly subjects with DKA or HONK coma are often not known to have diabetes, and care home residence is a risk factor for HONK coma and death. Both diabetic...
Macrovascular Disease
Macrovascular disease is a leading cause of morbidity and mortality in people with or without diabetes, and in both groups elderly people have more disease than their younger counterparts. However, people with diabetes develop more macrovascular disease from an earlier age and even premenopausal women are often affected. This needs to be taken into consideration in determining what is the 'older' population. People with diabetes also have a worse prognosis following a macrovascular event than...
Normoosmolar Nonketotic Hyponatraemic Hyperglycaemia Associated with Impaired
There are several case reports Ryder and Hayes 1983 Popli et al 1990 of subjects with hyperglycaemia who are relatively well with mild dehydration only, and hyponatraemia. The subjects are known to have preexisting renal impairment, and it is thought that the renal impairment protects the subject from osmotic diuresis. Because the plasma glucose is extracellular, it acts to draw water from the intracellular space and dilutes the plasma sodium. It is possible to adjust for the effect of...
Prevention Of Diabetic Retinopathy
The UKPDS and DCCT trials have provided sound clinical evidence that tight control of hyperglycaemia is a major factor in the prevention of all diabetic complications, including retinopathy. The DCCT demonstrated that for Type 1 diabetics maintaining an HbA1c of 7 or less resulted in a reduced risk of developing retinopathy of 76 and a reduction in mean risk of retinopathy progression of 54 , when compared with a parallel group with poorer glycaemic control HbA1c lt 9 . This reduction in...
Prevalence Trends Over Time
In developed and developing countries alike, prevalence rates for diabetes in the general population have been on the increase since the early 1900s. For example, Harris 1982 had drawn attention to an upward trend in US prevalence rates for diagnosed diabetes between the 1930s and 1980 Figure 1.1 . Prevalence rates rose in all age groups and in both sexes, with the number of known people with diabetes doubling between 1960 and 1980 Bennett 1984 . In one Australian community Glatthaar et al 1985...
What About Lipids
Diabetes is well known to be associated with hyper-lipidaemia, often as a part of the metabolic Reaven's syndrome. A lot of research has quantified the risks and benefits of lowering lipid levels. The benefits in Type 2 diabetes are relatively well recognized Tikka-nen et al 1998 Pyorala, Olsson and Pedersen 1997 . These studies have used or compared statins and fi-brates Jeck et al 1997 . Unfortunately these studies have not included many very elderly patients, though the 4S study, which...
Definition And Classification Of Diabetes And Impaired Glucose Regulation
Though definitions and classification are dealt with in detail in Chapter 3, it is necessary at this stage to explain briefly the terms used here. This is particularly important in view of some recent changes in diagnostic criteria, which impact on the interpretation of epide- miological studies. Such changes are perhaps best understood from a historical perspective. Up until the late 1970s, epidemiological research in diabetes was bedevilled by a lack of standardization in definitions, in...
Types Of Retinopathy
Clinically, retinopathy is best considered divided into categories which enable the clinician to plan management and explain prognosis. The four major subdivisions are background diabetic retinopathy preproliferative retinopathy Background and Pre-proliferative Diabetic Retinopathy Background diabetic retinopathy BDR is so called because the lesions associated with it lie within the retina itself and are not sight-threatening Figure 9.1 . Lesions seen in BDR are microaneurysms, blot...
Counterregulation
The human brain is dependent upon glucose as its principal source of energy and requires a continuous supply of glucose via the cerebral circulation. Depriving the brain of glucose rapidly causes neuro-glycopenia, which has various effects, including impairment of cognitive function. In humans, several mechanisms have evolved to maintain glucose homeostasis and so protect the integrity and functioning of the brain Cryer 1993 . A decline in blood glucose concentration activates a characteristic...
Metabolic And Other Problems Induced By Surgery
Anxiety, anaesthetic drugs and possibly the underlying disease requiring surgery may all contribute to metabolic destabilization in the diabetic surgical patient. The most important factors, however, are starvation and the pathophysiological metabolic and humoral response to trauma. All but the most minor of operations involve some interruption of normal food intake, and this may not infrequently last for several days. This poses obvious practical difficulties for diabetic patients whose...
REFERENCES Ckk
Beri MR, Klugman et al 1987 Anterior ischaemic optic neuropathy incidence of bilaterality and various influencing factors. Journal of Ophthalmology, 94, 1020-1028. Branch Retinal Vein Occlusion Study Group 1984 Argon laser photocoagulation for macula oedema in branch vein occlusion. American Journal of Ophthalmology, 98, 271-282. BRVOS Branch Vein Occlusion Study Group 1986 ellip Argon laser scatter photocoagulation for prevention of neovascular and vitreous haemorrhage in branch vein...
Acute Presentation
Diabetes in elderly patients with Type 2 diabetes may present acutely in several ways in diabetic ketoacidosis DKA or as hyperosmolar non-ketotic HONK coma, or more commonly as hyperglycaemia without significant ketosis or increased osmolality with or without coexisting acute illness e.g. acute cerebrovascular accident a mixed metabolic disturbance . Both DKA and HONK coma are covered in more detail in Chapter 5. Various precipitating factors for HONK coma have been identified Table 11.8 ....
Peripheral Sensorimotor Neuropathy
Peripheral sensorimotor neuropathy is a major contributory cause in 90 of diabetic foot ulceration Thomson et al 1991 . The incidence of diabetic peripheral sensorimotor neuropathy increases with the duration of diabetes. However, as the prevalence depends on the diagnostic criteria that are used, the prevalence rates reported from different epidemiological studies vary considerably Melton and Dyck 1987 . In a prospective study of a large cohort of diabetic patients followed over 25 years, 50...
Limited Joint Mobility
Diffuse collagen abnormalities are common in diabetic patients Larkin and Frier 1986 . The main pathogenic mechanism for these abnormalities is glycation of collagen which results in thickening and increased cross-linking of collagen bundles Goodfield and Millard 1988 . One of the clinical manifestations of this change is thick, tight and waxy skin, leading to restriction of joint movements. Patients with limited joint mobility are unable to oppose the palms of their hands the prayer sign see...
Mortality
Diabetes mellitus increases mortality risk and reduces life expectancy. Accordingly, Figure 8.2 shows that diabetic patients from Verona experienced higher mortality rates than the general population at all ages Muggeo et al 1995a . When the excess mortality related to diabetes is measured by the standardised mortality ratio SMR , the adverse effects of diabetes appears to be inversely related to both actual age and age at diagnosis Table 8.1 . In the Verona study the SMR ranged between 2 and...
Patient and Informal Carer Responsibilities
In most situations an individual care plan must be adopted and agreed by all concerned. This may be organized by the primary care physician general practitioner , although diabetes specialist nurses can play an important role in this decision-making. This will consist of identifying the principal informal carer, setting realistic glycaemic goals, planning the timing and frequency of visits, and being aware of the indications for hospital referral to a specialist Table 11.9 or admission....
Preoperative Assessment
Preoperative assessment of the elderly diabetic patient is aimed at checking general fitness for surgery, ensuring that diabetic management is appropriate, and confirming that glycaemic control is reasonable. By 'inappropriate' management is meant potentially hazardous drugs such as the potent and or long-acting sulphonylureas, glibenclamide and chlorpropamide. Regrettably a number of older diabetic patients remain on such preparations and treatment may need to be updated prior to surgery....
The Effect Of Intercurrent Illness On The Diabetes
Intercurrent illness may affect patients with diabetes in several ways. First, associated liver or renal disease may contraindicate the use of oral agents, when insulin in a basal bolus regimen may be used. Second, the treatment itself, e.g. steroids may cause hypergly-caemia, and again insulin treatment may be needed. Third, the illness may make dietary intake unreliable, and in this situation a basal bolus regimen omitting the bolus if the meal is omitted is very useful. At the end of the...
HONK Coma Risk Factors and Management
As with DKA, undiagnosed diabetes is a major risk factor for HONK coma, and infection is a common precipitant. In one series, 68 of subjects with HONK coma had undiagnosed diabetes, and infection was the precipitant in 55 Small, Alzaid and MacCuish 1988 . Residents of care homes are also at increased risk of HONK coma Wachtel et al 1991 , with a greater risk of fatal outcome. Often a patient a resident is not known to be diabetic and seems to have had a UTI recently whether they have had a UTI...
Country of residence
King and Rewers 1993 have collated data on the prevalence of abnormal glucose tolerance in over 150 000 people from 75 communities in 32 countries Figure 1.3 . As diabetes is an age-related disorder, its prevalence in individual countries varied according to Figure 1.3 Prevalence of abnormal glucose tolerance diabetes and impaired glucose tolerance in selected populations in the age range of 30-64 years, age standardized to the world population of Segi, sexes combined. , Upper income , middle...
Sulfonylureas And Hypoglycemia. Bmj 1988 296 949 -50
Amiel SA 1999 Risks of strict glycaemic control. In Frier BM, Fisher BM eds Hypoglycaemia in Clinical Diabetes. Chichester John Wiley, 147-166. Ashcroft FM, Gribble FM 2000 Tissue-specific effects of sulfonylureas. Lessons from studies of cloned KATP channels. Journal of Diabetes Complications, 14, 192-196. Asplund K, Wilholm BE, Lithner F 1983 Glibenclamide associated hypoglycaemia a report on 57 cases. Diabetologia, 24, 412-417. Asplund K, Wilholm BE, Lundman B 1991 Severe hypoglycaemia...
Multidisciplinary Diabetes Care
Elements of multidisciplinary diabetes care include the following An individualized diabetes care plan. Each resident with diabetes should play a part in establishing agreed objectives summarized in a care plan which should include a series of metabolic targets. An individualized dietary and nutritional plan as part of the overall care plan. An annual review assessment involving a diabetes eye check and foot check. Support and assistance in diabetes care from a named person who will be involved...
Painful And Painless Neuropathy
Diabetic neuropathy can affect both the peripheral and autonomic nervous systems resulting in such devastating sequelae as foot ulceration and infection, lower limb amputation, sexual dysfunction and cardiac arrhythmias. Of the neuropathies, peripheral sensory neuropathy is most widely seen in clinical practice and is primarily responsible for diabetic foot disease. This type of neuropathy is typically bilateral and symmetrical. This helps to distinguish it from other conditions commonly found...
References 1
Arner P, Pollare T, Lithell H 1991 Different Aetiologies of Type 2 non-insulin-dependent diabetes mellitus in obese and non-obese subjects. Diabetologia, 34, 483-487. Best JD, Kahn SE, Ader M, Watanabe RM, Ni TC, Bergman RN 1996 Role of glucose effectiveness in the determination of glucose tolerance. Diabetes Care, 19, 1018-1030. Berger M 1987 Human insulin much ado about hypoglycaemia un awareness. Diabetologia, 30, 829-833. Cassano PA, Rosner B, Vokonas PS, Weiss ST 1992 Obesity and body fat...