Diabetes (or Diabetes mellitus) is a complex group of diseases caused by a number of reasons. Individuals suffering from diabetes have hyperglycemia (high blood sugar) either because there is low production of insulin or body cells do not use the produced insulin. About 350 million people suffer from diabetes globally (Danaei et al., 2011). The World Health Organization (1999) has predicted that diabetes will rise to the top seventh cause of death worldwide by 2030. There are three common forms of diabetes: type 1 diabetes, type 2 diabetes and gestational diabetes. This paper mainly discusses these major forms of diabetes considering their causes and consequences.
Type 1 Diabetes
In type 1 diabetes mellitus, body cells fail to produce insulin due to a compromised immune system causing damage to the cells where production of insulin takes place. The cause and prevention of type 1 diabetes are not particularly known; however, it is suspected to be a consequence of certain genetic factors.
Type 2 Diabetes
In type 2 diabetes mellitus, there is low production of insulin by the body cells or the body does not effectively make use of the produced insulin. Type 2 diabetes is known to be the commonest type of diabetes; in fact, 90% of diabetes sufferers have type 2 diabetes (World Health Organization, 1999). The cause and cure of type 2 diabetes remains unknown; however, genetic factors and manner of living take part in its causes, and watching blood sugar level can control the disease.
Gestational diabetes happens when there is a development of high blood sugar level in pregnant women not previously diagnosed of diabetes. For mothers who had gestational diabetes during their first pregnancy, the probability that it will occur in subsequent pregnancies is approximately two-thirds. Furthermore, some patients may subsequently develop type 2 diabetes. After pregnancy, diabetes type 1 or 2 may occur and will require obligatory treatment.
Genetic Factors and Markers
The role of genetic factors as a cause of diabetes has been proven definitively. This is the main etiological factor for diabetes.
IDDM is considered to be a polygenic disease which is based on at least two of the mutant genes in diabetic chromosome 6. They are associated with the HLA system (D-locus), which determines the individual, genetically determined response of the body and B cells to various antigens.
The hypothesis of polygenic inheritance of IDDM suggests that diabetes is caused from two mutant genes (or two groups of genes) that have a recessive inherited predisposition to autoimmune lesions of the insular apparatus or increased sensitivity of B cells to viral antigens or attenuated antiviral immunity.
Genetic susceptibility is linked with particular genes of HLA systems, which are considered markers of such a predisposition.
Patients with a genetic predisposition to IDDM have an altered response to environmental factors. They have weakened antiviral immunity, and they are extremely susceptible to cytotoxic damage to the B cells by viruses and chemical agents.
Viral infection may be a factor that provokes the development of IDDM. The most common occurrence of IDDM clinically is preceded by the following viral infections: measles (rubella virus has a tropism to the islets of the pancreas, accumulates, and can be replicated in them), Coxsackievirus and hepatitis B virus (can be replicated in the insular apparatus), mumps (1-2 years after the epidemic of mumps, the incidence of IDDM in children dramatically increases), infectious mononucleosis, cytomegalovirus, influenza virus, etc. The role of viral infection is confirmed by seasonality in the incidence of IDDM development (often, the first diagnosed cases of IDDM among children occur in autumn and winter months, with a peak incidence in October and January), the detection of high titers of antibodies to the virus in the blood of patients with IDDM, and the detection by immunofluorescent methods for studying viral particles in the islets of Langerhans in people who have died of IDDM. The role of viral infections in the development of IDDM is confirmed in experimental studies. Viral infections among individuals with a genetic predisposition to IDDM are involved in the development of the disease as follows:
- the cause of acute injury to B cells (Coxsackievirus);
- leads to viral persistence (congenital cytomegalovirus infection, rubella) with the development of autoimmune reactions in the islet tissue.
In modern diabetology, the next staging of IDDM is expected.
First stage – a genetic predisposition, due to the presence of certain antigens in the HLA system, as well as genes of chromosomes 11 and 10.
Second stage – the initiation of the autoimmune process in islands of B cells influenced with viruses, cytotoxic agents and any other unknown factors. A crucial point in this step is the expression of B cells HLA-DR-antigen and glutamic acid, and therefore, they become autoantigens that cause the development of autoimmune response reactions.
Third stage – the stage of the active immunological process with formation of antibodies to B cells, insulin and autoimmune insulitis development.
Fourth stage – the progressive reduction of insulin secretion stimulated by glucose (1-phase secretion of insulin).
Fifth stage – clinical diabetes (the manifestation of diabetes). This step develops during the occurrence of the degradation and death of 85-90% of the B cells.
Many patients after the insulin treatment fall into remission of the disease (the “diabetic honeymoon”). Its length depends on the severity and degree of B cell damage, their ability to regenerate, and the level of residual insulin secretion, as well as the severity and frequency of related viral infections.
Sixth stage – the complete destruction of b-cells, and a complete lack of insulin secretion and C-peptide. Clinical signs of diabetes form and insulin treatment becomes necessary again.
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Diabetes is a long term condition that causes high blood glucose levels in an affected individual. The chronic condition affects people of all age groups but there are specific changes in the care of Diabetes for older people (Abdelhafiz and et.al., 2015). The present essay features the epidemiology of Diabetes among older population. In addition to this, it also explores the pathophysiology of Diabetes and its impact on an elderly patient. Apart from this, the study also examines and evaluates the effectiveness of present clinical practices in relation to evidence based approach. The essay also critically reviews literature on relevant policy initiatives related to the chronic condition. Further, the essay also discusses collaboration, teamwork and client involvement in the management of Diabetes.
Diabetes is a chronic condition which can be described as a group of metabolic diseases in which an individual has high blood sugar levels. The raised blood glucose levels in body is either due to inadequate production of insulin or inability of body cells to respond to the insulin. The prevalence of Diabetes is higher for any age group including children, working adults and pregnant women but older people are at potential risk for acute and chronic cardiovascular complications of the disease. It is linked to higher mortality and reduced functional activities among elderly patients. About 85 percent of people in UK are diagnosed with type 2 diabetes (Scheen, 2003). Among the older population, type 2 diabetes is a major problem that severely affects their health and mental well being.
Postprandial hyperglycemia is a prominent trait of type 2 diabetes in elderly patients. The epidemic of type 2 diabetes is directly linked to elevate the rate of obesity in UK. It has been studied that even if the rate of diabetes incidences level off, the prevalence of chronic condition will grow two folds due to aging of UK population in the next two decades. Other projections state that number of diagnosed cases of diabetes in individuals aged more than 65 years will likely to increase 4 times in the following years. The incidence of chronic condition increases with the increment in age. It has been observed that after 65 years of age, the prevalence and incidence get level off (Sinclair, Dunning and Rodriguez-Mañas, 2015). As a consequence, older adults may either have incident disease or long term diabetes with the onset during middle age. Clinical traits of these two groups make treatment recommendations for older diabetic patients more complex. No difference is observed in the prevalence of Cardiovascular diseases by the age of onset. Elderly individuals with diabetes have the elevated rates of visual impairment, myocardial infarction and other related diseases. The complications of diabetes are higher in older people aged more than 75 years as compared to those who aged 65- 74 years. The cases of deaths from the chronic condition is significantly higher in older people. The rate of hospital admissions due to diabetic emergencies is double among the older patient whose age is more than 75 years than the general population suffering from diabetes. Due to increased insulin resistance coupled with impaired pancreatic islet function with aging, older people are at increased risk for the development of type 2 diabetes. It is observed that age induced insulin resistance is associated with sarcopenia and adiposity. In addition to these, physical inactivity is also a causal factor of the insulin resistance.
The pathophysiology of type 2 diabetes in older patients can be elaborated as a heterogeneous disorder that is characterized by abnormalities of fat and carbohydrate metabolism (Kohei, 2010).There are multiple causal factors of type 2 diabetes which include both the genetic and environmental components. These factors influence beta cell function and sensitivity of tissues such as adipose tissues, muscle, pancreas and liver towards insulin. The beta cell dysfunction and lowered insulin sensitivity relatively contribute to the pathogenesis of type 2 diabetes. It is observed that both these determinants play vital role in diagnosing the chronic condition among older patients. However, the system that controls the interplay of these two determinants is not very clear. It has been studied in various medical researches that there are numerous factors that can be linked to beta cell dysfunction and insulin resistance in the pathogenesis of type 2 diabetes in older people. Adipose tissues play an important role in the pathogenesis of type 2 diabetes in individuals above 65 years of age as majority of people suffering from diabetes are overweight or obese. There are two new paradigms that can explain the link between obesity and diabetes.These are fat storage syndrome and adipose tissue as endocrine organ hypothesis. The fat storage syndrome is characterized as deposition of triglycerides in muscle, liver and pancreas (Mandal, 2013). The adipose tissue hypothesis is associated with production of several adipocytokins such as leptin, resistin and adeponectic. These two paradigms present a framework for the detailed study of interplay of beta cell dysfunction and insulin resistance in type 2 diabetes among older individuals. In addition to this, these paradigms play cardinal role in studying the genetic and environmental factors that are responsible for diabetes and its risk in the coming decades.
Diabetes is a lifelong condition that significantly impacts the health and well being of older patients. Older patients are diagnosed with type 2 diabetes experience symptoms that include lack of sleep, inability to concentrate, confusion, poor appetite, cognitive dysfunction, confusion, violent behavior, difficulty in speech and self-care, heart attacks and stroke etc. It is often observed that lack of early diagnosis of the long term condition severely impacts the mental health of older patients. Depression is very common among older diabetic patients due to painful neuropathy and negative effects of medication. In addition to this, foot ulceration also contributes to the development of depression among elderly population. Prolonged hospitalization also increases the risk of delirium and dementia which further complicate the management of type 2 diabetes in older individuals (Yaffe and et.al., 2013). Cognitive dysfunction increase the risk of Alzheimer's and other mental disorders in elderly patients suffering from type 2 diabetes. Another risk factors for functional impairment is contributed to both aging and diabetes. It has been found that peripheral neuropathy present in majority of elderly diabetic patients elevates the risk of balance problems and instability related to posture, minimal physical activity and higher risks of falls. Besides this, other medical conditions that follows diabetes in older patients and negatively affect functionality and physical activity are obesity, stroke, visual impairment, cardiovascular diseases and degenerative joint ailments.
Poly pharmacy severely hit older diabetic patients in which they are adversely affected by the side effects of drugs. Poly pharmacy can be referred to use of six or more prescription medication for treating diabetes in older care takers (Kirkman and et.al., 2012). It is the biggest challenge in the treatment of type 2 diabetes in older patients. Care professionals deliberately use drugs to control and reduce the risk of complications of the lifelong chronic disease. Other than this, falls and fractures are commonly found to impact diabetic patients. The risk of falls and fractures are higher in older female patients. It has been observed that prevention of severity of type 2 diabetes can significantly reduce the risk of falls and fractures among older people. Besides this, vision and hearing impairment are also prevalent in older people with diabetes which is significantly linked to neuropathy and vascular diseases. Apart from these, painful neuropathy and inadequate treatment may lead to severe outcomes in elderly care takers which include anxiety, depressions, sleep disturbances, reduced social interactions, increased health care costs (Mitchell, Lord, Harvey and Close, 2015).Therefore it is very important for devising an effective health policy to control and manage diabetes in older people in order to promote their physical and mental well being.
The National Service Framework (NSF) for Diabetes is a relevant policy initiative taken by the UK government to control and manage the risk associated with diabetes among all age groups including older patients aged 65 and more. The framework for diabetes include 12 standards that are meant for guiding the care services of National Health Services (NHS) which are the most important care organizations of UK for treating diabetic patients. Standard 1 of NSF focuses on prevention of type 2 diabetes (Chen, Magliano and Zimmet, 2012). Under this, NHS plans to develop, employ and monitor strategies to minimize the risk of developing type 2 diabetes in UK population and also to reduce the inequalities in the risk of the long term condition. Standard 2 of NSF for diabetes deals with identification of people with diabetes. NHS aims to develop, implement and regulate the strategies to identify people who are more prone to affect from the chronic condition. Standard 3 of the diabetes policy framework aims to empower individuals with diabetes. NHS focuses on encouraging partnership in decision making among affected individuals including children, adults and elderly people in order to support them in managing their chronic condition. This will help the individuals to opt for healthier lifestyle to ameliorate their health status. The care takers will be engaged in the decision making process through shared and agreed care plan which will have a particular format and language. Family members and relatives of diabetic patients are also included in the care plan. Standard 4 include Clinical care of older individuals with diabetes. Under this, all adults suffering from diabetes will receive superior quality of care throughout their life. This also involves care support to control their blood sugar levels, blood pressure and related risk factors which may complicate the condition among affected patients.
Standard 5 of NSF deals with clinical care of children and young adults with diabetes. This standard guides care professionals to provide consistent and superior quality of care to children and young people on a day to day basis. It also encourages active involvement of families of these care takers to optimize the control of high blood sugar levels and facilitate physical, psychological, emotional and social development of children and young adults. Standard 6 of NSF is an extension of Standard 5 of the diabetic policy which focuses on smooth and hassle free transformation of pediatric diabetes care services to adult services. This can be done either at hospitals or community based health care services. Standard 7 of the framework aims at effective management of diabetic emergencies (Kirkman and et.al., 2012). NHS will create, implement and monitor protocols for prompt and efficient treatment of diabetic emergencies by employing trained care professionals. These protocols will involve the management of acute complications and processes to reduce the risk of occurrence of diabetic emergencies in individuals. Standard 8 of the framework for diabetes deals with Care of diabetic people during hospital admissions. Under this, there is provision of providing effective care to hospitalized diabetic people including children, young individuals and adults. The care takers will be involved in the decision making processes regarding self management of the chronic condition. Standard 9 of the framework deals with Diabetes during pregnancy. The NHS focuses on developing, employing and monitoring tactics to empower and support females with already existing diabetes and those who are likely to develop the condition during pregnancy in order to reduce the risks associated with complications of diabetes.
Standard 10 of the diabetes framework lays emphasis on regular surveillance of young and adult diabetic patients for monitoring long term complications among them. Standard 11 and 12 of the NSF for diabetes deals with identification and management of long term complications among diabetic care takers. NHS aims to formulate, implement and monitor protocols and procedures of care to ensure that service users who develop long term diabetic complications receive prompt and effective assessment and treatment to minimize the risk of mortality and disability due to blindness and amputation. In addition to this, Standard 12 focuses on providing multidisciplinary support to diabetic patients that involves integrated health and social care. It can be critically analyzed that National Service Framework for Diabetes is an effective policy initiative in UK to control and manage lifelong chronic disease among diabetic patients of all age groups (Abdelhafiz and et.al., 2015). The framework is very beneficial in the effective management of diabetes in order to reduce the complications of the condition and increase the life expectancy among affected individuals including children, young adults and older people.
The effectiveness of current clinical practice in relation to evidence based approach can be critically evaluated. Good clinical practice guidelines were published by Diabetes UK. For older people in UK, diabetes management is divided into nursing care and social care. In nursing care, registered nursing staff provide foot care, regular monitoring of blood glucose, guidance on self management of diabetes etc. The clinical practice in relation to management and treatment of older people with diabetes in UK is effective (Prince and et.al., 2015). However, it can be critically evaluated that follow up practices are poor. Foot care is a important part of diabetes management. However, there are other complications that dioabeti9c patients suffer from. These include complications of kidneys, eyes etc. A gap exists as the clinical practice does not take into account these aspects efficiently. There are people who cannot self administer insulin. This is an important aspect which needs to be addressed. Sufficient services should be provided to these patients. However, there is a gap in the clinical practice as the different areas of service are not clear. There is confusion regarding who can give insulin in the nursing home, who can provide training for insulin administration, who will provide services regarding diabetes complications etc.
Collaborative working play very crucial role in health and social care sector in controlling and managing the long term chronic condition. The role of health and social care workers is very cardinal when it comes to effective treatment of diabetes in older patients. With the advancing age, the risk of complications of other medical conditions also increases in diabetic patients (Sherifali and Meneilly, 2015). Therefore it becomes very crucial for health professionals in early diagnosis of diabetes in elderly patients and effective care plan need to be developed to treat the condition. The care plan should be designed on the basis of person centric approach. The care needs of older patients should be assessed effectively by involving them in the decision making processes. Effective communication between care takers and health workers create a strong bond them which is very important for developing a personalized care plan to manage diabetes among patients. This shared decision making is considered as an effective approach to ameliorate the quality of care service.
The key aspects of shared decision making include setting collaboration working between older patients and care providers, vital information exchange, intention on choices and taking appropriate actions related to decisions. It has been observed that the health care objectives of older diabetic patients is focused mostly on their functional independence (Akrivos and et.al., 2015).The important element of improving the communication with patients is to find the harmony between care takers objectives and medical goals. Clinicians mainly focus on the congruence of both the objectives while treating and managing diabetes among older patients. The treatment becomes very difficult when patients do not cooperate with care givers as they do not comprehend the relevance of risk associated with complications of diabetes and value of minimizing the risk.
Therefore it is very crucial for care givers to educate patients regarding risk factors related to complications of diabetes and encourage them to cooperate as team member to control and manage their chronic condition (Bruce and et.al., 2015). Older people rely greatly on their family and friends to assist them with their decisions related to treatment decisions. This is due to their old age and dependence on others they lack the ability to take care of themselves in an effective manner. The care professionals need to consider the nutritional requirements of older people suffering from diabetes. Though energy needs of older people decline with age , their macro nutrients needs remain same throughout adulthood. Thus care professionals need to carefully conduct the assessment of nutritional needs of older people to meet their energy needs. In addition to this, self management of diabetes in older patients also include physical activity. Physical fitness is very important to treat the chronic condition among older care takers. With progressive age, muscle mass and strength tends to decline which is further exacerbated by the complications involved in the condition and admissions to hospitals (Huang and Davis, 2015). It has been observed that regular physical activity tend to ameliorate the functional status in older people. Thus collaborative working is very important for encouraging older people to self manage their condition through effective care plan which include proper medication, diet and exercise regime to reduce the complications of diabetes.
Evaluation of policy initiatives may inform future practice in various ways. These will also help in bridging the practice gap. There should be provided adequate services for managing diabetes associated complications such as diabetic neuropathy, diabetic nephropathy, retinopathy etc. each of these should be paid attention (Dunning, 2016). Moreover, there is a need to provide information to the patients regarding dietary requirements pertaining to diabetes. This is even more important as elderly people have special requirements for proper nutrition. Roles and responsibilities of Diabetes specialist nurse (DSN), practice nurse, district nurse should be made clear. Foot care and podiatry services should also be provided to the older people with diabetes. Provision of access to opthalmological services for residents of care homes will help in bridging the practice gap. Older patients with diabetes may also suffer from chronic pain, however, it is likely to be under reported. Hence approaches should be adopted to improve the detection of pain and its management. Assessment of pain should form an important aspect in the clinical practice for management of diabetes.
In a nutshell, diabetes is a lifelong disease that affects the phical and mental wellbeing of older patients. It is a lifelong disease that can be cured completely but the onset of type 2 diabetes can be delayed among older individuals through early diagnosis and effective care plan. Pathophysiology of type 2 diabetes presents detailed study of factors that trigger diabetes in older patients. In addition to this it significantly affect the physical and mental functionality of the afrfected person. The literature review of National Service Framework for diabetes is an effective initiative to control and reduce the risk associated with complications of diabetes. Besides this, collaborative working is very effective in providing care and support to older patients suffering from type 2 diabetes.
Books and Journals
- Abdelhafiz, A.H. and Sinclair, A.J., 2015. Epidemiology, aetiology, pathogenesis and management of diabetes in older people. Advanced Nutrition and Dietetics in Diabetes.
- Abdelhafiz, A.H. And et.al., 2015. Hypoglycemia in Older People-A Less Well Recognized Risk Factor for Frailty.Aging and disease.
- Akrivos, J. and et.al., 2015. Glycemic control, inflammation, and cognitive function in older patients with type 2 diabetes. International journal of geriatric psychiatry.
- Bruce, D.G. and et.al., 2015. Apathy in older patients with type 2 diabetes. The American Journal of Geriatric Psychiatry.
- Chen, L., Magliano, D.J. and Zimmet, P.Z., 2012. The worldwide epidemiology of type 2 diabetes mellitus—present and future perspectives. Nature Reviews Endocrinology.
- Scheen, A.J., 2003. Pathophysiology of type 2 diabetes. [Online] Available through: <http://www.ncbi.nlm.nih.gov/pubmed/15068125>.
- Kohei, K., 2010. Pathophysiology of Type 2 Diabetes and Its Treatment Policy. [Pdf] Available through: <https://www.med.or.jp/english/journal/pdf/2010_01/041_046.pdf>.
- Mandal, A., 2013. Diabetes Mellitus Type 2 Pathophysiology. [Online] Available through: <http://www.news-medical.net/health/Diabetes-Mellitus-Type-2-Pathophysiology.aspx>.
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